Legislative Webinar - September 17, 2010

Wellness & Prevention

Initiatives,2010 PPACA Provisions,

Health Insurance Exchanges, and

OTC Drug Reimbursements and Mini Med Plans

Presented by Sharon Alt

• Wellness & Prevention Initiatives

• 2010 PPACA Provisions

• Health Insurance Exchanges

• OTC Drug Reimbursements/Mini Med Plans

Today’s Agenda

Source: www.HealthCare.gov

Wellness & Prevention Initiatives Under PPACA

• Reduce “behavioral waste” – Preventable illnesses,

such as those caused by obesity and smoking.

• PricewaterhouseCoopers’ Health Research Institute survey disclosed approximately $303 billion to $493 billion is spent annually on treating preventable illnesses.

Wellness & Prevention InitiativesPurpose of Reform


Key Elements

• Elimination of co-payments for screenings and

preventive care

• Employee wellness discounts

• Break time for nursing mothers

• Posting of nutritional requirements

• Government funding for wellness programs

• Small business grants for wellness programs

Wellness & Prevention Initiatives


• Starting in September of 2010, employer-sponsored

(and other) group health plans and health insurance issuers are prohibited from requiring co-pays for all preventive services recommended by the United States Preventative Services Task Force (USPTF).

• Co-pays are eliminated for certain recommended immunizations, breast care screenings and other preventive care/screenings for women and children.

• Requirements do NOT apply to “grandfathered” health plans.

Wellness & Prevention Initiatives Elimination of Co-Payments for Screenings

and Preventive Care


• Starting January 1, 2014, PPACA enhances such

wellness discounts by permitting group health plans to give reductions of up to 30% of the cost of premiums to employees who participate in such wellness programs.

• May be expanded to 50% subject to the discretion of the Secretary of Health and Human Services (HHS).

Wellness & Prevention InitiativesEmployee Wellness Discounts


Effective immediately for employers covered by the Fair Labor Standards Act:

• Must provide reasonable break time and a private space – other than a restroom – for a nursing mother for up to one year after child birth.

• Employers are not required to compensate employees during such breaks.

• Employers with less than 50 employees may qualify for exceptions if it can be proven the requirement would impose an undo hardship.

Wellness & Prevention InitiativesBreak Time for Nursing Mothers


• By March of 2011, The Secretary of HHS must

publish regulations requiring all chain restaurants to disclose the nutritional content of all menu items.

• The number of calories for each item must be disclosed on menus, menu boards and drive through menus.

• Menus must also feature “a succinct statement concerning suggested daily caloric intake.”

• Includes buffet items and vending machines.

Wellness & Prevention InitiativesPosting of Nutritional Requirements


Prevention and Public Health Fund

The Prevention and Public Health Fund will be administered through HHS and will support prevention and public health programs. Beginning with the fiscal year 2010, $500 million will be appropriated to various programs within HHS, with the amount of appropriations increasing each year to $2 billion in the fiscal year 2015 and each year thereafter.

Wellness & Prevention InitiativesGovernment Funding for Wellness Programs



Prevention and Public Health FundUnder PPACA, funds are to be used for activities such as:

• Prevention research and health screenings

• Community Transformation grant program (designed to fund state and municipal wellness programs by creating walking paths, nutrition awareness programs, etc)

• Education and Outreach Campaign for Preventive Benefits (a planned public-private partnership to raise awareness on preventive care)

• Immunization programs.


Prevention and Public Health Fund

School-based health centers (facilities that provide primary health care to students on school campuses) will receive $50 million per year in grant funding through 2013. These grant monies are to be used only for expenditures on facilities and equipment, not for personnel hiring.



• Grant program to assist small businesses in providing

comprehensive workplace wellness programs.

• Grants will be awarded beginning in 2011.

• $200 million appropriated for a five year period.

Note: Money will likely go quickly. Small businesses need to be prepared with a wellness program proposal which meets the criteria and requirements as described in the PPACA, and developed by the Secretary of HHS.

Wellness & Prevention InitiativesSmall Business Grants for Wellness Programs


Who is an eligible employer?

• Employs fewer than 100 employees who work 25 hours of more a week; and

• Did NOT have a workplace program in place as of March 23, 2010 (date of PPACA enactment).



http://www.google.com/imgres?imgurl=http://www.preventiekompas.nl/gfx_content/news/Economist_cartoon.jpg&imgrefurl=http://www.preventiekompas.nl/nieuws.aspx?page_id=32&menu_id=0&news_id=12&page=0&usg=__h6TnDslt_z0f6zTU36amN1g834Y=&h=303&w=401&sz=26&hl=en&start=5&zoom=1&itbs=1&tbnid=C8wF3Zb_h0kepM:&tbnh=94&tbnw=124&prev=/images?q=cartoon+employees+working+out&hl=en&sa=N&gbv=2&ndsp=20&tbs=isch:1

Unresolved questions…

• How will wellness programs stand up to the scrutiny of GINA?

• How much grant money can a qualified employer receive?

• Money runs out in 2015?• Where is the money?



2010 PPACA Provisions

http://www.google.com/imgres?imgurl=http://www.2010calendar.org/2010-calendar-800.gif&imgrefurl=http://www.2010calendar.org/about.htm&usg=__sTWlttGDAOyjjONV0XoVW18M9KY=&h=649&w=800&sz=168&hl=en&start=10&zoom=1&itbs=1&tbnid=KZd2oMZ8w_pbsM:&tbnh=116&tbnw=143&prev=/images?q=2010+calendar&hl=en&gbv=2&tbs=isch:1

http://www.google.com/imgres?imgurl=http://www.2010calendar.org/2010-calendar-800.gif&imgrefurl=http://www.2010calendar.org/about.htm&usg=__sTWlttGDAOyjjONV0XoVW18M9KY=&h=649&w=800&sz=168&hl=en&start=10&zoom=1&itbs=1&tbnid=KZd2oMZ8w_pbsM:&tbnh=116&tbnw=143&prev=/images?q=2010+calendar&hl=en&gbv=2&tbs=isch:1

Provisions effective immediately, or in 2010

• An end to pre-existing conditions• Health Insurers cannot deny children health

insurance because of a pre-existing condition.• Small business tax credits

• Businesses with fewer than 25 “full time” employees can begin receiving a tax credit at 35% up to a maximum of 50% - subject to calculations and time frame.

• Seniors get donut hole rebate • Seniors will get a rebate to fill the donut hole in

Medicare drug coverage.


Source: www.DHHS.gov


• Transparency in insurance companies• Insurers must reveal how much money is spent on

overhead.• Customer appeals process

• Any new plan must now implement an appeals process for coverage determination and claims.

• Indoor tanning services tax• Imposes a 10% tax on indoor tanning services

(effective for services on, or after July 1, 2010).




• Enhanced fraud abuse checks• New screening procedures will be implemented to

help eliminate health insurance fraud and waste.• Medicare expansion to rural areas

• Medicare payment protections will be extended to small rural hospitals and other facilities that have a small number of Medicare patients.

• Deductions for Blue Cross Blue Shield• Non-profit Blue Cross Blue Shield organizations will

be required to maintain a medical loss ratio (MRL).




• Nutrient content disclosure• Chain restaurants will be required to provide a

“nutrient” content disclosure statement alongside their menus.

• Better coverage for early retirees• A temporary program for companies that provide

early health benefits for those aged 55-64. • Better consumer information on the web

• New website through HHS to make it easier for Americans in any state to seek out affordable health insurance options.




• Encouraging investment in new therapies• A two year temporary credit (to a maximum of $1

billion) to encourage investment in new therapies for the prevention and treatment of diseases.

• Break time for nursing mothers• Requires employers to furnish reasonable break

time and place for nursing mothers for up to one year after the child’s birth.

• Cost-sharing obligations for preventive services are prohibited




• Coverage for emergency room services at in-network cost-sharing level with no prior authorization is mandated.

• Group plans IRC section 105(h) rules • Group plans will be required to comply with the

IRC section 105(h) rules that prohibit discrimination in favor or highly compensated individuals – rules apply to both self-funded and fully-insured plans.

• Wellness grants for small employers• Small employers seeking to implement wellness

programs can now access federal grant money.



Provisions effective immediately, or in 2010Grandfathered Plans

• More young adults covered on parents’ plans• The cut-off age for young adults to continue to

be covered by their parents’ health insurance rises to the age of 26.

• No lifetime caps• Annual caps will be limited, and banned in 2014.

• Adults with pre-existing conditions covered• A temporary high-risk pool will be set up to cover

adults with pre-existing conditions – Health Insurance Exchanges will eliminate the program in 2014.



Provisions effective immediately, or in 2010Grandfathered Plans

• New insurance plans must include preventive care

• New plans must cover checkups and other preventive care without co-pays, ALL plans will be affected by 2018.

• The end of rescissions• Insurance companies can no longer cancel

policies when an individual gets sick.



Health Insurance Exchanges

A Health Insurance Exchange is an organized

marketplace for the purchase of health insurance set up as a governmental or quasi-governmental entity to help insurers comply with consumer protections.

Health Insurance ExchangesDefinition

Source: www.HealthReform.gov

Questions regarding Health Insurance Exchanges :


• Who will develop and implement policies and rules governing state-based Exchanges?

• When will Exchanges go in effect?

• What are Small Business Health Options Program Exchanges?

• Who can participate in the Exchange?

• Subsidies?


Key Elements

• The Office of Health Insurance Exchanges will develop and implement policies and rules governing state-based Exchange health coverage distribution entities.

• States are required to have their Exchanges up and running no later than January 1, 2014.

• Four plan choices and a catastrophic plan will be offered in each Exchange.

• States may form regional Exchanges or allow more than one exchange to operate in a state as long as each exchange serves a distinct geographical area.



Key Elements continued…

Existing health insurance plans will be allowed to participate in the exchange if they;

• Meet marketing requirements

• Have adequate provider networks

• Contract with the essential community providers

• Contract with navigators to conduct outreach and enrollment assistance

• Are accredited with respect to performance on quality measures

• Use a uniform enrollment form and use a standard format to present plan information.



Small Business Health Options (SHOP) Exchanges SHOP Exchanges will also be administered by a

government agency or a non-profit organization.

• State-based.

• Small businesses with up to 100 employees will be able to purchase qualified coverage no later than January 1, 2014.



Who is eligible to participate in an Exchange?

• The uninsured and self-employed would be able to purchase insurance through state-based Exchanges.

• Separate Exchanges will be created for small businesses to purchase coverage through the Exchange (SHOP).



Who is eligible for a subsidy?

• The unemployed, and self-employed, or, those who work for an employer that does not offer coverage.

• Those who work for an employer who does offer health coverage whose wages are less than the poverty cut-off level, would also be eligible for a subsidy if the portion of premium they are required to pay is more than 9.8% of their income.



OTC Drug Reimbursements and Mini Med Plans

The IRS issues guidance explaining 2011 changes to Flexible Spending Arrangements• The Affordable Care Act, enacted in March,

established a new uniform standard that, effective January 1, 2011, applies to FSAs, HRAs, HSAs, and MSAs.

• Under the new standard, the cost of an over-the-counter medicine or drug cannot be reimbursed from the account unless a prescription is obtained.

New IRS Guidance


Waiver Process for “Mini-Med” Plans


Department of HHS issues guidance on waiver process for “Mini-Med” plans

• For plan years beginning on or after January 1, 2014, no annual dollar limits on essential benefits may be imposed.

• Rules apply to grandfathered and new group health plans.



The Interim Final Regulations provided that these restricted annual limits may be waived by the Secretary of HHS if compliance with the IFR would result in a significant decrease in access to benefits or a significant increase in premiums. The preamble to the IFR further provided that guidance from HHS regarding the scope and process for applying for such a waiver would be issued in the near future. The memorandum issued by HHS on September 3, 2010 (the “HHS memorandum”), provides such guidance.



Waivers are only available or plans that were in existence before September 23, 2010. When does the waiver application have to be submitted? For plan years beginning before November 2, 2010, the waiver application must be submitted at least 10 days in advance of the start of the year. Otherwise, the application must be submitted at least 30 days before the beginning of the plan year. When will HHS process the wavier application? HHS will process complete requests generally within 30 days of receipt, but for plan years beginning before November 2, 2010, HHS will process the application no later than five days in advance of the year.



If granted, for how long will a waiver apply? Waivers will be granted initially only for the first plan year beginning between September 23, 2010, and September 23, 2011. New waiver applications must be submitted for later years and HHS may change the approval process in the future.

What information must be included in the application? • The terms of the plan for which a waiver is sought • The number of individuals covered by the plan• The annual limit(s) and rates applicable to the plan • A brief description of why compliance with the IFR on

annual limits would result in a significant decrease in access to benefits for those currently covered by the plan, or significant increase in premiums

• An attestation.

Thank You

Additional questions can be submitted through

HealthcareExchange.com

Legislative Webinar - September 17, 2010

Education

Transcript of Legislative Webinar - September 17, 2010