SUPPLEMENTAL HEALTH CARE EXHIBIT PART 3

Transcription

1 SUPPLEMENTAL HEALTH CARE EXHIBIT PART 3 This exhibit is intended t prvide disclsure f expenses by majr type f activity that imprves health care quality, as defined belw, as well as the amunt f thse expenses that is used fr ther activities, and reprted separately fr the cmprehensive health cverage (individual, small grup and large grup business), mini-med plans (individual, small grup and large grup business) and expatriate plans. This exhibit als shws the amunt f qualifying HIT expenses, reprted separately fr the cmprehensive health cverage (individual, small grup and large grup business), mini-med plans (individual, small grup and large grup business) and expatriate plans, brken dwn int the fur categries f Quality Imprvement expenses (see belw); similarly, the Other than HIT qualifying Quality Imprvement expenses are disclsed fr each f the fur categries f Quality Imprvement expenses. The definitins f Individual, Small Grup and Large Grup are fund in the instructins fr Parts 1 and 2 f this supplement exhibit. Imprving Health Care Quality Expenses General Definitin: Quality Imprvement (QI) expenses are expenses, ther than thse billed r allcated by a prvider fr care delivery (i.e., clinical r claims csts), fr all plan activities that are designed t imprve health care quality and increase the likelihd f desired health utcmes in ways that are capable f being bjectively measured and f prducing verifiable results and achievements. The expenses must be directed tward individual enrllees r may be incurred fr the benefit f specified segments f enrllees, recgnizing that such activities may prvide health imprvements t the ppulatin beynd thse enrlled in cverage, as lng as n additinal csts are incurred due t the nn-enrllees ther than allwable QI expenses assciated with self-insured plans. Qualifying QI expenses shuld be grunded in evidence-based medicine, widely accepted best clinical practice r criteria issued by recgnized prfessinal medical scieties, accreditatin bdies, gvernment agencies r ther natinally recgnized health care quality rganizatins. They shuld nt be designed primarily t cntrl r cntain cst, althugh they may have cst-reducing r cst-neutral benefits, as lng as the primary fcus is t imprve quality. Qualifying QI activities are primarily designed t achieve the fllwing gals set ut in Sectin 2717 f the PHSA and Sectin 1311 f the PPACA: Imprve health utcmes including increasing the likelihd f desired utcmes cmpared t a baseline and reducing health disparities amng specified ppulatins; Prevent hspital readmissins; Imprve patient safety and reduce medical errrs, lwer infectin and mrtality rates; Increase wellness and prmte health activities; r Enhance the use f health care data t imprve quality, transparency and utcmes. NOTE: Expenses that therwise meet the definitins fr QI but were paid fr with grant mney r ther funding separate frm premium revenues shall NOT be included in QI expenses.

2 Clumn 1 Imprve Health Outcmes Expenses fr the direct interactin f the insurer (including thse services delegated by cntract fr which the insurer retains ultimate respnsibility under the insurance plicy), prviders and the enrllee r the enrllee s representatives (e.g., face-t-face, telephnic, Web-based interactins r ther means f cmmunicatin) t imprve health utcmes as defined abve. This categry can include csts fr assciated activities such as: Effective case management, care crdinatin and chrnic disease management, including: Patient-centered interventin, such as; Making/verifying appintments, Medicatin and care cmpliance initiatives; Arranging and managing transitins frm ne setting t anther (such as hspital discharge t hme r t a rehabilitatin center); Prgrams t supprt shared decisin-making with patients, their families and the patient s representatives; and Reminding insured f physician appintment, lab tests r ther apprpriate cntact with specific prviders; Incrprating feedback frm the insured t effectively mnitr cmpliance; Prviding caching r ther supprt t encurage cmpliance with evidence-based medicine; Activities t identify and encurage evidence-based medicine; Use f the medical hmes mdel as defined fr purpses f Sectin 3602 f PPACA; Activities t prevent avidable hspital admissins; Educatin and participatin in self-management prgrams; and Medicatin and care cmpliance initiatives, such as checking that the insured is fllwing a medically effective prescribed regimen fr dealing with the specific disease/cnditin and incrprating feedback frm the insured in the management prgram t effectively mnitr cmpliance; Accreditatin fees by a natinally recgnized accrediting entity directly related t quality f care activities included in Clumns 1 thrugh 5; Expenses assciated with identifying and addressing ethnic, cultural r racial disparities in effectiveness f identified best clinical practices and evidence-based medicine; Quality reprting and dcumentatin f care in nn-electrnic frmat; and Health infrmatin technlgy expenses t supprt these activities (reprt in Clumn 5 see instructins) including: Data extractin, analysis and transmissin in supprt f the activities described abve; and Activities designed t prmte sharing f medical recrds t ensure that all clinical prviders have access t cnsistent and accurate recrds frm all participants in a patient s care.

3 Clumn 2 Activities t Prevent Hspital Readmissin Expenses fr implementing activities t prevent hspital readmissins as defined abve, including: Cmprehensive discharge planning (e.g., arranging and managing transitins frm ne setting t anther, such as hspital discharge t hme r t a rehabilitatin center) in rder t help ensure apprpriate care that will, in all likelihd, avid readmissin t the hspital; Persnalized pst-discharge cunseling by an apprpriate health care prfessinal; Any quality reprting and related dcumentatin in nn-electrnic frm fr activities t prevent hspital readmissin; and Health infrmatin technlgy expenses t supprt these activities (reprt in Clumn 5 see instructins) including: Data extractin, analysis and transmissin in supprt f the activities described abve; and Activities designed t prmte sharing f medical recrds t ensure that all clinical prviders have access t cnsistent and accurate recrds frm all participants in a patient s care. Clumn 3 Imprve Patient Safety and Reduce Medical Errrs Expenses fr implementing activities t imprve patient safety and reduce medical errrs (as defined abve) thrugh: The apprpriate identificatin and use f best clinical practices t avid harm; Activities t identify and encurage-evidence based medicine in addressing independently identified and dcumented clinical errrs r safety cncerns; Activities t lwer risk f facility acquired infectins; Prspective prescriptin drug utilizatin review aimed at identifying ptential adverse drug interactins; Any quality reprting and related dcumentatin in nn-electrnic frm fr activities that imprve patient safety and reduce medical errrs; and Health infrmatin technlgy expenses t supprt these activities (reprt in Clumn 5 see instructins), including: Data extractin, analysis and transmissin in supprt f the activities described abve; and Activities designed t prmte sharing f medical recrds t ensure that all clinical prviders have access t cnsistent and accurate recrds frm all participants in a patient s care. Clumn 4 Wellness & Health Prmtin Activities Expenses fr prgrams that prvide wellness and health prmtin activity as defined abve (e.g., face-t-face, telephnic r Web-based interactins r ther frms f cmmunicatin), including: Wellness assessment;

4 Wellness/lifestyle caching prgrams designed t achieve specific and measurable imprvements; Caching prgrams designed t educate individuals n clinically effective methds fr dealing with a specific chrnic disease r cnditin; and Public health educatin campaigns that are perfrmed in cnjunctin with state r lcal health departments.

5 Actual rewards/incentives/bnuses/reductins in c-pays, etc. (nt administratin f these prgrams) that are nt already reflected in premiums r claims shuld be allwed as QI with the fllwing restrictins: Only allwed fr small and large emplyer grups, nt individual business; and the expense amunt is limited t the same percentage as the HIPAA incentive amunt limit; Any quality reprting and related dcumentatin in nn-electrnic frm fr wellness and health prmtin activities; Caching r educatin prgrams and health prmtin activities designed t change member behavir (e.g., smking, besity); and Health infrmatin technlgy expenses t supprt these activities (Reprt in Clumn 5 See instructins). Clumn 5 HIT Expenses fr Health Care Quality Imprvements The PPACA als cntemplates Health Infrmatin Technlgy as a functin that may in whle r in part imprve quality f care, r prvide the technlgical infrastructure t enhance current QI r make new QI initiatives pssible. Include HIT expenses required t accmplish the activities reprted in Clumns 1 thrugh 4 that are designed fr use by health plans, health care prviders r enrllees fr the electrnic creatin, maintenance, access r exchange f health infrmatin, cnsistent with Medicare/Medicaid meaningful use requirements, in the fllwing ways: 1. Mnitring, measuring r reprting clinical effectiveness, including reprting and analysis csts related t maintaining accreditatin by natinally recgnized accrediting rganizatins, such as NCQA r URAC; r csts fr public reprting f quality f care, including csts specifically required t make accurate determinatins f defined measures (e.g., CAHPS surveys r chart review f HEDIS measures) and csts fr public reprting mandated r encuraged by law; 2. Advancing the ability f enrllees, prviders, insurers r ther systems t cmmunicate patient-centered clinical r medical infrmatin rapidly, accurately and efficiently t determine patient status, avid harmful drug interactins r direct apprpriate care this may include electrnic health recrds accessible by enrllees and apprpriate prviders t mnitr and dcument an individual patient s medical histry; 3. Tracking whether a specific class f medical interventins r a bundle f related services leads t better patient utcmes; 4. Refrmatting, transmitting r reprting data t natinal r internatinal gvernmentbased health rganizatins fr the purpses f indentifying r treating specific cnditins r cntrlling the spread f disease; r 5. Prvisin f electrnic health recrds and patient prtals. Exclude: Csts assciated with establishing r maintaining a claims adjudicatin system, including csts directly related t upgrades in HIT that are designed primarily r slely t imprve claims payment capabilities r t meet regulatry requirements fr prcessing claims (e.g., csts f implementing new administrative simplificatin standards and cde sets adpted pursuant t the Health Insurance Prtability and Accuntability Act (HIPAA), 42 U.S.C. 1320d-2, as amended, including the new ICD-10 requirements.

6 NOTE: a. Healthcare Prfessinal Htlines: Expenses fr healthcare prfessinal htlines shuld be included in Claims Adjustment Expenses t the extent they d nt meet the criteria fr the abve defined clumns f Imprve Health Outcmes, Activities t Prevent Hspital Readmissins, Imprve Patient Safety and Reduce Medical Errrs, and Wellness & Health Prmtin Activities. b. Prspective Utilizatin Review: Expenses fr prspective utilizatin review shuld be included in Claims Adjustment Expenses t the extent they d nt meet the criteria fr the abve defined clumns f Imprve Health Outcmes, Activities t Prevent Hspital Readmissins, Imprve Patient Safety and Reduce Medical Errrs, and Wellness & Health Prmtin Activities, AND the prspective utilizatin review activities are nt cnducted in accrdance with a prgram that has been accredited by a recgnized accreditatin bdy. The fllwing items are bradly excluded as nt meeting the definitins abve: All retrspective and cncurrent utilizatin review; Fraud preventin activities (all are reprted as cst cntainment, but Part 1, Line 4 includes MLR recgnitin f fraud detectin/recvery expenses up t the amunt recvered that reduces incurred claims); The cst f develping and executing prvider cntracts and fees assciated with establishing r managing a prvider netwrk; Prvider credentialing; Marketing expenses; Any accreditatin fees that are nt directly related t activities included in Clumns 1 thrugh 5; Csts assciated with calculating and administering individual enrllee r emplyee incentives; and Any functin r activity nt expressly included in Clumns 1 thrugh 5. NOTE: The NAIC will review requests t include expenses fr bradly excluded activities and activities nt described under Clumns 1 thrugh 5 abve. Upn an adequate shwing that the activity s csts supprt the definitins and purpses therein, r therwise supprt mnitring, measuring, r reprting health care quality imprvement, the NAIC may recmmend that the HHS Secretary certify thse expenses as Quality Imprvement. The sectins fr cmprehensive health cverage (individual, small grup and large grup business), mini-med plans (individual, small grup and large grup business) and expatriate plans are defined as per the cmprehensive health cverage (individual, small grup and large grup business), mini-med plans (individual, small grup and large grup business) and expatriate plans clumns in Parts 1 and 2 f this supplement. Fr questins n definitins, refer t the instructins fr the Annual Statement Expenses Schedule (i.e., the Underwriting and Investment Exhibit, Part 3 fr P/C and Health, and Exhibit 2 fr Life and Fraternal), fr the line references prvided belw. DIFFERENT FROM A/S EXPENSE REPORTING: Fr nn-affiliated management agreements/utsurced services, reprt all amunts in the supplement s Line 1.2, 2.2, 3.2, 4.2, 5.2, 6.2 r 7.2 fr Outsurced Services (nt just thse amunts less than 10% f ttal expenses). Cntinue t allcate all affiliated management agreements/utsurced services t the apprpriate expense lines as if the csts had been brne directly by the insurer.