Federal News
Supreme Court 2012 Review of Reform Law Likely
The recent ruling by the 11th Circuit Court of Appeals makes it almost certain the Supreme Court will decide the federal health care reform law’s constitutionality in its 2012 term. To date, two circuit courts have produced contradictory rulings on the law’s individual mandate. The Obama administration, by virtue of being the loser in the latest ruling, will file the appeal to the Supreme Court, which rarely turns down requests from the federal government.

9th Circuit Rejects Reform Suit
In another case against the federal health care reform law, the 9th Circuit Court of Appeals threw out a suit filed by a former California state lawmaker and the Pacific Justice Institute. The court upheld the decision by a lower court that neither party had a legal standing to challenge the law.
Read more at: http://bit.ly/odeg08

Congress Takes a Break; Supercommittee Formed
Congress has taken its annual August recess after completing a last-minute deal to increase the nation’s debt limit. The House and Senate will not return until after Labor Day. Shortly after leaving town, House and Senate leaders appointed their representatives to the new “supercommittee” that was created as part of the debt limit deal. The supercommittee is charged with creating a proposal to eliminate $1.5 trillion in government spending over the next ten years. Their first meeting is September 16, with results due by Thanksgiving. Members include Representatives Dave Camp (R-MI), Fred Upton (R-MI), Jeb Hensarling (R-TX), James Clyburn (D-SC), Chris Van Hollen (D-MD), and Xavier Becerra (D-CA) and Senators Patty Murray (D-WA), Max Baucus (D-MT), John Kerry (D-MA), John Kyl (R-AZ), Rob Portman (R-OH), and Pat Toomey (R-PA)

Administration Releases Regulations on Exchanges & Subsidies
The Obama administration has published three new proposed regulations to (1) establish processes for enrolling individuals and families in plans offered by state-based exchanges; (2) lay out how an estimated 20 million Americans will get tax credits to help them pay the premiums charged by insurers through the exchanges; and (3) establish a “seamless” enrollment process in which people benefit from “one-stop shopping” in exchanges to easily enroll in Medicaid or the Children’s Health Insurance Program if they don’t qualify for the tax credits. Comments on the proposed regulations are due by October 31. The regulations can be found in the Federal Register at:
Exchange enrollment processes: http://www.gpo.gov/fdsys/pkg/FR-2011-08-17/pdf/2011-20776.pdf

Premium tax credits: http://www.gpo.gov/fdsys/pkg/FR-2011-08-17/pdf/2011-20728.pdf

Medicaid/CHIP eligibility changes: http://www.gpo.gov/fdsys/pkg/FR-2011-08-17/pdf/2011-20756.pdf

HHS May Not Be Able to Fund Federal Exchanges
The U.S. Department of Health and Human Services (HHS) is facing a funding dilemma with respect to establishing a federal health insurance exchange. Although the federal health care reform law gives HHS the authority to create a federal exchange for states that don’t develop their own, it does not provide funding. In comparison, the law provides robust financial resources to help states build their own exchanges. One expert says HHS will have to “get creative about the [federal exchange] financing,” by asking contractors to delay getting paid until the exchange begins collecting fees.
http://www.politico.com/news/stories/0811/61513.html

NAIC Warns Feds about Exchange Loophole
A part of the federal health care reform law requires each state-based health insurance exchange to offer at least two plans which will be available in every exchange nationwide. In a letter to the U.S. Office of Personnel Management (OPM), NAIC President and Iowa Commissioner of Insurance Susan Voss has expressed concern the Multi-State Plan program will create an uneven playing field for insurers by favoring large national insurers who would offer these plans. “Insurance Commissioners and the NAIC have serious concerns about the potential for market disruption and adverse selection, and the resulting negative impact on consumers and health insurance markets which would arise if Multi-State Plans are allowed to operate under different rules than their competitors.” Voss wrote.
Read more at: here

Feds Issue Proposed Rule on Benefits, Coverage Disclosures
The IRS, the Department of Labor (DOL), and HHS have released proposed rules on insurance-related forms required by the federal health care reform law. The “summary of benefits and coverage” and a uniform glossary for group and individual health insurance were released almost five months late due to infighting between HHS and DOL over the extent to which large employer plans will be expected to comply with the provision. Both rules were published in the Aug. 22 Federal Register with comments due 60 days after publication.
The proposed rules can be found at: http://www.ofr.gov/OFRUpload/OFRData/2011-21193_PI.pdf

Issa Questions Why HHS Is Ending Waivers for Mini-Med Plans
House Oversight and Government Reform Chairman Darrell Issa (R-CA) is questioning HHS’s decision to end the waiver process for health plans to comply with certain requirements of the federal health care reform law. Issa said in a letter to HHS Secretary Kathleen Sebelius that he wants HHS to explain why they are shutting down the waiver program and provide the committee will all the documents and communications related to the decision to stop it.
Read more at: here

Under the Patient Protection and Affordable Care Act (or health care reform law), the secretary of Health and Human Services will establish a voluntary long-term care (LTC) insurance program called Community Living Assistance Services and Supports (CLASS) by January 1, 2011. The program will offer the CLASS Independence Benefit Plan, but the new law does not specify a date for enrollment. This is a government program.

What the provision does

The long-term care provision of health care reform law is designed to help individuals and families pay for long-term care. Fewer than 10% of older Americans currently have private LTC coverage. The CLASS program attempts to address gaps in coverage by offering a long-term care insurance plan. However, it offers limited benefits.

Who can enroll

Employers will need to decide if they will offer the CLASS program to employees. If an employer chooses to participate, employees age 18 and older must be automatically enrolled in the program, regardless of their pre-existing conditions. Employees can choose to “opt-out” if they don’t want to participate. CLASS is also available to individuals who are self-employed, have more than one employer or have an employer who chooses not to participate.

How the premiums will be determined

Premiums will be established by the U.S. Department of Health and Human Services secretary and will be based on age and not health risk. Based on the information available, we believe premium subsidies will be available for workers with incomes below the federal poverty level and full-time students age 18 to 21 who work.

How to qualify for benefits

After paying premiums for five years, enrollees will be eligible to receive benefits.CLASS will be administered by the U.S. Department of Health and Human Services

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This content is provided solely for informational purposes. It is not intended as and does not constitute legal advice. The information contained herein should not be relied upon or used as a substitute for consultation with legal, accounting, tax and/or other professional advisers.

Interim final rules contain details about the preventive care provision

As you may know, the health care reform law includes a provision requiring health insurers to cover preventive services with no member cost sharing. Recently-published interim final regulations clarify this provision. Non-grandfathered plans issued or renewed on or after September 23, 2010, will not include member cost sharing or copays for the following preventive care provided in-network:

- Evidence-based items or services that have a rating of A or B in the current recommendations of the United States Preventive Services Task Force.

- Immunizations for routine use in children, adolescents, and adults that are recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention.

- For infants, children and adolescents, evidence-informed preventive care and screenings provided for in comprehensive guidelines supported by the Health Resources and Services Administration.

- For women, to the extent not otherwise addressed by the United States Preventive Services Task Force recommendations, evidence-informed preventive care and screenings provided for in comprehensive guidelines supported by the Health Resources and Services Administration.

Other key points:

- This impacts non-grandfathered plans issued or renewed on or after September 23, 2010.

- This applies to in-network services. Out-of-network services will have the same cost-sharing requirements as they do today.

- Most of the recommended screenings, immunizations and exam services are already on our preventive services list. We are adding the new, required preventive services to this existing list.

- An example of a new preventive service is counseling related to aspirin use, tobacco cessation, obesity and alcohol use.

- Some services currently covered as medical/maternity will now be considered preventive services. This includes several recommended screenings for pregnant women.

As with the other provisions in the health care reform law, we’re committed to implementing this provision in a manner that helps members have access to quality health care services. If you have any questions, talk with your sales representative.

Grandfathering allowed for most standard and non-standard plans

As we recently communicated with you, the federal government has issued Interim Final Regulations for the grandfathering provision. Because there are advantages to grandfathering, we will grandfather most standard and non-standard plans in our portfolio. To help you better understand what this means to you, we’ve put together this Grandfathering Fact Sheet. It explains:

£ More about grandfathering

£ What changes can be made without losing grandfathered status

£ What changes will result in losing the grandfathered status

This is an important provision for many individuals and group policyholders. You can expect more information about grandfathering, including how we will implement it. As always, please talk with your consultant if you have any questions.

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Grandfathering Fact Sheet

Under the recently enacted federal health care reform legislation, health plans can be grandfathered. Interim Final Regulations have been published to provide further clarification on grandfathering. These rules are designed, according to the Obama administration, to allow grandfathered plans to “innovate and contain costs by allowing insurers and employers to make routine changes without losing grandfather status.” In general, grandfather status will be lost if there are significant reductions to benefits or increases in out-of-pocket spending for consumers, such as deductibles or co-pays.

We believe there are benefits to grandfathering for our groups and individual members who wish to maintain their existing health benefit coverage. For this reason, we will grandfather most group and individual plans. In a continued effort to simplify our plan offerings, we are reviewing our current options by state to determine which ones we will offer as grandfathered plans. More information explaining how we will implement grandfathering for our individual and group customers will be provided in the near future.

Additionally, in limited situations, the legislation allows clients that made benefit changes after March 23, 2010, that would not meet the grandfathering rules to regain grandfathered status at the next renewal in 2011. We are working to determine how to help plans possibly regain grandfathered status.

What is grandfathering?

Grandfathering allows groups and individual members that keep their existing plan from March 23, 2010, to January 1, 2014, to be exempt from the new product and rating framework that is effective in 2014. To maintain grandfathered status, a client must continue to keep the plan and the plan’s benefits essentially the same. Grandfathering also exempts plans from some of the requirements of the plan-related provisions effective September 23, 2010.

The following changes can be made without impacting grandfathered status:

 Changes in premiums of a policy or plan
 Changes required to comply with federal or state law
 Changes to increase benefits, or voluntarily comply with provisions of the Patient Protection and Affordable Care Act
 Changes to plan structure, for example, switching from a health reimbursement arrangement to major medical coverage, or from insured to self-funded coverage
 Changes to a provider network
 Changes to a prescription drug formulary
 Changes to accommodate mergers and acquisitions (as long as the merger or acquisition is not done solely to allow a group to move from one grandfathered plan to another when the plan change would reduce benefits or increase cost sharing in excess of that allowed by the regulations)

 Changes to an ASO plan’s third-party administrator

The following changes would cause a loss of grandfathered status:
 Eliminate all (or substantially all) benefits to diagnose or treat a particular condition.
 Increase coinsurance (or another percentage cost-sharing requirement) above the level at which it was set on March 23, 2010. In other words, any increase in an insurer or plan’s coinsurance will result in a loss of grandfathered status.
 Increase fixed-amount cost-sharing requirements other than copayments, such as a deductible or an out-of-pocket limit, by a total percentage (measured from March 23, 2010) that is more than the sum of medical inflation plus 15%.
 Increase copayments above the level in effect on March 23, 2010, by an amount that exceeds the greater of (a) the sum of medical inflation plus 15%, or (B) $5 increased by medical inflation.
 Reduce employer contributions (calculated by cost or formula, such as hours worked) toward any tier of group health insurance coverage or a group health plan by more than 5% below the contribution rate on March 23, 2010.
 Impose an annual limit on the dollar value of benefits if an annual or lifetime limit had not been previously imposed on all benefits or, for plans that previously imposed a lifetime limit of all benefits, impose an overall annual dollar limit that is lower than the lifetime limit, or, for plans that
previously imposed an annual limit on all benefits, decreases the dollar value of the annual limit.
 Issuer or plan sponsor does not disclose to participants and beneficiaries that the plan or coverage is a grandfathered health plan.
 Change from one insurer to another

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New government website lets consumers compare insurance plans

The U.S. Department of Health and Human Services (HHS) has just launchedHealthCare.gov, a website designed to help individuals and small businesses compare both private and public health insurance plans. Through HealthCare.gov, consumers can find information on literally thousands of private and public health care products.

Important note about how some products appear on the site

Please note that the products are listed under the legal entities – not their brand names, which may cause confusion. Companies currently working with HHS to correct this matter, and they hope to have their familiar brand names appear on the website soon. Until then, please be aware of how our products are listed on the website, state by state:

£ California: Blue Cross of California, Anthem Blue Cross Life & Health Insurance Company

£ Colorado: Rocky Mountain Hospital and Medical Service, Inc.

£ Connecticut: Anthem Health Plans, Inc.

£ Georgia: Blue Cross and Blue Shield of Georgia, Inc., Blue Cross Blue Shield Healthcare Plan of Georgia, Inc.

£ Indiana: Anthem Insurance Companies, Inc.

£ Kentucky: Anthem Health Plans of Kentucky, Inc.

£ Maine: Anthem Health Plans of Maine, Inc.

£ Missouri: RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC),

£ Nevada: Rocky Mountain Hospital and Medical Service, Inc.

£ New Hampshire:  Anthem Health Plans of New Hampshire, Inc.

£ New York: Empire HealthChoice HMO, Inc., Empire HealthChoice Assurance, Inc.,

£ Ohio: Community Insurance Company

£ Virginia: Anthem Health Plans of Virginia, Inc.

£ Wisconsin: Blue Cross Blue Shield of Wisconsin, Compcare Health Services Insurance Corporation

In October, HealthCare.gov will also start including rate estimates for private insurance plans. Insurance companies are working with the government to determine how small group information will appear in states with no community ratings.

HealthCare.gov can be a valuable tool for you, which is why Insurance Companies are working hard to have their recognizable names appear on it soon. We’ll keep you posted as more information becomes available to us. If you have any comments or questions, please talk with your sales representative.

Getting to the bottom of health care costs

Did you know: Only three cents of every premium dollar is profit?

On average, 87 cents of every premium dollar you pay is spent covering medical care and services that members receive like doctor visits, hospital costs, prescription drugs and more according to a PriceWaterhouseCoopers medical cost trend report for 2009. Another 10 cents funds services we provide like claims processing, enrollment and billing and provider credentialing. That leaves 3 cents of every premium dollar for profits. Kaiser Health news has reported that the combined annual profits of the top 10 health insurers are equal to just two days work of national health care expenditures or just 0.5% of the estimated $2.5 trillion the nation spent on health care in 2009.

The Federal Mental Health Parity Act requires our fully-insured employers with 50-2,999 employees, as well as self-funded customers, to offer the same level of coverage for mental health and substance use disorder services as that offered for medical and surgical services through their plan.

The 154-page Federal Mental Health Parity Interim Regulations and comments, were published in February in the Federal Register. Highlights of new/updated information from the interim  regulations are as follows:

Effective Date/Applicability

• Regulations published as the Interim Final Rule are effective on the first day of the plan year beginning or renewing on or after July 1 and must be complied with even though it is not the Final Rule.
• The U.S. Department of Labor (DOL), Department of The Treasury and Centers for Medicare and Medicaid Services (CMS) are seeking feedback on the interim final regulations via an open comment period which ends May 3.
• Regulations are not applicable to Medicaid Managed Care Plans. Separate regulations will be provided from CMS for those plans, but they are still subject to the law.

Benefit Requirements
Establish six classifications of benefits: Parity for treatment limits and financial requirements defined by the regulations, is to be applied classification by classification:

1. Inpatient In-Network
2. Inpatient Out-of-Network
3. Outpatient In-Network
4. Outpatient Out-of-Network
5. Emergency
6. Prescription Drugs

• The definitions of what constitutes Inpatient, Outpatient and Emergency are not defined by the regulations but instead defined by the plan or applicable state law. However, the terms cannot be defined differently for mental health/substance use disorder than for medical/surgical.
• Benefits for mental health and substance use disorder are not mandated, but to the extent benefits are provided in one of the six classifications, they must be in parity with that classification’s medical benefits. Plans are not required to cover all mental health conditions or all substance use disorders but may define which they will or will not cover.  Fully-insured plans are still subject to state mandates which may require certain mental health or substance use disorder benefits.
• Financial requirements and quantitative treatment limitations must be in parity with the requirements and limitations applied to substantially all benefits for the applicable classification on medical benefits. “Substantially all” means the requirement/limitations apply to at least two-thirds of the benefits in that classification.
• Regulations do not allow recognition of distinction between primary and specialty financial requirements/treatment limitations for parity purposes.
• Regulations prohibit separate cost sharing, e.g., no separate but equal deductibles or out-of-pocket maximums.
• Parity applies to non-quantitative limits and specifically lists the following classifications and specifies these mustbe in parity:
  • Medical management standards, such as medical necessity
  • Formulary design for prescription drugs
  • Standards for provider admission to network, including reimbursement rates
  • Plan methods for determining usual and customary rates Fail-first or step therapy requirements (e.g., must try certain treatment before obtaining approval for another treatment
  • Exclusions for failure to complete a course of treatment   These limits must be comparable to and applied no more stringently for mental health/substance use disorder benefits than they are for medical benefits.

Product Requirements

• Employee Assistance Program (EAP) gatekeeper models are prohibited.
• A plan sponsor cannot avoid parity requirements by establishing a separate group health plan for mental health/substance use disorder benefits.
• Plan sponsors with multiple medical benefit plans but a single mental health/substance use disorder plan must ensure compliance for parity purposes between the mental health/substance use disorder benefit plan and eachmedical plan.
• No guidance is available yet on cost exemption. (This remains under development.)

Parity Relevance
Federal Mental Health Parity is relevant to all group health plans (fully insured and self-funded) with few exceptions, such as self-funded non-ERISA government (non-federal) plans that have expressly opted out under existing law and groups with 50 or fewer total employees.

Reference Materials
The Federal Mental Health Parity — A Summary of the Interim Final Rules: What You Need to Know brochure (available upon request) provides an overview of the new Federal Mental Health Parity regulations. The document highlights the key provisions, including implementing parity regulations for financial requirements and treatment limitations.

For more information please contact your Catalist Health Representative

When are these changes effective?
The 2010 Medicare Supplement changes will be effective on any policy sold effective June 1, 2010.

When can I start marketing the new plans?
The new plans are effective June 1, 2010, so the kickoff for selling to those clients who will turn 65 in June will actually be January 1, 2010.

How competitive will the new plans M & N be?
We expect them to be very competitive. Co-Pays and Co-Insurance will always drop the premium.

Why were plans E, H, I and J eliminated?
Plan E was eliminated because the new Plan D would contain exactly the same benefits. Plans H, I and J were eliminated because with the other dropped benefits these plans would also duplicate other plans available.

What will happen in the plan your client has is dropped?
Any plan that was purchased prior to June 2010 will remain inforce. Keep in mind these new plans are for new issues with effective dates of June 2010 and beyond. Your clients’ current Medigap plan is guaranteed renewable for life. Even if their health changes, they cannot be terminated or forced to change to one of the new plans.

What is the new hospice benefit?
All plans will now include the Hospice Benefit as part of the “Core Benefits.” Medicare provides coverage for inpatient respite care up to 5 days less a co-payment amount of 5% of the daily benefit. The new Hospice benefit will pick up this 5% co-pay.

Why was the At-Home Recovery benefit dropped?
It was determined that the benefit was confusing and difficult to understand and administer.

Why was Preventive Care dropped from all plans?
Because Medicare Part B has changed to cover many more preventive benefits, effectively rendering this benefit redundant.

For Personal Advice or to talk to a Customer Care Consultant call 1-866-460-4321 or to e-mail us click here.

New Hospice Benefit
All plans will now include the Hospice Benefit as part of the “Core Benefits.” Medicare pays for all but very limited co-payments for outpatient drugs ($5). Included in all Medigap plans a benefit to pay this co-payment will be included.

Medicare provides coverage for inpatient respite care up to 5 days less a co-payment amount of 5% of the daily benefit. The new Hospice benefit will pick up this 5% co-pay.

New Plans
The new regulation also makes the following two new plan options available to beneficiaries, which have higher cost–sharing responsibilities and lower estimated premiums:

• New Plan M includes 50 percent coverage of the Medicare Part A deductible and does not cover the Medicare Part B Deductible. Plan M has all the core benefits plus the foreign Travel Emergency Benefit.
• New Plan N does not cover the Medicare Part B deductible and adds a new co–payment structure of $10 for each physician visit and $50 for each emergency room visit (waived upon admission to the hospital). Plan N has all the core benefits plus the foreign Travel Emergency Benefit.

Benefit Chart of Medicare Supplement Plans Sold for Effective Dates on or After June 1, 2010

*Plan F also has an option called a high deductible plan F. This high deductible plan pays the same benefits as Plan F after one has paid a calendar year [$1900] deductible. Benefits from high deductible plan F will not begin until out-of-pocket expenses exceed [$1900]. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. These expenses include the Medicare deductibles for Part A and Part B, but do not include the plan’s separate foreign travel emergency deductible.

For help understanding how this may impact your Medicare Plans or Health Care costs, please contact a representative at CATALIST HEALTH by calling – 1 – 866 – 460 – 4321 or by e-mailing info@catalistfinancial.com

Promises Made; Promises Broken. Senate Majority Leader Harry Reid is in full get-a-bill mode. Virtually every promise of reform has been thrown out the window, even as those willing to work with the president have been thrown under the bus. Just consider some of the promises broken.

Promises:

• Family health insurance premiums will drop by $2,500 a year by the end of the president’s first term.
• Everyone will be covered.
• If you like your current health insurance plan you can keep it.
• Electronic medical records will save significant amounts of money.
• The president will sit down with members of Congress and go over the legislation line by line.
• Discussions will be an open process that even C-Span could broadcast.
• Health care reform will cost about $60 billion a year (which would only be $600 billion over 10 years).

All those promises and more have been broken; they aren’t even considered serious anymore. And yet reform efforts move on. That’s one of the reasons those of us opposing the reform effort are so frustrated. No one — and certainly not the media — appears to be holding the president accountable.

Déjà vu. Actually, this effort isn’t all that different than the 1993-4 Clinton health care reform debate. When Clinton was elected there was also a sense of inevitability about the success of the bill. Most of the various trade associations — the AMA, PMA (now PhRMA), the AHA, the big business groups, and even HIAA — wanted to work with the administration and have a “seat at the table.”

It wasn’t until January or February of the following year (1994) — about where we are now — that many of the major groups started turning against the plan. The business groups have been turning, and some of the associations are turning.

Of course, there are differences. The Democrats are much further along this time than in 1993-4. And some of the trade associations have continued their support, even when it’s clear they will be hammered by the legislation.

But don’t let people tell you things are completely different this time. There are a lot of similarities.

No More Cards. Last week Senator John McCain (R-AZ) went on the floor of the Senate to complain that AARP has opposed every past cut to Medicare, even as it supports the proposed new cuts to Medicare — which are substantially larger than anything the Republicans ever proposed. And so McCain urged seniors to cut up their AARP membership cards.

It’s an important point. The media regularly refer to AARP as a seniors’ lobby or a consumer group. It’s not. It has effectively become an arm of the Democratic Party. Yes, AARP supported the Republican-led Medicare prescription drug legislation that passed in 2003. But Democrats roundly chastised AARP for doing so — even though several Democrats voted for the bill — and AARP apparently learned its lesson. If Democrats say something’s good, AARP must say something’s good. I just wish the media would recognize the relationship.

As these plans are still evolving, please visit us often for future updates.

Background

The changes to Medicare Supplement come as a result of HR 6331, the Medicare Improvements for Patients and Providers Act (MIPPA, passed on July 9, 2008), which authorized implementation of the NAIC’s proposed Medigap modernization changes, which were approved by the NAIC Plenary in March 2007.

Major Changes

The 2010 Medicare Supplement changes are an effort to modernize the Medigap Market by dropping some coverage options and adding others. See Below.

Summary of changes for 2010 Medigap plans purchased effective June 1, 2010:

• “At-Home Recovery” benefit will be dropped from all 2010 Medicare Supplement plans
• Preventative Care will be dropped from all 2010 Medicare Supplement plans
• Medigap Plans E, H, I and J will no longer be available for new sales
• Plan G will be modified to increase excess charges from 80% to 100%
• New Hospice Benefit will be added to all plans
• Two new Medigap Plans M & N will be available in 2010
• Insurance carriers will be allowed to offer plans that include “New” or Innovative Benefits, such as eyewear or hearing aid benefits. They may not include outpatient prescription drug benefits.

FOR HELP ON HOW THE PLANS AFFECT YOU OR WHAT OPTIONS YOU HAVE TO LOWER HEALTH COSTS PLEASE CALL (866) 460-4321 or e-mail info@catalistfinancial.com