Changes to Private Insurance By: Brooklyn, Abby, McKenna, Derek

Dependent Coverage Abby Church ❖ Coverage for children up to age 26 ❖ Increases profit for insurance companies ❖ Get covered or pay a fee

Dependent Coverage Abby Church ❖ Young adults have highest rate of uninsured of any other group ❖ Wisconsin: coverage for unmarried dependents through a parent’s insurance offered until age 27 ❖ Wisconsin: full-time students called to active duty in the armed forces can be covered beyond 26 depending on various factors

Medicaid Abby Church ❖ Joined state and federal program ❖ Helps with medical costs ❖ Benefits: nursing home and personal care services

Prescription Drugs Abby Church ❖ Covered under ACA ❖ “Donut Hole”: coverage gap that begins after a consumer and their drug plan has reached a spending stand still on covered drugs ❖ at least one drug in every category must be covered

Waste, Fraud, and abuse Abby Church ❖ $10.7 billion of health care fraud in last 3 years ❖ Enhanced Screening: license checks and site visits for higher risk providers and suppliers of fraud ❖ New Resources: $350 million over 10 years to boost anti-fraud efforts

Temporary High-Risk Pools Derek Seibel Citizens with pre-existing conditions that have been uninsured for more than 6 months are eligible for a high-risk pool. Once in the high-risk pool they will receive subsidized premiums. This also means that insurance companies can only charge high risk individuals 4x more than their healthiest individuals. This part also limits insurance companies from charging more than the tax-free limit on HSA accounts.

Medical Loss Ratio Derek Seibel Makes health plans report what premium dollars were spent on. Makes patients state the quality of the care given to them. If money spent is less that 85% of out every dollar towards quality health care for large groups, they need to give the customer a rebate to meet the 85% requirement. For small groups the requirement is 80%. This forces insurance companies to either be more efficient in administrative cost or it cuts into their profits.

Premium Rate Reviews Derek Seibel Every price increase in a health plan is reviewed and determined if the price increase is justified or not. The insurance companies have to state why the price is increasing instead of just increasing it for no reason. States need to supply premium increase trends. New standards for administrative transactions in an attempt to simplify administration.

Insurance Market Rules Derek Seibel Prohibits insurance companies from placing lifetime caps on plans. Also prohibits insurance companies from rescinding coverage after acceptance except in cases of fraud. Insurance companies can’t place annual limits on coverage. Grandfather old plans in but new rules still apply. All rules that apply to large group insurance also apply to small group and individual insurance.

Insurance Market Rules Cont. Derek Seibel All new policies must comply with one of the four benefit categories. Deductibles are limited to $2000 for individuals and $4000 for families. Waiting periods are limited to 90 days. States can merge individual and small markets.

Cost Containment Medicare

Adopting a single set of operating rules for eligibility verification and claims status Basically this is just a simple and standard set of rules and guidelines for everyone. ●It helps hospitals and it helps keeps costs down Reduce annual market basket updates (Reduce the yearly rise of inflation) *Inpatient hospitals *Home health *skilled nursing facility *Hospice *Other medicare providers Brooklyn B

Medicare Part B and D ( ) : ●Freeze threshold for medicare part B premiums (Any medically necessary doctor services) ●Reduce the medicare part D premium (Outpatient prescription drug insurance) for those who have incomes above 85,000 Brooklyn B DHS (Disproportionate Share Hospital) ●Reduce DHS payments by 75% ●Increase payments based on % on population uninsured and the amount of uncompensated care provided (Effective 2014) Eliminate the Medical Improvement fund

Shared savings program (January 1, 2012) ●ACO’s (accountable care organizations) ●To qualify as an ACO: ○Agree to be responsible for overall care of their medicare beneficiaries ○participation of primary care physicians ○report on quality and costs ○Coordinate care ■Must voluntarily meet quality thresholds to share in the cost savings the the medicare program Brooklyn B Independent Payment Advisory Board (15 Members) ●The board will submit proposals such as: ○Ration care ○Increase revenues ○Change benefits ○Eligibility or medicare beneficiary cost sharing (Parts A & B) ○Recommendations every other year to slow the growth in the national health expenditures. ★ Hospitals and hospices and clinical labs will not be subject to cost reductions proposed by the board.

Restructure payments to Medicare Advantage (MA) By: ●Setting payments to different percentages of medicare fee-for-services rates (FFS) ●Modify rebate system ●cap total payments including bonuses ●Require medicare advantage plans to remit partial payments to secretary ○IF the plan has medical loss ratio of less than 85% - Require the secretary to suspend enrollment for three years. Brooklyn B

Creating Innovation Center Jan 1, 2011 ●Helps within centers for medicare and medicaid services. ●evaluates and expand in medicare ●different payment structures (CHIP) ●Reduce program expenditures ●Improve quality and reduce the rate of cost growth could be expanded throughout Medicare, Medicaid, and CHIP programs Brooklyn B Reduce Medicare payments that would be made to hospitals by specified percentages to account for preventable hospital readmissions. Reduce Medicare payments to certain hospitals for hospital acquired conditions by 1%

Administrative Simplification McKenna Koehler ●Health care providers using any electronic device to transfer funds must follow a standard set of rules. ●Must follow the privacy rule (protects an individual’s health information) ●Must follow security rule (protects confidentiality,integrity, and availability) ●The enforcement rule provides enforcement for all the rules under Administrative Simplification

Consumer Protections McKenna Koehler ●The Bureau of Consumer Protections stops unfair treatment from insurance providers ●Works to protect people from fraud ●Protects consumer’s rights when it comes to their health insurance ●Rules developed that providers have to follow to insure the rights of their consumers ●Providers can be sued if laws are broken

Health Care Choice Compacts and National Plans McKenna Koehler ●States can agree to form compacts with each other to permit cross-selling of insurance ●They have to follow laws of the state they are selling insurance in ●Only insurance of equal or lesser value than the companies they are in exchange with can be sold ●Gives opportunity for better and more affordable insurance

Health Insurance Administration McKenna Koehler ●Helps people choose appropriate coverage ●Organize insurance things in different work settings (hospitals, dentists, ect.) ●Administrative costs account for 25% of health care spending ●Some consider it a waste of money

State Role McKenna Koehler ●Must provide insurance for all employers ●Most of the population is insured under a family member’s employer ●enroll those eligible for Medicare ●Many states are trying to improve their insurance as a way to address rising healthcare costs ●States require help from the federal government

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