Federal

With Congress on recess last week, there is no Federal report for this week.

States

ARIZONA: Governor Jan Brewer has vetoed a bill that would have authorized cross-border sales of Arizona health insurance in the state. In the weeks since the bill passed out of the legislature, her office was bombarded by both opponents and proponents of the bill, including state Senator Nancy Barto, the bill sponsor and chairman of the Banking and Insurance Committee, whose op-ed on the legislation ran in the Arizona Republic last week. While acknowledging the need for a competitive and vigorous insurance market in Arizona, the governor cited two reasons for the veto: First, a concern that the Department of Insurance would have limited jurisdiction over foreign carriers, potentially putting the state’s citizens at risk; and second, discomfort over the fact that foreign insurers would be able to sell policies free of the mandated benefits legislators had determined should be afforded to consumers.

CALIFORNIA: The Assembly’s Health Committee voted 12-7, along party lines, to approve Assembly Member Mike Feuer’s bill that would allow state officials to reject California health insurance rate hikes deemed “excessive” in the individual, small or large group business segments. The measure would allow state regulators to deny, approve or modify proposed increases in health insurance premiums, deductibles or copayments. In addition, the bill would allow any consumer to intervene in a regulator’s decision by filing a civil lawsuit.  Intervener fees would be paid by the insurer submitting the rate increase proposal. The bill secured the 12 votes it needed to move out of the health committee and will be debated by the full Assembly before the end of June. Similar legislation passed the Assembly last year but was defeated in the Senate. Hospitals, physician groups and business organizations have joined health insurers in opposing the bill.

COLORADO:  After a rocky start, the Colorado health insurance exchange bill passed the Senate by a vote along party lines. It is now in the Republican-controlled House where it has yet to be placed on the hearing calendar. House co-sponsor Amy Stephens is expected to seek non-substantive amendments aimed at reframing the legislative declaration portion of the bill. Rep. Stephens has publically stated her support of an exchange mechanism in the absence of a federal requirement. The goal of the amendments is to provide her with some political cover in the face of expected opposition by fellow Republicans, and the Tea Party in particular, who are opposed to any federal health reform implementation. Also, after circulating late-in-the-session drafts of legislation to bring state law into conformity with the ACA concerning preventive care and adverse determinations and appeals, the Division of Insurance has decided not to file the bills.

CONNECTICUT: Under a legislative agreement with Governor Dannel Malloy announced last week, the Connecticut health insurance SustiNet bill is going to be amended from a broad public option to a more limited version of the Connecticut Healthcare Partnership pooling bill. The compromise removes two pieces of the SustiNet proposal: opening the state employee pool to small businesses and individuals, and offering state-run insurance to the public (the public option). The compromise bill would allow municipalities and nonprofits to enter the state employee plan but not small business or individuals. It also would create a new SustiNet board that would serve in an advisory capacity to the governor on health reform efforts in the state. SustiNet supporters last week held a rally to try to revive their original bill. But the governor is unlikely to agree to a public option, given its very significant costs to the state. When the SustiNet concept was created, federal health reform had not yet passed.  Now that it has, the governor is looking toward ACA as a way to increase access to health care affordably.

MAINE: The Republican Chairs of the Insurance Committee have introduced sweeping health care reform legislation designed to increase consumer options by attracting more carriers to the state and allowing more flexibility in products. The bill would expand rating bands in the small group and individual markets, repeal the geographic access provision that requires plans to contract with virtually every provider in the state, repeal the rule mandating certain standardized benefit plans, return to a file-and-use rate review process, allow captive insurers in Maine, allow cross-border selling in Maine, and create an Individual market reinsurance mechanism to be known as the “Maine Guaranteed Access Plan.” The new reinsurance fund would levy an assessment on all covered lives to fund a portion of the premiums for high-cost claimants. The new assessment would be capped at $4 per covered life. The bill was voted “Ought to Pass” out of the Insurance Committee along party lines.

MONTANA:  Both legislative chambers passed a joint resolution that calls for an interim study on establishing a health insurance exchange. Citing the wide ranging potential implications of not creating an exchange, the resolution requests a legislative council to direct an interim joint committee to consider the feasibility of creating an exchange or participating in a regional exchange. Issues for study include: options being considered in other states; variations on exchange functions; the scope of services to be offered by the exchange; potential for an exchange to facilitate cross-border sales; impact of including an application for a Medicaid waiver to allow premium assistance inside the exchange; whether the exchange should define levels of contributions and plan criteria; feasibility of premium aggregation; and interactions with producers and effect on compensation.  The interim committee would also be charged with studying potential cost savings and the provisions that would be needed to neutralize the cost of state employees participating in the exchange. Following the study,    recommendations will be made to the legislature regarding whether the state should proceed with establishing its own exchange or joining a multi-state exchange.  Stakeholders, including health insurer representatives, will be included in the deliberations.

NEVADA: A bill that would create the Silver State Nevada Health Insurance Exchange has been referred to the Commerce, Labor and Energy Committee but is not yet scheduled for its first hearing. Concurrently, Commissioner Brett Barratt continues to host stakeholder informational meetings across the state. The vast majority of the attendees at the five meetings held to date have been brokers. On another ACA issue, the state was advised that its application for a one-year medical loss ratio (MLR) waiver has been deemed “complete” by HHS. In other business, the Speaker’s rate review bill has passed in the House and is now in the Senate. In its current form, the bill would require prior approval of rates and forms with a 30-day deemer; transparency with completed filings published on the DOI website and all of a carrier’s policies, certificates of coverage and medical loss ratio data published on its own website; public hearings at the request of consumers or insurers; and the establishment of a Consumer Advocate position to represent the public.

NEW YORK: Senate Insurance Chair Jim Seward and Senate Health Chair Kemp Hannon held a roundtable discussion on insurance exchanges last week. About 10 representatives of stakeholder organizations invited to participate and generally urged caution and called for maintaining consumer choice, not creating a new regulatory bureaucracy, including all state mandates, and not incurring additional regulatory burdens and duplications of authority.  The Senate is expected to introduce a fairly lean exchange bill, with the goal of creating a governance framework for 2011. This could take the form of a public benefit corporation or a quasi-public authority, but not a new agency or nonprofit corporation.

NORTH DAKOTA:  The legislature has passed an insurance exchange bill that is expected to be signed by Governor Jack Dalrymple.  This would be the first exchange bill to be passed by a Republican legislature and signed by a Republican governor. The purpose of the bill is to establish a framework for developing more specific policy positions and eventually an implementation plan for the exchange in North Dakota.

OKLAHOMA: A Senate bill that would create an Oklahoma health insurance exchange was filed last week shortly after Oklahoma’s Governor, Speaker of the House and President of the Senate announced an agreement to move forward on the issue. The bill would create the Health Insurance Private Enterprise Network, which would fulfill the stated purposes and functions of a federal exchange under ACA. The bill is short on details but would create a seven-member Board of Directors, including three   gubernatorial appointees (one representing carriers, one representing employers, and one representing providers). The board would also include a consumer representative (appointed by the Speaker of the House, an agent/broker (appointed by the Senate Pro Tem), the Insurance Commissioner (who also serves as Chair), and the Secretary of HHS. The Board will also appoint an executive director. The bill would require as-yet unspecified “public and private funding”, not to include the $54 million early innovator grant from the federal government. The stated goals of the Network are to promote/encourage portability of coverage; promote a competitive, market-based system that includes an aggregate premium system/defined-contribution insurance alternative; encourage carriers and providers to work together to provide quality, cost effective care; and establish a fair and impartial producer referral network for individuals and small employers. The Network would not have regulatory authority, discriminate against any qualified plan, or replace the outside market. Proponents of the bill will attempt passage before the legislature adjourns May 27.

TEXAS:  The Senate unanimously approved Sen. Jane Nelson’s bill to find extensive cost savings in Texas health insurance Medicaid program, the primary health care provider for children, the disabled and the very poor. The measure would expand Medicaid managed care into South Texas, where it has long been carved out. The move is expected to save the state $290 million over the biennium. Pulling prescription drug sales into the managed care program, the changes would require most Medicaid patients to use medicines on a state preferred drug list at a projected savings of $51 million a biennium. And, it would ensure people with disabilities receiving attendant care services at home are using a Medicaid contractor, saving an estimated $28 million a biennium. The measure also directs the comptroller to continue to collect a $5 per-person fee on patrons of strip clubs — a proposal that’s been tied up in court — until a final legal judgment has been reached. The projected cost savings have already been worked into the budget proposal Senate lawmakers are trying to bring to a vote.

VERMONT: The Senate voted 21-9 to approve an amended version of the single-payer legislation that previously passed the House on March 24. The bill will now go to a conference committee. As passed by the House, the bill would establish an exchange by 2014 that would eventually become the foundation for a single-payer system. The single-payer system, Green Mountain Care, would begin in 2017, the year when the ACA allows states to request waivers to opt out of certain requirements as long as an alternative approach would achieve the same coverage goals. The bill would permit earlier implementation of the system, upon receipt of federal approval. Other provisions include new rate review requirements. For rate increases that cumulatively would be 5 percent or greater during the plan year, health insurers would be required to submit a summary that includes a brief justification of requested rate increases, additional information for rate increases of over 10 percent, and any other information required by the insurance commissioner. Senate amendments, however, include a series of requirements that would have to be met before the Green Mountain System can be established, including a demonstration that the system would slow the growth of medical costs. Governor Peter Shumlin has indicated that he will sign either form of the legislation.

Federal
Last week a Florida federal judge clarified (at the request of the Obama Administration) his earlier decision back in January 2011 in which he ruled that the PPACA’s individual health insurance mandate is unconstitutional. He also wrote that the mandate could not be severed from the rest of PPACA and, therefore, the whole law had to be set aside as unconstitutional.  In last week’s rather colorful ruling, the judge chided the government for sitting on its hands for weeks before asking for the clarification. He re-emphasized that the mandate and the whole law are unconstitutional and chastised the government both for failing to appreciate, as a matter of law, that the prior Declaratory Judgment was the “functional equivalent” of an injunction (meaning that the government could not proceed with implementation) and for having the temerity to suggest otherwise. The judge did not stop there, which would have halted all implementation of the PPACA had he done so. He instead decided that the government’s motion to clarify was also a motion to “stay” the imposition of the original ruling, and he granted the stay.  But he conditioned it with the requirement that the government file an appeal within seven days seeking an expedited “fast-track” appellate review, either in the Court of Appeals (11th Circuit) or the U.S. Supreme Court. This filing requirement is the major takeaway from last week’s ruling because it accelerates the timeline for the litigation, to the applause of the state and others who oppose the law. The Administration and the proponents of the law are less happy, since stringing out the ultimate decision would make it more difficult, if not impossible, to dismantle.

With House approval (314 to 112) last week, Congress is well on the way to repealing the 1099 provision of the PPACA, which imposes a costly and burdensome reporting requirement on employers.  Earlier this year, the Senate also voted to repeal the 1099 provision; however, the two chambers are worlds apart with respect to paying for the repeal. While the House version pays for the repeal by revising the rules for repayment of excess premium subsidies down the road, the Senate version doesn’t directly pay for it and only gives OMB the authority to go find the money. A House-Senate Conference (or an unofficial compromise) will be needed to resolve this impasse.

The anticipated government shut-down on March 4 was put off last week when both chambers passed (and the President signed) a two-week extension of a continuing resolution to keep the government officially funded until March 18.  This particular resolution actually cuts federal spending for the current fiscal year by $4 billion, which means that the House Republican savings target of $60 billion for FY 2011 is now down to $56 billion. Congress could very well bump along with such short-term resolutions throughout the spring. But at some point, the Republicans in the House and the Democrats in the Senate will have to permanently fund FY 2011 and get on with the FY 2012 budget, which is supposed to be in the works right now.
Multiple health-care-related hearings were held on Capitol Hill last week. In testimony before the House Energy and Commerce Committee, Mississippi Gov. Haley Barbour voiced support for funding Medicaid with block grants, under which the federal government would give states a set dollar amount for Medicaid rather than paying a percentage of costs. Under this system, states would have “total flexibility” to manage their Medicaid programs, according to Barbour.  The panel’s Democrats were quick to dismiss the idea of block grants, saying the change would harm vulnerable beneficiaries. Karen Ignagni, the President and CEO of America’s Health Insurance Plans, testified before the House Ways and Means Committee Subcommittee on Oversight Health Plan Programs to Combat Fraud, Waste, and Abuse. Her testimony addressed two issues: how health plans’ fraud detection units are using cutting-edge techniques to identify practices leading to substandard care – including overuse, underuse, or misuse of medical treatment; and suggestions for improving fraud detection and prevention in both public and private programs.  Part of her testimony also focused on the medical loss ratio (MLR) regulation, which she said will hurt the insurance industry’s efforts to detect and prevent fraud.

The Government Accounting Office (GAO) last week released a study that shows “nearly 10 percent all Medicare payments are fraudulent or otherwise improper, and the government isn’t doing enough to stop them.”  The Medicare “fraud margin” is 9 percent, nearly triple the profit margin for the health plan industry (3.58 percent). The GAO also provided correspondence to the Hill on Medicare Private Sector Initiatives to Bundle Hospital and Physician Payments for an Episode of Care.  As one of the five largest national payers, Aetna insuranceae was interviewed and provided relevant materials. The GAO found that ongoing private sector bundling initiatives that achieve savings are an important consideration, in light of Medicare’s financial challenges. Bundled payments are feasible for Medicare, but there are several obstacles to overcome — such as manual claim processing systems, resistance to limiting provider choice and the lack of standard definitiions.

States

With the California health insurance deadline for the introduction of legislation during the 2011 session looming, and now passed. several health care-related measures were reintroduced, such as a single payer/universal care bill, prior approval and rate regulation, and mandatory autism coverage. In addition, a host of bills are in play that take another step toward implementing federal reform but appear to be inconsistent with PPACA. As in past years, legislators have proposed a host of new mandated benefits – 15 in total. They include several new ones, including the proposed elimination of step therapy for pain medications, fertility preservation services and forensic medical evaluations. The state’s mandate commission is reviewing the cost and public benefit of each of these proposed mandates and will issue a report that should be publicly available by the end of March.

Democratic Senator Irene Aguilar, the sponsor of a Colorado health insurance single-payer bill, engaged in a verbal confrontation last week with a representative of the Colorado Association of Industry and Commerce regarding the potential impact of her bill on employment in the state. Subsequent to a rally on the steps of the Capitol, the bill was voted out of committee, 4 to 3, along party lines. The bill has little hope in the Republican-controlled House and may not reach the Senate floor without some Republican support.

As in the past two years, the Connecticut Health Insurance Committee approved Speaker Chris Donovan’s bill called An Act Establishing the Connecticut Healthcare Partnership. This bill would open the expensive state employee health plan to small businesses, nonprofits and other groups. The goal is to attract a number of new employee groups to the state employee plan – nearly all of whom already have health insurance. In addition, the new state-run health plan would compete directly against the private marketplace. Given the high benefit levels, state employee plans are among the most expensive in the state. As such, this bill would not offer small businesses any real cost relief, achieve intended cost savings or increase the number of people with insurance. It could lead to substantial cost increases for taxpayers. The 11-9 committee vote was mostly along party lines, with most Democrats supporting the measure (except Sen. Joan Hartley and Rep. Linda Schofield), and all Republicans opposing it. This bill passed in 2008 and again in 2009, but was vetoed both times by former Governor M. Jodi Rell.

The Governor and Commissioner of Georgia Health Insurance are considering issuing an executive order that would create an Exchange Review Board. The Board would then consider and possibly develop legislation to implement a state insurance exchange in 2012. A bill is expected to be filed creating this advisory committee and is supported by the Governor’s office. The Governor may then follow with an executive order. Also, Aetna insurance expects an MLR waiver request to be filed by the DOI sometime this month.

The Department of Louisiana Health Insurance has indicated it will file an MLR waiver request this week despite indications from the Governor’s office that he does not approve of the request.

The Senate Appropriations Subcommittee on Oklahoma Health Insurance and Human Services passed a bill last week that would create a website to permit Oklahomans to see approximate pricing information for medical procedures and pharmaceutical products. The bill requires the Insurance Department, in collaboration with the State Department of Health, to establish and maintain an online health care information system that permits consumers to see pricing information from different types of providers and pharmaceuticals. The bill states that the purpose of the website is to serve as a resource for insurers, employers, providers, purchasers of health care and state agencies to continuously review health care utilization, expenditures and performance. It would also enhance the ability of consumers and employers to make informed, cost-effective health care choices. The bill would require that the presentation of data in the system allow for comparisons in the context of geography, demographics, general economic factors and institutional size.

Also of interest is a bill passed by the Senate Rules Committee last week that would allow Oklahoma to opt out of federal health care reform requirements. The bill asserts state control in the regulation of health care, would create a compact between certain states and would set forth formulas for figuring the right to federal funds for each member state. The bill also would create the Interstate Advisory Health Care Commission and establish membership requirements and duties of the commission. Primarily the commission would assist the legislatures of member states in the regulation of health care. It states the formation of this compact is contingent upon approval from the U.S. Congress. Democrats in Oklahoma’s Senate opposed the bill, some saying that it would force Oklahoma to rely on other states for regulating Oklahomans. Both bills will continue through the legislative process, which is scheduled to end in late May.

Rep. John Zerwas’ bill authorizing the creation of a state Texas health insurance exchange encountered mostly smooth sailing last week when it was heard by the House Insurance Committee. Going by the name of the Connector in the bill, the primary purpose of the exchange is to prepare Texas for changes in health insurance markets set to roll out in three years as part of federal health system reform. One important change in the new bill language presented at the hearing was the absence of an individual mandate to buy an insurance product. Groups expressing support for the bill included the Texas Association of Business and the Texas Hospital Association, among others. The bill was left pending by the Committee and will likely see more changes before it is brought to a vote. The Texas legislature continues in its regular session until June 1, 2011.

A pattern seems to be developing on the House side of Congress as Republicans are now flexing their majority muscles via Congressional hearings aimed at questioning the legality and practicality of the health care reform act passed in 2010. It was the Ways & Means Committee’s turn last week as the committee heard from two small business owners who expressed concern about future health insurance costs, their ability to maintain current levels of coverage, and barriers to expanding and hiring new employees. Committee Chairman Dave Camp (R-MI) noted the inherent conflict of imposing new taxes (e.g., on insurers) and expecting cost containment nonetheless. Rep. Richard Neal (D-MA) discussed the importance of the individual health insurance coverage requirement, emphasizing that the success of market reforms is closely linked to bringing everyone into the system. Austan Goolsbee, Chairman of the President’s Council of Economic Advisors, testified regarding the Administration’s expectation that the new law will succeed in holding down costs, and he highlighted the value of the small employer tax credits.  On the flip side, Douglas Holtz-Eakin, former CBO Director and President of the American Action Forum, cautioned that the law frontloads new taxes and backloads new spending, thereby creating the illusion of federal deficit reduction. Holtz-Eakin testified that the law will have a detrimental impact on employment, wages, and economic growth.

Another health care hearing last week was held by the House Budget Committee, which focused on the fiscal consequences of the health reform law. Rep. Paul Ryan (R-WI), the committee chairman, emphasized that “health care spending is driving the explosive growth in our spending and our debt.”  He criticized the new law as a “centrally planned, bureaucratically run health care system” and expressed interest in building bipartisan support for policies that create incentives to enhance quality, reduce costs, and promote patient satisfaction. Richard Foster, chief actuary of the Centers for Medicare & Medicaid Services (CMS), testified that the health reform law (from 2010 through 2019) will increase national health expenditures by an estimated $311 billion, or 0.9 percent, compared to prior law. He also discussed the impact of Medicare funding cuts and indicated that some of the savings may be “unrealistic.”  Foster expressed particular concern about productivity adjustments for hospitals, skilled nursing facilities, and home health agencies, stating that simulations by his office suggest that roughly 15 percent of Part A hospital providers would become unprofitable within 10 years as a result of the productivity adjustments.

Arizona health insurance : While the legislature is focused primarily on the budget and the governor’s request for a Medicaid waiver, bills are beginning to be introduced. Of interest are: a proposed requirement that state employees be offered a wellness program as part of their health benefits; a mental-health parity mandate; a proposed requirement that the sponsor of a benefit mandate review data evaluating the effectiveness of the treatment or service; and a proposed exemption of health-care-sharing ministries from regulatory oversight on the premise that such practices do not constitute the business of insurance.

California health insurance : As the legislature continues to introduce bills in advance of the February 18 deadline, several repeat bills have already been introduced, including mandates on mental health, acupuncture and maternity services. A new mandate has been proposed to require health plans to cover fertility preservation services for cancer patients. The legislation, sponsored by the American Society for Reproductive Medicine, would require coverage of services such as ovarian suppression, freezing of eggs and ovarian tissue, and fertility services after treatment of the cancer.

Illinois health insurance : A formal health insurance exchange bill has not yet been introduced for consideration in the General Assembly. However, the Health Insurance Rate Review Act has been introduced to create an independent, quasi-judicial Health Insurance Rates Review Board to determine whether proposed “insurance rates are reasonable and justified.”  The bill sets forth duties and prohibited activities concerning the board, and it would allow the Governor to make all of the appointments.  The bill would set requirements and procedures that health insurance carriers must follow in filing current and proposed rates and rate schedules, and it would allow the new board to review and approve/reject all rates and rate schedules filed or used by a carrier. Rate standards, public notice, and hearings are all addressed. The General Assembly is expected to consider quite a few bills and hold hearings on both exchanges and rate review during the current session.

Oklahoma health insurance : Last week the Department of Insurance held a meeting of the Oklahoma State Healthcare Exchange as a first step in the creation of a strategic road map. The Department announced the creation of Key Advisory Work Groups to develop recommendations on exchange-related issues.    Each work group and sub-group will be responsible for researching and developing recommendations on language to be used for the development of a strategic plan during the next three months. The key issues of study will include: governance and administrative structure, eligibility process and infrastructure,  enrollment, information technology, carrier and plan selection,  financial management, and education and marketing. Stakeholders attending the meeting were asked to volunteer to participate on groups for which they have knowledge and leadership experience. The Department hopes to assign volunteers to their preferred committees in the next few weeks so that workgroup meetings can get underway.

Texas health insurance : While publicly affirming his opposition to the federal health care reform bill, Rep. John Zerwas is explaining health insurance exchange legislation he drafted through an op-ed piece published in multiple major newspapers in the state. Zerwas argues that Texas could be forced to cede regulatory control of a significant chunk of its health insurance market to the federal government if it fails to create its own exchange this session. He explained that a desire to avoid such oversight has generated broad support for his bill from groups that include the Texas Association of Business, Texas Hospital Association, Texas Medical Association, Texas Restaurant Association and two Texas health insurance industry groups, as well as Republicans and Democrats in the legislature. Though supportive of efforts by Texas Attorney General Greg Abbott and others to have the health care bill ruled unconstitutional,    Zerwas said his connector proposal is about bringing down the cost of coverage by promoting competition and ensuring that Texas families and Texas employers have the right to choose their own coverage. He called passage of the bill good policy, regardless of whether PPACA is repealed, replaced or unfunded. The legislature will debate the bill during the current session, which will end June 1, 2011.

Certain provisions of the Affordable Care Act are effective starting with plan years (in the individual market, policy years) beginning on or after Sept. 23, 2010. We believe that some of our members or groups may not recognize or understand the plan/policy year concepts and mistakenly assume that certain Affordable Care Act provisions will immediately apply to their coverage on Sept. 23, 2010.

We ask that you call us with any questions regarding certain provisions of the Affordable Care Act that may not immediately apply to your coverage, but will apply starting with plan/policy years beginning on or after Sept. 23, 2010.

New EOBs and Language Notifications

Beginning Sept. 23, 2010, members and providers will see a new section in Explanation of Benefits (EOBs) and denial letters that is referred to as “Important Updates (not applicable to all policies or plans)”. The new section informs members that if their plan/policy is non-grandfathered, as defined in the Affordable Care Act, and if their plan/policy has renewed after Sept. 23, 2010, then the information in the new section may apply to them. This would also apply to new plans that are effective on or after Sept. 23, 2010.

These requirements do not apply to grandfathered plans. However, you should note that the new notification language will be included on all EOBs and denial letters, including those to members of grandfathered plans. Our call center Customer Advocates will be prepared to help members determine whether or not their plan is grandfathered or non-grandfathered.

Appeals and External Review

Concerning external review of denials, all non-grandfathered plans that are not required to follow an existing state external review law – for example, most self-insured plans – the option to choose to follow either the existing state external review process (when permitted by the state’s Department of Insurance) or to follow the new federal external review process, as of their effective date.

Non-grandfathered ASO self-funded plans to submit an External Review Election Form for their medical benefit plan(s) to their account representative at least 30 calendar days prior to their renewal date. If they do not make their own selection by completing the form at least 30 calendar days prior to renewal, the states external review process will review it. At this time there will be no additional charge for this new service.

Essential Health Benefits

Starting with plan years beginning on or after Sept. 23, 2010, the Affordable Care Act generally prohibits group health insurance coverage from having annual limits on the dollar amount of essential health benefits.

However, for plan years beginning prior to Jan. 1, 2014, group health insurance coverage may have certain restricted annual limits on the dollar amount of essential health benefits in accordance with federal regulations.

Federal regulations and guidance also provide for the waiver of the restricted annual limit requirements under certain circumstances.

Pre-existing Under 19

Starting with plan years beginning on or after Sept. 23, 2010, the Affordable Care Act prohibits group health insurance coverage from imposing pre-existing condition exclusions on enrollees under age 19. If you missed this announcement earlier, you should note that we have now aligned our benefits with the Affordable Care Act by not allowing pre-existing exclusion only for enrollees up to age 19. This is for our fully insured and individual business – ASO/custom accounts may still vary their coverage to provide richer benefits.

Child-only Policies

We are awaiting state Department of Insurance approvals for our new child-only policy. Our target date to begin enrolling members is May 2011.

Special Open Enrollments

Some groups may be having their open enrollment now for plans starting Oct. 1, 2010. Included in open enrollment for these groups is a special open enrollment for adding dependents under the provision of the Affordable Care Act that extends adult child dependent coverage up to age 26. Those individuals who also reached a plan’s lifetime limit are also eligible for the special open enrollment.

The health insurance reform act that was passed in March requires that policies starting now or in the future cannot exclude, limit, or deny medical coverage to children under 19 based on any health problems that developed before seeking medical coverage. Therefore, there will be no more exclusions for children with pre-existing conditions.

Premiums could double for everyone by mid 2011. Your best choice is to buy health insurance now and lock in a low rate for several years. Many carriers allow you to lock in rates for more than a year at a very small cost per month.

A group of 129 progressive House of Representatives Democrats, seeking to revive the public option, introduced legislation on July 22 to establish a public health insurance plan that would compete with private health insurers. It is highly unlikely that the House will vote on the legislation this year. Republicans and some moderate Democrats remain strongly opposed to the public option, and Democratic leaders have little interest in reigniting the divisive health care reform debate before the November elections.

Supporters of the Public Option Act (H.R. 5808) claim that the legislation would sharply reduce the federal deficit. The non-partisan Congressional Budget Office (CBO) estimates that the bill would reduce the federal deficit by approximately $68 billion from 2014 to 2020.

The public plan would be administered by the Secretary of Health and Human Services and would be offered through the new health insurance exchange beginning in 2014.  The bill would require the public plan to charge premiums that fully cover its costs for benefit payments and administrative expenses. The plan’s provider payment rates would be based on Medicare reimbursement rates. The legislation has been referred to the House Energy and Commerce Committee.

President Obama Signs Unemployment Insurance Extension Bill into Law

President Barack Obama signed H.R. 4213, the Unemployment Compensation Extension Act of 2010, into law on Thursday, July 22, ending months of partisan squabbling over the measure. Moments after the late Senator Robert Byrd’s (D-WV) replacement, Carte P. Goodwin, was sworn into office, the Senate quickly voted to invoke cloture on the legislation, sending it back to the House, which then passed the measure by a vote of 272-152.

The legislation did not include an extension of the COBRA health insurance subsidies and other safety-net programs that had also expired earlier this year. The legislation will provide unemployment insurance for those who have already exhausted their normal six months of benefits through Nov. 30, 2010; it is retroactive to June 2, 2010. The Congressional Budget Office estimates this extension will add $33.9 billion to the federal deficit over 10 years.

House Republicans Criticize New Rules for $27 Billion Electronic Health Records Program

House Ways and Means Health Subcommittee Republicans alleged during a July 20 hearing that eligibility criteria for the new $27 billion federal electronic health records (EHR) program are too lenient. The EHR program will provide additional Medicare and Medicaid payments, beginning in 2011, to health professionals and hospitals that adopt certified EHRs. The additional payments, which were enacted in 2009 as part of the American Recovery and Reinvestment Act, will likely encourage many physicians and hospitals to purchase and implement EHR systems.

In order to be eligible for additional Medicare and Medicaid payments, hospitals and health care professionals must adopt and make “meaningful use” of certified EHR technology. Dr. David Blumenthal, the National Coordinator for Health Information Technology (IT), testified that the eligibility criteria were designed to accommodate diverse providers, while appropriately encouraging the adoption of EHRs. The Obama Administration had originally proposed more strict eligibility requirements that were denounced by the health care industry as unrealistic.

The new qualification standards are the first in a series of rules, and they apply only to additional payments before 2013. Dr. Blumenthal stated that HHS will place higher demands on providers in the future.

• Temporary retiree reinsurance program.
• National risk pool, small business tax credit.
• $250 rebate for Medicare members who reach the “doughnut hole”.

Health Insurance Reforms:

• No lifetime benefit limits based on dollar amounts.
• Allowed restricted yearly limits on the dollar value of certain benefits.
• No coverage rescissions/cancellations (except for fraud or internal misrepresentation).
• No cost-sharing obligations for preventive services.
• Must have dependent coverage up to age 26.
• New internal and external appeal process.
• No pre-existing condition exclusions for dependent children (under 19 years of age).
• New health plan disclosure and transparency requirements.

2011
Insurance Reforms:

• New uniform coverage documents and standard definitions are developed.
• Must have minimum medical loss ratios.

Medicare Reforms:

• Start of Medicare Advantage cost-sharing limits.
• Medicare beneficiaries who reach the doughnut hole to get a 50% discount on brand name drugs.
• Primary care doctors and general surgeons practicing in underserved areas, such as inner city and rural communities to get a 10% bonus.
• Medicare Advantage plans begin having payments frozen.

Other:

• Yearly fee for brand-name drug manufacturers.
• Start of voluntary long-term care insurance program giving a cash benefit to help those with disabilities stay in their homes or pay nursing home cost: benefit starts 5 years after paying coverage fee.
• Increased funding for community health centers to provide care for many low-income and uninsured people.

2012

• Hospitals, doctors and payers encouraged to join forces in “accountable care organizations”.
• Hospitals with high rates of preventable readmissions facing reduced Medicare payments.

2013

• Individuals making $200,000 a year or couples making $250,000 would have a higher Medicare payroll tax of 2.35% on earned income – up from the current 1.45%. A new 3.8% tax on unearned income, such as dividends and interest, also added.
• Contributions to flexible spending accounts (FSAs) limited to $2,500 a year – indexed for inflation. And the threshold for deducting medical expenses on taxes goes from 7.5% to 10% income.
• Medical device manufacturers have a 2.9% sales tax on medical devices; with exemptions for some, like eyeglasses, contact lens, and hearing aids.
• No more deduction for expenses allocable to Medicare Part D subsidy for employers who maintain prescription drug plans for their Medicare Part D-eligible retirees.

2014
Coverage Mandates & Subsidies:

• New Individual and employer coverage responsibilities.
• New Individual affordability tax credit and expanded small business tax credits.

Health Insurance Exchange & Insurance Reforms:

• State individual and small group health insurance exchanges operational.
• Guaranteed issue, guaranteed renewability, modified community rating and minimum benefit standards (“essential benefits” plan) effective.
• No more lifetime and yearly dollar limits for essential benefits.
• New taxes on health insurers.

2018

• New tax (“Cadillac tax”) on employer-sponsored health plans that offer policies with generous coverage levels.

2020

• Doughnut hole coverage gap in Medicare prescription benefits is fully phased out. Seniors continue to pay the standard 25% of their drug costs until they reach the threshold for Medicare catastrophic coverage.

These are some of the arguments of more than a dozen states that have filed lawsuits. The lawsuits challenge the constitutionality of the reform. Their arguments also include that the government should not force citizens to buy health insurance.

It will be several years before the reforms take effect, and opponents are trying to ensure that they never will.

But significant improvements have already been made and insurers are also moving into compliance ahead of schedule. New rules forbid insurance companies from denying coverage to children, young adults can now stay on their guardians’ policies until age 26, and setting a lifetime limit on benefits will be banned soon.

Let’s not forget the true objective and that is to reduce costs. The Obama administration  must demonstrate that reforms will eventually bring down costs. This is the true test.

In the never-ending roll-out of proposed health care reform regulations, the Administration last week published yet another set of Interim Final Regulations. This set deals with coverage for dependent children up to age 26 pursuant to the requirement that insurers and group plans allow kids to stay on their parents’ policies or coverage until age 26.  Comments are due by August 11, but the rule is effective July 12, 2010. Many insurers have already announced that they will implement this provision early (e.g., May 31 for Aetna) to cover graduating college students who may have otherwise faced the summer without insurance. Whether self-funded employers follow suit is not as clear. Also, with the temporary fix of Medicare physician reimbursement rates set to run out the end of May, the House is expected to take up a more lasting fix sometime this week. If the House proceeds as expected it will attempt to install a five-year suspension of any physician rate cuts. Aetna supports the change, as it will give this market predictability.

According to the New York Times Sunday Edition
“New York’s insurance system has been a working laboratory for the core provision of the new federal health care law — insurance even for those who are already sick and facing huge medical bills — and an expensive lesson in unplanned consequences. Premiums for individual and small group policies have risen so high that state officials and patients’ advocates say that New York’s extensive insurance safety net for people like Ms. Welles is falling apart.

The problem stems in part from the state’s high medical costs and in part from its stringent requirements for insurance companies in the individual and small group market. In 1993, motivated by stories of suffering AIDS patients, the state became one of the first to require insurers to extend individual or small group coverage to anyone with pre-existing illnesses.
New York also became one of the few states that require insurers within each region of the state to charge the same rates for the same benefits, regardless of whether people are old or young, male or female, smokers or nonsmokers, high risk or low risk.

Healthy people, in effect, began to subsidize people who needed more health care. The healthier customers soon discovered that the high premiums were not worth it and dropped out of the plans. The pool of insured people shrank to the point where many of them had high health care needs. Without healthier people to spread the risk, their premiums skyrocketed, a phenomenon known in the trade as the “adverse selection death spiral.”

That death spiral has nearly wiped out the individual health insurance market in the state.  New York has the highest annual premiums for individual policies in the country, at over $6600 for an individual and double for families.

Obama Care supporters argue that the federal individual health insurance mandate will solve this problem. However, the mandate in Massachusetts hasn’t kept costs in line. The New York Times is also skeptical.

“The new federal health care law tries to avoid the death spiral by requiring everyone to have insurance and penalizing those who do not, as well as offering subsidies to low-income customers. But analysts say that provision could prove meaningless if the government does not vigorously enforce the penalties, as insurance companies fear, or if too many people decide it is cheaper to pay the penalty and opt out.

Under the federal law, those who refuse coverage will have to pay an annual penalty of $695 per person, up to $2,085 per family, or 2.5 percent of their household income, whichever is greater. The penalty will be phased in from 2014 to 2016.”

The math is very simple. If an individual has to pay $6600 per year for a policy they feel they don’t really need or pay $2500 on a salary of $100,000, which one will healthy young earners take? Of course this is based on the assumption that the government will actually enforce the mandate, which Democrats insisted the Obama Care bill couldn’t do.

Arguments to this will be that most young  people earn much less and will get federal subsidies, but that still depends on them deciding whether to pay anything for a policy that clearly doesn’t suit them.  The argument has neglected the fact that the actual costs will absolutely skyrocket and that taxpayers will be on the hook for the subsidies, which will have to increase to match the premium hikes to remain effective.  Instead of having premiums based on a rational risk assessment, we have the young and healthy subsidizing premiums for the older and the much less healthy in comparison, who then subsidize the younger and healthier through federal handouts. A crazy way to run health care in the U.S.

The individual health insurance mandate is nothing more than a way to get young people to create a proxy welfare state by forcing them into a extorting health insurance model.  It does nothing to reduce actual costs at all, and in fact makes cost increases both more frequently and more rapidly.

Easy To Insure ME .com would also like to note that this story was buried in the regional section and not the front page.  This reflects on the arrogance of the whole Obama administration and their gag orders on speaking out about health insurance reform.