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.

There are no silver bullets or quick fixes but there is a recipe and it tastes good and is healthy.  Even if the feds take over insurance there is a role for leaders to lead.

If you would like to see some eye popping data on the value of work-site clinics, just contact BILL CRIMMINS (see below)

The root problem in health care costs defined is lifestyle:  thinking and actions by membership.  It’s the same old stuff…think right, eat right, exercise, don’t do certain behaviors, sleep enough.  All the things your mom told you. Your heart told you.

Any solution will incorporate a system and people that can influence membership to the extent that they take responsibility for their own life and health and do the right things.  It may have simplistic characteristics but in reality it will be a well orchestrated effort and balance of simplistic tools synced with timing tools like a finely tuned engine or orchestra.

The most significant tool available today that creates an environment for change and potentially creates a win/win situation for all involved if managed by the most appropriate team without conflict of interest…Work Site-Clinics.  It’s not the be all by itself but it may be the Keystone that can be a dynamic and central part of the solution.

It appears from all the data that by itself even if not carefully managed that the work-site clinic model saves money significantly.  Like many strong foundational tool’s it has the potential to significantly impact all the players positively.  However if not carefully laid (managed) it can become another reproduction of the current system and may prove to be a passing phase.

So…how can you help make your work-site clinic pay off for the long term?  Really make a difference?

Make sure it’s managed by people who have a mission and vision to positively influence change in membership and the provider community.  They must want to play a role in creating a win/win for all involved.

Make sure they have no conflict of interest beyond being a reasonably profitable business with staying power.

Make sure they charge you enough to do the job correctly.  You really do get what you pay for.  Don’t be penny wise and pound-foolish.  The work-site clinic can be done within your clients current benefit budget but the base pricing may not be enough to really orchestrate the kind of strategy needed to take advantage of the possibilities.

Some examples of tools that will compliment work-site clinic efforts include but are not limited to: A powerful and cooperative benefit administrator, a willing and cooperative provider community partner(s), a reasonably discounted network, a reporting engine that captures clinical and financial data that becomes actionable, a wellness and disease management firm that syncs and is integrated into the medical practices of the provider community and work-site clinic and coaches members visiting the clinic and even those not visiting the clinic, an independent data base that helps members distinguish the highest quality providers within your network of providers, a communications company that reaches out to your membership in their homes not only telephonically but via mail and email so that members are reached where they live out the behaviors we need them to embrace.

Make sure they have reporting tools that will hold you, your membership and all the players accountable.

Don’t be afraid to pay for these services.  I can assure you, even if you pay’s the full retail price for these services you will be paying less than every company not using these services.

All these tools independently have impact but synchronized and integrated will powerfully influence members to do the right things.  This will have long-term productivity and cultural dividends for employers who want to win over the long haul.

Let me know how I may assist.

Warmly,

Bill Crimmins - Ambassador (Ofc:  765-720-0392)

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Bill Crimmins is an experienced consultant serving national markets with a wide array of wholesaling services, he works with brokers, consultants, vendors, TPA’s and Employers to facilitate the changes needed for cost reductions for employers and employees by helping create happy, healthy cultures espcially as it relates to integrating wellness programs with insurance benefits.

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

“Ben’s ability to connect people is impressive. He works very hard to be in the right places at the right times in order to take advantage of opportunities as they arise. His personal integrity as well as his knowledge of the Health Care industry provides unique value to those who work with him.” - Craig Wells – President / CEO – Franklin Development Corporation

“Ben helped me understand benefits. As a small business owner, I don’t get the ins-and-outs of insurance benefits. He saved me a lot of money and headache.” Nick Carter – President AddressTwo – February 20, 2009