Wellness Provisions in the Affordable Care Act

Transcription

1 Wellness Provisions in the Affordable Care Act September 11, 2012

2 Arthur J. Gallagher & Company Founded 1927 Traded under NYSE symbol AJG since 1984 Over 13,000 employees Operations in 15 countries and network of correspondent brokers and broker consultants in more than 100 countries One of the world s largest insurance brokerages Listed among Forbes Platinum 400 as one of the best big businesses in America Arthur J. Gallagher & Co. Property/Casualty Property/Casualty 3 rd Party Administration Wholesale Services Employee Benefits

3 About Gallagher Benefit Services Subsidiary of Arthur J. Gallagher & Co. Established in 1961 Full range of employee benefit services employees in over 100 offices Extensive experience with Higher Education Over 200 Higher Education nationally GBS Higher Education Niche Commitment to Excellence Innovation & Creativity Gallagher Difference

4 GBS Core Practice Areas Health & Welfare Strategic & Annual Planning Vendor Marketing, Due Diligence, & Negotiations Benefit Plan Design & Implementation Administration Support Compliance Support Employee Communications Wellness & Disease Management Healthcare Analytics Multi Year Financial Projections Medical Management Vendor Audits Healthcare Informatics Customized Benchmarking Network Evaluation Actuarial Consulting Software Retirement Services Fiduciary Risk Mitigation and Management Qualified Plan Consulting Non qualified Plan Consulting Institutional Investment Advisory Services Actuarial Services Plan Design, Benchmarking, and Monitoring Compliance Assistance Human Resources Business Strategy Development Strategic Plan Design Workforce Planning Compensation Design Executive Compensation HR Efficiency and Compliance Executive Benefits Individual Investment Planning Non qualified Plans Life Insurance and Disability Planning Estate and Wealth Transfer Business Succession Planning Voluntary Benefits Integrated Approach Balanced with Core Offerings Managed Implementation Enrollment Capabilities Education based Communication

5 2,562 13,000 Pages

6 What is Healthcare Reform? Insurance Reform Carriers Employee Employer Exchanges TRANSPARENCY AND PROGRAM INTEGRITY Title VI IMPROVING ACCESS TO INNOVATIVE MEDICAL THERAPIES Title VII CLASS ACT Title VIII Reform of Insurance Market, Individual Mandate, Employer Responsibilities Title I ROLE OF PUBLIC PROGRAMS Title II IMPROVING THE QUALITY AND EFFICIENCY OF HEALTH CARE Title III Multiple Supporting Changes to Health Care Related Laws and Programs HEALTH CARE WORKFORCE Title V PREVENTION OF CHRONIC DISEASE AND IMPROVING PUBLIC HEALTH Title IV

7 Overview Employer Mandate Individual Mandate Near Term Ins. Market Reforms Employer Notification Requirements Healthcare Reform Title I Longer Term Ins. Market Reforms Government Assistance Other Provisions Taxes

8 Background: Context of Wellness in the ACA Congressional intent: promote wellness/healthier lifestyles Increased employer interest New requirements Increased opportunities

9 Wellness Services as Essential Health Benefits Prohibition/restriction on lifetime/annual limits on essential health benefits from 9/23/10 Wellness included in categories of essential health benefits Preventive and wellness services and chronic disease management No precise definition of wellness service Additional guidance anticipated

10 Wellness Program Reporting Requirements Non grandfathered group health plans required to submit annual report HHS/enrollees on quality of care measurements Information about benefits and reimbursement plan components that implement wellness and health promotion activities. Provided, coordinated, or maintained by health care provider wellness and prevention plan manager health, wellness or prevention services organization

11 HIPAA Wellness Program Basics Exception to HIPAA nondiscrimination rules Contains an incentive dependent upon individual meeting a health standard E.g. premium contribution reduction tied to BMI or cholesterol Does not include participation only programs Requirements to get the exception (HIPAA wellness rules): Reward must be no more than 20% of cost of coverage (30% in 2014) Program must be designed to promote health/prevent disease Program must give individuals an opportunity to qualify for the reward at least once a year Reward must be available to similarly situated individuals (including alternative standard**) Plan must disclose that alternative standard/waiver available

12 Reasonable Alternative Subject to External Review Reasonable alternative standard Alternative must be available to individuals for whom attempting to meet standard is unreasonably difficult due to a medical condition or medically inadvisable E.g. individual who has genetic high cholesterol; individual with overweight due to thyroid condition; smokers addicted to nicotine Examples of alternative standards Agreement to adhere to medication regimen Doctor approved/prescribed exercise program Smoking cessation program Denial of request for waiver/reasonable alternative standard subject to ACA appeals requirements, including external review by an Independent Review Organization

13 Increased Financial Incentives Permitted Cap on reward under standard based wellness programs increased up to 30% of cost of coverage Agencies may increase cap to 50% of cost of coverage, if such action is deemed appropriate Plan years beginning on of after 1/1/14

14 Small Business Wellness Grants Basics $200 million federal grant money to provide employees with access to comprehensive workplace wellness program Awarded to small businesses over 5years, beginning 2011 Employer eligibility For profit/nonprofit Fewer than 100 employees who work 25 hrs/week No wellness program in place as of March 23, 2010 Must be made available to all employees

15 Small Business Wellness Grants: Requirements Health awareness initiatives (health education, preventive screenings, and HRAs Efforts to maximize employee engagement (mechanisms to encourage participation Initiatives to change unhealthy behaviors/lifestyle choices (counseling, seminars, online programs, self help materials) Supportive environment efforts (workplace policies to encourage health lifestyles, healthy eating, increased physical activity, and improved mental health)

16 Technical Assistance to Businesses CDC to provide businesses assistance to evaluate/launch wellness programs Technical assistance/consultation Web portals, call centers Help with activities such as: Creation of methods to increase employee participation, Measurement of impact of wellness programs (employee health and health care expenditures) Access to measurement tools for productivity, absenteeism, changes in employee health, medical costs

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