Although the appeals provision of the health care reform law was effective in 2010, the U.S. Department of Labor provided an enforcement grace period until July 2011 for some requirements until additional guidance is issued. We are anticipating further guidance, which we believe may address some requirements that we and other carriers have expressed concern about, including:
· Diagnosis codes and treatment codes ( and their descriptions) on explanation of benefit forms, which raises privacy concerns
· Group-specific language requirements, which put additional responsibilities on customers
For details on our current implementation efforts, please review the fact sheet that outlines our implementation efforts for both parts of the appeals provision: (1) adverse benefit determinations and (2) appeals process.
New fact sheets outline market reforms in 2014
In 2014, some of the most significant requirements of the health care reform law will take effect. In addition to the availability of exchanges, 2014 will bring changes to health insurance markets, product designs and employer responsibilities.
We’ve developed a new fact sheet that outline key changes coming in 2014, including:
· Health plan product framework
· Additional product requirements
· Free choice vouchers
· Rating requirements (small group only)
· Combined risk pool (small group only)
The information in the fact sheet is based on the provisions in the health care reform law. Many of the details about 2014 market reforms will need to be clarified by regulations.
In a recent sit down in Washington, regulators and policymakers from several key agencies and associations sat down to discuss several issues. Amongst those issues discussed were:
Several common themes emerged during the meetings:
- Both the public and private sector policy experts appear to be genuinely concerned about addressing PPACA’s quick timelines for implementation. Beyond the politics, there appears to be an apolitical sentiment that we need to move more slowly. However, the regulators would need additional legislative or regulatory guidance to change the major timelines that were established through PPACA statutory requirements.
- Most states are busy sorting out the governance structure of the public exchanges and beginning to identify some of the key exchange operational elements in 2011.
- PPACA authorizes a variety of options related to how the exchange models can be configured ranging from the Massachusetts’ “active purchaser” model to Utah’s “all comers” approach.
- The Small Business Health Options Program (SHOP) exchange concept appears to be a legislative after-thought and more details need to be sorted out.
- The same rating rules should be implemented both inside and outside each public exchange to help avoid adverse selection.
- Tracking eligibility for individuals and families overtime is going to be a challenge and might generate privacy concerns.
- Policymakers were very interested in learning more about how private exchanges, such as BenefitMall, have been successful.
- The definition of the essential benefit package(s) offered through the exchanges will have a profound impact on PPACA’s ultimate success.
- Existing and future federal/state m andated benefits will likely be unaffordable.
- After the BenefitMall meetings, regulators appear to have a greater underst anding of the wide range of current benefit offerings (which supports the premise that one size does not fit all.)
- Many of PPACA’s original cost estimates were not accurate.
- Significant cost and implementation challenges lie ahead – both at the state and federal levels.
- The threat of de-funding PPACA and the ongoing budget battles are having a chilling effect on some regulatory activities.
- Underst anding the Market
- There appears to be a greater appreciation of how PPACA could help and hurt the private sector.
- More attention needs to be devoted to the impact of PPACA’s insurance market reforms.
- Regulators are interested in learning more about local market purchasing trends from experts like BenefitMall.
- Supporting the Consumer2
- Meeting participants appear to recognize that inexperienced Navigators (a concept embedded in PPACA) should not replace the role of a licensed broker.
o A greater awareness of the backend support services is more apparent, including the need for a broker’s services to help consumers answer health questions.
Current PPACA activities in the pipeline include:
- On Thursday, Representatives Mike Rogers and John Barrow introduced legislation to exempt broker compensation from the medical loss ratio calculations.
- A myriad of funding and defunding measures continue to wind their way through the halls of Congress.
- Health care providers continue to wait for the Centers for Medicare and Medicaid Services (CMS) to publish regulations governing accountable care organizations (ACOs).
- The Institute of Medicine is currently studying how PPACA’s Essential Benefit packages should be designed.3
- State activity continues to heat up with almost 500 bills recently introduced in the majority states which reference PPACA’s state-based exchanges.4
- The five court cases challenging PPACA’s individual m andate will likely be appealed to the U.S. Supreme Court.5
- With Republicans beginning to announce their intention to run for President, the 2012 campaign season will begin shortly – which will provide an opportunity to re-evaluate PPACA’s insurance market pre-suppositions and legislative policy goals.
- Congress is still addressing the repeal of the 1099 reporting requirements.6
- With 42 out of 100 Senators firmly opposed to the nomination of Don Berwick as CMS Administrator, President Obama will likely need to consider new c andidates since 60 senators must vote for the nomination.
Interestingly, this week HHS Chief Sibelius again signaled more flexibility in how the states can implement PPACA. However, Republicans continue to complain that they are not seeing enough follow-up to these promises.7
1. BenefitMall’s Issue Brief on Exchanges at https://www.benefitmall.com/PORTAL/Portals/0/BenefitMall Brief.pdf
2. Unfortunately, many policy experts still believe that offering an online web portal will be enough to empower employers and individuals to make a health insurance purchasing decision. This is just not the case.
4. Based upon Westlaw search run on March 17, 2011 (Search Terms “Patient Protection and Affordable Care Act” and “Exchanges” used in the same bill).
6. https://www.benefitmall.com/PORTAL/Portals/0/Legislative Alert/20101029LegislativeAlert.pdf