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Private Health Insurance

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Lorie G

on 7 October 2013

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Transcript of Private Health Insurance

Pre



Pre-existing Conditions



Secretary of Health
and Human Services
=
Discretion
Opportunities For
Emergency Medicine

PRIVATE HEALTH INSURANCE REQUIREMENTS
By Lorie Grushka, Patricia Llanos, Andrew Trejo, & Stephen Dunn
Subtitle A—Immediate Improvements in Health Care Coverage for All Americans
Sec. 1001. Amendments to the Public Health Service Act.

‘‘PART A—INDIVIDUAL AND GROUP MARKET REFORMS

‘‘SUBPART II—IMPROVING COVERAGE

‘‘Sec. 2711. No lifetime or annual limits.

‘‘Sec. 2712. Prohibition on rescissions.

‘‘Sec. 2713. Coverage of preventive health services.

‘‘Sec. 2714. Extension of dependent coverage.

‘‘Sec. 2715. Development and utilization of uniform explanation of coverage
documents and standardized definitions.

‘‘Sec. 2716. Prohibition of discrimination based on salary.

‘‘Sec. 2717. Ensuring the quality of care.

‘‘Sec. 2718. Bringing down the cost of health care coverage.

‘‘Sec. 2719. Appeals process.

Sec. 1002. Health insurance consumer information.

Sec. 1003. Ensuring that consumers get value for their dollars.

Sec. 1004. Effective dates.


Subtitle C—Quality Health Insurance Coverage for All Americans

PART I—HEALTH INSURANCE MARKET REFORMS
Sec. 1201. Amendment to the Public Health Service Act.

‘‘SUBPART I—GENERAL REFORM

‘‘Sec. 2704. Prohibition of preexisting condition exclusions or other discrimina­tion based on health status.

‘‘Sec. 2701. Fair health insurance premiums.

‘‘Sec. 2702. Guaranteed availability of coverage.

‘‘Sec. 2703. Guaranteed renewability of coverage.

‘‘Sec. 2705. Prohibiting discrimination against individual participants and beneficiaries based on health status.

‘‘Sec. 2706. Non-discrimination in health care.

‘‘Sec. 2707. Comprehensive health insurance coverage.

‘‘Sec. 2708. Prohibition on excessive waiting periods.

PART II—OTHER PROVISIONS
Sec. 1251. Preservation of right to maintain existing coverage.
Sec. 1252. Rating reforms must apply uniformly to all health insurance issuers and
group health plans.
Sec. 1253. Effective dates.

Subtitle D—Available Coverage Choices for All Americans
PART I—ESTABLISHMENT OF QUALIFIED HEALTH PLANS
Sec. 1301. Qualified health plan defined.

Sec. 1302. Essential health benefits requirements.

Sec. 1303. Special rules.

Sec. 1304. Related definitions.

PART II—CONSUMER CHOICES AND INSURANCE COMPETITION THROUGH HEALTH

BENEFIT EXCHANGES

Sec. 1311. Affordable choices of health benefit plans.

Sec. 1312. Consumer choice.

Sec. 1313. Financial integrity
"Grandfathered" Plans
How have Private Insurers responded?
4/11
8/12
8/16
Adverse Selection
DEATH SPIRAL
Platinum: 90%

Gold: 80%

Silver: 70%

Bronze: 60%
GRANDFATHERED PLANS:
The What, the Why, the How

Essential Health Benefits
Creating An Opportunity
For Emergency Services

Essential Health Benefits Minimums


60% of AV
Limits Annual Cost Sharing
As Extensive as Typical Employer Based Plan
Not Required to Cover Abortion
Ambulatory Patient Services
Emergency Services
Hospitalization
Maternity and Newborn Care
Mental Health & Substance Use Disorder Services
Prescription Drugs
Rehabilitative and Habilitative Services & Devices
Laboratory Services
Preventative and Wellness Services
Pediatric Services

10 Categories
Case Study
80 y/o Female with Chief Complaint of hypoglycemia
The Promise
"Love your doctor?" -- ACA §1251

Date of Enactment: March 23, 2010

Renewals

Family Members

New Employees

Exempt from most -- not all -- requirements

Scenario #1
Problems with EM
Overcrowding - Pt's held up to 24 hours regularly waiting for rooms
ED act as primary care provders
Ambulance Diversion
Opportunities For EM with EHB
Community Paramedicine
Treat & Release
ACO Coordination
Traditional EMS Call
1. Arrive on Scene, treat PT with
gluclosamine
2. Take Pt to hospital to get cleared
3. Pt arrives at hospital, generally waits
hours
Senario #2
1. Treat Pt. with glucosamine
2. Release
3. Ambulance Company gets Paid
4. ER's are less crowded
The term “preexisting condition exclusion” means, with respect to coverage, a limitation or exclusion of benefits relating to a condition based on the fact that the condition was present before the date of enrollment for such coverage, whether or not any medical advice, diagnosis, care, or treatment was recommended or received before such date. - 42 U.S.C.A. sec. 300gg-3
A Typical Grandfathered Plan
For purposes of establishing a process for determining eligibility, and subject to HHS
approval, a PCIP may elect to apply any one or more of the following criteria in determining whether an individual has a preexisting
condition for purposes of this section:
(1) Refusal of coverage.
(2) Exclusion of coverage.
(3) Medical or health condition.
(4) Other.
- 45 C.F.R. sec. 152.14
Pre-existing conditions are medical conditions or other health problems that existed before the date of an individual’s enrollment in a health insurance plan. Such conditions include chronic conditions like asthma and heart disease, as well as shorter-term medical conditions such as back injuries or pregnancy. - Kaiser
Major Changes = Goodbye Grandfathered Status
Elimination of benefits
Increase in percentage of cost-sharing
Increase in fixed amount cost-sharing requirement other than copayment
Increase in fixed amount copayment
Decrease in contribution rate by employer/employee organizations
Changes in annual limits
Case Study
78 y/o Male with c/c of chest pain
Scenario
Caregiver is stealing grandpa's Heparin

Coordinating with an Accountable Care Organization (ACOs), EMS personnel can initiate investigation seamlessly.
The Future of Grandfathered Plans
Cost to Employers

Impact on Small Employers

Impact on Large Employers
"Objective standard" - a pre-existing condition is any condition for which the patient has already received medical advice or treatment prior to enrollment in a new medical insurance plan.
"Prudent person" - a pre-existing condition is anything for which symptoms were present and a prudent person would have sought treatment.
Children - covered since 2010
Exceptions!?!
- certain newborns
- certain adopted children
- pregnancy
- loss if break of coverage
Reclassifying certain "conditions"???
Regulations
actuarial value (AV)” is the percentage paid by a health plan of the total allowed costs of benefits
“percentage of the total allowed costs of benefits” as the anticipated covered medical spending for EHB coverage
“pediatric services” mean services for individuals under the age of 19 years. We noted that states have the flexibility to extend pediatric coverage beyond the 19-year age baseline.
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