Health Care ReformDee FitzGerald

Terms of Endearment

• Personal Protection and Affordable Care Act• Previous Conditions• Exchanges• Medical Loss Ratio• Rate Review• HIPPA-exception Plans• Essential Therapy• Comprehensive Major Medical Coverage

ACA

• Passed in 2010• Staggered implementation• Court challenges• Target for repeal or major revision• Can not work independent of inclusion

Pre-existing Conditions

• One of two elements already in place• Popular desire – HIPAA• Minor insurance effect for large groups• Broad interpretation• Recidivism• Rescission

Exchanges in 2014

Large Group Plans (101+ lives)

Government Programs

• Medicare

• Medicaid

• CHIP

• TRICARE

• Veterans

Offered Outside

Exchange

Grandfathered Plans(Individual, Small or Large Group)

Individual or Small Group Plans (≤100 lives)

Offered Inside

Exchange

• Everyone must be enrolled in one of segments below• “Essential” benefits (still undefined) mandated for

individual and small group market• Stand-alone dental will have opportunity to separately offer

“essential” children’s dental inside, but not outside exchanges• HHS and States to determine rules of the exchange, and whether

non-essential benefits can be sold there

Medical Loss Ratio

• Set by regulation and law• Dictated by a business model• The dilemma of corporate bonuses• Shareholders versus the Public• Wall Street versus Main Street• Medical costs related to GNP• Disparity of medical costs by age

Rate Review

• WellPoint and the Individual Market• United Health and Medicare• Regulators and the Public

HIPPA-excepted Plans

• The Delta Dental Story• What HIPAA was designed to fix• HIPAA and the electronic medical record

Essential Therapy

• What is Essential and Why?• Rehabilitation versus Habilative services• Who makes the interpretation?• Cross-state competition

Ten General Categoriesand problem areas

• Ambulatory Patient Services– Varicose vein treatment

• Emergency Services– Non-emergency care in ER

• Hospitalization– Total hip replacement

• Maternity & Newborn Care– Fertility treatments

• Mental Health & Substance Abuse– Unlimited stay

• Prescription Drugs– “lifestyle” drugs

• Rehabilitative and Habilitative Services & Devices– Unlimited physical therapy

• Laboratory Services– Biometric testing, DNA markers

• Preventive & Wellness Services & Chronic Disease Management– Nutritional counseling

• Pediatric Services; including oral & vision care– braces

Comprehensive Major Medical

• The concept of rationing care• Medical choice

What Does the Future Hold?

• What is likely to happen and when?• What is unlikely to happen?• What might affect this group?

Questions?www.drdeekay.com

www.deefitzgerald.com