BSI and Federal Health Care Reform

Patient Protection and Affordable Care Act, as amended by Reconciliation

Behavioral Screening andIntervention (BSI) Symposiums

Pris Boroniec, MPPDirector of Health Care Reform

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Overview of Federal Reform

Patient Protection and Affordable Care Act PPACA was enacted into law on March 23, 2010 and was amended by

additional reforms in Reconciliation enacted on March 30, 2010.

Law provides framework for reform, but regulations now being promulgated by the federal Department of Health and Human Services, other federal agencies and the States will provide specific guidance on implementation

Proposed rules

Interim Final regulations

State administrative rules and regulations

State Medicaid Director Letters and Other Federal/State Guidance

PPACA has an individual mandate, Medicaid expansion and subsidies, state-based Insurance Exchanges, changes to insurance, Medicare and Medicaid, and incentives for quality, payment reform, workforce and prevention/wellness

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Overview of Federal Reform

Focus on Prevention and Wellness Promotes use of evidence-based preventive services – Expands coverage

for preventive services throughout the health care delivery system, particularly to those recommended by the U.S. Preventive Services Task Force (USPSTF).

Reduces financial barriers to preventive services – Eliminates cost sharing for preventive services. Most Americans currently use preventive services at half the recommended rate.

Improves health, productivity and the nation’s health care costs – Extends access to preventive services to an estimated 88 million people in new employer and individual plans by 2013, to all Medicare beneficiaries and to newly eligible and existing recipients in Medicaid.

Builds on multiple initiatives to promote prevention – Includes direct coverage of prevention services, grants for employer wellness, value-based purchasing incentives, tobacco cessation, and chronic disease reduction.

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Overview of Federal Reform

Preventive Services

USPSTF recommendations include Grade A and B preventive services for:

Alcohol misuse screening and behavioral counseling interventions for adult men, women and pregnant women

Depression screening for adult men and women

Tobacco use and tobacco-caused disease counseling for adult men, women and pregnant women

New USPSTF recommendations become subject to reform requirements one year after the recommendation is made

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Overview of Federal Reform

Coverage of Prevention Services Insurance – Beginning Sept 23, 2010, requires health plans (except

grandfathered plans) to provide coverage without cost-sharing for preventive services rated A or B by the U.S. Preventive Services Task Force (USPSTF), for recommended immunizations, and for prevention for infants, children, adolescents and women.

Medicare – Beginning January 1, 2011, requires Medicare to cover 100% of the cost, including an initial and annual wellness physical exam, personalized prevention plan, and any covered preventive service recommended by the USPSTF with a grade of A or B.

Medicaid – Effective January 1, 2013, expands Medicaid state plan amendment authority to cover preventive services recommended by the USPSTF with a grade of A or B and, for States that cover services under Medicaid without cost sharing, provides a one percentage point increase in federal match for these services.

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Insurance and Prevention Services

Key Provisions of Law and Interim Final Rule (July 19, 2010) Effective Date: For plan years (or, for individuals, policy years) on or after Sept 23, 2010 (6

months after enactment).

Benefits and Cost Sharing: Requires group health plans and a health insurance issuer to provide benefits for and prohibit the imposition of cost sharing requirements with respect to:

Prevention Benefits Evidence-based items or services with a rating of A or B in the USPSTF recommendations Recommended immunizations Preventive care and screenings for infants, children, adolescents and women. For a complete list, see http://edocket.access.gpo.gov/2010/pdf/2010-17242.pdf

Cost Sharing Billing for office visits and preventive services is clarified

• Prevention service is billed separately/separate encounter data • Purpose of visit

Billing for out-of-network care is allowed Billing for treatment that results from a preventive service is allowed

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Insurance and Prevention Services Key Laws and Rules (Continued)

Applicable to: Group health plans and health insurance issuers in the group and individual markets, including self-insured plans. Only applies to plans that are not “grandfathered.”

Grandfathered plans. Group health plan or health insurance in which an individual was enrolled as of March 23, 2010 (includes renewals / new family members / new employees). Existing plans will lose their “grandfather” status if they choose to significantly cut benefits or increase out-of-pocket spending for consumers.

Loss of grandfathered status is triggered by:

Estimated Impact: Estimated to improve access to preventive services for 31 million in new employer plans and 10 million in new individual plans in 2011, with premiums projected to rise by roughly 1.5% for non-grandfathered plans. Many of the 98 million in existing group health plans currently have preventive services coverage.

Elimination of benefits Increase in fixed-dollar co-pays

Increase in the percentage of cost sharing Decrease in contribution rate by employers

Increase in fixed-amount cost sharing, not co-pays Increase in annual dollar limits

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Medicare and Prevention Services Key Provisions

Effective Date: January 1, 2011 Proposed Rule: Improve the health status of Medicare beneficiaries by expanding access to

preventive services, and promoting early detection and prompt treatment of medical conditions.

Elimination of Cost Sharing. Waives the Part B deductible and the 20 percent coinsurance for Medicare-covered preventive services recommended as A or B by the USPSTF (including new tobacco counseling), the initial preventive physician exam and the annual wellness visit

Annual Wellness Visit Providing a Personalized Prevention Plan. Creates annual wellness visit with personalized prevention plan services (PPPS), including:

Estimated Impact: Improved access to preventive services for Medicare beneficiaries is estimated to result in increased Medicare payments of $110 million for FY 2011.

Medical and family history

Current providers/suppliers and all prescribed medications

Record measurements (height, weight, body mass index, blood pressure, other)

Detect any cognitive impairment

Establish a screening schedule for the next 5 to 10 years (appropriate & patient risk factors)

Personal health advice, coordinate referrals / health education

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Medicaid and Prevention Services

Key Provisions

Effective Date: January 1, 2013

Statute : States will have the authority to expand Medicaid coverage of preventive services through a state plan amendment to cover:

Preventive services recommended by the USPSTF with a grade of A or B;Recommended immunizations for adults; andTobacco cessation services for pregnant women.

Enhanced Reimbursement: For States that cover services under Medicaid without cost sharing, a one percentage point increase in federal match, or FMAP, will be provided for these prevention services.

Note: Wisconsin Medicaid and BadgerCare Plus currently cover SBI services

For more information, please contact:

Pris BoroniecDirector of Health Care Reform

608.234.7372pboroniec@sellersdorsey.com

www.sellersdorsey.com

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