Calculator property of Small Business Majority and its subsidiary website California Health Coverage Guide

MFH has allocated a total of $250,000 in 2012 to fund Community Partnerships projects in its service region.  Depending on the populations of their target areas, applicants can request between $15,000 and $50,000 to cover costs of project activities.  The anticipated start date for the Community Partnerships projects is November 2012. The application deadline is April 16. There is a pre-application conference call next Wednesday, March 28 at 10:00 am for those organizations interested in applying. To RSVP, contact Jenny Minelli at jminelli@mffh.org. 

The application can be accessed by going to the Systems Development portion of our website and clicking on the Community Partnerships RFA located on the right hand side of the page. Kathleen Holmes, Program Director can be contacted with questions about the RFA at kholmes@mffh.org or at 314-345-5572 .

Please feel free to share this information with organizations you believe would find it helpful.

Affordable Care Act Ensures Women Receive Preventive Services at No Additional Cost

Historic new guidelines that will ensure women receive preventive health services at no additional cost were announced today by the U.S. Department of Health and Human Services (HHS). Developed by the independent Institute of Medicine, the new guidelines require new health insurance plans to cover women’s preventive services such as well-woman visits, breastfeeding support, domestic violence screening, and contraception without charging a co-payment, co-insurance or a deductible.

“The Affordable Care Act helps stop health problems before they start,” said HHS Secretary Kathleen Sebelius.  “These historic guidelines are based on science and existing literature and will help ensure women get the preventive health benefits they need.”

Before health reform, too many Americans didn’t get the preventive health care they need to stay healthy, avoid or delay the onset of disease, lead productive lives, and reduce health care costs.  Often because of cost, Americans used preventive services at about half the recommended rate.

Last summer, HHS released new insurance market rules under the Affordable Care Act requiring all new private health plans to cover several evidence-based preventive services like mammograms, colonoscopies, blood pressure checks, and childhood immunizations without charging a copayment, deductible or coinsurance. The Affordable Care Act also made recommended preventive services free for people on Medicare.

Today’s announcement builds on that progress by making sure women have access to a full range of recommended preventive services without cost sharing, including:

• well-woman visits;
• screening for gestational diabetes;
• human papillomavirus (HPV) DNA testing for women 30 years and older;
• sexually-transmitted infection counseling;
• human immunodeficiency virus (HIV) screening and counseling;
• FDA-approved contraception methods and contraceptive counseling;
• breastfeeding support, supplies, and counseling; and
• domestic violence screening and counseling.

New health plans will need to include these services without cost sharing for insurance policies with plan years beginning on or after August 1, 2012.  The rules governing coverage of preventive services which allow plans to use reasonable medical management to help define the nature of the covered service apply to women’s preventive services.  Plans will retain the flexibility to control costs and promote efficient delivery of care by, for example, continuing to charge cost-sharing for branded drugs if a generic version is available and is just as effective and safe for the patient to use.

The administration also released an amendment to the prevention regulation that allows religious institutions that offer insurance to their employees the choice of whether or not to cover contraception services. This regulation is modeled on the most common accommodation for churches available in the majority of the 28 states that already require insurance companies to cover contraception.  HHS welcomes comment on this policy.

Previously, preventive services for women had been recommended one-by-one or as part of guidelines targeted at men as well.  As such, the HHS directed the independent Institute of Medicine to, for the first time ever, conduct a scientific review and provide recommendations on specific preventive measures that meet women’s unique health needs and help keep women healthy.  HHS’ Health Resources and Services Administration (HRSA) used the IOM report issued July 19, when developing the guidelines that are being issued today. The IOM’s report relied on independent physicians, nurses, scientists, and other experts to make these determinations based on scientific evidence.

Today’s announcement is another part of the Obama Administration’s broader effort to address the health and well-being of our communities through initiatives such as the President’s Childhood Obesity Task Force, the First Lady’s Let’s Move! campaign, the National Quality Strategy, and the National Prevention Strategy.

For more information on the HHS guidelines for expanding women’s preventive services, please visit: http://www.healthcare.gov/news/factsheets/womensprevention08012011a.html. The guidelines can be found at: www.hrsa.gov/womensguidelines/.

To learn more about the Affordable Care Act, please visit www.healthcare.gov.

You Tube Video- Small Business Owner Gets Help Covering Employees Health Care

Today, many insurance companies spend a substantial portion of consumers’ premium dollars on administrative costs and profits, including executive salaries, overhead, and marketing.  Thanks to the Affordable Care Act, consumers will receive more value for their premium dollar because insurance companies will be required to spend 80 to 85 percent of premium dollars on medical care and health care quality improvement, rather than on administrative costs, starting in 2011.  If they don’t, the insurance companies will be required to provide a rebate to their customers starting in 2012.

On November 22, 2010, the Obama Administration issued a regulation implementing this policy, known as the “medical loss ratio” provision of the Affordable Care Act.  This regulation will make the insurance marketplace more transparent and make it easier for consumers to purchase plans that provide better value for their money. 

Over 20 percent of consumers who purchase coverage in the individual market today are in plans that spend more than 30 cents of every premium dollar on administrative costs.  An additional 25 percent of consumers in this market are in plans that spend between 25 and 30 cents of every premium dollar on administrative costs.  And in some extreme cases, insurance plans spend more than 50 percent of every premium dollar on administrative costs.  This regulation will help consumers get good value for their health insurance premium dollar.

In 2011, the new rules will protect up to 74.8 million insured Americans, and estimates indicate that up to 9 million Americans could be eligible for rebates starting in 2012 worth up to $1.4 billion.  Average rebates per person could total $164 in the individual market.  Important details regarding the new regulation are included below.

How These New Rules Will Help You – Ensuring Value for Consumers

The new medical loss ratio rules will hold insurance companies accountable and increase value for consumers by: 

• Establishing Greater Transparency and Accountability:  Beginning in 2011, the law requires that insurance companies publicly report how they spend premium dollars.  This information will provide consumers with meaningful information on how their premium dollars are spent, clearly accounting for how much money goes toward actual medical care and activities to improve health care quality versus how much money is spent on administrative expenses like marketing, advertising, underwriting, executive salaries and bonuses. 

• Ensuring Americans Receive Value for their Premium Dollar:  Beginning in 2011, the law requires insurance companies in the individual and small group markets to spend at least 80 percent of the premium dollars they collect on medical care and quality improvement activities.  Insurance companies in the large group market must spend at least 85 percent of premium dollars on medical care and quality improvement activities. 

• Providing Rebates to Consumers:  Insurance companies that are not meeting the medical loss ratio standard will be required to provide rebates to their consumers.  Insurers will be required to make the first round of rebates to consumers in 2012.  Rebates must be paid by August 1st each year.  Enrollees owed a rebate will see a reduction in their premiums, receive a rebate check, or, if the enrollee paid by credit card or debit card, a lump-sum reimbursement to the same account that the enrollee used to pay the premium.  In some cases, the rebate may go to the employer that paid the premium on the enrollee’s behalf.  Regardless of whether the rebate is provided to enrollees directly or indirectly through their employer, each enrollee must receive a rebate that is proportional to the premium amount paid by that enrollee. 

Working with State Experts: Developing the Medical Loss Ratio Regulation

The Affordable Care Act required the National Association of Insurance Commissioners (NAIC) to develop uniform definitions and methodologies for calculating insurance companies’ medical loss ratios.  Insurance commissioners in every State have a responsibility to protect the interests of the general public, policyholders, and enrollees within their respective States.  Today’s regulation certifies and adopts the recommendations submitted to the Secretary of Health and Human Services (HHS) on October 27, 2010, by the NAIC.  It also incorporates recommendations from a letter sent to the Secretary by the NAIC on October 13, 2010.  The NAIC report was approved unanimously by representatives from every State and the District of Columbia and is the product of months of public hearings and consultation with consumers, employers, insurers, and other stakeholders.  The NAIC has a long history of developing these types of rules through a transparent process with stakeholder input, and this process was no exception.

The medical loss ratio regulation outlines disclosure and reporting requirements, how insurance companies will calculate their medical loss ratio and provide rebates, and how adjustments could be made to the medical loss ratio standard to guard against market destabilization. 

Insurer Reporting Requirements

Beginning in 2011, insurance companies that issue policies to individuals, small employers, and large employers will have to report the following information in each State it does business:

&middot                     Total earned premiums;

&middot                     Total reimbursement for clinical services;

&middot                     Total spending on activities to improve quality; and

&middot                     Total spending on all other non-claims costs excluding federal and State taxes and fees.

These reports will be posted publicly by HHS so residents of every State will have information on the value of health plans offered by different insurance companies in their State.

An insurer will report aggregate premium and expenditure data for each market, except for so-called “expatriate” and “mini-med” plans.  For these plans, insurers will be allowed to report their experience separately.  Although the NAIC did not make a formal recommendation on this subject, in their letter sent to Secretary Sebelius on October 13, 2010, the NAIC recommended that the Secretary exclude expatriate plans—health insurance provided to U.S. citizens who are living or working abroad – from the new requirements.  The regulation accelerates data collection and creates a special methodology that follows this recommendation to the extent permitted by the Affordable Care Act.  HHS is allowing the same treatment for mini-med plans — insurance products with very low annual dollar limits and low premiums – to allow this type of coverage to continue until 2014 when better, more affordable options will be available to consumers.

Activities That Improve Health Care Quality

Following NAIC recommendations, this regulation specifies a comprehensive set of “quality improving activities” that allows for future innovations and may be counted toward the 80 or 85 percent standard.  Quality improving activities must be grounded in evidence-based practices, take into account the specific needs of patients and be designed to increase the likelihood of desired health outcomes in ways that can be objectively measured.

In order to maintain incentives for innovation, insurers will not be required to present initial evidence in order to designate an activity as “quality improving” when they first begin implementing it.  However, to ensure value, the insurer will have to show measurable results stemming from the quality improvement activity in order to continue claiming that it does in fact improve quality.

Timing of Reporting and Rebates

The regulation generally requires health insurance companies to report to the Secretary by June 1 of each year.  The first report, containing calendar year 2011 data, will be due in 2012, which gives insurers adequate time to make necessary reporting adjustments.  Insurers will be required to make the first round of rebates to consumers by August 2012 based on their 2011 medical loss ratio.  Under the regulation, expatriate and mini-med plans that report separately will be required to report data to the Secretary on an accelerated basis.

Treatment of Taxes in the Rebate Calculation

Consistent with NAIC recommendations, the regulation will allow insurers to deduct federal and State taxes that apply to health insurance coverage from an insurer’s premium revenue when calculating its medical loss ratio.  As NAIC recommended, taxes assessed on investment income and capital gains will not be deducted from premium revenue.  In the case of non-profit plans, assessments they are required to pay in lieu of taxes may be deducted.

Accommodations to Ensure Continued Access to Coverage by Consumers

In order to guard against market destabilization, the Affordable Care Act stipulates that the reporting requirements and methodologies for calculating the medical loss ratio “be designed to take into account the special circumstances of small plans, different types of plans, and new plans.”

• Smaller Plans.  Consistent with NAIC recommendations, this regulation allows insurers to add to their medical loss ratio a “credibility adjustment” when the insurer’s medical loss ratio for a market within a State is based on less than 75,000 people enrolled for an entire calendar year.  The credibility adjustment recommended by the NAIC and adopted in the regulation addresses the statistical unreliability of experience based on a small number of people of covered.  Specifically:

•  
  • An insurer that has less than 1,000 people enrolled for an entire calendar year lacks sufficient experience to calculate a reliable or meaningful medical loss ratio.  The experience of these very small insurers cannot sufficiently confirm that they have or have not met the medical loss ratio standard, and as a result those insurers are deemed non-credible and will not be required to provide rebates.     
  • An insurer with 1,000 to 75,000 people enrolled for an entire calendar year is considered to have “partially credible” experience, and, accordingly, the regulation adds a “credibility adjustment” to its medical loss ratio. 
  • An insurer with 75,000 or more people enrolled in a plan for an entire calendar year is considered to have “fully credible” experience and will pay rebates based on its actual medical loss ratio without any credibility adjustment.

The NAIC commissioned an extensive analysis by a well-known national actuarial consulting firm, and relied on these findings to develop its credibility adjustment calculation.  In developing its recommendations, the NAIC noted that the credibility adjustment methods and factors should be monitored and re-evaluated in light of developing experience.  The Administration intends to carefully monitor the effects and suitability of the regulation’s initial approach to credibility adjustment over the next three years.

• Newer Plans.  Consistent with NAIC recommendations, certain insurers that have newly joined the insurance market may be able to delay reporting their medical loss ratio until the next year.  When 50 percent or more of an insurer’s premium income accounts for policies that have not been effective for an entire calendar, they are eligible to delay reporting until the following year.   This means that more than half of an issuer’s overall premium revenue within a particular market in a State would have to be from policies that are newly issued policies after January 1 of the year.  In this instance, the issuer’s MLR for the following year will include the deferred experience, as well as the current MLR reporting year experience. 

Allowing insurance companies to defer reporting newer business reduces barriers to market entry by reducing the risk of failing to meet the MLR standard and having to pay a rebate.  

• Mini-Med and Expatriate Plans.  In order to address the special circumstances of mini-med and expatriate plans, HHS will apply a methodological adjustment to the way the medical loss ratio is calculated for those plans.  The methodological adjustment will address the unusual expense and premium structures of mini-med and expatriate plans, and enable their issuers to apply for an adjustment to reported medical claims and quality improvement expenses.  Because limited data are available to inform such an adjustment, this regulation requires accelerated reporting by issuers of mini-med and expatriate plans so that HHS may receive and review data on their expense structures and profitability.  These changes to the methodology for reporting and rebates apply only in calendar year 2011, and as noted above, such plans are required to provide early reporting to the Secretary if they claim such an adjustment.  To improve transparency and ensure consumers are aware of the product they are purchasing, HHS will require insurers that sell mini-med policies to provide prominent notice regarding the benefits and coverage provided by the policy.

Accommodations to Avoid Market Destabilization

In the individual market, the Affordable Care Act allows the Secretary to adjust the medical loss ratio standard for a State if it is determined that meeting the 80 percent medical loss ratio standard may destabilize the individual market.  Consistent with NAIC recommendations, the regulation establishes a process for States to request such an adjustment.  In order to qualify for this adjustment, a State must demonstrate that requiring insurers in its individual market to meet the 80 percent MLR has a likelihood of destabilizing the individual market and could result in fewer choices for consumers. 

The approach taken in the regulation is designed to give States and other interested parties full opportunity to present relevant information that the Secretary needs to make a timely determination about whether an adjustment to the statutory medical loss ratio standard is justified for insurers in that particular individual market.  It is consistent with the recommendations in the NAIC letter dated October 13, 2010. 

Enforcement

The Affordable Care Act gives the Secretary direct enforcement authority for the medical loss ratio requirements.  However, HHS recognizes States’ capacity to assist in enforcement and will accept the findings of a State audit of MLR compliance if they are based on the medical loss ratio requirements set forth in federal law and regulations. 

The regulation also requires insurers to retain documentation that relates to the data they reported and to provide access to those data and their facilities to HHS, so compliance with reporting and rebate requirements can be verified. 

Finally, the regulation imposes civil monetary penalties if an insurer fails to comply with the reporting and rebate requirements set forth in the regulation, and it details the criteria and process for determining whether and in what amount such penalties should be imposed.  Although the law allows HHS to develop separate monetary penalties for medical loss ratio non-compliance, HHS has adopted the HIPAA penalties in this regulation.  The regulation’s penalty for each violation is $100 per entity, per day, per individual affected by the violation.

 By Guest Blogger:

Below is the blog entry from Joel Ferber on the Center for Children and Families blog found here.

http://theccfblog.org/2010/11/medicaid-managed-care—states-should-look-before-they-leap-again.html

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No TrackBacks By Joel Ferber, Legal Services of Eastern Missouri and nationally recognized expert on Medicaid A recent article in USA Today focused on Medicaid managed care and its implications for health reform. Health insurance companies are clamoring for the substantial new business that will become available when Medicaid coverage is expanded to an estimated 16 million new individuals under the Affordable Care Act. Medicaid managed care is already well-established in state Medicaid programs although a few states (like Oklahoma and North Carolina) have moved away from capitated managed care for alternatives such as primary care case management and medical homes. At the same time that they gear up for the Affordable Care Act’s Medicaid expansion and the new health insurance exchanges, states are also grappling with budget shortfalls and looking increasingly to managed care to help control the costs of their Medicaid programs.

For example, Missouri is considering a statewide geographic expansion of managed care for the remaining children, families and pregnant women that still receive care on a fee-for-service basis. At a forum this summer, several provider groups including the Missouri Hospital Association and a coalition of community mental health centers, spoke out against such an expansion. Legal Services’ Advocates for Family Health programs reported on their uneven experience with Missouri’s existing managed care program, including inadequate provider networks, extreme travel distances to providers, inconsistent prior authorization processes, and burdensome administrative practices. They indicated that these problems should be addressed if a geographic expansion is to go forward. Moreover, recent reports from state consultants Alicia Smith and Associates and the National Health Law Program indicate less than stellar performance by Missouri’s Medicaid HMOs while other state consultants, The Lewin Group, found insufficient State oversight to support an expansion of Medicaid managed care. Finally, the State’s own Medicaid Director acknowledges that the State has not done as well as it could have “in holding [managed care] health plans fully accountable to provide services for people.”

Even more troubling than a geographic expansion of managed care is the potential expansion of managed care to additional populations including people with disabilities to achieve budgetary savings. Another recent report released by two Missouri disability advocacy coalitions documents the many problems and pitfalls with expanding managed care to people with disabilities as a cost-saving measure, including the challenge of developing sufficient provider networks to meet the more intensive needs of these beneficiaries and the significant likelihood of underservice to people with serious health needs. These are significant concerns in light of states’ continuing interest in extending managed care to these populations.

This discussion raises concerns for both health reform and the interim period between now and 2014 when the Affordable Care Act’s Medicaid expansion kicks in. Managed care’s inconsistent performance certainly raises questions about the dramatic expansions of Medicaid managed care that are anticipated under the ACA. Of particular concern is the fact that the new group of Medicaid eligibles (particularly childless adults) is likely to have serious and complex health needs as the research and state experience (in states that already cover childless adults) suggests. Therefore, states need to carefully consider other models such as primary care case management and “health homes” as alternatives to expanding managed care when they expand Medicaid. If they do turn to managed care for the new Medicaid expansion group, then states must implement strong oversight mechanisms (including secret shopper surveys) to ensure adequate provider networks, and prevent improper denials of care. In the meantime, states should be very careful about expanding Medicaid managed care to people with disabilities to achieve cost-savings, which could lead to rampant underservice for especially needy individuals. Missouri advocates have argued for alternative models such as patient-centered medical homes (provided for in the Affordable Care Act) and reducing long-term care costs through more home and community based options (which are also expanded in the ACA). These may well be more effective ways of dealing with State budget shortfalls than expanding managed care to highly vulnerable populations.

The views expressed by Guest Bloggers do not necessarily reflect the views of the Center for Children and Families. If you experience trouble viewing the links to PDF files included in this blog, try hitting return after clicking on the link.

_Allow individuals to keep their current health care plans, no matter what.

_Require insurance plans to cover preventative health care, like breast and colon cancer screenings.

_Give small businesses tax credits that make it easier for them to purchase health care for their employees.

_Make prescription drugs more affordable for seniors by closing the gap in Medicare prescription drug coverage that leaves seniors with huge bills for medications.

_Make it illegal for an insurance company to cut off your coverage when you get sick or have hidden caps on
your coverage.

_Have a voluntary program where workers can purchase insurance that helps pay for personal care and
supportive services in your home instead of going into a nursing home.

_ Protect against price-gouging by insurance companies, making it illegal for them to charge outrageous rates
when health care is needed the most.

_Make it illegal for an insurance company to deny care based on pre-existing conditions.

Confused about how the new health reform law really works? This short, animated movie — featuring the “YouToons” — explains the problems with the current health care system, the changes that are happening now, and the big changes coming in 2014.

Written and produced by the Kaiser Family Foundation. Narrated by Cokie Roberts, a news commentator for ABC News and NPR and a member of Kaiser’s Board of Trustees. Creative production and animation by Free Range Studios.

Specifically, the proposed rule will:

• Establish the requirements for suspending payments to providers and suppliers based on credible allegations of fraud in Medicare and Medicaid;
• Establish the authority for imposing a temporary moratorium on Medicare, Medicaid, and CHIP enrollment on providers and suppliers when necessary to help prevent or fight fraud, waste, and abuse without impeding beneficiaries’ access to care.
• Strengthen and build on current provider enrollment and screening procedures to more accurately assure that fraudulent providers are not gaming the system and that only qualified  health care providers and suppliers are allowed to enroll in and bill Medicare, Medicaid and CHIP;
• Outline requirements for states to terminate providers from Medicaid and CHIP when they have been terminated by Medicare or by another state Medicaid program or CHIP;
• Solicit input on how to best structure and develop provider compliance programs, now required under the Affordable Care Act, that will ensure providers are aware of and comply with CMS program requirements.

For more information click here.

Interested in what you can do to take action?  Check this out.  Click here.

Small businesses dominate the rural economy. In fact, small businesses dominate the American economy in terms of the number of business firms. For that reason it is important to know, understand and accurately portray the effects of the “Patient and Affordable Care Act” (Public Law 111-148), the newly adopted health care reform law, on small businesses. This report will examine some important provisions of the new law and how they affect small businesses while dispelling some of the common myths about health care reform and small businesses.

It is important to understand what the new law means by “small business.” In many respects, “small employer” is a more accurate term. In fact, Section 1421 (Credit for Employee Health Insurance Expenses of Small Businesses) uses that term. Self employed sole proprietors who are not employers (non-employers in statistical parlance) and their immediate family members do not qualify for the small business tax credit benefits described below. They will qualify for the individual credits and premium assistance beginning in 2014 and the more immediate health insurance reforms.

MYTH No. 1: Small businesses have to provide health insurance to their employees or face penalties.

Not true. There is a general employer mandate in The Patient and Affordable Care Act as a part of the “shared responsibility” for providing health insurance. But the law specifically exempts from this employer responsibility any business with 50 or fewer employees (Section 1513). The result is that nearly all businesses in the nation, including those in rural areas, are exempt from any requirements or mandates to provide health insurance to employees and are free from any penalties for not doing so. According to the U.S. Census Bureau’s County BusinessPatterns, 95 percent of all business establishments in the nation have fewer than 50 employees. The House of Representatives Small Business Committee further estimates that when considering this exemption and the number of businesses that already provide health insurance to employees the employer mandate will apply to less than two percent of businesses.

MYTH No. 2: Small businesses cannot afford the health insurance they are required to provide.

In many respects the health insurance reform law is all gain and no pain for small businesses, particularly initially. As discussed above, Section 1513 of the law exempts all businesses with 50 or fewer employees from providing health insurance for their employees and frees them from any penalty for not doing so. Section 1421 of the law establishes a Small Business Tax Credit for those businesses who do provide health insurance for their employees in order to make health insurance more affordable and to provide an incentive for employer-provided insurance in small businesses. The initial credit exists for tax years 2010 through 2013. It is a sliding scale credit for businesses with fewer than 25 full-time equivalent employees and average wages of less than $50,000 who provide health insurance for their employees. A second credit exists for any two years beginning in 2014 when the health insurance Exchanges begin. The chart on the following page outlines the basics of both tax credits.

The Center on Rural Affairs has a new report out that lays out what is true and what is myth in the new legislation when it refers to small rural business and family farmers.   Find it here.