Private Employer Health Plans and Implementation of the Public Health Services Act and ACA:DOL & Wellness

Private Employer Health Plans- and Implementation of the  Public Health Services Act and the Accountable Care Act Mandates in 2014

Department of Labor requirements mandate that employers who offer ERISA health and welfare plans must report plan data in an annual Form 5500, which includes plan enrollment, funding, and other information. Form 5500 filings are required for pension and health and welfare plans. Generally employers who have 100 or more employees in their health plan must report, but self-funded plans with fewer participants must also report. And some other types of benefit programs, like Section 125, 127, or  129 flexible benefit plans may also require Form 5500 reporting, depending on the benefit program.  This article uses information from Form 5500 filing data to provide a profile of private employer health plan status, with a view toward changes next year.[1]

Department of Labor Health & Welfare Plan Reporting

Department of Labor(DOL)  Form 5500 plan filings are typically reported ninety days after the end of the plan year, so generally between March 30, 2011 and September 30, 2011 for the 2010 plan years. The 2011 fiscal year 5500 reports were not due until as late as the fourth quarter of 2012, and hence not yet available as of this publishing date. The DOL indicates that 41% of private employers with health and welfare plans reported  self insured plans under Form 5500. To be considered a self-insured plan the risk portion which funds the payment of health care services is separated from the administrative expenses of the plan. Another 4,000 employers had partially self funded plans, which are a cross between a fully insured and a self-insured plan. The remaining 25,000 employers reported traditionally insured health plans, like HMO’s.

ERISA or self-funded plans and  Affordable Care Act Mandates

The Affordable Care Act amends portions of the precursor, the Public Health Services Act of 2010 including section  715 (a) (1) of the Employee Retirement Income Security Act (ERISA) to require self-insured or ERISA plans to conform to certain health plan mandates.[2]These stipulations apply for plan years after January 2014:

1.       Waiting Period before an employee is enrolled on a health plan cannot exceed ninety days

2.       Employees who work 1,200 hours per year are considered full-time for purposes of qualifying for health plan participation

3.       Public Health Services Act Section 2708 provides guidance for determining when an employee working variable hours must meet the criteria for inclusion in the health plan, including the 13 month rule when a variable hour worker must be added to the plan[3]

4.       DOL Technical Release 2013-01 extends the compliance phase-in period for the Uniform Health Carrier External Review Process as mandated by Public Health Services Act section 2719 (b) (1) from January 1,2014 to January 1,2016 if the organizations comply with the temporary National Association of Insurance Commissioner Standards.

Final Regulations for Qualifying Health Plan Wellness Programs

The Public Health Services Act section 2705 mandated Wellness coverage for medical insurance plans effective January 1, 2014. On November 26, 2012, Department of Labor regulations for the Accountable Care Act wellness benefit mandates for health insurance plans were issued, including  amending HIPAA from 2006. Wellness plans may include any of the following components:

1.       Cost of membership in a fitness center

2.       Diagnostic testing which reward participation and do not punish participants for their outcomes

3.       Monthly no-cost health education programs

4.       Health risk assessment

5.       Smoking aversion programs

6.       Rewards for health contingent wellness plans, such as logging miles per week, weight loss, etc.

For more information on the regulations for the wellness plan mandates please feel free to read all 123 pages of the federal regulations.[4] This article has provided employers with some crib notes on the pending 2014 health care reform mandates, but for more information, read Unraveling U.S. Health Care-A Personal Guide, available July 14^th on Amazon or pre-order now from Rowman and Littlefield.

http://www.amazon.com/books/dp/1442222972

https://rowman.com/ISBN/9781442222984

 And this is the healthpolicymaven signing off. Feel free to share this article with others.

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[1] http://www.dol.gov/ebsa/pdf/ACA-ARC2013.pdf

[2] http://www.dol.gov/ebsa/pdf/90dayreg.pdf

[3] http://www.dol.gov/ebsa/pdf/90dayreg.pdf

[4] http://www.ofr.gov/OFRUpload/OFRData/2013-12916_PI.pdf

Your Health Care System At Work-A Primary Care Conundrum

Your Health Care System At Work

Today, at 9:00AM I received a call from the school nurse indicating my sixteen year old son was in her office with a very low heart rate (in the 40’s). This in and of itself was not that distressing to me since my resting heart rate was 52 in my twenties,  and it is a family trait. However, between the time I received her call and attempted to contact my son’s primary care provider, I received another call indicating that his heart rate was so erratic they had called 911. The triage system then required that he be evaluated by the fire department paramedic and transported to the local emergency department. Once there, he was admitted and then evaluated with X-rays and other diagnostic equipment. In the meantime, I had called my primary care provider at Washington’s Community Health Plan three times, was on hold for 15 minutes, and been patched through a “call center,” all the while never having spoken with a clinician. So, the delivery of “primary care” to my son was handled by non-primary clinicians, because the primary care provider was not available.

This scenario illustrates one of the problems in our health care system, which is we have a shortage of primary care clinicians.  It is important to note this reflects a dearth of doctors who are willing to work within the basic pediatric reimbursement level, so the patients are forced to pursue other health care options, AKA the emergency department of your local hospital. This method of treatment is of course expensive and abhorred by health care policy analysts, but when you do a root-cause analysis, this pattern is informed by the lack of treatment options for basic health care in the USA.

This scenario happened in Washington State, which is fairly well off financially, and it concerned a child of a parent well versed with the health care system, so you can imagine how this plays out for ESL parents or others with less familiarity. In Washington, Virginia Mason Medical Center has excellent primary care and a  high level of patient safety, based on their Leapfrog Patient Safety evaluations, their Malcolm Baldridge Quality Award, and personal experience. However, the Virginia Mason system is not available to everyone, especially outside the Seattle area. So, where do the children of parents who are not covered under the luxurious private health care system or the realm of Medicare obtain their basic health care? More than likely they have deferred health care, which is to say very little. I can remember going through at least one Minnesota winter with untreated bronchitis, in a district with no school nurse, and with parents who were barely getting by.

  All of this relates to the lack of basic health care for children, a pattern that hasn’t changed in decades. Though the Children’s Health Insurance Plan (CHIP) which provides federal funding for children who are in the lower economic rung of our society ( which turns out to be quite a few at 7.6 million in 2010 alone) has indeed expanded health insurance coverage for acute care for children, has it increased access to primary care?

The problem with primary health care in the United States is it is so reimbursement driven that the patients experience many obstacles to obtaining timely care. In the case of my son, even with the ED intervention, the soonest the “health plan” could see him was several days away. And the Children’s Health Plan is one of the country’s most well-funded programs. Imagine how it is for adults.

Also, nationally children’s hospitals are the most well funded facilities in the country, monuments to our willingness to throw money at the most dramatic health care interventions, but lack of national motivation to provide accessible basic health care for the country. Do we need to have traumatic injuries or cancer to gain access to the best health care in American, it would seem so.

Anyway, the next time you don't approve your school bond issue, think about the lives that are at stake and this is the healthpolicymaven signing off.

This article was written by Roberta Winter, MHA, MPA, health care journalist and advocate.

Bagaimana Menulis Cepat Dan Berkulitas

Kamu tipe orang yang sulit menyeimbangkan waktu untuk mengerjakan proyek dan hal lainnya? Jika ya, kita sama loh! Sebagai seorang freelance writer sekaligus mahasiswa tingkat akhir sekaligus tingkat awal, saya memiliki kecenderungan sulit menyeimbangkan waktu untuk bekerja, menyelesaikan skripsi, mengerjakan tugas kuliah, dan waktu untuk menyenangkan diri saya sendiri *curhat. Saya seringkali terlalu fokus pada satu hal yang sedang dikerjakan sampai benar-benar selesai, baru bisa berpindah ke task lainnya. Bisa dibilang, sebagai freelance writer, saya tidak multitasking untuk keadaan tertentu. Membutuhkan waktu luang yang ekstra untuk membuat tulisan. Akan tetapi, dengan waktu yang tetap 24 jam, dengan pekerjaan dan tugas lain yang tetap harus dikerjakan, tidak mungkin memohon untuk menambah sehari menjadi 25 jam. Saya harus mulai berpikir bagaimana caranya bisa menulis lebih cepat di waktu luang yang terbatas tanpa menurunkan kualitas tulisan.Tetap kualitas harus diutamakan karena freelance writer memang bekerja untuk menulis.

Kamu mempunyai masalah serupa? Sebagai sesama freelance writer, yuk kita berbagi tipsbagaimana menulis cepat tapi tetap berkualitas!

Menulislah di Waktu Produktif

Pasti semua orang mengira pagi hari adalah waktu yang pas untuk menulis karena otak kita masih fresh. Akan tetapi, tidak semua orang menggunakan waktu paginya untuk menulis. Bisa jadi, freelance writer yang juga seorang pelajar, belajar di pagi hari. Atau malah tidur di pagi hari, bekerja malam hari. Untuk sebagian orang, waktu produktif untuk menulis bisa pada tengah malam, setelah makan siang, dll. Kapanpun waktu produktif Anda, tandai dan keepwaktu tersebut untuk dijadikan waktu menulis, tidak untuk hal lainnya. Saya biasanya memulainya dengan mengecek email, media sosial, dan artikel terbaru di internet. Misalnya saja, saya hanya bisa bekerja pada sore hari dan dilanjutkan malam hari.

Menutup Browser Internet

Begitu berada di depan laptop siap untuk bekerja, saya biasanya langsung menghubungkan modem untuk mengecek email, media sosial, dan artikel terbaru untuk dijadikan referensi. Setelah semuanya dilakukan dan mendapatkan artikel yang cocok, saya langsung men-disconnect-an modem internet. Lalu, membaca artikel-artikel yang menjadi referensi untuk tulisan saya. Ingat, freelance writer penting untuk suka membaca Dan, mulailah menulis.

Perencanaan itu Penting

Jika pada akhir hari tersebut kamu masih mempunyai waktu luang untuk menulis, biasanya sih termotivasi untuk menulis menyelesaikan deadline di hari berikutnya. Sebaiknya, jangan terlalu keras pada diri kamu sendiri. Kamu akan kesulitan memotivasi diri kamu untuk hari-hari berikutnya jika terlalu lelah. Buatlah perencanaan. Mulailah dengan pekerjaan/tugas yang mudah kamu lakukan, yang ‘bahan-bahan’-nya sudah siap sedia kamu gunakan. Apapun pekerjaan/tugas yang kamu lakukan, membuat perencanaan itu penting. Ketika segala sesuatunya sudah direncanakan, kamu tidak perlu kebingungan lagi ketika sudah waktunya memulai. Tidak ada waktu yang terbuang percuma untuk stuck pada pikiran tertentu.

Buat Kerangka Tulisan

Kerangka tulisan (outline) mempermudah kamu untuk menulis. Jika pedoman tersebut diikuti, tulisan akan selesai dengan cepat. Terkadang, kerangka tulisan tersebut sudah bisa dikatakan sebagai artikel setengah jadi. Jika pada hari akhir Tersebut kamu masih ingin menulis, lebih baik buat kerangka untuk 1-2 tulisan untuk hari berikutnya. Otak tidak akan terlalu berpikir keras tapi tidak juga mengabaikan inspirasi yang datang.

Atur Timer!

Sebuah timer penting untuk membantu kamu tetap fokus. Di sisi lain, timer bisa memaksa kamu untuk beristirahat. Istirahat penting untuk menjaga pikiran tetap segar. Pikiran itu aset berharga, harus tetap dijaga kecemerlangannya *hehe. Misalnya kamu set waktu untuk menulis 30 menit, istirahat 5 menit. Untuk pekerjaan lainnya yang ringan 10 menit, istirahat 2 menit. Kamu cukup mengatur berapa waktu yang terbaik yang kamu perlukan untuk pekerjaan tertentu.

Itu dia tips sekaligus sharingnya. Mudah-mudahan bermanfaat. Ada yang mempunyai tipslainnya? Yuk di share!

Artikel ini diambil dari website www.ruangfreelance.com yang ditulis oleh Puput Pebrianti Rusmana

Affordable Care Act-Pragmatic Implementation

Health care Reform Implementation-A Pragmatic View of the Affordable Care Act

This article addresses the implementation of the medical insurance mandate under the Affordable Care Act of 2010, which will be implemented next year. Federal insurance purchasing subsidies, health insurance exchange plan design, and tax penalty information is highlighted for businesses and individuals.

Small Businesses Eligible for Government Assistance to Purchase Medical Insurance

Small businesses with less than twenty-five employees who meet certain criteria are eligible to receive federal subsidies to purchase health insurance for their employees. One of the criteria is an average wage of $50,000 or less for the entire workforce in determining any federal subsidy for insurance.

How much is the subsidy?

Only employer sponsored health plans with an actuarial value of 60% or higher will be eligible to receive the tax credit subsidies, so this is important information for small businesses who are considering starting or modifying their health insurance plans. Also, if the employee’s share of the premium would exceed 9.5% of their income that makes them eligible for a federal tax credit subsidy. So there are two ways an individual may qualify for a federal subsidy to buy insurance through their employer, either through the plan design or the income level of the individual.

Penalties for Noncompliance

The penalty is $2,000 times the number of employees less thirty employees.[1]So, this means employers with fewer than thirty would not have a tax penalty. Also, $2,000 is less than half of what it would cost for a typical employer to provide medical insurance for a single employee, so some employers may still choose to opt out of the mandated coverage. The Kaiser Family Foundation has a nice algorithm of the PPACA and employer impact on their insurance reform web site.

Individuals

Government Assistance to Purchase Medical Insurance

You will be eligible for a government subsidy to purchase medical insurance if your income falls within 133% of the poverty thresholds, which are listed below for 2012. The government subsidy is 98% of the health insurance premium, which will be based on a Blue Cross Blue Shield calculation each year for people who fall within this threshold.

Single individuals-                                  No more than $14,856

Individual plus one dependent-               $20,123

Individual plus two dependents-             $25,390

Individual plus three dependents-           $30,657

Individual plus four dependents-             $35,923

Individual plus five dependents-              $41,190

Individual plus six dependents-               $46,457

Individual plus seven dependents-          $51,724

If your income is within 250% to  400% of the federal poverty level, the government subsidy, via a tax credit will be roughly equal to 93.7% to 90.5% of the national Blue Cross Blue Shield annual health insurance premium calculation. Here is what those income thresholds were in 2012:

Individual plus one dependent-                $ 80,492

Individual plus two dependents-              $101,559

Individual plus three dependents-            $122,628

Individual plus four dependents-              $143,693

Individual plus five dependents-               $164,760

Individual plus six dependents-                $185,828

Individual plus seven dependents-           $206,895

Insurance Exchange Coverage

For those whose income is within 250% of the annual federal poverty calculation, they will also have a cap on the total amount per year that the individual is expected to pay for health care, based on a government formula. For example, if your income falls within 100% to 200% of the federal poverty limits, then the total amount for which you are responsible for health care costs within your insurance plan is reduced by 66%. The thought here is someone who is of low income will not be able to access health care services if their out-of-pocket expenses are too high. This is also a concern for middle class people, which is why the government has also limited the maximum out of pocket charges for those who are within 400% of the federal poverty level as well. This subsidy impacts only those plans offered through the federal insurance exchanges. Using 2012 figures, a family within 150% of the poverty level would have a maximum for total out of pocket expenses for the year of $3,963, including co-payments and premiums.

Penalties for Not Purchasing Insurance

For individual tax payers who do not obtain medical insurance and submit proof with their income tax return, a monetary penalty will be assessed. Though there are no civil penalties associated for failure to obtain the insurance, failure to file income taxes can be considered tax evasion and is prosecuted as a crime in the United States. For those who are considering not obtaining health insurance, be prepared to pay the fine. The penalty will start at $95 per year and increase to $695 by 2016 for individuals.

Impact on Larger Businesses

Businesses which have ERISA exempt health and welfare trust plans AKA which are self-insured, will not have to comply with much of the insurance reforms as their plans are already exempted, however the limitations on pre-existing condition waiting periods and extension of coverage for adult children provisions do apply to these plans. Larger businesses will do what they have always done, which is using their broker/consultant to scout around and figure out ways to tweak their plans to meet budget.

For more information on the healthpolicymaven’s analysis of the Patient Protection and Accountable Care Act, please look for Unraveling U.S. Health Care-A Personal Guide, this summer. You can read more about the book and its reviews on Rowman & Littlefield Publishing Group’s web site by following this link: https://rowman.com/ISBN/9781442222984

And this is the healthpolicymaven signing off.

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[1] http://healthreform.kff.org/the-basics/employer-penalty-flowchart.aspx

Medicaid Changes from the Accountable Care Act-Whether or Not Your State Adopted the Revised Eligibility Guidelines

What State Medicaid Expansions May look like in 2014

This article reviews the draft model for one state’s answer to the Medicaid Expansion under the Accountable Care Act. Washington State has posted the preliminary benchmarks and plan design for accommodating this act.[1]Warning to readers-this article may contain acronyms which are mind numbing, but part of the lumbering vernacular, and wherever possible the full name is cited.

Medicaid Eligibility

 To start with there are a dozen categories of “fast track” exemptions for Medicaid applicants and here is that list:

1. Health care for disabled workers
2. Family planning extension (more on this later)
3. Take charge family planning (whoa Nelly)
4. Psychologically indigent inpatient program (example-homeless folks)
5. Involuntary treatment act (hopefully this will apply to some of the nut-jobs who manage to obtain machine guns)
6. Kidney disease program (for those on dialysis)
7. ADATSA(Alcohol Drug Addiction Treatment Support Act)
8. Social Security Income qualifiers based on their low income status
9. Basic Health Plan qualifiers (subsidized medical insurance program for WA state residents with incomes no more than 200% of the Federal Poverty Level)
10. Medical Care Services Program (This is a managed care program run by the WA State Health Care Authority)
11. Medicaid qualifiers by virtue of low-income status
12. Children’s Health Insurance Plan Enrollees (CHIP)

Benchmark Plan Coverage

Next up are the definitions of the benchmark plan for insurance coverage mandates and here are those potential confounders:

1. Essential health benefits,
2. Essential health benefits reference plan
3. Base benchmark plan, benchmark
4. Alternative benefits plans

The benchmark plan must cover the following criteria in the benefit design:

1. BCBS-This refers to the bench mark equivalent coverage based on Blue Cross/Blue Shield plans
2. EPSTD-Early and Periodic Screening, Diagnosis, and Treatment Program which applies to children under 21 who are covered by the state Medicaid program
3. Non emergency transportation-What is this, a taxi to town?
4. Family planning services & supplies-AKA birth control options

People who are Exempt from the Benchmark Criteria and Eligible for Standard Medicaid Benefits include:

1. Pregnant women 
2.  Individuals who qualify for Medicaid based on being blind or disabled
3. Dual eligible enrollees, which is a category of people on both Medicare and Medicaid plans 
4.  Terminally ill hospice patients
5. Inpatients in hospitals, nursing home and ICF (assisted living facilities) who must spend all but a minimal amount of their income for the cost of medical care 
6.  TANF/Section 1931 enrollees, which is for parents and caretakers of incapacitated persons
7. Medically frail individuals, including those with disabilities that impair ability in one or more activities of daily living
8. Children in foster care 
9.  Individuals who qualify for LTC (long term care) services based on their medical condition
10. Individuals who only qualify for emergency care (?) 
11.  Individuals who qualify based on the  “spend down” of their total resources-such as senior citizens needing help with nursing home care.

Essential Health Benefits in 2014

The federal government has created ten essential health benefit plans for the states to adopt. Each state may have more than one benchmark Medicaid plan for eligible adults, which differs from the insurance exchange mandates, which are slated to have only one benchmark plan. Also, under current law, the mental-health-parity benefits for Medicaid only apply to Medicaid Managed Care Plans, and not the general Medicaid plans, but this is changing in 2014. According to federal mandates, essential health benefits must include the following insurance benefits:

1. Ambulatory services
2. Emergency services
3. Hospitalization
4. Maternity and newborn care
5. Mental health and substance use disorder services
6. Prescription drugs
7. Rehabilitative and habilitativeservices and devices
8. Laboratory services
9. Preventive and wellness services and chronic disease management
10. Pediatric services, including oral and vision care

With regard to the habilitative services and devices, this sounds like assistance for home living and a new word invented by the government order.

Benchmarking the New Medicaid Plan Design

Criteria which will be considered to establish a state benchmark for the Medicaid expansion plans include any of the following factors: the largest small group plan by enrollment (Blue Shield/Regence), the three largest state employee plans by enrollment, the largest three federal employee plans, and the largest commercial HMO in the state (Group Health Cooperative). The insurance companies will need to determine if their plans comply with the new criteria if they choose to participate in the Medicaid insurance offering, however, since so many of the state’s children are enrolled on the Children’s Health Insurance Plan (CHIP) it is expected that most carriers will. According to the Casey Foundation, 23% of the children in the United States live in poverty and in Washington State this metric was 18% in 2011.[2]In 2009, 57% of Washington’s Medicaid enrollees were children and this is true for other states as well.[3] The state with the most children living in poverty at that time was Mississippi at 32%.

Areas Not Affected by the Accountable Care Rules (ACO)

The ACA rules still allow Medicaid cost sharing in co-payments, deductibles, and contributions for services, which vary depending on the enrollee category. Medicaid does have the demonstration waiver provision under Section 1115, which allows states to petition for plan design changes which may have higher cost sharing provisions. Families with incomes equal to or less than the federal poverty level are allowed to have co-payments or cost sharing up to 5% of their income without any premium payments.  Allowable co-payments for 2012 are $3.80 for most services and $7.60 for none-life threatening-emergency room visits, as well as $3.80 for prescription drugs. There are also enrollees who are exempt from these co-payment requirements and they are as follows:

1. Pregnant women
2. Terminally ill people in hospice care
3. Medicaid enrollees who are already spending most of their income on health care costs during a hospitalization
4. Family Planning Services and supplies
5. Services provided by Indian Health Care entities for American Indians
6. Emergency services
7. All services are limited to one co-payment per service

Section 1115 Waiver Programs under Medicaid

Currently, forty states require some co-payment from parents enrolled on Medicaid and twenty-six states require co-payments for adults enrolled on their Section 1115 waiver programs. According to the Kaiser Commission Survey on Medicaid for the 2011 year, both Illinois and Wisconsin charge co-payments to Medicaid enrollees with incomes in excess of 150% of the federal level.

Bottom line, even for states not adopting the Affordable Care Act Medicaid expansion standards, there will still be an increase in their Medicaid enrollment for the following four reasons:

1. National insurance mandate requires insurance, so those who are of low income will become enrolled on Medicaid
2. Federal Subsidies through the insurance exchanges
3. Ease of enrollment process which integrates Medicaid and the insurance exchange offerings
4. In plain English, there will continue to be growth in Medicaid enrollment as long as there are so many people who are poor in this country

 And this is enough complexity and regulation analysis for a single setting so the healthpolicymaven is signing off.

This article was written by Roberta E. Winter, MHA, MPA and may be freely shared, with proper acknowledgement.

Additional sources for this article include the Center for Medicare and Medicaid- Medicaid Overview dated September 11, 2012 and the Kaiser Family Foundation Commission on Medicaid and the Uninsured report in November 2012.

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[1] http://www.hca.wa.gov/me/documents/Bnchmrk_Benefit_Cost_Sharing_December_2012.pdf

[2] http://datacenter.kidscount.org/data/acrossstates/Rankings.aspx?ind=43

[3] http://www.statehealthfacts.org/profileind.jsp?cat=4&sub=52&rgn=49