Transcript Overview of Federal Reform Patient Protection and

BSI and Federal Health Care Reform
Patient Protection and Affordable Care Act,
as amended by Reconciliation
Behavioral Screening and
Intervention (BSI) Symposiums
Pris Boroniec, MPP
Director of Health Care Reform
Overview of Federal Reform
Patient Protection and Affordable Care Act
 PPACA was enacted into law on March 23, 2010 and was amended by
additional reforms in Reconciliation enacted on March 30, 2010.
 Law provides framework for reform, but regulations now being
promulgated by the federal Department of Health and Human Services,
other federal agencies and the States will provide specific guidance on
implementation
 Proposed rules
 Interim Final regulations
 State administrative rules and regulations
 State Medicaid Director Letters and Other Federal/State Guidance
 PPACA has an individual mandate, Medicaid expansion and subsidies, state-based
Insurance Exchanges, changes to insurance, Medicare and Medicaid, and
incentives for quality, payment reform, workforce and prevention/wellness
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Overview of Federal Reform
Focus on Prevention and Wellness
 Promotes use of evidence-based preventive services – Expands coverage
for preventive services throughout the health care delivery system,
particularly to those recommended by the U.S. Preventive Services Task
Force (USPSTF).
 Reduces financial barriers to preventive services – Eliminates cost sharing
for preventive services. Most Americans currently use preventive services
at half the recommended rate.
 Improves health, productivity and the nation’s health care costs – Extends
access to preventive services to an estimated 88 million people in new
employer and individual plans by 2013, to all Medicare beneficiaries and to
newly eligible and existing recipients in Medicaid.
 Builds on multiple initiatives to promote prevention – Includes direct
coverage of prevention services, grants for employer wellness, value-based
purchasing incentives, tobacco cessation, and chronic disease reduction.
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Overview of Federal Reform
Preventive Services
 USPSTF recommendations include Grade A and B preventive
services for:
 Alcohol misuse screening and behavioral counseling interventions for
adult men, women and pregnant women
 Depression screening for adult men and women
 Tobacco use and tobacco-caused disease counseling for adult men,
women and pregnant women
 New USPSTF recommendations become subject to reform
requirements one year after the recommendation is made
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Overview of Federal Reform
Coverage of Prevention Services
 Insurance – Beginning Sept 23, 2010, requires health plans (except
grandfathered plans) to provide coverage without cost-sharing for
preventive services rated A or B by the U.S. Preventive Services Task Force
(USPSTF), for recommended immunizations, and for prevention for infants,
children, adolescents and women.
 Medicare – Beginning January 1, 2011, requires Medicare to cover 100% of
the cost, including an initial and annual wellness physical exam,
personalized prevention plan, and any covered preventive service
recommended by the USPSTF with a grade of A or B.
 Medicaid – Effective January 1, 2013, expands Medicaid state plan
amendment authority to cover preventive services recommended by the
USPSTF with a grade of A or B and, for States that cover services under
Medicaid without cost sharing, provides a one percentage point increase in
federal match for these services.
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Insurance and Prevention Services
 Key Provisions of Law and Interim Final Rule (July 19, 2010)
 Effective Date: For plan years (or, for individuals, policy years) on or after Sept 23, 2010 (6
months after enactment).
 Benefits and Cost Sharing: Requires group health plans and a health insurance issuer to
provide benefits for and prohibit the imposition of cost sharing requirements with respect
to:
Prevention Benefits
 Evidence-based items or services with a rating of A or B in the USPSTF recommendations
 Recommended immunizations
 Preventive care and screenings for infants, children, adolescents and women.
 For a complete list, see http://edocket.access.gpo.gov/2010/pdf/2010-17242.pdf
Cost Sharing
 Billing for office visits and preventive services is clarified
• Prevention service is billed separately/separate encounter data
• Purpose of visit
 Billing for out-of-network care is allowed
 Billing for treatment that results from a preventive service is allowed
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Insurance and Prevention Services
 Key Laws and Rules (Continued)
 Applicable to: Group health plans and health insurance issuers in the group and
individual markets, including self-insured plans. Only applies to plans that are not
“grandfathered.”
 Grandfathered plans. Group health plan or health insurance in which an individual was
enrolled as of March 23, 2010 (includes renewals / new family members / new
employees). Existing plans will lose their “grandfather” status if they choose to
significantly cut benefits or increase out-of-pocket spending for consumers.
 Loss of grandfathered status is triggered by:
Elimination of benefits
Increase in fixed-dollar co-pays
Increase in the percentage of cost sharing
Decrease in contribution rate by employers
Increase in fixed-amount cost sharing, not co-pays
Increase in annual dollar limits
 Estimated Impact: Estimated to improve access to preventive services for 31 million in
new employer plans and 10 million in new individual plans in 2011, with premiums
projected to rise by roughly 1.5% for non-grandfathered plans. Many of the 98 million
in existing group health plans currently have preventive services coverage.
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Medicare and Prevention Services
 Key Provisions
 Effective Date: January 1, 2011
 Proposed Rule: Improve the health status of Medicare beneficiaries by expanding access to
preventive services, and promoting early detection and prompt treatment of medical
conditions.
 Elimination of Cost Sharing. Waives the Part B deductible and the 20 percent coinsurance for
Medicare-covered preventive services recommended as A or B by the USPSTF (including new
tobacco counseling), the initial preventive physician exam and the annual wellness visit
 Annual Wellness Visit Providing a Personalized Prevention Plan. Creates annual wellness visit
with personalized prevention plan services (PPPS), including:
Medical and family history
Current providers/suppliers and all prescribed medications
Record measurements (height, weight, body mass index, blood pressure, other)
Detect any cognitive impairment
Establish a screening schedule for the next 5 to 10 years (appropriate & patient risk factors)
Personal health advice, coordinate referrals / health education
 Estimated Impact: Improved access to preventive services for Medicare beneficiaries is
estimated to result in increased Medicare payments of $110 million for FY 2011.
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Medicaid and Prevention Services
 Key Provisions
 Effective Date: January 1, 2013
 Statute : States will have the authority to expand Medicaid coverage of
preventive services through a state plan amendment to cover:
 Preventive services recommended by the USPSTF with a grade of A or B;
 Recommended immunizations for adults; and
 Tobacco cessation services for pregnant women.
 Enhanced Reimbursement: For States that cover services under Medicaid
without cost sharing, a one percentage point increase in federal match, or
FMAP, will be provided for these prevention services.
 Note: Wisconsin Medicaid and BadgerCare Plus currently cover SBI services
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For more information, please contact:
Pris Boroniec
Director of Health Care Reform
608.234.7372
[email protected]
www.sellersdorsey.com
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