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University Health Services
Student Services Building
100 W. Dean Keeton
The Influence of Health
Insurance on College Health:
Do you want to be In-Network?
ACHA 2014 Annual Meeting
Wednesday, May 28, 2014
University Health Services
Student Services Building
100 W. Dean Keeton
Presenter
LeAnn Gutierrez, PhD, MBA
The University of Texas at Austin
Associate Director, Business and Ancillary Services
University Health Services
Student Services Building
100 W. Dean Keeton
Objectives
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Discuss the influence of the Affordable Care
Act on college health
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Identify alternative funding models
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Recognize important factors to consider when
shifting to insurance billing
University Health Services
Student Services Building
100 W. Dean Keeton
What You Should Take
Away Today
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Increased knowledge of key provisions of
Affordable Care Act that can impact college health
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Increased awareness about funding model
alternatives and considerations
Understanding of key factors to consider for
participation in insurance billing for a more
informed decision-making process
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University Health Services
Student Services Building
100 W. Dean Keeton
Affordable Care Act
Overview
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Background
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Goals
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Timeline
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Key Provisions
University Health Services
Student Services Building
100 W. Dean Keeton
Background
The Affordable Care Act Becomes Law in
March 2010
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The law implements comprehensive health
insurance reforms
Reforms scheduled from 2010 through 2015
Department of Health and Human Services
(HHS) issued a proposed regulation to ensure
students enrolled in these plans benefit from
important consumer protections in the ACA in
February 2011
HHS issued final rule on March 21, 2012
University Health Services
Student Services Building
100 W. Dean Keeton
Affordable Care Act Goals
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Holds insurance companies accountable
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Lowers health care costs
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Guarantees more choice
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Enhances the quality of care for all Americans
(http://www.whitehouse.gov/healthreform/healthcare-overview)
University Health Services
Student Services Building
100 W. Dean Keeton
Affordable Care Act
Timeline: 2010
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New Consumer Protections
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Improving Quality And Lowering Costs
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Increasing Access To Affordable Care
(http://www.healthcare.gov/law/timeline/full.html)
University Health Services
Student Services Building
100 W. Dean Keeton
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Student Health Coverage Goals
Ensure that students have access to coverage
and benefits from the ACA’s Patient’s Bill of
Rights
Treat student health insurance plans as
individual market plans to extend all of the
protections provided to enrollees in with
several adjustments given plan uniqueness
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Self-funded plans exempt
Grandfathered plans exempt until 2014
(http://www.healthcare.gov/news/factsheets/2012/03/student-health-plans03162012a.htm)
University Health Services
Student Services Building
100 W. Dean Keeton
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2010 Key Provisions:
New Consumer Protections
Prohibits denying coverage of children based on
pre-existing conditions
Prohibits insurance companies from rescinding
coverage
Eliminates lifetime limits on insurance coverage
Regulates annual limits on insurance coverage
Effective for health plan years beginning on or after September 23, 2010.
Rule doesn’t apply to “grandfathered” individual health insurance policies.
(http://www.healthcare.gov/law/timeline/full.html)
University Health Services
Student Services Building
100 W. Dean Keeton
2010 Key Provisions:
Improving Quality and Lowering Costs
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Providing small business health insurance tax
credits
Offers relief to Seniors who hit Medicare
prescription drug “donut hole”
Provides Free Preventative Care
Cracks down on Fraud
University Health Services
Student Services Building
100 W. Dean Keeton
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2010 Key Provisions:
Increasing Access to Affordable Care
Provides state-based programs for access to
insurance with pre-existing conditions
Extends coverage for young adults
Extends coverage for early retirees
Rebuilds primary care workforce
Holding insurance companies accountable for
unreasonable rate hikes
Allows states to cover more residents for Medicaid
Increases payments to rural health care providers
Strengthens community health centers
University Health Services
Student Services Building
100 W. Dean Keeton
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2011 Key Provisions
Offers RX discounts to Seniors (Medicare)
Provides Free Preventative Care to Seniors
HHS Quality Improvement Plan
Community care transitions program for Seniors
Proposal to extend life of Medicare Trust Fund
Increase access to services at home/community
Lowers health care premiums
Addresses overpayments
University Health Services
Student Services Building
100 W. Dean Keeton
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2012 Key Provisions
Value-Based Purchasing Program (Medicare)
Encourages Integrated Health Systems
Reduces paperwork/administrative costs
Understands and fights health disparities
Provides options for new, voluntary options for
long-term care insurance
University Health Services
Student Services Building
100 W. Dean Keeton
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2013 Key Provisions
Improves preventative health coverage (Medicaid)
Expands authority to bundle payments
Increases Medicaid payments for primary care
providers
Provides additional funding for CHIP
University Health Services
Student Services Building
100 W. Dean Keeton
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2014 Key Provisions
Prohibits discriminations (pre-existing/gender)
Eliminates annual limits on coverage
Ensures coverage for participants on clinical trials
Tax Credits for individuals between 100-44% FPL
Establishes affordable insurance exchange
Increases access to Medicaid
Promotes individual responsibility
Ensures free choice
University Health Services
Student Services Building
100 W. Dean Keeton
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Annual Limits on essential health benefits
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Student Insurance Coverage
Special Timelines
No less than $100,000 for policy years
beginning on or after 7/1/12 but before 9/23/12
$500,000 for policy years beginning on or after
9/23/12 but before 1/1/14
No annual limits as of 1/1/14
Medical Loss Ratio-changes to methodology
for reporting and rebates only in 2013
Notice Requirement until 2014
University Health Services
Student Services Building
100 W. Dean Keeton
Plan Design Differences as a result of ACA & New
Vendor Administration of ACA in 2012
Benefit
Dependent Eligibility
Routine STI Testing
11-12 Plan
Unmarried children not self supporting
Under Health Center Charges ($500
12-13 ACA Change -New Plan
All children up to age 26
Now covered at 100%
maximum and $25 copay)
Allergy Medicines and Prescriptions
for STI treatment
$1,300 maximum prescription benefit $1,300 limit removed
Inpatient Psychotherapy
Covered up to 30 day maximum
Medical Emergency Benefits, $75 Copay Covered up to $1,000
Flu Shot Benefit
Covered at 80% up to $20
Benefits for HPV and Cervical Cancer
Covered at 80% up to $75
Screening (under X-rays and Labs)
Prescriptions
Covered up to $1,300, with copays
Limited to 20 visits per year, daily
Outpatient Psychotherapy
limits of $65 per day individual/$20
for group visits
Ambulance Services
$300 maximum
Previously covered under mental
Alcohol/Drug Abuse
health with limits
Wellness Benefit/ Routine Preventive Paid at 100% in network and 60%
(including immunizations)
out-of-network, to $500 maximum
Covered as any other sickness (30
day limit removed)
$1,000 limit removed
Now covered at 100% (no maximum)
Now covered at 100% (no maximum)
Limit of $1,300 removed.
Birth Control covered at 100%
20 visit limit removed, paid as any
other sickness, internal limits
removed
$300 limit removed
Covered without daily limits
Now paid at 100% (no maximum)
University Health Services
Student Services Building
100 W. Dean Keeton
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Key ACA Factors Influencing
College Health
Provides Free Preventative Care
Pre-existing conditions (For Children until 2014)
Extends coverage for young adults (All Plans,
Except for one temporary exception until 2014)
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Eliminates lifetime limits on insurance
coverage (All Plans)
Regulates annual limits on insurance
coverage (Not required for grandfathered plans until 2014)
Access to state/federal exchange plans
University Health Services
Student Services Building
100 W. Dean Keeton
UT at Austin
Insurance Claim Volume Trends
2010 – 2011
2011 – 2012
Per month
Per year
Per month
Per year
3,000
36,000
4,200
50,400
2012 – 2013
2013 - 2014 thru 4-13
Per month
Per year
Per month
Per year
3,500
42,000
4,500
36,456
UT at Austin
Insurance Utilization Trends
University Health Services
Student Services Building
100 W. Dean Keeton
2010 - 2011
2011 - 2012
Students using
insurance at UHS
Students not
using insurance
at UHS
Students using
Insurance at UHS
Students not
using insurance
at UHS
63%
37%
66%
34%
2012 - 2013
Students using
insurance at UHS
Students not
using insurance
at UHS
69%
31%
UT at Austin
Insurance Payor Trends
University Health Services
Student Services Building
100 W. Dean Keeton
Insurance Payor Mix
2010 -2011 Payors
BCBS
Aetna
SHIP
United HealthCare
Other
%
44%
11%
22%
10%
13%
2011 - 2012 Payors
BCBS
Aetna
SHIP
United HealthCare
Other
%
2012 -2013 Payors
BCBS
Aetna
SHIP
United HealthCare
Other
%
44%
11%
14%
16%
15%
2013 - 2014 thru 4-14
Payors
%
BCBS
SHIP
United HealthCare
Aetna
Other
46%
12%
15%
12%
15%
52%
20%
12%
8%
8%
University Health Services
Student Services Building
100 W. Dean Keeton
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Alternative Funding Models
Faculty and Staff Services
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Ancillary services or self-supporting arm (physical therapy)
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Flu shot campaigns, Travel services
Explore Potential Campus Partnerships
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Summer programs
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Research support (example: lab)
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Physical exam clinics for club sports
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Visiting scholars, post-docs, ESL
In-Network Status with insurance payors
University Health Services
Student Services Building
100 W. Dean Keeton
Considerations for Insurance Billing
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HIPAA Compliance
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Clinical Documentation
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Coding: CPT, HCPCS, ICD-9/ICD-10
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Contracting: credentialing, NPI, CAQH, referrals
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Charges Structure: charges philosophy, discounts,
co-pays, ancillary reimbursement
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Financial
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patient collections and revenue potential
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Expenses related to third-party filing
University Health Services
Student Services Building
100 W. Dean Keeton
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Charges Philosophy
UHS charges for services
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Provider encounters, minor procedures, lab tests, x-rays,
medications, supplies, immunizations, nutrition services, and
physical therapy
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Charges based on 150% Allowable Medicare Fee Schedule (in
some exceptions cost is used)
Miscellaneous/Administrative Charges: missed appointments,
after-hours, medical records release, service extension fees
Discounts
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Insurance contractual adjustments
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Self-pay amounts: students and faculty/staff
University Health Services
Student Services Building
100 W. Dean Keeton
Patient
responsibility
-Collect from
patient in C/I or
Bursar
Appointment
Scheduled
Check-In
-Registration into EHR
-Insurance information
-Reason for visit
Claim Appeals
Processing
-Documentation
reviewed and submitted
for reconsideration
-Claim re-files and
processes
Claim Payment or
Denial
-Payment posted and
processed
-Denial appealed
Claim Lifecycle
Patient Encounter
-What's Wrong
-Plan of Action
-EHR Documentation
-EHR Coding
Claim Filing/Billing
-Charges review and post
-Claim Submission
-Clearinghouse for errors
-Claim goes to payer
University Health Services
Student Services Building
100 W. Dean Keeton
Questions?
University Health Services
Student Services Building
100 W. Dean Keeton
Thank You!
University Health Services
Student Services Building
100 W. Dean Keeton
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References
ACHA. Health Care Reform FAQ. Retrieved from
http://www.acha.org/Topics/Health_Care_Reform/FAQs
_for_IndividualCoverageClassification.cfm.
Healthcare.gov. (2011). Affordable care index.
Retrieved from http://www.healthcare.gov/law/timeline
/index.html.
Healthcare.gov. (2011). Glossary. Retrieved from
http://www.healthcare.gov/glossary/d/donuthole.html.
Healthcare.gov. (2011). Preventative services.
Retrieved from http://www.healthcare.gov/news/
factsheets/2010/07/preventive-services-list.html.
University Health Services
Student Services Building
100 W. Dean Keeton
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References
Healthcare.gov. (2012). Student Health Plans.
Retrieved from http://www.healthcare.gov/news/
factsheets/2012/03/student-health-plans03162012a.
html.
The White House. (2011). The affordable care act.
Retrieved from http://www.whitehouse.gov/healthreform
/healthcare-overview.