Agenda A year by year look at Health care reform

Transcription

1 Understanding National Health Care Reform Presented by Linda Huber President Benefits Solutions Group Agenda A year by year look at Health care reform What has happened in 2010 What changed in Exchanges and guarantee issue in 2014 What happened In 2010! Health care reform passed and signed into law 3/23/2010 Effective 90 days after enactment temporary high risk pool early retiree reinsurance programs Begin Closing The Medicare Part D donut hole Effective 6 months after enactment 9/23/2010 Grandfathering Dependent coverage through birth month of age 26 Elimination of dollar limits on essential heath benefits Eliminates lifetime dollar limits on essential health benefits Patient protections No Pre existing condition exclusions on children to age % coverage for preventive services in network No prior authorization for emergency services or higher costsharing for out of network emergency services Revised appeal process Non discrimination in favor of highly compensated employees (delayed) 1

2 Grandfathering Keeping grandfather status: there is some flexibility to modify a plan without losing the grandfathered status. This includes: changes to comply with federal or State laws routine premium changes of a policy or plan to keep pace with medical inflation adding new benefits and making modest adjustments to existing benefits Changes to voluntarily comply with the health care reform law Changes in third party administrators Changes in premiums Losing grandfathered status: The following changes to a plan will result in the loss of a grandfathered status: Eliminating all (or substantially all) benefits to diagnose or treat a particular condition Increasing coinsurance by any amount above the level set on 3/23/2010 Increasing fixed amount cost sharing (other than co-pays) more than the sum of medical inflation plus 15% points from the level of 3/23/2010 Increasing co-pays by an amount that exceeds the formula Reducing employer or employee contributions based on the cost of coverage by the formula Reducing an overall annual dollar limit or adding a new overall annual dollar limit, compared with what was in effect on 3/23/10 Buying and/or merging with another plan to avoid complying with the health care reform law Comparison between grandfathered & non grandfathered plans Provision Grandfathered Non-Grandfathered X X No lifetime benefit maximum limits Dependent coverage for adult children up to age 26 X X No annual limits on certain types of benefits X X 100% coverage for preventive care In network X No prior authorization for ER services or higher cost X sharing for out of network ER services No pre-existing limitations for children under the age of 19 X X Coverage of routine patient costs for clinical trials X Reporting the value of employer sponsored coverage's on X X W-2s (2011) optional in 2012 Automatic enrollment in long term care program Uniform explanation of coverage (2012) X Delayed X Delayed Pre-enrollment document sent explaining benefits and X X Exclusions (2012) 60-day notice for material modifications (2012) X X 90-day limit on waiting periods for coverage (2014) X X Employer requirements to offer minimum essential coverage X X (50+employees) (2014) Nondiscrimination in favor of highly compensated employees X Delayed Pended for 2011 Preventive Health Services Children birth to 18 years Screenings, Tests and Counseling Vaccines Vision Screening Hepatitis A Hearing Screening Hepatitis B Oral Health Screening Diphtheria, tetanus, pertussis (DtaP) Screening for Lead exposure Varicella (chicken pox) Anemia screening Influenza (flu) Tuberculosis Screening Pneumococcal conjugate (Pneumonia) Pelvic Exam and Pap test Human Papillomavirus (HPV) Newborn screenings Haemophilus Influenza type b (Hib) Development and behavior tests Polio Cholesterol and lipid level screening Measles, mumps, rubella (MMR) Screening for depression Meningococcal polysaccharide Obesity screening and counseling (expanded coverage) Rotavirus Behavior Counseling to promote a health diet Screening for sexually transmitted infections 2

3 Adults 19 years and older Screenings, Tests and Counseling Vision eye chart test Hearing screening Cholesterol and lipid level screening Diabetes screening Prostate cancer screening, digital rectal exam and PSA test Breast Exam, breast cancer screening and mammography Screening for sexually transmitted infections Screening for HIV (expanded d coverage) Bone density test to screen for osteoporosis Colorectal cancer screening including fecal occult blood test, barium enema, flexible sigmoldoscopy and screening colonoscopy Aortic Aneurysm Screening (new) Pregnancy screening including, but not limited to Hepatitis Asymptomatic bacteriuria RH incompatibility Syphilis Iron Deficiency anemia Gonorrhea Chlamydia Note: these services were previously covered under maternity benefits instead of preventive. Screening and intervention services (including counseling and education) for Obesity Genetic testing for breast and ovarian cancer (new) Behavioral counseling to promote a healthy diet Breastfeeding (new) Aspirin use for the prevention of cardiovascular disease (new) Tobacco use and diseases caused by tobacco use (new) Alcohol use (new) Vaccines Hepatitis A Hepatitis B Tetanus, diphtheria (td) Varicella (chicken pox) Influenza (flu) Pneumococcal conjugate (pneumonia) Human Popillomavirus (HPV) Measles, Mumps, Rubella (MMR) Meningococcal polysaccharide Herpes zoster (shingles) As of January 2011 Prescription required for health savings accounts reimbursement for over-the-counter medications 20% tax for non qualified HSA withdrawals Medical loss ratio standards go into effect (80% for small group) Grants for qualifying small employer wellness programs Federal rate review 1099 Reporting [taken out of the bill] 2012 Uniform summary of benefits and coverage/60- day notice for material modifications (delayed until final regulations are issued) First year medical loss ratio rebates may be issued 3

4 2013 Value of employer-sponsored coverage on W-2s for 2013 tax year meaning w-2s issued in January 2014 (originally required earlier, but the IRS made reporting optional for 2011 and 2012 tax years for employers who issue fewer than 250 W-2s Employee notification of exchanges and premium subsidies Medical flexible spending account contributions limited to $2,500 per year Annual per-member fee for Patient-Centered Outcomes Research Institute (for fiscal year 2013, which technically begins October 1, 2012 Elimination of tax exclusion for Medicare Part D retiree drug subsidy payments 2014 Penalties for employees who don t provide minimum coverage to fulltime employees (50+employees) Employer requirement to auto-enroll employees into health benefits (200+employees) 90-day limit on waiting periods for coverage Small group redefined as (states may defer until 2016) No annual dollar limits on essential health benefits Annual cost-sharing for essential health benefits can t exceed the maximum out-of-pocket limits for a high-deductible health plan (fully insured small group) Individual mandate Guaranteed Issue 30% incentive cap for wellness programs Coverage of routine patients costs for clinical trials of lifethreatening diseases (not required for grandfathered group health plans) Looking Forward Employer responsibility to provide coverage Automatic enrollment Health insurance exchanges Small group rating changes Employer reporting requirements Requirements for minimum coverage Requirements for exchange plans 4

5 What services are considered essential health benefits? Late in 2011, HHS released a bulletin on its approach for essential Health benefits. Instead of defining a specific package or rules, HHS will let states choose based on a benchmark plan. If a state choose not to select a benchmark, HHS suggests that the default benchmark will be the small group plan with the largest enrollment in the state. We do know that essential health benefits include at least these General categories: Ambulatory patient services Emergency Services Hospitalization Maternity and newborn care Mental health and substance use disorder services, including behavioral health treatment Prescription drugs Rehabilitative and habilitative services and devices Laboratory services Preventive and wellness services Chronic disease management Pediatric Services, including oral and vision care How will health care reform affect small group health plans starting in 2014? All fully insured small group plans (whether sold inside or outside an exchange) Will need to: include essential health benefits Provide 60% actuarial value minimum Ensure that annual cost-sharing for essential health benefits doesn t exceed the maximum out-of-pocket limits for a high-deductible health plan. Comply with one of the four benefit tiers with specified actuarial values (60%, 70%, 80% or 90%). 5