Source: www.USHealthcare.gov. A federal government Website managed by the U.S. Department of Health & Human Services 200 Independence Avenue, S.W. – Washington, D.C. 20201
2010
NEW CONSUMER PROTECTIONS
Putting Information for Consumers Online. The law provides for an easy-to-use website where consumers can compare health insurance coverage options and pick the coverage that works for them. Effective July 1, 2010.
Prohibiting Denying Coverage of Children Based on Pre-Existing Conditions. The new law includes new rules to prevent insurance companies from denying coverage to children under the age of 19 due to a pre-existing condition. Effective for health plan years beginning on or after September 23, 2010 for new plans and existing group plans.
Prohibiting Insurance Companies from Rescinding Coverage. In the past, insurance companies could search for an error, or other technical mistake, on a customer’s application and use this error to deny payment for services when he or she got sick. The new law makes this illegal. After media reports cited incidents of breast cancer patients losing coverage, insurance companies agreed to end this practice immediately. Effective for health plan years beginning on or after September 23, 2010.
Eliminating Lifetime Limits on Insurance Coverage. Under the new law, insurance companies will be prohibited from imposing lifetime dollar limits on essential benefits, like hospital stays. Effective for health plan years beginning on or after September 23, 2010.
Regulating Annual Limits on Insurance Coverage. Under the new law, insurance companies’ use of annual dollar limits on the amount of insurance coverage a patient may receive will be restricted for new plans in the individual market and all group plans. In 2014, the use of annual dollar limits on essential benefits like hospital stays will be banned for new plans in the individual market and all group plans. Effective for health plan years beginning on or after September 23, 2010.
Appealing Insurance Company Decisions. The law provides consumers with a way to appeal coverage determinations or claims to their insurance company, and establishes an external review process. Effective for new plans beginning on or after September 23, 2010.
Establishing Consumer Assistance Programs in the States. Under the new law, states that apply receive federal grants to help set up or expand independent offices to help consumers navigate the private health insurance system. These programs help consumers file complaints and appeals; enroll in health coverage; and get educated about their rights and responsibilities in group health plans or individual health insurance policies. The programs will also collect data on the types of problems consumers have, and file reports with the U.S. Department of Health and Human Services to identify trouble spots that need further oversight. Read a list of those who have received CAP grants. Grants Awarded October 2010.
Providing Small Business Health Insurance Tax Credits. Up to 4 million small businesses are eligible for tax credits to help them provide insurance benefits to their workers. The first phase of this provision provides a credit worth up to 35 percent of the employer’s contribution to the employees’ health insurance. Small non-profit organizations may receive up to a 25 percent credit. Effective now.
Offering Relief for 4 Million Seniors Who Hit the Medicare Prescription Drug “Donut Hole.” An estimated four million seniors will reach the gap in Medicare prescription drug coverage known as the “donut hole” this year. Each such senior will receive a $250 rebate. First checks mailed in June, 2010, and will continue monthly throughout 2010 as seniors hit the coverage gap.
Providing Free Preventive Care. All new plans must cover certain preventive services such as mammograms and colonoscopies without charging a deductible, co-pay or coinsurance. Effective for health plan years beginning on or after September 23, 2010. Learn more about preventive care benefits
Preventing Disease and Illness. A new $15 billion Prevention and Public Health Fund will invest in proven prevention and public health programs that can help keep Americans healthy – from smoking cessation to combating obesity. Funding begins in 2010.
Cracking Down on Health Care Fraud. Current efforts to fight fraud have returned more than $2.5 billion to the Medicare Trust Fund in fiscal year 2009 alone. The new law invests new resources and requires new screening procedures for health care providers to boost these efforts and reduce fraud and waste in Medicare, Medicaid, and CHIP. Many provisions effective now.
INCREASING ACCESS TO AFFORDABLE CARE
Providing Access to Insurance for Uninsured Americans with Pre-Existing Conditions. A new Pre-Existing Condition Insurance Plan will provide new coverage options to individuals who have been uninsured for at least six months because of a pre-existing condition. States have the option of running this new program in their state. If a state chooses not to do so, a plan will be established by the Department of Health and Human Services in that state. National program effective July 1, 2010.
Extending Coverage for Young Adults. Under the new law, young adults will be allowed to stay on their parents’ plan until they turn 26 years old (in the case of existing group health plans, this right does not apply if the young adult is offered insurance at work). While the provision takes effect in September, many insurance companies have already implemented this new practice. Check with your insurance company or employer to see if you qualify. Effective for health plan years beginning on or after September 23.
Expanding Coverage for Early Retirees. Too often, Americans who retire without employer-sponsored insurance and before they are eligible for Medicare see their life savings disappear because of high rates in the individual market. To preserve employer coverage for early retirees until more affordable coverage is available through the new Exchanges by 2014, the new law creates a $5 billion program to provide needed financial help for employment-based plans to continue to provide valuable coverage to people who retire between the ages of 55 and 65, as well as their spouses and dependents. Applications for employers to participate in the program available June 1, 2010. For more information on the Early Retiree Reinsurance Program, visit www.ERRP.gov.
Rebuilding the Primary Care Workforce. To strengthen the availability of primary care, there are new incentives in the law to expand the number of primary care doctors, nurses and physician assistants. These include funding for scholarships and loan repayments for primary care doctors and nurses working in underserved areas. Doctors and nurses receiving payments made under any State loan repayment or loan forgiveness program intended to increase the availability of health care services in underserved or health professional shortage areas will not have to pay taxes on those payments. Effective 2010 .
Holding Insurance Companies Accountable for Unreasonable Rate Hikes. The law allows states that have, or plan to implement, measures that require insurance companies to justify their premium increases will be eligible for $250 million in new grants. Insurance companies with excessive or unjustified premium exchanges may not be able to participate in the new health insurance Exchanges in 2014. Grants awarded beginning in 2010.
Allowing States to Cover More People on Medicaid. States will be able to receive federal matching funds for covering some additional low-income individuals and families under Medicaid for whom federal funds were not previously available. This will make it easier for states that choose to do so to cover more of their residents. Effective April 1, 2010.
Increasing Payments for Rural Health Care Providers. Today, 68 percent of medically underserved communities across the nation are in rural areas. These communities often have trouble attracting and retaining medical professionals. The law provides increased payment to rural health care providers to help them continue to serve their communities. Effective 2010.
Strengthening Community Health Centers. The law includes new funding to support the construction of and expand services at community health centers, allowing these centers to serve some 20 million new patients across the country. Effective 2010.
2011 IMPROVING QUALITY AND LOWERING COSTS
Offering Prescription Drug Discounts. Seniors who reach the coverage gap will receive a 50 percent discount when buying Medicare Part D covered brand-name prescription drugs. Over the next ten years, seniors will receive additional savings on brand-name and generic drugs until the coverage gap is closed in 2020. Effective January 1, 2011. Download a brochure to learn more (PDF, 3.6 MB)
Providing Free Preventive Care for Seniors. The law provides certain free preventive services, such as annual wellness visits and personalized prevention plans for seniors on Medicare. Effective January 1, 2011.
Improving Health Care Quality and Efficiency. The law establishes a new Center for Medicare & Medicaid Innovation that will begin testing new ways of delivering care to patients. These methods are expected to improve the quality of care, and reduce the rate of growth in health care costs for Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP). Additionally, by January 1, 2011, HHS will submit a national strategy for quality improvement in health care, including by these programs. Effective no later than January 1, 2011.
Improving Care for Seniors After They Leave the Hospital. The Community Care Transitions Program will help high risk Medicare beneficiaries who are hospitalized avoid unnecessary readmissions by coordinating care and connecting patients to services in their communities. Effective January 1, 2011.
Introducing New Innovations to Bring Down Costs. The Independent Payment Advisory Board will begin operations to develop and submit proposals to Congress and the President aimed at extending the life of the Medicare Trust Fund. The Board is expected to focus on ways to target waste in the system, and recommend ways to reduce costs, improve health outcomes for patients, and expand access to high-quality care. Administrative funding becomes available October 1, 2011.
INCREASING ACCESS TO AFFORDABLE CARE
Increasing Access to Services at Home and in the Community. The new Community First Choice Option allows States to offer home and community based services to disabled individuals through Medicaid rather than institutional care in nursing homes. Effective beginning October 1, 2011.
HOLDING INSURANCE COMPANIES ACCOUNTABLE
Bringing Down Health Care Premiums. To ensure premium dollars are spent primarily on health care, the new law generally requires that at least 85% of all premium dollars collected by insurance companies for large employer plans are spent on health care services and health care quality improvement. For plans sold to individuals and small employers, at least 80% of the premium must be spent on benefits and quality improvement. If insurance companies do not meet these goals, because their administrative costs or profits are too high, they must provide rebates to consumers. Effective January 1, 2011.
Addressing Overpayments to Big Insurance Companies and Strengthening Medicare Advantage. Today, Medicare pays Medicare Advantage insurance companies over $1,000 more per person on average than is spent per person in Traditional Medicare. This results in increased premiums for all Medicare beneficiaries, including the 77 percent of beneficiaries who are not currently enrolled in a Medicare Advantage plan. The new law levels the playing field by gradually eliminating this discrepancy. People enrolled in a Medicare Advantage plan will still receive all guaranteed Medicare benefits, and the law provides bonus payments to Medicare Advantage plans that provide high quality care. Effective January 1, 2011.
2012 IMPROVING QUALITY AND LOWERING COSTS
Linking Payment to Quality Outcomes. The law establishes a hospital Value-Based Purchasing program (VBP) in Traditional Medicare. This program offers financial incentives to hospitals to improve the quality of care. Hospital performance is required to be publicly reported, beginning with measures relating to heart attacks, heart failure, pneumonia, surgical care, health-care associated infections, and patients’ perception of care. Effective for payments for discharges occurring on or after October 1, 2012.
Encouraging Integrated Health Systems. The new law provides incentives for physicians to join together to form “Accountable Care Organizations.” These groups allow doctors to better coordinate patient care and improve the quality, help prevent disease and illness and reduce unnecessary hospital admissions. If Accountable Care Organizations provide high quality care and reduce costs to the health care system, they can keep some of the money that they have helped save. Effective January 1, 2012.
Reducing Paperwork and Administrative Costs. Health care remains one of the few industries that relies on paper records. The new law will institute a series of changes to standardize billing and requires health plans to begin adopting and implementing rules for the secure, confidential, electronic exchange of health information. Using electronic health records will reduce paperwork and administrative burdens, cut costs, reduce medical errors and most importantly, improve the quality of care. First regulation effective October 1, 2012.
Understanding and Fighting Health Disparities. To help understand and reduce persistent health disparities, the law requires any ongoing or new Federal health program to collect and report racial, ethnic and language data. The Secretary of Health and Human Services will use this data to help identify and reduce disparities. Effective March 2012
INCREASING ACCESS TO AFFORDABLE CARE
Providing New, Voluntary Options for Long-Term Care Insurance. The law creates a voluntary long-term care insurance program – called CLASS — to provide cash benefits to adults who become disabled. The Secretary shall designate a benefit plan no later than October 1, 2012.
2013 IMPROVING QUALITY AND LOWERING COSTS
Improving Preventive Health Coverage. To expand the number of Americans receiving preventive care, the law provides new funding to state Medicaid programs that choose to cover preventive services for patients at little or no cost. Effective January 1, 2013.
Expanding Authority to Bundle Payments. The law establishes a national pilot program to encourage hospitals, doctors, and other providers to work together to improve the coordination and quality of patient care. Under payment “bundling,” hospitals, doctors, and providers are paid a flat rate for an episode of care rather than the current fragmented system where each service or test or bundles of items or services are billed separately to Medicare. For example, instead of a surgical procedure generating multiple claims from multiple providers, the entire team is compensated with a “bundled” payment that provides incentives to deliver health care services more efficiently while maintaining or improving quality of care. It aligns the incentives of those delivering care, and savings are shared between providers and the Medicare program. Effective no later than January 1, 2013.
INCREASING ACCESS TO AFFORDABLE CARE
Increasing Medicaid Payments for Primary Care Doctors. As Medicaid programs and providers prepare to cover more patients in 2014, the Act requires states to pay primary care physicians no less than 100 percent of Medicare payment rates in 2013 and 2014 for primary care services. The increase is fully funded by the federal government. Effective January 1, 2013.
Providing Additional Funding for the Children’s Health Insurance Program. Under the new law, states will receive two more years of funding to continue coverage for children not eligible for Medicaid. Effective October 1, 2013. Learn more
2014
NEW CONSUMER PROTECTIONS
Prohibiting Discrimination Due to Pre-Existing Conditions or Gender. The law implements strong reforms that prohibit insurance companies from refusing to sell coverage or renew policies because of an individual’s pre-existing conditions. Also, in the individual and small group market, the law eliminates the ability of insurance companies to charge higher rates due to gender or health status. Effective January 1, 2014.
Eliminating Annual Limits on Insurance Coverage. The law prohibits new plans and existing group plans from imposing annual dollar limits on the amount of coverage an individual may receive. Effective January 1, 2014.
Ensuring Coverage for Individuals Participating in Clinical Trials. Insurers will be prohibited from dropping or limiting coverage because an individual chooses to participate in a clinical trial. Applies to all clinical trials that treat cancer or other life-threatening diseases. Effective January 1, 2014.
IMPROVING QUALITY AND LOWERING COSTS
Making Care More Affordable. Tax credits to make it easier for the middle class to afford insurance will become available for people with income between 100 percent and 400 percent of the poverty line who are not eligible for other affordable coverage. (In 2010, 400 percent of the poverty line comes out to about $43,000 for an individual or $88,000 for a family of four.) The tax credit is advanceable, so it can lower your premium payments each month, rather than making you wait for tax time. It’s also refundable, so even moderate-income families can receive the full benefit of the credit. These individuals may also qualify for reduced cost-sharing (copayments, co-insurance, and deductibles). Effective January 1, 2014.
Establishing Health Insurance Exchanges. Starting in 2014 if your employer doesn’t offer insurance, you will be able to buy insurance directly in an Exchange — a new transparent and competitive insurance marketplace where individuals and small businesses can buy affordable and qualified health benefit plans. Exchanges will offer you a choice of health plans that meet certain benefits and cost standards. Starting in 2014, Members of Congress will be getting their health care insurance through Exchanges, and you will be able buy your insurance through Exchanges too. Effective January 1, 2014.
Increasing the Small Business Tax Credit. The law implements the second phase of the small business tax credit for qualified small businesses and small non-profit organizations. In this phase, the credit is up to 50 percent of the employer’s contribution to provide health insurance for employees. There is also up to a 35 percent credit for small non-profit organizations. Effective January 1, 2014.
INCREASING ACCESS TO AFFORDABLE CARE
Increasing Access to Medicaid. Americans who earn less than 133 percent of the poverty level (approximately $14,000 for an individual and $29,000 for a family of four) will be eligible to enroll in Medicaid. States will receive 100 percent federal funding for the first three years to support this expanded coverage, phasing to 90 percent federal funding in subsequent years. Effective January 1, 2014.
Promoting Individual Responsibility. Under the new law, most individuals who can afford it will be required to obtain basic health insurance coverage or pay a fee to help offset the costs of caring for uninsured Americans. If affordable coverage is not available to an individual, he or she will be eligible for an exemption. Effective January 1, 2014.
Ensuring Free Choice. Workers meeting certain requirements who cannot afford the coverage provided by their employer may take whatever funds their employer might have contributed to their insurance and use these resources to help purchase a more affordable plan in the new health insurance Exchanges. Effective January 1, 2014.
2015 IMPROVING QUALITY AND LOWERING COSTS Paying Physicians Based on Value Not Volume. A new provision will tie physician payments to the quality of care they provide. Physicians will see their payments modified so that those who provide higher value care will receive higher payments than those who provide lower quality care. Effective January 1, 2015.
Hello. It’s been awhile, hope you’re all well. To all who have inquired, my thanks for your concern, but all’s good. Hectic, but good. Lot’s going on and an awful lot of travel. I’ve had a chance to meet and talk with with insurance carriers, Health Human Services, Trade Groups, Broker panels and most importantly customers with spirited opinions such as yourselves. It’s been a great time to learn, recharge and stay a bit too busy to write any meaningful posts. While staying busy appears to be the new constant, I’ll try to find something worthy to share on a more regular basis. Before I get into it some news at MMS Corp:
Check our new 360peo.com this summer. We began the redesign and update of our web site to make it more user friendly and features packed with the following:
1-Quoting Module – The quoting engine will offer cross leading plans based on your location, income and employee total. Not all plans and carriers will participate and it is recommended that you get in touch with us. 2-Health Care Reform Section-this tab is dedicated to the new PPACA law. 3 Instant Chat – Scheduled Fall 2011 4. Social 2.0- Find us on Facebook, Linkedin and Twitter. 5. HR Log In- For clients only. Some of you have already begun using this online HR Kiosk. We’ve deployed this in partnership with HR Connect Technologies to offer employers tools for common HR tasks such as Benefit Plan Admin, Forms for new hires, terminations, work-site postings and employee record keeping. HR-Connect is a secure, HIPAA-compliant, Internet driven system designed to simplify your human resource department. Employees can review their own personal information, but not other employee’s data. Click Video Demo here and just ask us to set it up for your business at no charge!
Lastly, we have been appointed earlier in 2011 to the Empire Broker Advisory Council which consists of top 10 of 5000 brokers that meets throughout the year to discuss relevant topics such as market insights, health reform changes and input on future plan designs. We take this opportunity seriously in giving voice to our clients and shaping a more consumer friendly plan. To Empire’s credit, they have been indeed listening and have taken suggestions seriously. New plan options released in the Fall will be examples of this.
For now, however, let’s play some catch-up:
Latest new is that US Court of Appeals has ruled that the Affordable Care Act is constitutional. The ruling is online here. The ruling stated that this is in synch with the commerce clause of interstate commerce. Furthermore, since Congress can force someone to buy health insurance because even if they don’t need insurance today they will at some point in their life. While this ruling is impactful and could influence future rulings, this is expected by many to go to Supreme Court. They have been loudly silent on this touchy topic thus far.
Regardless, this Individual Mandate has little teeth with penalties @ $95 or 1% for 2014, $325 or 2% in 2015 and $695 or 2.5% in 2016. In other words if one can still buy health insurance, face little penalties and no pre-existing condition whats stopping someone form buying insurance when they’re in the hospital?!
To date, many key provisions have already been enacted. Some of those are:
Extending the age of adult children eligible for coverage under their parents’ health care plan to age 26
Prohibiting individual and group health plans from placing lifetime limits on the dollar value of coverage
Preventing health insurers from rescinding coverage (except in cases of fraud)
Prohibiting health insurers from imposing pre-existing condition exclusions for children
Mandating coverage for recommended immunizations and preventive care
PPACA items that died in 2011.
1. The non-discrimination provision for Group Health Plans have been delayed. The short answer is that IRS needs more funding to enforce this as well as additional guidance. See blog here
3. W2 Reporting delayed- the IRS said employers who file fewer than 250 Forms W-2 in 2011 will not be required to report the cost of health care coverage prior to January 2014
Items that have funding delays:
1. Free Choice Voucher Program Takes a Hit- The program would have provided funding of vouchers for lower income employees to subsidize the employer contribution. Under this provision, plan sponsors of employer-based plans (including self-funded benefit plans) would have been required to offer vouchers to employees who fall below a pre-defined income threshold, while the state-based exchanges would credit the employee the amount of the voucher that exceeded their monthly premium.
2. No Health Co-Ops- The goal of the program was to spur the creation of qualified nonprofit health insurance issuers that could offer health plans for individuals and small businesses in states where insurance issuers are licensed to offer them. The program also would have provided loans and grants to fund start-up and maintenance costs for these plans.
This is a bit disappointing as we looked to the highly rated Seattle-based Group Health Cooperative program as a successful at managing costs and offering consumer centric care, click here for more info.
3. Wellness Funding for Small groups- no updates as of yet on the $750 Million funding. This was forward thinking incentives for small groups to afford a a Wellness Program for smoking cessation, diet/nutrition, gym etc. Typically large groups have had these programs as their rates are directly linked to “experience” of their members. In small market the rates are spread over thousands of other small groups. This is a first come first serve funding that we are closely monitoring to help our groups.
We are partnering with Wellness Companies and Health Insurers on establishing a program for small groups. The ROI on this is typically 1.6 :1. If you think your group could benefit please drop us a note at info@medicalsolutionscor.com.
The biggest news really will be the Health Exchanges schedule to open by 2014. NYS in particular than most states has enjoyed 2 rounds of Federal seed capital with almost $30 million for this effort. Each state has to set up an exchange, or marketplace, where small employers and individuals whose employers don’t provide coverage, or who can’t afford the employer plans, can purchase insurance. About 2.7 million New Yorkers are uninsured.
Sponsors say it should also result in one statewide, online, streamlined system for enrolling and renewing enrollment in government-supported Medicaid, Child Health Plus and Family Health Plus programs.
Each state can implement their own version. Several states have rejected funding and do not want to participate in the exchange. By discounting health plan rates based on income its unclear of how much will fall as a state burden?
Florida is one state that has decided not to implement a state health insurance exchange altogether. That state is seeking to shift virtually all of its Medicaid population from government coverage into private plans starting in July 2012.
Two states, Massachusetts and Utah, each have existing state exchanges that differ fundamentally. The Massachusetts exchange is considered an “active purchaser” model, has a large organization and a sizeable budget. The state’s model does not allow all licensed insurers to participate in the exchange. The Utah model, on the other hand, is an “all-comer” model that allows any licensed health insurer to participate. Utah’s exchange initiative is much smaller in scope with only two full-time employees and a limited budget. Currently, the Massachusetts state exchange is suffering major cost overruns.
Rebecca Vesely, writing in Business Insurance, makes this clear in her article describing how two states, Vermont and Florida, are taking strikingly different paths in addressing health care reform. Vermont has taken the first step toward creating a single payer system by 2017. Legislation to set up a five member board to move the state in this direction has already been enacted. And while many details need to be worked out (funding, to name one) and Vermont will need to obtain a waiver from the Centers for Medicare and Medicaid Services to put the package together, the state is further down the road to single payer than any other.
With healthcare becoming a hot issue for 2012 both parties are entrenched. Democrats are promoting Medicare as an effective low cost plan that provides insurance for millions of people. The fact that it is imploding is seemingly lost. Republicans, on the other hand, are touting touting free enterprise system but the Medicare Part D law enacted by Bush in 2003 had been under estimated by half! Along with Medicare Advantage plans that have cost the Gov in excess of what was expected.
Rita Redberg, UCF professor of medicine writes an amazing editorial in NYT “Squandering Medicare Money”. While this war of words by both parties goes on no one is really minding the issues. There are things that can be done right now while Washington tries to get its own house in order. An honest appraisal of Medicare Advantage shows that the program doesn’t deserve a fatter payday; it demands a serious crackdown.
Limitations on funding both at the federal and state levels will need to be addressed to avoid a rise in government deficit levels. In the short term, PPACA will continue to face significant political and legal hurdles. Nonetheless, implementation will continue, with more provisions and offices becoming established under the law.
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As more information becomes available, MMS Corp is committed to keeping you up-to-date in a timely manner. Coming soon 360peo.com to view past Legislative Alerts in the “Newsroom” section. Or, you may visit alexmiller.wordpress.com for blog posts, polls, surveys and numerous resources. If you have any questions, please contact us. Thank you for taking the time to read through this important notification.
Accountable Care Organization (ACO) – These organizations coordinate patient care and provide the full range of health care services for patients. The health reform law provides incentives for providers who join together to form such organizations and who agree to be accountable for the quality, cost, and overall care of Medicare beneficiaries who are enrolled in the traditional fee-for-service program who are assigned to the ACO. Annual Benefit Limit – In the past, some insurance plans have placed a limit on the dollar amount of claims they will pay in a given year for an individual. Beginning in 2010, annual benefit limits on certain “essential health benefits” are restricted on a graduated basis, and annual limits will eventually be prohibited in 2014. Basic Health Plan – Beginning in 2014, states will have the option of creating a basic health plan to provide coverage to individuals with incomes between 133 and 200 percent of poverty instead of enrolling in the health insurance exchange and receiving premium subsidies. The federal government will provide states that choose to offer this plan with 95 percent of what it would have paid to subsidize these enrollees in the health insurance exchange. Benefit Package – The set of health services, such as physician visits, hospitalizations, and prescription drugs, that are covered by a member’s insurance policy or group health plan. Capitation – Under a capitation system health care providers are paid a set amount for each enrolled person assigned to that physician or group of physicians, whether or not that person seeks care. Case Management – The coordination of medical care for patients with specific diagnoses or high health care needs, performed by case managers who can include medical directors or nurses. Catastrophic Coverage – A coverage option with a limited benefit plan design accompanied by a high Deductible. The plan design is intended to protect primarily against the cost for unforeseen and expensive illnesses or injuries. These plans are attractive to young adults in relatively good health. CHIP – The Children’s Health Insurance Program (CHIP) is a program administered by the United States Department of Health and Human Services that provides matching funds to states for health insurance to low income families with children. The program was designed with the intent to cover uninsured children in families with incomes that are modest but too high to qualify for Medicaid. Chronic Care Management – The coordination of health care and supportive services to improve the health status of patients with chronic conditions, such as diabetes and asthma. The goals of these programs are to improve the quality of care and manage costs. COBRA – Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) applies to employers who generally employ 20 or more full time equivalent employees. Employees who lose their jobs are able to continue their employer-sponsored coverage for a set period of time. For example, employees are typically entitled to extend coverage for 18 months, however if they are deemed disabled by the Social Security Administration, coverage may continue for up to 29 months. Co-insurance – The amount or percentage of the reimbursed amount of covered expenses a plan member must pay for health services after the Deductible has been met. Community Living Assistance Services and Supports (CLASS) Program – The CLASS program establishes a national voluntary long-term care insurance program for the purchase of non-medical services and support necessary for enrollees who have paid premiums into the program and become eligible (due to disability or chronic illnesses). Enrollees would receive benefits that help pay for assistance in the home or in a facility in future years. Enrollment begins January 1, 2011 (targeting working adults who can make voluntary premium contributions through payroll deductions or directly). The first benefits will be paid out to enrollees in 2016. Community Rating – A method of pricing health insurance plans, where all policyholders are charged the same premium, regardless of health status, age or other factors. “Modified community rating” generally refers to a method where health insurers may vary premiums based on specified demographic characteristics (e.g. age, gender, location), but cannot vary premiums based on the health status or claims history of policyholders. Comparative Effectiveness Research – Research is federally sponsored to compare existing health care interventions to determine which work best for which patients and which pose the greatest benefits and harms. The research also aims to improve the quality of care and to control costs. Consumer-Directed Health Plans – These health plans seek to increase consumer awareness about health care costs and provide incentives for consumers to consider costs when making health care decisions. These plans usually have a high Deductible accompanied by a savings account for health care services. There are two types of savings accounts – Health Savings Accounts (HSAs) and Health Reimbursement Accounts (HRAs). Co-payment – A fixed dollar amount paid by an individual receiving a health care service covered by the member’s plan. Cost-Sharing – Health plan members are required to pay a portion of the costs of their care. Examples of these costs include Co-payments, Co-insurance and annual Deductibles. Deductible – The dollar amount that a plan member must pay for health care services each year before the insurer begins to reimburse for health care services. Beginning in 2014, deductibles for small group insurance plans will be limited to $2,000 for individual policies and $4,000 for family policies. Disease Management – The coordination of care for the entire disease treatment process, including preventive care, patient education and outpatient care in addition to inpatient and acute care. The process is intended to reduce costs and improve the quality of life for an individual with a chronic condition. Donut Hole – A gap in prescription drug coverage under Medicare Part D, where beneficiaries pay 100% of their prescription drug costs after their total drug costs exceed an initial coverage limit until they qualify for a second tier of coverage. Under the standard Part D benefit, Medicare covers 75% of drug costs below the initial coverage limit ($2,830 in 2010), and 95% of spending within the second tier level ($6,440 in 2010). The “donut hole” specifically refers to the range between these two levels. Health care reform also provides a $250 rebate for all Medicare Part D enrollees who enter the donut hole in 2010, increases discounts in subsequent years and completely closes the donut hole by 2020. Dual Eligibles – A term used to describe an individual who is eligible for Medicare and for some Medicaid benefits. Electronic Health Record/Electronic Medical Records – Computerized patient health records, including medical, demographic, and administrative information. These records can be created and stored within one organization or shared across multiple health care organizations and sites. Employee Retirement Income Security Act of 1974 (ERISA) – Enacted in 1974 to provide minimum Federal standards for welfare benefit plans in private industry, and protect the interests of employee benefit plan participants and their beneficiaries by requiring the disclosure to them of financial and other information concerning the plan; by establishing standards of conduct for plan fiduciaries; and by providing for appropriate remedies and access to the Federal courts. Employer Mandate – Beginning in 2014 pursuant to the health reform law, employers meeting size or revenue thresholds will be required to offer minimum essential health benefit packages or pay a set portion of the cost of those benefits for use in the Exchanges. Episode of Care – Refers to all the health services related to the treatment of a condition. For acute conditions (such as a concussion or a broken bone), the episode includes all treatment and services from the onset of the condition to its resolution. For chronic conditions (such as diabetes), the episode refers to all services and treatments received over a given period of time. Some payment reform proposals involve basing provider payment on episodes of care instead of paying on a Fee-for-Service basis. Essential Health Benefits – The health reform law placed certain coverage requirements on essential health benefits, and provides a broad set of benefit categories that would be considered essential to a health benefits package — including hospitalization, outpatient services, emergency care, prescription drugs, maternity care, preventive services and other benefits. The Secretary of HHS will, in the future, define what constitutes “Essential Health Benefits” and this will be guided by the current scope of benefits provided under a typical employer plan. For plan years beginning in 2010 the only requirement for “Essential Health Benefits” is that if they are included in the plan they may not be subject to a lifetime limit and until 2014 can only be subject to a “restricted annual limit”. Exchange or Health Insurance Exchange – The health care reform law creates Health Benefit Exchanges (competitive insurance marketplaces) in each state, where individuals and employers can shop for health plans. External Review – Health care reform requires all health plans (except Grandfathered plans) to provide an external review appeal process that meets minimum standards. With the exception of a few state processes currently in existence, external review has typically been limited to appeals of clinical decisions. The health reform law has expanded the scope of external review for self-funded health plans to non-eligibility administrative appeals as well. Administrative appeals deal with such issues as benefit exclusions, benefit limits and disputes over member financial responsibility for payments such as Co-payments, Co-insurance and Deductibles. Fee-for-Service – A traditional method of paying for medical services where doctors and hospitals are paid a fee for each service they provide.
FTE – Full Time Equivalent -The percent of time worked is based on a standard of 100% or 1.0. For example, an employee who is working 60% and employee who is working 40% of the time would equal 100% or an FTE of 1.0.
For example, a firm has 35 full-time employees (30+ hours). In addition, the firm has 20 part time employees who all work 24 hours per week (96 hours per month). These part-time employees’ hours would be treated as equivalent to 16 full-time employees, based on the following calculation: 20 employees x 96 hours / 120 = 1920 / 120 = 16
Grandfathered Plan – A health plan that was in place on March 23, 2010, when the health reform law was enacted, is exempt from complying with some parts of the health reform law, so long as the plan does not make certain changes (such as eliminating or reducing benefits, increasing cost-sharing, or reducing the employer contribution toward the premium). Once a health plan makes such a change, it becomes subject to other health reform provisions (e.g., appeals and cost sharing restrictions on preventive services).
Group Health Plan – Health insurance that is offered by a plan sponsor, typically an employer on behalf of its employees. Guarantee Issue/Guarantee Renewability – Beginning in 2014, the health reform law requires insurers to offer and renew coverage to non-Grandfathered plans, without regard to health status, use of services, or pre-existing conditions. Health Insurance Portability and Accountability Act of 1996 (HIPAA) – This law sets standards for the security and privacy of personal health information. In addition, the law makes it easier for individuals to change jobs without the risk of extended waiting periods due to pre-existing conditions. Health Maintenance Organization (HMO) – A health plan that provides coverage through a network of hospitals, physicians and other health care providers. HMOs usually require the selection of a primary care physician who is responsible for managing and coordinating all health care. Usually, referrals to specialist physicians are required, and the HMO pays only for care provided by an in-network provider. Health Reimbursement Account (HRA) – A tax-exempt account that can be used to pay for qualified health expenses. HRAs are usually paired with a high-Deductible health plan and are funded solely by employer contributions. Health Savings Account (HSA) – A tax-exempt savings account that can be used to pay for qualified medical expenses. Individuals can obtain HSAs from most financial institutions, or through their employer. Both employers and employees can contribute to the plan. To open an HSA, an individual must have health coverage under an HSA-qualified high-Deductible health plan which has Deductibles of at least $1,200 for an individual and $2,400 for a family in 2010. High-Deductible Health Plan – These health insurance plans have higher Deductibles and lower premiums than traditional insurance plans. High-Risk Pool – The health reform law expands upon the current state-based high-risk pool system. The law requires the government to establish or issue contracts to establish a temporary high risk pool (through 2013) to provide coverage for eligible individuals with pre-existing conditions by appropriating $5 billion to subsidize premiums. Eligibility is limited to individuals who have been uninsured for at least six months prior to applying for pool coverage, and who have a pre-existing condition. Individual Mandate – A requirement that most individuals obtain health insurance or pay a penalty beginning in 2014. Massachusetts was the first state to impose an individual mandate that all adults have health insurance. Interim Final Rule (IFR) – A final rule that has the full force and effect of law; thus, affected parties have an obligation to comply with its requirements. An IFR allows interested parties to submit comments during a public comment period and prior to issuing revised guidance. Internal Review – An internal review of an adverse claim determination. Lifetime Benefit Maximum – A limit on the amount an insurer will pay toward the cost of health care services over the lifetime of the policy. Health care reform prohibits lifetime dollar limits on “essential health benefits” effective for plan/policy years beginning on or after September 23, 2010. Long-Term Care – Services needed for an individual to live independently in the community, such as home health and personal care, as well as services provided in institutional settings such as nursing homes. Many of these services are not covered by Medicare or private insurance (see also the Community Living Assistance Services and Supports program defined above). Managed Care – A health care delivery system that seeks to reduce the cost of providing health benefits and improve the quality of care. These arrangements often rely on primary care physicians to manage the care their patients receive. Mandatory Benefits – A state or federal requirement that health plans provide coverage for certain benefits, treatment or services. Medicaid – A federal and state funded program that provides medical and health related services to certain low-income Americans. The health reform law expands Medicaid eligibility to non-Medicare eligible individuals with incomes up to 133% of the Federal poverty level, establishing uniform eligibility for adults and children across all states by 2014. Medical Loss Ratio (MLR) – The minimum percentage of premium dollars a commercial insurance company must spend on the reimbursement of certain medical costs. The health reform law requires insurers in the large group market to have an MLR of 85% and insurers in the small group and individual markets to have an MLR of 80% (with some waivers granted to states to reduce the threshold for certain markets). Medicare – A federal program that provides health care coverage to people age 65 and older, and to those who are under 65 and are permanently physically disabled or who have a congenital physical disability; or to those who meet other special criteria such as end-stage renal disease. Eligible individuals can receive coverage for hospital services (Medicare Part A), physician based medical services (Medicare Part B) and prescription drugs (Medicare Part D). Medicare Advantage – Also referred to as Medicare Part C, the Medicare Advantage program allows Medicare beneficiaries to receive their Medicare benefits through a private insurance plan. Out-of-Pocket Costs – Health care costs that are not covered by insurance, such as Deductibles, Co-payments, and Co-insurance. Out-of-pocket costs do not include premium costs. Out-of-Pocket Maximum – An annual limit on the amount of money individuals are required to pay out-of-pocket for health care costs, excluding premiums. The health reform law, beginning in 2014, prevents an employer from imposing cost sharing in amounts greater than the current out-of-pocket limits for high-Deductible health plans ($5,950 for an individual policy or $11,900 for a family policy in 2010). These amounts will be adjusted annually. Patient Centered Medical Home – A term defining a health care setting where patients receive comprehensive primary care services, have an ongoing relationship with a primary care provider who directs and coordinates their care; and have enhanced access to non-emergent care. Patient Protection and Affordable Care Act (PPACA) – Also referred to as the “health reform law,” this Act begins the implementation of a staged set of rules with an initial effective date of March 23, 2010. The law is intended to increase access to health care for more Americans, and includes many changes that impact the commercial health insurance market, Medicare and Medicaid. Pay for Performance – A payment system where health care providers receive incentives for meeting or exceeding quality and cost benchmarks. Some systems also penalize providers who do not meet established benchmarks. The goal of pay for performance programs is to improve the quality of care over time. Pre-existing Condition – An illness or medical condition for which a person is diagnosed or treated within a specified period of time prior to becoming insured in a new plan. The heath reform law prohibits the denial of coverage due to a pre-existing condition for plan and policy years beginning after September 23, 2010 for children under 19, and for all others beginning in 2014. Preferred Provider Organization (PPO) – A type of managed care organization that provides health care coverage through a network of providers. Plan members typically pay higher costs when they seek care from out-of-network providers. Premium – The amount paid, often on a monthly basis, for health insurance. The cost of the premium may be shared between employers or government purchasers, and individuals. Premium Subsidies – A fixed amount of money, or a designated percentage of the premium cost, that is provided to help people purchase health insurance. The health reform law provides premium subsidies to individuals with incomes between 133% and 400% of the federal poverty level who purchase policies through the health insurance Exchanges, beginning in 2014. Preventive Care Services – Health care that emphasizes the early detection and treatment of disease. The health reform law requires certain health plans (excludes Grandfathered plans) to provide coverage without member cost-sharing for certain preventive services. Primary Care Provider – A provider, usually a physician, specializing in internal medicine, family practice, or pediatrics, who is responsible for providing primary care and coordinating other necessary health care services for patients. Qualified Health Plan – Insurance plans that are sold through a Health Insurance Exchange must have been certified as meeting a minimum benchmark of benefits (i.e., essential health benefits) under the health reform law. Rate Review – Review by insurance regulators of a health plan’s proposed premium and premium increases. Rates are reviewed to ensure they are sufficient to pay claims, are not unreasonably high in relation to the medical claim costs and the benefits provided, and are not discriminatorily applied. Reinsurance – Insurance purchased by insurance companies and employers that self-insure their employees’ medical costs, to limit liability or exposure to high claims or increased cost trends. The health reform law includes a temporary federal reinsurance program for employers that insure early retirees over age 55 who are not eligible for Medicare. Rescission – Refers to a practice where an approved policy is voided from its inception by the insurer, usually on the grounds of material misrepresentation or omission on the initial application. Under health reform, rescissions are prohibited except in cases of fraud or intentional misrepresentation. Risk Adjustment – The process of increasing or reducing payments to health plans to reflect higher or lower than expected spending. Risk adjusting is designed to compensate health plans that enroll a sicker population as a way to discourage plans from selecting only healthier individuals. Section 125 Plan – These plans are otherwise known as a “cafeteria plan” offered pursuant to Section 125 of the Internal Revenue Code. Its name comes from a set of benefit plans that allows employees to choose between different types of benefits, similar to the ability of a customer to choose among available items in a cafeteria, and the employees’ pretax contributions are not subject to federal, state, or Social Security taxes. Self-Insured Plan – The employer assumes the financial responsibility of health care benefits for its employees in a self-insured or self-funded plan. Employer sponsored self-insured plans typically contract with a third-party administrator to provide administrative services for the plan. Small Business Tax Credit – The health reform law includes a tax credit equal to 50 percent (35 percent in the case of tax-exempt eligible small employers) for qualified small employers that provide health coverage to their employees. The tax credit is available to employers with 25 or fewer employees with average annual wages of less than $50,000. Small Group Market – Businesses with typically 2-50 employees, or eligible employees depending on applicable state law, can purchase health insurance for their employees through this market, which is regulated by states. Tax Credit – An amount that a person or business can subtract from the income tax that they owe. If a tax credit is refundable, the taxpayer can receive a payment from the government to the extent that the credit is greater than the amount of tax they would otherwise owe. Tax Deduction – An amount that a person can subtract from adjusted gross income when calculating the taxes that they owe. Generally, people who itemize deductions can deduct the portion of medical expenses, including health insurance premiums, that exceeds 7.5% of their adjusted gross income. Under health reform, the threshold for deducting medical expenses increases to 10% in 2013 (this increase is waived for individuals 65 and older for tax years 2013-2016). Value-Based Purchasing – A payment reform which provides bonuses to hospitals and other providers based upon their performance against quality measures. Wellness Plan/Program – An employer program to improve health and prevent disease
Change in tax treatment for over-age dependent coverage
Accounting impact of change in Medicare retiree drug subsidy tax treatment
Early retiree medical reinsurance
Medicare prescription drug “donut hole” beneficiary rebate
Break time/private room for nursing moms
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[tab_item title=”2011″]
No lifetime dollar limits on essential health benefits
Restricted annual dollar limits on essentail health benefits, phased amounts until 2014
No pre-existing condition limitations for enrollees up to age 191 and no recissions
No health FSA/HRA/HSA reimbursement for non-prescribed drugs
Increased penalties for non-qualified HSA distributions
Additional standards for new or “non-grandfathered” health plans, including preventive care in network with no cost-sharing appeal and external review, provider choice and non-discrimination provisions for insured plans
Income-based Medicare Part D premiums
Pharmaceutical importers and manufacturers’ fees start
Medicare, Medicare Advantage benefit and payment reforms
Insurers subject to medical loss ratio rules
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[tab_item title=”2012″]
Employers to distribute uniform summary of benefits and coverage (SBC) to participants (deadlines vary with group of recipients)
60-day advance notice of mid-year material modifications to SBC content
Form W-2 reporting for health coverage (track in 2012 for W-2 form provided in early 2013)
Coverage for additional women’s preventive care services5
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[tab_item title=”2013″]
$2,500 per plan year health FSA contribution cap (plan years on or after January 1, 2013)
Comparative effectiveness group health plan fees first due
Annual dollar limits on essential health benefits cannot be lower than $2 million
Employers notify employees about exchanges
Medical device manufacturers’ fees start
Higher Medicare payroll tax on wages exceeding $200,000/individual; $250,000/couples
Change in Medicare retiree drug subsidy tax treatment takes effect
Health Insurance exchanges initial open enrollment period
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[tab_item title=”2014″]
Health insurance exchanges
Individual coverage mandate
Financial assistance for exchange coverage of lower-income individuals
States Medicaid expansion (possibly only some states)
Employer shared responsibility
Dependent coverage to age 26 for any covered employee’s child
No annual dollar limits on essential health benefits
No pre-existing condition limits
No waiting period over 90 days
Wellness limit increase allowed
Health insurance industry fees
Additional standards for non-grandfathered health plans, including limits on out-of-pocket maximums,
provider nondiscrimination, and coverage of routine medical costs of clinical trial participants
Small market, non-grandfathered insured plans must cover essential health benefits with limited deductibles (initially $2,000/individual, $4,000/family), using a form of community rating
Insurers must apply guaranteed issue and renewability to non-grandfathered plans of all sizes
Auto enrollment sometime after 2014
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[tab_item title=”2015″]
Temporary reinsurance fees first due in late 2014/early 2015
Additional employee-specific reporting and disclosure of 2014 coverage
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[tab_item title=”2018″]
40% excise tax on “high cost” or Cadillac coverage
The Personal Health Advocate is a trained professional, typically a Registered Nurse, who understands the intricacies of the healthcare system and how to navigate through it. As soon as a member contacts us he/she establishes a relationship with a Personal Health Advocate who stays with them through to the resolution of the problem. Our Personal Health Advocates demonstrate a commitment to service excellence, have strong problem solving skills and support members as they seek healthcare services and interact with providers and insurers. Personal Health Advocates work in tandem with Medical Directors and with our team of administrative experts who handle claims, benefits, grievances and paperwork issues.
Health Advocate is available 24 hours a day, 7 days a week using a toll free phone number. Regular hours extend from 8 AM to 6 PM weekdays. After-hours calls are handled by the Personal Health Advocate on call.
CARE COORDINATION
The Personal Health Advocate helps members coordinate care among physicians and medical institutions in various ways:
Helping members understand tests, treatments and medications recommended or prescribed by their physician.
Assisting members through a complex medical condition.
Facilitating the transfer of medical records, x-rays and lab results prior to a scheduled appointment with a new physician.
Arranging for home-care equipment following discharge from the hospital.
Facilitating a review of test results with another physician for confirmation of a diagnosis.
Coordinating and making arrangements for diagnostic tests.
Coordinating care for a member with complicated medical issues.
Consolidating a multiple-day testing schedule for special needs members.
Arranging for a member to be evaluated for participation in a clinical trial.
Arranging hospice and other services for terminally ill patients.
Facilitating transfer from a community hospital to a tertiary care facility.
Fostering communication and coordinating benefits between physicians and with insurance companies.
ADVOCATES OF EXCELLENCE™
Helps members with rare, serious or complex medical conditions identify top medical institutions, critical illness providers and specialized medical programs across the country. Our Personal Health Advocates will schedule appointments and coordinate transportation and lodging when necessary.
BENEFITS ADVANTAGE™
Claims Assistance: Personal Health Advocates help sort out and solve claims and related paperwork problems. We work on coverage issues and help members understand the coding and payment rules that apply to their circumstances. Examples of other services include:
Researching a member’s outstanding out-of-pocket responsibilities and resolving errors with providers and/or their health plan.
Correcting balance-billing problems.
Resolving eligibility problems and benefit and claim denials.
Correcting charges incorrectly applied to the member’s deductible.
Resolving questions over whether services are condition specific or related to preventive care.
Coordinating benefits between dental, medical, workers comp and disability carriers.
Resolving incorrect plan procedure interpretations such as emergency room claims denied for a lack of precertification.
Assuring correct application of provider network status.
Correcting errors in processing of “blind” network provider discounts.
Providing payers with additional information required to correctly pay a claim or apply a benefit.
Resolve coordination of benefits disputes between multiple carriers.
Satisfying plan requests for copies of referrals.
Resolving errors in the application of deductibles and co-payments.
Providing the correct member insurance information to providers.
Fee Negotiation: When necessary, Health Advocate can attempt to negotiate fees with healthcare providers to lower the member’s out-of-pocket costs. This is often done prior to the member receiving services. We can also review questionable bills to catch duplicate or erroneous charges.
Grievance Advice: Our first approach is to resolve disputes and issues through discussion; however, when necessary we will provide advice or assistance to members when filing a complaint or grievance with their health insurer or health plan administrator. We can provide the member with guidance regarding their appeal rights and when all other means have failed and we agree that the issues are valid, help the member formulate the argument, gather supporting documentation and write the letter of appeal to the health plan.
COVERAGE ADVANTAGE™
If there are questions of coverage for a particular service, or if coverage for clinical care has been denied, the Personal Health Advocate can help members through the review and appeals process. We can also assist in identifying alternative coverage options when necessary.
Obtaining exceptions for a member to see providers outside of their captivated relationships.
Obtaining referrals for required services.
Locating in-network suppliers and obtaining plan approval for the use of out of network suppliers for necessary healthcare equipment and supplies that are not available from in-network suppliers.
Obtaining transitional care coverage at an in-network benefit level when medically necessary.
Resolving questions of denial of benefits deemed to be non-covered, not medically necessary or ineligible.
Counseling members regarding current benefit costs and the cost of alternatives approaches.
Helping members understand the process for obtaining coverage for medical equipment, devices, supplies. (e.g., hearing aids, diabetic supplies, compression stockings)
Answering coverage questions.
Providing information regarding benefit level coverage comparisons for various providers.
Transitioning members from out of network to in-network providers.
Assisting members with the preauthorization and predetermination process.
Locating “hard-to-find” IV drugs or home care services to facilitate hospital discharge.
Assisting employees with disability coverage questions and helping them back to work.
Resolving eligibility questions involving disabled dependent rules, Family Medical Leave Act, COBRA, etc.
RX ADVOCATE™
The Personal Health Advocate can provide members with assistance on prescription drug issues including formulary and benefit questions.
Providing information for renewing prescriptions.
Providing information on generic drugs.
Locating lower cost sources for prescription drugs that are not covered by the health plan.
Assisting members in obtaining mail order prescriptions.
Resolving questions between members and pharmacies regarding the amount of product requested and the amount dispensed.
Obtaining coverage for medications that require mail order.
HEALTH ADVOCATE CAREQUEST™
Helps locate and makes arrangements for members’ special services needs. The individual member is responsible for payment of any specific services arranged on a fee-for-service basis that are not covered by an insurance plan. Examples of the kind of services we can help members with include:
Locating homemaker, adult day care and rehabilitation services not covered by the member’s health plan.
Locating inpatient private duty nursing.
Finding a group home for individuals with special needs.
Locating home health aides.
Helping members complete qualification applications for individual coverage options, including Medicaid and Medicare.
M.D. Direct™: In the case of serious medical illness, Health Advocate can provide members with access to experts for consultations and second opinions. Every step is taken so that members and their families are advised in full as to the diagnosis, treatment, medications and support systems available to them.
Complementary and Alternative Medicine: Health Advocate helps to identify and coordinate a range of wellness services including those offered by Complementary and Alternative Medicine (CAM) practitioners in areas such as acupuncture, chiropractic care and massage therapy.
Mind Matters™: If necessary, Health Advocate can help members find an appropriate mental health provider to meet their specific needs.
Appeals Representation: When all other means of dispute resolution have failed and we believe that the member’s position is valid, Health Advocate will represent members during the appeals process including attending health plan hearings. (Representation at appeals hearings will be billed at an hourly rate, plus travel expenses, if any.)
Healthy Wheels™: Health Advocate helps arrange transportation services to support our members’ healthcare needs.
Senior Care Navigator: For employees or family members approaching retirement or already retired, we offer access to a wide array of services specifically geared for seniors. Our Personal Health Advocates understand senior members’ needs and can help members select the appropriate professionals. Among the kind of issues we have worked on are:
Locating alternative care facilities.
Obtaining coverage for medical supplies.
Providing information on adult day care programs.
Coordinating coverage for home care services with Medicare and Medicaid.
Assisting with the transition of insurance coverage and benefits from private insurance to Medicare.
Locating physicians who make house calls for people who cannot easily get to the doctor’s office.
Wellness Advantage™: For those members looking for a personalized approach to weight management, getting and staying in shape, stress management, Health Advocate can help locate providers and arrange appointments for these services.
Source: www.USHealthcare.gov. A federal government Website managed by the U.S. Department of Health & Human Services 200 Independence Avenue, S.W. – Washington, D.C. 20201
2010
NEW CONSUMER PROTECTIONS
Putting Information for Consumers Online. The law provides for an easy-to-use website where consumers can compare health insurance coverage options and pick the coverage that works for them. Effective July 1, 2010.
Prohibiting Denying Coverage of Children Based on Pre-Existing Conditions. The new law includes new rules to prevent insurance companies from denying coverage to children under the age of 19 due to a pre-existing condition. Effective for health plan years beginning on or after September 23, 2010 for new plans and existing group plans.
Prohibiting Insurance Companies from Rescinding Coverage. In the past, insurance companies could search for an error, or other technical mistake, on a customer’s application and use this error to deny payment for services when he or she got sick. The new law makes this illegal. After media reports cited incidents of breast cancer patients losing coverage, insurance companies agreed to end this practice immediately. Effective for health plan years beginning on or after September 23, 2010.
Eliminating Lifetime Limits on Insurance Coverage. Under the new law, insurance companies will be prohibited from imposing lifetime dollar limits on essential benefits, like hospital stays. Effective for health plan years beginning on or after September 23, 2010.
Regulating Annual Limits on Insurance Coverage. Under the new law, insurance companies’ use of annual dollar limits on the amount of insurance coverage a patient may receive will be restricted for new plans in the individual market and all group plans. In 2014, the use of annual dollar limits on essential benefits like hospital stays will be banned for new plans in the individual market and all group plans. Effective for health plan years beginning on or after September 23, 2010.
Appealing Insurance Company Decisions. The law provides consumers with a way to appeal coverage determinations or claims to their insurance company, and establishes an external review process. Effective for new plans beginning on or after September 23, 2010.
Establishing Consumer Assistance Programs in the States. Under the new law, states that apply receive federal grants to help set up or expand independent offices to help consumers navigate the private health insurance system. These programs help consumers file complaints and appeals; enroll in health coverage; and get educated about their rights and responsibilities in group health plans or individual health insurance policies. The programs will also collect data on the types of problems consumers have, and file reports with the U.S. Department of Health and Human Services to identify trouble spots that need further oversight. Read a list of those who have received CAP grants. Grants Awarded October 2010.
Providing Small Business Health Insurance Tax Credits. Up to 4 million small businesses are eligible for tax credits to help them provide insurance benefits to their workers. The first phase of this provision provides a credit worth up to 35 percent of the employer’s contribution to the employees’ health insurance. Small non-profit organizations may receive up to a 25 percent credit. Effective now.
Offering Relief for 4 Million Seniors Who Hit the Medicare Prescription Drug “Donut Hole.” An estimated four million seniors will reach the gap in Medicare prescription drug coverage known as the “donut hole” this year. Each such senior will receive a $250 rebate. First checks mailed in June, 2010, and will continue monthly throughout 2010 as seniors hit the coverage gap.
Providing Free Preventive Care. All new plans must cover certain preventive services such as mammograms and colonoscopies without charging a deductible, co-pay or coinsurance. Effective for health plan years beginning on or after September 23, 2010. Learn more about preventive care benefits
Preventing Disease and Illness. A new $15 billion Prevention and Public Health Fund will invest in proven prevention and public health programs that can help keep Americans healthy – from smoking cessation to combating obesity. Funding begins in 2010.
Cracking Down on Health Care Fraud. Current efforts to fight fraud have returned more than $2.5 billion to the Medicare Trust Fund in fiscal year 2009 alone. The new law invests new resources and requires new screening procedures for health care providers to boost these efforts and reduce fraud and waste in Medicare, Medicaid, and CHIP. Many provisions effective now.
INCREASING ACCESS TO AFFORDABLE CARE
Providing Access to Insurance for Uninsured Americans with Pre-Existing Conditions. A new Pre-Existing Condition Insurance Plan will provide new coverage options to individuals who have been uninsured for at least six months because of a pre-existing condition. States have the option of running this new program in their state. If a state chooses not to do so, a plan will be established by the Department of Health and Human Services in that state. National program effective July 1, 2010.
Extending Coverage for Young Adults. Under the new law, young adults will be allowed to stay on their parents’ plan until they turn 26 years old (in the case of existing group health plans, this right does not apply if the young adult is offered insurance at work). While the provision takes effect in September, many insurance companies have already implemented this new practice. Check with your insurance company or employer to see if you qualify. Effective for health plan years beginning on or after September 23.
Expanding Coverage for Early Retirees. Too often, Americans who retire without employer-sponsored insurance and before they are eligible for Medicare see their life savings disappear because of high rates in the individual market. To preserve employer coverage for early retirees until more affordable coverage is available through the new Exchanges by 2014, the new law creates a $5 billion program to provide needed financial help for employment-based plans to continue to provide valuable coverage to people who retire between the ages of 55 and 65, as well as their spouses and dependents. Applications for employers to participate in the program available June 1, 2010. For more information on the Early Retiree Reinsurance Program, visit www.ERRP.gov.
Rebuilding the Primary Care Workforce. To strengthen the availability of primary care, there are new incentives in the law to expand the number of primary care doctors, nurses and physician assistants. These include funding for scholarships and loan repayments for primary care doctors and nurses working in underserved areas. Doctors and nurses receiving payments made under any State loan repayment or loan forgiveness program intended to increase the availability of health care services in underserved or health professional shortage areas will not have to pay taxes on those payments. Effective 2010 .
Holding Insurance Companies Accountable for Unreasonable Rate Hikes. The law allows states that have, or plan to implement, measures that require insurance companies to justify their premium increases will be eligible for $250 million in new grants. Insurance companies with excessive or unjustified premium exchanges may not be able to participate in the new health insurance Exchanges in 2014. Grants awarded beginning in 2010.
Allowing States to Cover More People on Medicaid. States will be able to receive federal matching funds for covering some additional low-income individuals and families under Medicaid for whom federal funds were not previously available. This will make it easier for states that choose to do so to cover more of their residents. Effective April 1, 2010.
Increasing Payments for Rural Health Care Providers. Today, 68 percent of medically underserved communities across the nation are in rural areas. These communities often have trouble attracting and retaining medical professionals. The law provides increased payment to rural health care providers to help them continue to serve their communities. Effective 2010.
Strengthening Community Health Centers. The law includes new funding to support the construction of and expand services at community health centers, allowing these centers to serve some 20 million new patients across the country. Effective 2010.
2011 IMPROVING QUALITY AND LOWERING COSTS
Offering Prescription Drug Discounts. Seniors who reach the coverage gap will receive a 50 percent discount when buying Medicare Part D covered brand-name prescription drugs. Over the next ten years, seniors will receive additional savings on brand-name and generic drugs until the coverage gap is closed in 2020. Effective January 1, 2011. Download a brochure to learn more (PDF, 3.6 MB)
Providing Free Preventive Care for Seniors. The law provides certain free preventive services, such as annual wellness visits and personalized prevention plans for seniors on Medicare. Effective January 1, 2011.
Improving Health Care Quality and Efficiency. The law establishes a new Center for Medicare & Medicaid Innovation that will begin testing new ways of delivering care to patients. These methods are expected to improve the quality of care, and reduce the rate of growth in health care costs for Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP). Additionally, by January 1, 2011, HHS will submit a national strategy for quality improvement in health care, including by these programs. Effective no later than January 1, 2011.
Improving Care for Seniors After They Leave the Hospital. The Community Care Transitions Program will help high risk Medicare beneficiaries who are hospitalized avoid unnecessary readmissions by coordinating care and connecting patients to services in their communities. Effective January 1, 2011.
Introducing New Innovations to Bring Down Costs. The Independent Payment Advisory Board will begin operations to develop and submit proposals to Congress and the President aimed at extending the life of the Medicare Trust Fund. The Board is expected to focus on ways to target waste in the system, and recommend ways to reduce costs, improve health outcomes for patients, and expand access to high-quality care. Administrative funding becomes available October 1, 2011.
INCREASING ACCESS TO AFFORDABLE CARE
Increasing Access to Services at Home and in the Community. The new Community First Choice Option allows States to offer home and community based services to disabled individuals through Medicaid rather than institutional care in nursing homes. Effective beginning October 1, 2011.
HOLDING INSURANCE COMPANIES ACCOUNTABLE
Bringing Down Health Care Premiums. To ensure premium dollars are spent primarily on health care, the new law generally requires that at least 85% of all premium dollars collected by insurance companies for large employer plans are spent on health care services and health care quality improvement. For plans sold to individuals and small employers, at least 80% of the premium must be spent on benefits and quality improvement. If insurance companies do not meet these goals, because their administrative costs or profits are too high, they must provide rebates to consumers. Effective January 1, 2011.
Addressing Overpayments to Big Insurance Companies and Strengthening Medicare Advantage. Today, Medicare pays Medicare Advantage insurance companies over $1,000 more per person on average than is spent per person in Traditional Medicare. This results in increased premiums for all Medicare beneficiaries, including the 77 percent of beneficiaries who are not currently enrolled in a Medicare Advantage plan. The new law levels the playing field by gradually eliminating this discrepancy. People enrolled in a Medicare Advantage plan will still receive all guaranteed Medicare benefits, and the law provides bonus payments to Medicare Advantage plans that provide high quality care. Effective January 1, 2011.
2012 IMPROVING QUALITY AND LOWERING COSTS
Linking Payment to Quality Outcomes. The law establishes a hospital Value-Based Purchasing program (VBP) in Traditional Medicare. This program offers financial incentives to hospitals to improve the quality of care. Hospital performance is required to be publicly reported, beginning with measures relating to heart attacks, heart failure, pneumonia, surgical care, health-care associated infections, and patients’ perception of care. Effective for payments for discharges occurring on or after October 1, 2012.
Encouraging Integrated Health Systems. The new law provides incentives for physicians to join together to form “Accountable Care Organizations.” These groups allow doctors to better coordinate patient care and improve the quality, help prevent disease and illness and reduce unnecessary hospital admissions. If Accountable Care Organizations provide high quality care and reduce costs to the health care system, they can keep some of the money that they have helped save. Effective January 1, 2012.
Reducing Paperwork and Administrative Costs. Health care remains one of the few industries that relies on paper records. The new law will institute a series of changes to standardize billing and requires health plans to begin adopting and implementing rules for the secure, confidential, electronic exchange of health information. Using electronic health records will reduce paperwork and administrative burdens, cut costs, reduce medical errors and most importantly, improve the quality of care. First regulation effective October 1, 2012.
Understanding and Fighting Health Disparities. To help understand and reduce persistent health disparities, the law requires any ongoing or new Federal health program to collect and report racial, ethnic and language data. The Secretary of Health and Human Services will use this data to help identify and reduce disparities. Effective March 2012
INCREASING ACCESS TO AFFORDABLE CARE
Providing New, Voluntary Options for Long-Term Care Insurance. The law creates a voluntary long-term care insurance program – called CLASS — to provide cash benefits to adults who become disabled. The Secretary shall designate a benefit plan no later than October 1, 2012.
2013 IMPROVING QUALITY AND LOWERING COSTS
Improving Preventive Health Coverage. To expand the number of Americans receiving preventive care, the law provides new funding to state Medicaid programs that choose to cover preventive services for patients at little or no cost. Effective January 1, 2013.
Expanding Authority to Bundle Payments. The law establishes a national pilot program to encourage hospitals, doctors, and other providers to work together to improve the coordination and quality of patient care. Under payment “bundling,” hospitals, doctors, and providers are paid a flat rate for an episode of care rather than the current fragmented system where each service or test or bundles of items or services are billed separately to Medicare. For example, instead of a surgical procedure generating multiple claims from multiple providers, the entire team is compensated with a “bundled” payment that provides incentives to deliver health care services more efficiently while maintaining or improving quality of care. It aligns the incentives of those delivering care, and savings are shared between providers and the Medicare program. Effective no later than January 1, 2013.
INCREASING ACCESS TO AFFORDABLE CARE
Increasing Medicaid Payments for Primary Care Doctors. As Medicaid programs and providers prepare to cover more patients in 2014, the Act requires states to pay primary care physicians no less than 100 percent of Medicare payment rates in 2013 and 2014 for primary care services. The increase is fully funded by the federal government. Effective January 1, 2013.
Providing Additional Funding for the Children’s Health Insurance Program. Under the new law, states will receive two more years of funding to continue coverage for children not eligible for Medicaid. Effective October 1, 2013. Learn more
2014
NEW CONSUMER PROTECTIONS
Prohibiting Discrimination Due to Pre-Existing Conditions or Gender. The law implements strong reforms that prohibit insurance companies from refusing to sell coverage or renew policies because of an individual’s pre-existing conditions. Also, in the individual and small group market, the law eliminates the ability of insurance companies to charge higher rates due to gender or health status. Effective January 1, 2014.
Eliminating Annual Limits on Insurance Coverage. The law prohibits new plans and existing group plans from imposing annual dollar limits on the amount of coverage an individual may receive. Effective January 1, 2014.
Ensuring Coverage for Individuals Participating in Clinical Trials. Insurers will be prohibited from dropping or limiting coverage because an individual chooses to participate in a clinical trial. Applies to all clinical trials that treat cancer or other life-threatening diseases. Effective January 1, 2014.
IMPROVING QUALITY AND LOWERING COSTS
Making Care More Affordable. Tax credits to make it easier for the middle class to afford insurance will become available for people with income between 100 percent and 400 percent of the poverty line who are not eligible for other affordable coverage. (In 2010, 400 percent of the poverty line comes out to about $43,000 for an individual or $88,000 for a family of four.) The tax credit is advanceable, so it can lower your premium payments each month, rather than making you wait for tax time. It’s also refundable, so even moderate-income families can receive the full benefit of the credit. These individuals may also qualify for reduced cost-sharing (copayments, co-insurance, and deductibles). Effective January 1, 2014.
Establishing Health Insurance Exchanges. Starting in 2014 if your employer doesn’t offer insurance, you will be able to buy insurance directly in an Exchange — a new transparent and competitive insurance marketplace where individuals and small businesses can buy affordable and qualified health benefit plans. Exchanges will offer you a choice of health plans that meet certain benefits and cost standards. Starting in 2014, Members of Congress will be getting their health care insurance through Exchanges, and you will be able buy your insurance through Exchanges too. Effective January 1, 2014.
Increasing the Small Business Tax Credit. The law implements the second phase of the small business tax credit for qualified small businesses and small non-profit organizations. In this phase, the credit is up to 50 percent of the employer’s contribution to provide health insurance for employees. There is also up to a 35 percent credit for small non-profit organizations. Effective January 1, 2014.
INCREASING ACCESS TO AFFORDABLE CARE
Increasing Access to Medicaid. Americans who earn less than 133 percent of the poverty level (approximately $14,000 for an individual and $29,000 for a family of four) will be eligible to enroll in Medicaid. States will receive 100 percent federal funding for the first three years to support this expanded coverage, phasing to 90 percent federal funding in subsequent years. Effective January 1, 2014.
Promoting Individual Responsibility. Under the new law, most individuals who can afford it will be required to obtain basic health insurance coverage or pay a fee to help offset the costs of caring for uninsured Americans. If affordable coverage is not available to an individual, he or she will be eligible for an exemption. Effective January 1, 2014.
Ensuring Free Choice. Workers meeting certain requirements who cannot afford the coverage provided by their employer may take whatever funds their employer might have contributed to their insurance and use these resources to help purchase a more affordable plan in the new health insurance Exchanges. Effective January 1, 2014.
2015 IMPROVING QUALITY AND LOWERING COSTS Paying Physicians Based on Value Not Volume. A new provision will tie physician payments to the quality of care they provide. Physicians will see their payments modified so that those who provide higher value care will receive higher payments than those who provide lower quality care. Effective January 1, 2015.
