GUIDANCE ISSUED ON ACA’S SUMMARY

The Affordable Care Act (ACA) requires each employer group health plan to provide a 4-page summary of its benefits to all individuals who are eligible for coverage.  This requirement takes effect on March 23, 2012 (two years after the enactment of the ACA).  The three agencies charged with implementing many of the ACA’s requirements have just issued proposed regulations, along with templates of proposed formats, under which a plan may furnish this new “summary of benefits and coverage” (SBC).

Under the proposed rules, employers or plan administrators (for self-funded plans) and insurers (for insured plans) must provide participants and beneficiaries with SBCs detailing, in a “culturally and linguistically appropriate manner,” simple and consistent information about health plan benefits and coverage.  Conceding that this cannot be done in only four pages, the agencies propose to read the statutory reference to “four pages” as four double-sided pages (i.e., eight pages).  Plans also must provide a separate glossary with uniform definitions of specific medical and coverage-related terms.

Each SBC must include the following:

  • Uniform definitions of standard insurance terms and medical terms;
  • A description of the coverage, including cost sharing, for certain benefit categories;
  • Exceptions, reductions, and limitations on coverage;
  • Cost-sharing provisions of the coverage, including deductible, coinsurance, and copayment obligations;
  • Renewability and continuation of coverage provisions;
  • Coverage examples illustrating three common benefit scenarios;
  • Beginning January 1, 2014, a statement as to whether the plan provides “minimum essential coverage” (a determination that will be important under the “Exchanges” that are to be established as of that date);
  • A statement that the SBC is only a summary and that the plan document, policy, or certificate of insurance should be consulted to determine the governing contractual provisions of the coverage;
  • A contact number to call with questions and an Internet address where a copy of the actual individual coverage policy or group certificate of coverage can be reviewed and obtained;
  • An Internet address or directions for obtaining a list of network providers, if applicable;
  • An Internet address or directions for obtaining information about the prescription drug formulary, if applicable;
  • An Internet address to access and review the uniform glossary; and
  • Premium information (or the cost of coverage under self-insured plans).

The SBC templates were prepared by the National Association of Insurance Commissioners (NAIC), and even the NAIC concedes that they will need some tweaking before they can be used by a self-funded plan.  They include not only a blank template, but also detailed instructions for completing the template and a sample of an SBC with the blanks completed.

The templates also include the glossary of uniform definitions, which would have to be used without modification.  Both the templates and the uniform definitions are designed to allow individuals (and employers looking to purchase a health insurance policy) to more easily compare the provisions of multiple plans or policies on an apples-to-apples basis.

Group health plans must provide SBCs as a part of their written enrollment materials (or if none, upon eligibility for enrollment); upon a change in information included in the SBC; upon a special enrollment event; and within seven days of a request.  SBCs need only be provided with respect to benefit packages in which a participant or beneficiary is enrolled, unless an individual requests an SBC for another option as to which he or she is eligible.

SBCs may be furnished in paper form or electronically.  For ERISA plans, SBCs may be delivered electronically so long as the Department of Labor’s electronic disclosure safe-harbor requirements are satisfied.  Group health plan sponsors should note that the obligation to provide SBCs is in addition to any current duty to furnish ERISA summary plan descriptions, summaries of material modifications, or other disclosures.

The proposed rules also require plans to give covered individuals at least 60 days’ advance notice of any mid-year material modifications that affect SBC content.  For this purpose, a “modification” includes not only a benefit reduction, but also a benefit improvement.  A plan (or its administrator) that willfully fails to provide an SBC may be fined up to $1,000 for each affected individual.

Comments on the proposed rules are due by October 21, 2011.  The agencies specifically request input on special considerations for self-funded plans and the feasibility of meeting the March 23, 2012, deadline to begin providing SBCs.  It appears likely that changes will be made to the proposed rules; therefore, group health plans should pay close attention to any changes in the final guidance, which should be issued within the next several months.

 

Expanding Access to Preventive Services for Women

Affordable Care Act Rules on Expanding Access to Preventive Services for Women

New private health plans must cover the guidelines on women’s preventive services with no cost sharing in plan years starting on or after August 1, 2012.

Additional women’s preventive services that will be covered without cost sharing requirements include:           

  • Well-woman visits: This would include an annual well-woman preventive care visit for adult women to obtain the recommended preventive services, and additional visits if women and their providers determine they are necessary. These visits will help women and their doctors determine what preventive services are appropriate, and set up a plan to help women get the care they need to be healthy.
  • Gestational diabetes screening: This screening is for women 24 to 28 weeks pregnant, and those at high risk of developing gestational diabetes. It will help improve the health of mothers and babies because women who have gestational diabetes have an increased risk of developing type 2 diabetes in the future. In addition, the children of women with gestational diabetes are at significantly increased risk of being overweight and insulin-resistant throughout childhood.
  • HPV DNA testing: Women who are 30 or older will have access to high-risk human papillomavirus (HPV) DNA testing every three years, regardless of pap smear results.  Early screening, detection, and treatment have been shown to help reduce the prevalence of cervical cancer.
  • STI counseling, and HIV screening and counseling: Sexually-active women will have access to annual counseling on HIV and sexually transmitted infections (STIs). These sessions have been shown to reduce risky behavior in patients, yet only 28% of women aged 18 to 44 years reported that they had discussed STIs with a doctor or nurse. In addition, women are at increased risk of contracting HIV/AIDS. From 1999 to 2003, the CDC reported a 15% increase in AIDS cases among women, and a 1% increase among men. 
  • Contraception and contraceptive counseling: Women will have access to all Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling. These recommendations do not include abortifacient drugs. Most workers in employer-sponsored plans are currently covered for contraceptives. Family planning services are an essential preventive service for women and critical to appropriately spacing and ensuring intended pregnancies, which results in improved maternal health and better birth outcomes.
  • Breastfeeding support, supplies, and counseling: Pregnant and postpartum women will have access to comprehensive lactation support and counseling from trained providers, as well as breastfeeding equipment. Breastfeeding is one of the most effective preventive measures mothers can take to protect their children’s and their own health. One of the barriers for breastfeeding is the cost of purchasing or renting breast pumps and nursing related supplies.
  • Domestic violence screening: Screening and counseling for interpersonal and domestic violence should be provided for all women. An estimated 25% of women in the U.S. report being targets of intimate partner violence during their lifetimes. Screening is effective in the early detection and effectiveness of interventions to increase the safety of abused women. 

UnitedHealthcare/Oxford Contract with East End Hospitals in Jeopardy of Cancellation

The East End Health Alliance Hospitals (Southampton, Peconic Bay and Eastern Long Island) and UnitedHealthcare/Oxford are currently in good faith efforts to negotiate a new contract.  If they are unable to reach an agreement the current agreement may terminate on July 15, 2011.

In the event of a contract termination, the State of New York requires insurance carriers and hospitals to observe a two month “cooling off period,” which is simply a period of time after the termination of a contract when fully insured commercial and Medicare members can still access the terminated hospitals on an in-network basis in the hopes that the hospital and the carrier can reach a new agreement.

Since this cooling off period does not apply to commercial self-funded groups and members, in the event of a termination, EEHA would become non-participating for those members on July 15, 2011. For fully insured commercial, Medicare and Medicaid members, EEHA, and physicians without admitting privileges somewhere other than an EEHA hospital, would become non-participating on September 15, 2011

UnitedHealthcare/Oxford will have Transitional Care guidelines in place so members who have scheduled or ongoing medical treatments at EEHA hospitals will continue to get care as appropriate.

Fully insured commercial, Medicare and Medicaid members would continue to have access to EEHA hospitals on an in-network basis through the New York State cooling off period, which would end September 15, 2011. Transitional Care may be available after the cooling off period in accordance with the member’s Certificate of Coverage.

After July 14, 2011, a primary care physician or specialist should not refer members to an EEHA hospital for any treatment or test. Instead, members should be referred to one of the major neighboring hospitals in the network listed below.

Brookhaven Memorial, John T. Mather Hospital, St. Charles Hospital, Stony Brook University Medical Center, St. Catherine of Siena Medical Center and Southside Hospital.

Given the Most Recent SONY Security Breech How is your Company Protecting Sensitive Data?

Cook, Hall & Hyde, Inc. is a recognized industry leader in the commercial insurance, employee benefits and risk management business.  Risk management can be complex and often goes far beyond the insurance components.  In the past few years, the necessity for greater business attention to the risk issues surrounding information security, protection of data, and data breaches has taken center stage in many risk management departments.  The threats to a company’s most sensitive data, including that which is entrusted to us by clients, have become significantly greater and data compromises much more prevalent and costly.  The operational and system expectations as well as the attendant liability, regulatory, and reputational consequences have also increased dramatically.

Our clients have worked hard to build a successful businesses and Cook, Hall & Hyde wants to support you in making sure that it is not stolen or undermined by a lack of awareness, preparation and protection around data management risk issues.  A few simple questions for your consideration:

  • When it comes to the protection of your confidential company information including the information entrusted to you by your customers, clients and employees – do you have it right?  What about other sensitive company information regarding financial, strategic, intellectual property and other sensitive data?  
  • Are you confident that you, your management team, and your Information Technology shop understands and has executed against the complexities of the legal, regulatory, operational, and systemic data risk management protection requirements for material that contains Personally Identifiable Information (PII); Protected Health Information (PHI); Payment Card Industry Data Security Standards (PCI-DSS), other sensitive and classified data?
  • If your company’s systems or bank access credentials were compromised and funds were stolen from your bank account, would your bank immediately repay those funds?  Would the loss be covered by the current insurance that you have in effect?
  • If your company’s confidential information was compromised by a data breach tomorrow, would you know what to do?  Do you have the appropriate plans and resources in place to respond effectively?

Cook, Hall & Hyde, your risk management partner, has identified existing and emerging risks associated with the vulnerabilities of many companies’ current data protection practices that are leading to significant exposures, data compromises, financial losses and reputational risks to our clients.  We have established a relationship with a leading provider in the area of data risk management services, to assist Cook, Hall & Hyde in providing the necessary experience and expertise to assist our clients with assessing their current data risk management practices and programs.   Where appropriate they can help build cost effective data risk management programs to enhance the client’s protection protocols, risk mitigation, privacy compliance and breach preparedness planning and response posture to cover sensitive data.

The threats and requirements can be complex and require a holistic and layered approach to protection.    Data is a powerful tool, be sure that yours’ works for you, not against you.  Don’t let data risk be your point of vulnerability, make it a strength.  We can help contact us 631-329-7268 or email me at jsbradley@chhins.com

The Latest Health Care Reform Update, April 15, 2011

Obama Signs Repeal of Health Reform 1099 Reporting Rule 

On April 14, President Barack Obama signed legislation that repeals a much-criticized health care reform law provision requiring employers doing more than $600 in business with a corporate vendor to furnish Form 1099 statements. Small employers, in particular, complained that the burden imposed by the reporting provision, which had been scheduled to go into effect in 2012, was too great.

Obama’s Medicare Proposal: How Would It Work?

President Obama’s debt-relief plan differs profoundly with Republicans’ on the fate of Medicare.  As outlined on Wednesday, a central aspect of the president’s plan would be to double down on one of the most controversial aspects of his health care reform law: an independent board with the power to slow costs in the Medicare system if the program’s spending rises faster than set limits.

Under the health care law, this Independent Payment Advisory Board (IPAB) would start to work if Medicare spending rises faster than the annual growth of the U.S. gross domestic product, plus 1 percent.  Under the plan outlined by President Obama on Wednesday, the board would act if Medicare spending rises faster than GDP plus 0.5 percent.

As it is now structured, the IPAB is supposed to be an organization of 15 members appointed by the president and confirmed by the Senate.  The health care reform law calls for the board to have varied geographic and professional representation, with experts in health care finance, hospital management and health insurance, as well as physicians.

If Medicare spending surpasses its targets, these people are supposed to put their heads together and come up with ways to cut the program so the costs remain under the set threshold.  Their recommendations are then submitted to Congress.

  • If lawmakers vote to approve them, and they are signed by the president, they become law. 
  • If Congress does not vote on the recommendations, they become law.
  • If Congress votes the recommendations down, but the president vetoes what Congress did, and Congress cannot override the veto, they become law.

One thing that makes it controversial is that it takes away some of Congress’s power to deal with Medicare issues.  Former Obama budget director Peter Orszag has said the board might be “the largest yielding of sovereignty from the Congress since the creation of the Federal Reserve.”

According to an analysis of the current law by the Kaiser Family Foundation, the board is prohibited from making recommendations that would:

  • Ration health care procedures,
  • Increase taxes,
  • Change Medicare benefits, or
  • Make the program more expensive for beneficiaries.

What would the board be able to change?  

  • Things Medicare pays for,
  • What it pays to providers, and
  • The program’s structure, among other things.

Since a big target of spending reductions probably would be things that supply income to doctors, hospitals, and other providers, the IPAB is intensely unpopular in the medical establishment.  Changing or repealing it is one of the American Medical Association and the American Hospital Association’s highest priorities.

New Report Offers Consensus on Patient Centered Medical Home and ACO

New report offers consensus on PCMH, ACO’s

The evidence of success of the medical home combined with the need for accountable delivery system reform demands action–and stakeholders have arrived at a consensus about what that consensus should look like, according to Better to Best: Value-Driving Elements of the PCMH and ACO a new report from the Patient-Centered Primary Care Collaborative, in partnership with The Commonwealth Fund and the Dartmouth Institute for Health Policy and Clinical Practice. The report outlines action steps and recommendations for policy, demonstration programs and research.

HealthGrades Announces America’s 50 Best Hospitals

HealthGrades America’s 50 Hospitals are located in 28 cities in 19 states. The West Palm Beach, Fla. area leads the nation with six of these top-performing hospitals. Chicago and Cleveland come in next with four recognized hospitals each.  New York had no hospitals make the list this year but NJ had both Hackensack University Medical Center – Hackensack, NJ and Community Medical Center – Toms Rivers, NJ make the list.

To find out if one of these elite hospitals is in your community, click here.

America’s 50 Best hospitals demonstrated superior and sustained clinical quality over an eleven year time period, based on an analysis of more than 140 million Medicare patient records. To be recognized with this elite distinction, hospitals must have had risk-adjusted mortality and complication rates that were in the top 5% in the nation for the most consecutive years.

On average, patients treated at America’s 50 Best Hospitals had a nearly 30% lower risk of death and 3% lower rate of complications. HealthGrades study found that if all U.S. hospitals had performed at this level, more than a half million Medicare deaths could have been prevented between 1999 and 2009.

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