With the Presidential election now over, many are expecting a heavy dose of proposed rules, regulations, delays and negotiations between HHS/CMS and individual state governments as they struggle to comply with many looming mandates of the controversial health care reform bill originally passed in March of 2010. Many states had chosen to wait until after the Presidential election before moving forward with creating state-based health exchanges, choosing a benchmark plan for their essential health benefits package, or whether to expand their Medicaid enrollment to 133% of the Federal Poverty Level. HHS has already delayed a key deadline on the creation of the state-based exchanges and provided the first window into HHS thinking on the essential health benefits packages that will be sold on the exchanges.
Pre-Existing Conditions and Essential Health Benefits Earlier this week, HHS issued a proposed rule on the essential health benefits plans. Starting in 2014, the Patient Protection and Affordable Care Act will make it illegal for health insurance companies to discriminate against people who have pre-existing conditions, which HHS estimates affect some 129 million nonelderly Americans. In the proposed rule, health insurance issuers would generally be barred from denying coverage for such conditions, and individuals would have new special enrollment opportunities in the individual market when they have certain losses of other coverage.
Under the regulation, insurance companies will be permitted to vary premiums within limits based on age, tobacco use, family size and geography, but not on the basis of their being an amputee, etc. Health insurance companies will also no longer be able to use factors such as pre-existing conditions, health status, claims history, gender and occupation as reasons to increase premiums under the proposed rule. Twenty-six states have already chosen an existing health plan as a benchmark identifying what “essential benefits” their state’s insurers must provide. In those states that don’t establish a benchmark, the administration is empowered to choose one. Source: Modern Healthcare.comUntil the government does, insurers say they are hampered in devising what kind of insurance policies to offer. Read the full proposed rule here: http://www.ofr.gov/OFRUpload/OFRData/2012-28428_PI.pdf
Creation of State-Based Health Insurance Exchanges — Seventeen states have submitted their plans to HHS on the creation of their own state-based health insurance exchange. Many others waited until after the election for clarity and are still exploring their options. States have the option of creating their own exchange, creating a partnership with the federal exchange, or allowing a federal exchange to operate in their state. HHS has now twice delayed the deadline for states to submit their intentions on the insurance exchanges, but until many governors receive additional guidance on the preferred makeup of the exchanges, expect to see 10-15 states continue to hold out moving up to the deadline.
Medical Device Excise Tax Set to Begin January 2013 — The Internal Revenue Service released a proposed rule last year that was seen as favorable to orthotics and prosthetics being include in the “retail exemption”, therefore being exempt from the 2.3% excise tax on medical devices beginning January 1, 2013. However, until the rules and exemptions are final, the orthotics and prosthetics profession must remain vigilant in our advocacy of being included in the exemption, both patient care facilities and manufacturers.
Decreasing Hospital Payment for Uninsured Due to ACA — Hospitals that treat uninsured or poor patients have been reimbursed by the federal government to the tune of $35 billion annually. The ACA assumes fewer uninsured and that patients with lesser means will be added to state Medicaid roles. However, with the Supreme Court making the Medicaid expansions voluntary, hospitals face a precarious position of still treating this block of patients without being reimbursed at all. How the Obama Administration chooses to allocate these dwindling resources will be very important to how hospitals choose to treat people without insurance after the individual mandate is activated in January 2014.
Bundled Payments for Accountable Care Organizations — HHS will also be announcing the selection of the first round of Accountable Care Organizations that will participate in the initial bundled payment initiative. In a bundled payment model, the ACO receives one bulk payment to treat a patient with an identified disease, illness or procedure and will include hospital stays, long-term care stays, physician visits, readmission, etc. Applicants have tailored their proposals to specify whether it covers just one part of the patients’ medical treatment, such as post-hospital care, or all the services in the episode.
Applicants to the bundled payment initiative have also selected specific diagnoses that they will use to test this new payment method. The goal is the same as the other ongoing experiments: to move providers away from being paid piecemeal for each service. So, for an O&P practice to make themselves attractive to ACO, they need to be able to show that their patients have better health outcomes then our competitors. Providing this value would be very attractive to an ACO, especially in a bundled payment model where increased efficiencies are directly related to savings (ie, profit).
There will undoubtedly be more regulations, rules, delays and negotiations over the next 13 months until the individual mandate is activated in 2014, but these are a few of the major releases many are waiting to see before the end of the year.
Contact OPGA with any questions about Obamacare, or pending legislation/regulations.