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Faculty Patricia E. Kefalas Dudek Patricia E. Kefalas Dudek & Associates 30445 Northwestern Hwy, Suite 250 Farmington Hills, MI 48334 (248) 254-3462 Email:

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Presentation on theme: "Faculty Patricia E. Kefalas Dudek Patricia E. Kefalas Dudek & Associates 30445 Northwestern Hwy, Suite 250 Farmington Hills, MI 48334 (248) 254-3462 Email:"— Presentation transcript:

1 Faculty Patricia E. Kefalas Dudek Patricia E. Kefalas Dudek & Associates 30445 Northwestern Hwy, Suite 250 Farmington Hills, MI 48334 (248) 254-3462 Email:

2 Overview & Implementation of ACA 2

3 Health Care Reform: A Look at the Basics The patient Protection & Affordable Care Act was signed into law on March 23, 2010. The companion bill, the Health Care and Education Reconciliation Act, was signed on March 30, 2010. Together, these two bills constitute the national health care reform law, known as the Affordable Care Act. Beginning in 2014, U.S. Citizens and legal residents will be required to have health insurance – weather they purchase it on their own, get it through an employer or are covered by a government program such as Medicaid or Medicare. The law requires everyone to have a standard set of basic medical benefits covered on his or her plans. The Affordable Care Act also introduces the Heath Insurance Marketplace. 3

4 Health Care Reform: A Look at the Basics (cont) What is the Health Insurance Marketplace? Starting on Oct. 1, 2013, eligible individuals may buy health insurance through the federal Heath Insurance Marketplace. If your employees do not get insurance through your business, their parents or a government- sponsored program, the Marketplace is where they can go to buy insurance if they meet the eligibility requirements. To view full article: Heath Care ReformHeath Care Reform 4

5 ACA SBC Mandate Overview As amended by the Affordable Care Act amended the Public Health Services Act (PHS)§ 2715, Employee Retirement Income Security Act (ERISA) § 715 and the Internal Revenue Code (Code) §§ 9815 require that Health Plans provide a SBC and a “Uniform Glossary” that “accurately describes the benefits and coverage under the applicable plan or coverage” in a way that meets the format, content and other detailed SBC standards set for the Affordable Care Act as implemented by the Departments regulatory guidance. To view: The Summary of Benefits and Coverage and Uniform Glossary Final RegulationThe Summary of Benefits and Coverage and Uniform Glossary Final Regulation 5

6 Affordable Care Act Implementation Part VII For all mental health and substance use disorder benefits, my group health plan requires prior authorization form the plan’s utilization reviewer that a treatment is medically necessary, but the plan does not require such prior authorization for any medical/surgical benefits. Is this permissible? No. The plan is applying a nonquantitative treatment limitation to mental health and substances use disorder benefits that is not applied to medical/surgical benefits. This violates MHPAEA’s prohibition on separate treatment limitations that are applicable only to mental health or substance use disorder benefits To view full article: Affordable Care Act Implementation Part VIIAffordable Care Act Implementation Part VII 6

7 Keeping Up with Regs is Biggest ACA Challenge What is the most challenging part of the Patient Protection and Affordable Car Act (ACA)? Well, according to HR professionals surveyed by the Society for Human Resource Management (SHRM), the biggest challenge for HR professionals is keeping up with the various regulations issued by government agencies. What is the main ACA implementation barrier for organizations? About two out of five organizations (41 percent) find the complexity of the law to be the main implementation barrier. Sited from Wolters Kulwer Law & Business To view full article: Keeping Up with RegsKeeping Up with Regs 7

8 Health Reform Implementation Timeline According to The Henry Kaizer Family Foundation, the implementation timeline is an interactive tool designed to explain how and when the provisions of the Affordable Care implemented over the next several years. You can show or hide all the changes occurring in a year by clicking on that year. Click on the link below to get more information. Customize the timeline by checking and unchecking specific topics Provisions By Year To view full article: Implementation TimelineImplementation Timeline 2010 (26 in total, 26 in effect)2011 (20 in total, 18 in effect) 2012 (11 in total, 10 in effect)2013 (14 in total, 10 in effect) 2014 (17 in total, 3 in effect)2015 (1 in total, 0 in effect) 2016 (1 in total, 0 in effect)2018 (1 in total, 0 in effect) 8

9 State Milestones for ACA Implementation As sited from the State Health Reform Assistance Network Policy Brief April 2012 This document identifies critical Affordable Care Act (ACA) implementation milestones for states to have achieved by the end of 2012. Organized under the major areas of Health Insurance Exchange To view full article: April 2012 Policy BriefApril 2012 Policy Brief 9

10 Congress contemplating small tweaks to help small businesses weather health care reform According to The Washington Post’s J.D. Harrision, Published June 26, 2013: An effort to repeal a tax on insurance companies in the new healthcare reform law is gaining momentum in Congress, fueled by concerns that the fee would hit small businesses particularly hard. Amanda Austin, NFBI’s director of federal public policy says, the HIT tax repeal "is now teed up” for a serious debate in the fall, once lawmakers have completed work on immigration reform and other issues taking precedent right now in Washington. To view full article : The Washington PostThe Washington Post 10

11 Employers increasingly adopting payment strategies to improve how they pay for health care Data by Aon Hewitt, according to the survey of nearly 800 large and mid-size U.S. employers covering more that 7 million employees, 53 percent said that moving toward provider payment models that promote cost effective, high quality health care results will be a part of their future health care strategy, and one in five identified it as one of their three highest priorities. Sited from Wolters Kulwer Law & Business To view article: Health Reform TalkHealth Reform Talk What are you and your clients doing? 11

12 Best Resource I’ve Seen on Implementation State Health Reform Assistance Network Policy Brief April 2013 State’s Medicaid ACA Checklist for 2014 To view full article: Medicaid ACA Checklist for 2014Medicaid ACA Checklist for 2014 12

13 Essential Benefits vs. Private Coverage 13

14 Essential Benefits When fully implemented in 2014, the Affordable Care Act will establish a range of reform under various federal laws that are intended to make insurance coverage fairer and more accessible to individuals with heightened health needs. Among other things, the law will: 14

15 Prohibit discrimination in coverage based on health status – that is, prohibit plans from denying coverage to individuals, and from utilizing varying health insurance premium, based on factors other than family size, region, age, or whether the individual participate in wellness programs Bar the use of preexisting condition exclusions; guarantee the renewability of coverage Bar lifetime and annual limits on coverage Establish medical-loss ratio standards Prohibit cost-sharing for certain preventive services Require coverage of routine patient costs associated with certain clinical trials 15

16 For This Reason… The law also broadly defines what benefits need to be covered through policies offered in the individual and small-group markets. Under the Public Health Service Act (PHSA) as amended by the Affordable Car Act, all insurers operating in the individual and small-group markets must cover an “essential health benefits” package. The Affordable Care Act further directs that qualified health plans sold in the state health insurance exchanges (including co-op) cover these essential health benefits 16

17 Ambulatory patient services Emergency services Hospitalization Maternity and newborn care Mental health and substance use disorder services Prescription drugs Rehabilitative and habilitative services and devices Laboratory services Preventive and wellness service Chronic disease management Pediatric services, including oral and vision care 17

18 Essential Benefit Package What are the cost-sharing rules for the essential health benefits? The ACA links the essential health benefits package to limits on cost-sharing. So health plans that are required to provide essential health benefits will also be required to limit the amount consumers will have to pay out-of-pocket. Specifically, health plans will be prohibited from requiring consumers to pay annual cost-sharing that is greater than the limits for high deductible plans linked to health savings accounts. Currently, those limits are $5,950 per year for individuals and $11,900 per year for families. In addition, small group plans must limit deductibles to $2,000 for individual coverage and $4,000 for family coverage. As with all health plans under the ACA, there is no cost-sharing for certain preventive health services recommended by the United States Preventive Services Task Force.high deductible plans linked to health savings accountssmall group plansdeductibles To view full article: Essential BenefitsEssential Benefits 18

19 Are your employees ready for consumer-driven health care? If you’re an employer, it’s likely that your workers have been reluctant to educate themselves about their choices in light of upcoming changes to the health care scene, such as the implementation of state and federal exchanges under the Patient Protection and Affordable Care Act (ACA). That may be because they’re waiting for you to make the first move. According to results from the recently released 2013 Aflac WorkForces Report, 75% of workers surveyed said that they thought their employers would educate them about changes to their health care coverage as a result of the ACA;s health care reform provisions, but only 13% of employers said that educating employees about health care reform was important to their organization.Report 19

20 According to results reported by Aflac, 53% of employers have implemented a high-deductible health plan (HDHP) in the last three years, and Aflac says this is a growing trend. The survey also shows that, despite the shift toward HDHPs and defined contribution health care plans by employers, along with the upcoming implementation of state and federal exchanges, 55% of workers said they had done nothing to prepare for possible changes to the health care system. Sited from Wolters Kulwer Law & Business To view full article: Consumer-Driven Health CareConsumer-Driven Health Care 20

21 Insurance Exchanges 21

22 State Implementation of Health Insurance Exchanges According to the Center on Budget and Policy Priorities as of June 14, 2013 States choosing to establish a State-based Exchange (SBE) were required to submit their exchange proposals to HHS by December 14, 2012 while those considering a Partnership Exchange had until February 15, 2013. As of December 17, 2012, seventeen states and the District of Columbia have declared their intention to establish a State-based Exchange (SBE), and an additional six states are pursuing a State Partnership Exchange. All twenty-four State- based and Partnership Exchanges have been conditionally approved by HHS. Twenty-seven states have declined the opportunity to operate an SBE or State Partnership Exchange, and instead will default to a Federally-facilitated Exchange (FFE) (Figure 1). 22

23 Figure 1 – Status of 2014 Exchange Implementation 23

24 HHS issues proposed regulations on financial integrity, oversight standards for Exchanges The Department of Health and Human Services (HHS) has issued proposed regulations on a number of policies related to the implementation of the Patient Protection and Affordable Care Act (ACA), including provisions regarding Affordable Insurance Exchanges, also known as Health Insurance Marketplaces. Much of the proposed rule focuses on program integrity regarding state Exchanges, issuers offering coverage in the Federally-facilitated Exchanges (FFE), advance payments of the premium tax credit and cost-sharing reductions, and premium stabilization programs. 24

25 HHS issues proposed regulations on financial integrity, oversight standards for Exchanges (cont) The rule also proposes establishing standards for HHS- approved enrollee satisfaction survey vendors, standards for the handling of consumer complaints by issuers in the Exchange, and other provisions meant to ensure smooth operation of the Exchanges, protect consumers, and give flexibility to states. To see the actual rule that was published on June 19, 2013: Federal RegisterFederal Register 25

26 CMS issues Program Integrity guidelines for Marketplace Press release for Centers for Medicare & Medicaid Services For immediate release on Friday, June 14, 2013 CMS released a proposed rule outlining program integrity guidelines for the Health Insurance Marketplace (Marketplace) and premium stabilization programs. Through the Affordable Care Act, consumers and small businesses will have access to new Marketplaces where they can access quality, affordable private health insurance. To access the proposed rule released today, visit: To view a fact sheet on the proposed rule, visit: and-FAQs/pi-nprm-6-14-2013.html and-FAQs/pi-nprm-6-14-2013.html 26

27 HHS launches Health Insurance Marketplace educational tools The Obama administration today kicked off the Health Insurance Marketplace education effort with a new, consumer-focused website and the 24-hours- a-day consumer call center to help Americans prepare for open enrollment and ultimately sign up for private health insurance. The new tools will help Americans understand their choices and select the coverage that best suits their needs when open enrollment in the new Health Insurance Marketplace begins October “The new website and toll-free number have a simple mission: to make sure every American who needs health coverage has the information they need to make choices that are right for themselves and their families—or their businesses,” said Health and Human Services Secretary Kathleen Sebelius. 27

28 HHS launches Health Insurance Marketplace educational tools New Marketplace coming October 1, 2013 To view: Health Insurance MarketplaceHealth Insurance Marketplace 28

29 Health Insurance Marketplace What is the health insurance marketplace? The Marketplace is a new way to find health coverage that fits your budget and meets your needs. With one application, you can see all your options and enroll. When you use the Health Insurance Marketplace, you'll fill out an application and find out if you can get lower costs on your monthly premiums for private insurance plans. You'll find out if you qualify for lower out-of-pocket costs.get lower costs on your monthly premiumslower out-of-pocket costs The Marketplace will also tell you if you qualify for free or low-cost coverage available through Medicaid or the Children's Health Insurance Program (CHIP).MedicaidChildren's Health Insurance Program (CHIP) Open enrollment starts October 1, 2013. Coverage starts as soon as January 1, 2014. 29

30 Health Insurance Marketplace Compare options in the Health Insurance Marketplace While all insurance plans are offered by private companies, the Marketplace is run by either your state or the federal government. Find out if your state is operating the Marketplace by using the menu at the bottom of this page. If your state runs the Marketplace, you'll get health coverage through your state’s website, not this one. Your Marketplace may not include all private options! 30

31 Health Insurance Marketplace What is the SHOP Marketplace? The Small Business Health Options Program (SHOP) is a new program that simplifies the process of buying health insurance for your small business. The SHOP Marketplace gives you choice and control over health costs. You control the coverage you offer and how much you pay toward employee premiums. You can compare health plans online on an apples-to-apples basis, which helps you make a decision that's right for your business. You may qualify for a small business health care tax credit worth up to 50% of your premium costs. You can still deduct from your taxes the rest of your premium costs not covered by the tax credit. Beginning in 2014 it is available only for plans purchased through SHOP.small business health care tax credit 31

32 Health Insurance Marketplace Compare plans and apply online The Small Business Health Options Program (SHOP) is designed for busy small employers with 50 or fewer full-time equivalent employees. With one online application, on your own or with the help of an agent, broker, or other assister, you can compare price, coverage, and quality of plans in a way that's easy to understand.agent, broker, or other assister You can enroll starting October 1, 2013 for coverage starting as soon as January 1, 2014. You can also enroll and begin coverage any time after January 1, 2014. You decide what you'll pay toward employee premiums, and then your employees can enroll.your employees can enroll There will be a SHOP Marketplace in each state. You must have an office or employee work site within the SHOP's service area to use that particular SHOP. The online application will guide you to the right SHOP for application 32

33 Health Insurance Marketplace What if I’m self-employed? If you're self-employed with no employees, you're not considered an employer. You can use the individual Marketplace to find coverage that fits your needs. How to know if you’re "self-employed" If you run an income-generating business with no employees, then you're considered self-employed (not an employer) and can get coverage through the Marketplace. You’re not considered an employer even if you hire independent contractors to do some work. If you have employees (generally, workers whose income you report on a W-2 at the end of the year) you’re considered an employer. Then you could get coverage for yourself and your employees through the SHOP Marketplace. Learn more about how to determine if you have employees.SHOP Marketplacehow to determine if you have employees 33

34 Health Insurance Marketplace New options for the self-employed Starting October 1, 2013, you can use the Marketplace to find health coverage that fits your budget and meets your needs. You can compare important features of several plans side-by-side, all of them offering a full package of essential health benefits. You can see what your premium, deductibles, and out-of-pocket costs will be before you decide to enroll.essential health benefits premiumdeductiblesout-of-pocket costs You can't be denied coverage or charged more because you have a pre-existing health condition.pre-existing health condition If you currently have individual insurance--a plan you bought yourself, not the kind you get through an employer--you may be able to change to a Marketplace plan. Learn more about changing individual insurance plans.Learn more about changing individual insurance plans. 34

35 Medicaid Expansion Update 35

36 ORIENT: Dissecting the case for Medicaid Expansion Free money for Obamacare comes with strings attached According to The Washington Post’s Dr. Jane M. Orient, A free $9 billion sounds like a deal that is too good to turn down — the kind that needs a really careful look. First, the aid is temporary. It works like bait to tempt states to expand a program that is already bankrupting them. If the states don’t expand Medicaid to 133 percent of federal poverty level, those vulnerable people are supposed to be able to get federal subsidies to buy private insurance on the new exchanges, according to John Goodman of the National Center for Policy Analysis.John GoodmanNational Center for Policy Analysis 36

37 ORIENT: Dissecting the case for Medicaid Expansion Free money for Obamacare comes with strings attached (cont) That would bring more than twice as much as $9 billion of federal aid into the state. So how is money for Medicaid better than twice the amount for private insurance for the same people? Of course, there are conditions and caveats for getting the exchange money. They are complicated enough to baffle even a Nobel laureate economist. Sited: Dr. Jane M. Orient practices internal medicine in Tucson, Ariz., and is executive director of the Association of American Physicians and Surgeons. To view full article: Medicaid Expansion Medicaid Expansion 37

38 ACA’s Medicaid Plans Took Heat from Court According to an article written by David Pittman, Washington Correspondent, MedPage Today on June 28, 2013. Fewer than half the states -- 23, plus the District of Columbia -- have opted to expand Medicaid. Another 21 have outright rejected it, while six are still weighing options even a year after the Supreme Court ruling. Their interactive map shows you which states are doing what.Their interactive map shows you which states are doing what. 38

39 Where each states stands on ACA’s Medicaid expansion A roundup of what each state’s leadership has said about their Medicaid plans For a link to the map: Where the states standWhere the states stand 39

40 Where each states stands on ACA’s Medicaid expansion A roundup of what each state’s leadership has said about their Medicaid plans Check out more than 30 other infographics, including:more than 30 other infographics Tactics to get your staff rowing in the right direction.rowing in the right direction An interactive map on pay-for-performance programs.interactive map A look at how your health compares to an Olympian' your health compares to an Olympian's A field guide to Medicare payment innovations.field guide 40

41 States Urged to Expand Medicaid With Private Insurance Ohio and Arkansas are negotiating with the Obama administration over plans to use federal Medicaid money to pay premiums for commercial insurance that will be sold to the public in regulated markets known as insurance exchanges. Advocates for beneficiaries are torn. On one hand, they want to provide cover; private insurance may be the only way to entice Republicans to support the expansion of Medicaid Sited from The New York Times, Robert Pear To view full article: The New York TimesThe New York Times 41

42 Expanding Medicaid Using Premium Assistance Why would a state want to use premium assistance instead of traditional Medicaid for the Medicaid expansion? There could be a lot of reasons. In some states, the governor or legislature might be politically or philosophically opposed to expanding traditional Medicaid. In those states, premium assistance might be the only way to move the Medicaid expansion forward. Also, some governors or legislators might look at premium assistance as a way to let people keep the same health coverage if their income fluctuates and they move in and out of Medicaid eligibility. In those situations, it could improve continuity of care. 42

43 Expanding Medicaid Using Premium Assistance Premium Assistance and the Medicaid Expansion: Guidelines from CMS In March 2013, the Centers for Medicare and Medicaid Services (CMS) issued a series of questions and answers that offer some guidance for states that are interested in using premium assistance to cover their Medicaid expansion populations. The information in this section is based on that document. To view full brief: Expanding Medicaid Using Premium AssistanceExpanding Medicaid Using Premium Assistance 43

44 The Medicaid Long-Term Services and Supports Provision in the Health Care Reform Law According to the National Senior Citizen Law Center’s April 2010 article, “The Medicaid Long-Term Services and Supports Provision in the Health Care Reform Law” State Balancing Incentive Payments Program (Section 10202) All other participating states must have a targeted spending percentage of %50 for their HCBS coverage (also to be reached by October 1, 2015). These states will receive an enhanced reimbursement rate of two percentage points for HCBS covered during the balancing incentive period. States must use the additional funds they receive for new or expanded HCBS services. 44

45 Improvements to the HCBS State Plan Benefit (Section 2402) Historically, Medicaid enrollees who require a package of community-based services to help them stay out of institutions have had to qualify for HCBS waivers, two requirement of which are that the waiver participants have a level of need equal to their state’s nursing facility clinical eligibility standard and that the states not spend more on the care for the waiver participants than they would if the participants were institutionalized. The DRA, however, created the HCBS state plan benefit, which authorizes states top provide packages of HCBS services to individuals who have lower levels of need without the budget neutrality requirement of HCBS waiver programs. Iowa, Nevada, Colorado, and Washington have adopted the option. 45

46 Money Follows the Person (Section 2403) The DRA authorized $1.7 billion for the Money Follows the Person program (MFP), under which 31 states were awarded grants to transition Medicaid-enrolled nursing facility residents to their homes or other community settings. The “grants” states have received come in the form of an enhanced federal match for the services provided to program participants for the first 12 months after a participant’s transition. Approximately 37,000 individuals were projected to be transitioned under MFP. The DRA authorized MFP through 2011. 46

47 Temporary Expansion of Spousal Impoverishment Protections (Section 2404) While current federal law requires that states extend the spousal impoverishment protections to the spouses of nursing facility residents, the law makes the extension of the protections to the spouses of HCBS waiver enrollees discretionary for states. The PPACA will therefore take a critical step toward reducing this bias when its spousal impoverishment provision become effective in 2014. The only drawback of the changes in this section is that they would sunset after five years. 47

48 Additional Support for Aging and Disability Resource Center (Section 2405) For several years, the federal government has been supporting state efforts to establish Aging and Disability Resource Centers (ADRCs). The goal of the ADRC program is to have states create one-stop shops for consumer information on LTSS. In 2006, Congress mandated that the Assistant Secretary on Aging implement an ADRC program in all states for the purpose of having the ADRCs “serve as visible and trusted sources of information on the full range of long-term care options, including both institutional and home and community-based care, which are available in the community.” 48

49 Interactions 49

50 American Association of People with Disabilities First public hearing was held today June 27, 2013 according to the AAPD Press Team. AAPD looks forward to the recommendations of the federal commission on long-term care. To view full press release: AAPD Press ReleaseAAPD Press Release 50

51 Identifying and Selecting Long-Term Services and Supports Outcome Measures Disability Rights Education & Defense Fund: A Guide for Advocates, January 2013 addition. To view pdf: Long-Term ServicesLong-Term Services 51

52 Summary of CMS Guidance on Managed Long-Term Services and Supports Summary May 2013 The Centers for Medicare and Medicaid Services (CMS) has released long-awaited guidance for states and stakeholders on the use of managed care for long-term services and supports (LTSS). The guidance consists of two documents, each of which sets forth 10 elements that CMS believes should be incorporated into managed LTSS (MLTSS) programs. To view full article: SummarySummary 52

53 Summary of CMS Guidance on Managed Long-Term Services and Supports Element #1: Adequate Planning and Transition Strategies Element #2: Stakeholder Engagement Element #3: Enhanced Provision of Home and Community- Based Services Element #4: Alignment of Payment Structures with Managed LTSS Programmatic Goals Element #5: Support for Beneficiaries Element #7: Comprehensive and Integrated Service Package Element #8: Qualified Providers Element #9: Participant Protections Element #10: Quality 53

54 New NCD Report on Medicaid Self-Direction In recent years, self-direction has emerged as a game-changing strategy in organizing and delivering Medicaid funded services, a means of affording people with disabilities enhanced opportunities to live fulfilling lives of their own choice in local communities. Yet, despite the growth in self-directed services, many key questions remain to be answered about the most effective ways of promoting individual choice and control within a Medicaid funding environment. To view full report: Report on Medicaid Self-DirectionReport on Medicaid Self-Direction 54

55 Dual Eligible Projects 55

56 Top 10 Concerns with Dual Eligible As Voice by (List Group) 1. Transparency 2. Ombuds Programs 3. Financing Structure 4. Quality Measures 5. Passive Enrollment 6. Size and Speed 7. State and Plan Readiness 8. Continuity of Care and Transitions 9. Enrollment Broker 10. Supplemental 56

57 1. Transparency Oversee a transparent three-way contract development process by sharing for comment drafts of three-way contracts with consumer advocates PEKD Note: Should allow beneficiaries the right as 3 rd party beneficiaries to enforce the contract terms – bring breach of contract suits 57 2. Ombuds Programs Put into place additional designated funding, staffing, and appropriate training before individuals enroll in the demonstrations.

58 3. Financing Structure Provide clear information about how Medicaid rates are calculated and about underlying assumptions for Medicaid and Medicare savings targets. Use individual prior cost information to risk adjust payments for dual eligible's enrolled in the demonstrations until more data are collected on beneficiaries’ functional status. Shield plans from large losses for individuals whose annual costs exceed an appropriate threshold, e.g., $100,000. Implement tighter risk corridors all three years of the demonstration to protect the most complex and costliest beneficiaries. Total risk to each health plan should be strongly limited, so that none will lose or profit by more than roughly three percent. Forgo the requirement that demonstrations show savings in the first year. Any savings amounts required in future years should be justified by publicly shared data. 58

59 4. Quality Measures Develop consistent long-term services and supports (LTSS) quality measures, including consumer-level measures. Include consumer experience, direct workforce (i.e., employee turnover, training, and availability of the direct care workforce), and quality-of-life outcomes in the MOUs. Use existing measures while continuing to develop other new measures. Ensure that all MOUs include rebalancing measures. Require that health plan performance on quality measures is collected and reported in a star rating system that is available to the public. 59

60 5. Passive Enrollment Require states to utilize at least a four-month voluntary enrollment period before beginning capped (similar to Illinois process), phased passive enrollment, beginning with those who have less complex needs. Allow passive enrollment only to plans deemed ready to accept certain populations, and numbers, of dual eligibles. Require states to employ a hybrid approach that uses only voluntary enrollment in some geographic areas while using passive enrollment in others. This approach would permit a valid comparison between the two groups. 60

61 6. Size and Speed Approve only real demonstrations, comprising fewer than one million beneficiaries nationwide. Programs should be phased in gradually and only be expanded across a whole state or population when they have proven to be successful in terms of enhanced quality of care and not just savings. 61

62 7. State and Plan Readiness Review and approve states, not just plans, for their readiness to manage and oversee the demonstrations prior to enrolling individuals into the demonstration. The results of state and plan readiness review should be public. Provide details about the state readiness review process and ensure that states have the infrastructure and oversight mechanisms in place before people are enrolled in the demonstration. Slow down the readiness review process. The timeline for the process should not be set by arbitrary implementation dates. Include more on site review and testing of systems as part of the readiness process to ensure that new plan policies and procedures have been operationalized. 62

63 8. Continuity of Care and Transitions Establish strong minimum care continuity standards that are applicable across all demonstrations. Extend care continuity protections for access to services and treatment regimes, not just providers. Offer meaningful opportunities to provide a beneficiary perspective on drafts of beneficiary communications about care continuity rights to ensure that they understand their rights during the transitions. 63 9. Enrollment Broker Clarify CMS position on the inclusion of independent, conflict-free enrollment brokers in future MOUs and state demonstrations.

64 10. Supplemental Ensure that states require managed care plans participating in the demonstrations to include supplemental services. Also, ensure that provisions for plan flexibility to deliver services do not erode consumer rights to services. For detailed summary and letter: LetterLetter 64

65 Dual Eligible Benefits Sample from Michigan The Michigan Department of Community Health (MDCH) is providing guidance on the Plan Benefit Package to organizations seeking to participate as integrated care organizations (ICOs) in Michigan’s integrated care demonstration program. This guidance may be used to prepare entries into the Centers for Medicare and Medicaid Services (CMS) Health Plan Management System (HPMS) for Michigan’s state specific benefit requirements due June 3, 2013. To view full article: Sample from MichiganSample from Michigan 65

66 CMS Establishes Enrollment Rules for the Dual Eligible Financial Alignment Demonstrations CMS recently released extensive guidance on enrollment and disenrollment for the dual eligible financial alignment demonstration projects. The guidance, which builds on the enrollment chapter in the Medicare Advantage Manual, also includes a model application form and model notices for multiple enrollment and disenrollment situations. To view full Guidance: GuidanceGuidance 66

67 Additional Resources/Information Continuity of Care in the Dual Eligible Demonstrations: A Tool for Advocates To view: Tool for AdvocatesTool for Advocates Dual Eligible Demonstrations: A potential sea change in service delivery for the neediest clients To view: Delivery for the neediest clientsDelivery for the neediest clients 67

68 Appeals & Other Issues 68

69 Affordable Care Act: Working with States to Protect Consumers On July 23, 2010, the Departments of Health and Human Services, Labor, and the Treasury published an interim final rule regarding standards for internal claims and appeals and external review processes for group health insurance plans and health insurance issuers offering coverage in the group and individual markets. This rule works to give people in most plans better information about what their rights are and why their claims were denied or coverage rescinded or taken away. Under the rule, consumers have the: Right to information about why a claim or coverage has been denied. Health plans and insurance companies have to tell you why they’ve decided to deny a claim or chosen to end your coverage – and how you can appeal that decision. 69

70 Affordable Care Act: Working with States to Protect Consumers (cont) Right to appeal to the insurance company. If you’ve had a claim denied or had your coverage rescinded, you have the right to an internal appeals process, a process in which you ask your insurance company to conduct a full and fair review of its decision. If the case is urgent, your insurance company must speed up this process. Right to an independent review. Often, insurers and their policyholders can resolve disputes during the internal appeals process with their insurer. If you can’t work it out through the internal appeals process, you now have the right to take your appeal to an independent third-party for review of the insurer’s decision. This is called “external review.” This way, the insurance company no longer gets the final say regarding your benefits, and patients and doctors get a greater measure of control over health care. 70

71 HHS-Administered Federal External Review Process for Health Insurance Coverage The Affordable Care Act (ACA) ensures that consumers have the right to appeal health insurance plan decisions. This means they are able to ask that the plan reconsider its decision to deny payment for a service or treatment. New rules spell out how plans must handle an appeal (usually called an “internal appeal”). These rules apply to health insurance policies that were first sold or significantly modified after March 23, 2010. These plans are calls non-grandfathered plans. If the plan still denies payment after considering the internal appeal, the law permits a consumer another step. 71

72 HHS-Administered Federal External Review Process for Health Insurance Coverage (cont) Consumers may choose to have an independent review organization (an outside independent decision-maker) decide whether to uphold or overturn the plan’s decision. This additional check is often referred to as an “external review.”Rules issued by the U.S. Departments of Health and Human Services (HHS), Treasury, and Labor (DOL) provide for three different ways to process external reviews. 72

73 A General Overview of the HHS - Administered Federal Review Process If a health insurance plan denies a benefit or refuses to pay for a service that has already been received, this is called an adverse benefit determination. If a health insurance plan upholds its earlier decision to deny a benefit or payment for a service, this is called a final internal adverse benefit determination. Consumers may ask for an external review of a final internal adverse benefit determination. In some instances, consumers may ask for an external review when the initial denial (adverse benefit determination) is made. A consumer or their authorized representative (called the “claimant”) may file a written request for an external review. 73

74 A General Overview A consumer may file a request with MAXIMUS within four months after the date of receipt of a notice of an adverse benefit determination or final internal adverse benefit determination. Consumer may send requests by mail, facsimile, or email. In the near future, they will be able to file a request through a secure, online portal. After MAXIMUS receives an external review request, MAXIMUS contacts the health insurance issuer. The issuer must provide all documents and information related to the denial to the MAXIMUS within five business days. Claimants may also submit any additional information they want MAXIMUS to consider during the external review. MAXIMUS will review all of the information and documents that are submitted on time. 74

75 A General Overview: Time Frames For a standard external review, the MAXIMUS examiner must provide written notice of the final external review decision as expeditiously as possible and no later than 45 days after the examiner receives the request for the external review. Claimants will receive external review determinations in writing. For urgent care situations, claimants may file an expedited external review for either an adverse benefit determination or a final internal adverse benefit determination if: 75

76 A General Overview: Time Frames An adverse benefit determination involves a medical condition of the claimant for which the timeframe for completion of an expedited internal appeal would seriously jeopardize the life or health of the claimant, or would jeopardize the claimant's ability to regain maximum function and the claimant has filed a request for an expedited internal appeal; or 76

77 A General Overview: Time Frames A final internal adverse benefit determination involves a medical condition where the timeframe for completion of a standard external review would seriously jeopardize the life or health of the claimant or would jeopardize the claimant's ability to regain maximum function, or if the final internal adverse benefit determination concerns an admission, availability of care, continued stay or health care service for which the claimant received emergency services, but has not been discharged from a facility. 77

78 Resources to guide you and your client through the Review/ Appeals Process Health Care Reform and Settling Grievances: FAQ Answers to common questions about handling grievances with your health insurance company To view: Health Care ReformHealth Care Reform How to appeal a Health Insurance Denial To view: AppealAppeal 78

79 Appeals According to the States’ Medicaid ACA Checklist for 2014, CMS is proposing new, and in some cases significantly different, requirements and options to promote coordination between the fair hearing process required under Medicaid and the right to appeals of eligibility determinations for other IAPs: Methods to File Appeals: CMS is proposing that Medicaid agencies allow individuals to file an appeal by telephone, by mail, in person, and through other commonly available electronic means, including email and possibly fax or other electronic systems. States can opt to allow filing of appeals through a website. 79

80 Appeals Additional Requirements for Medicaid Fair Hearings: In cases where the Medicaid agency is conducting the Medicaid fair hearing, CMS proposes to clarify that Medicaid may not request information or documentation that has already been provided in the electronic account or to the IAP entity. Medicaid also must accept any finding of fact relating to eligibility made by another IAP appeals entity if it was made in accordance with policies applied or approved by Medicaid. In conducting fair hearings, Medicaid agencies must assess individuals for potential eligibility for other IAPs for individuals determined ineligible for Medicaid at initial application or renewal. Information about the hearing must be accessible to individuals with limited English proficiency or disabilities. 80

81 Appeals Expedited Appeals: CMS proposes that state Medicaid agencies provide an expedited appeal for an individual with an urgent health need, as is now required for Medicaid managed care organizations. Appeal of QHP Enrollment and PTC/CSR Automatically Triggers Medicaid Appeal: CMS is proposing to require Medicaid agencies to treat any appeal of QHP enrollment and premium tax credit and cost-sharing reduction (PTC/CSR) amounts as automatically triggering a Medicaid fair hearing. CMS is considering a later effective date of January 1, 2015, to allow states more time to operationalize the new policy if implemented. 81

82 Appeals Secure Electronic Interfaces: To ensure coordination between appeals entities, CMS directs Medicaid agencies to establish a secure electronic interface through which an Exchange appeals entity can notify the Medicaid agency regarding appeals filed and transmit or receive an individual’s electronic account. This interface can be the same one used by the Medicaid agency and Exchange for electronic transfers. Applicability to CHIP: CMS is proposing conforming changes to CHIP to ensure the appeals process is consistent and coordinated with Medicaid and other IAPs. 82

83 Appeals Option to Delegate Medicaid Fair Hearings (Optional): CMS is proposing to permit state Medicaid agencies to delegate authority to conduct a fair hearing of a MAGI-based Medicaid eligibility denial in cases where an individual is also appealing the amount of an advance payment of the PTC or cost-sharing reductions for enrollment in a QHP. Medicaid agencies must provide notice to the individual appealing the Medicaid decision and the right to have the fair hearing on the Medicaid denial conducted by the Medicaid agency instead. Delegation can only be made to an Exchange that is a governmental agency maintaining merit protections for its employees, including either a State-Based or Federal Exchange.51 Under this proposal, state Medicaid agencies that have delegated fair hearing authority will have to receive and accept an Exchange entity’s Medicaid eligibility decision. 83

84 Appeals Timeframe: CMS is proposing to make the automatic Medicaid fair hearing trigger from any QHP enrollment and PTC/CSR appeal effective January 1, 2015. 84

85 Others Medicaid Administrative Funding Availability for Long Term Care Ombudsman Program Expenditures This informational bulletin review existing policy regarding when Medicaid is available for certain administrative costs related to activities conducted by state Long-Term Care Ombudsman (LTCO) programs that benefit the state’s Medicaid program. 85

86 Other CMA – Observations Status & Bagnall v. Sebelious To view: Observation StatusObservation Status Jimmo v. Sebelius Settlement Agreement Fact Sheet To view: Jimmo v. SebeliusJimmo v. Sebelius Medicare’s ‘improvement standard’ for physical therapy has changed To view: Improvement StandardImprovement Standard 86

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