THE AFFORDABLE CARE ACT IMPACT ON YOUR MEDICAL PRACTICE

Transcription

1 THE AFFORDABLE CARE ACT IMPACT ON YOUR MEDICAL PRACTICE Dennis Olmstead, MPA Vice President Practice Economics & Payer Relations Pennsylvania Medical Society

2 Kaiser Health Tracking Poll Poll (March 2013) finds majority of Americans are unsure how the law will impact them Two-thirds of two key groups, the uninsured and lowincome do not understand what the ACA offers them Many Americans think the law will make things worse rather than better for their families 2

3 ACA Challenges The money chase Getting the word out Counter messages The infrastructure build-out State inaction 3

4 Affordable Care Act Includes Insurance reforms (insurance for the uninsured) Deficit reduction Health care delivery and finance reforms Public health initiatives Medicare and Medicaid reforms Details left to regulatory control of DHHS, CMS, and other federal and state regulators 4

5 ACA Implementation What will be the true cost of implementation? According to the Congressional Budget, the ACA will reduce the deficit by $109 billion from 2013 to Misaligned incentives persist, rewarding providers for volume instead of quality and value. 5

6 Costs Are Back-End Loaded 6

7 Funding 7 Reducing Medicare payments by $335 billion. Drug companies charged additional fees of $107 billion. Device manufacturer fees. Excise tax on Cadillac high-end insurance plans worth over $27,500 for families ($10,200 for individuals) estimated at $32 billion. Taxes on high-income earners > $200,000 per individual and couples > $250,000 will generate $210 billion. Employer penalties could contribute $65 billion.

8 Front-End Loaded Benefits Keep children on policy until age 26. No pre-existing condition exclusion. Prohibits lifetime limits on dollar value of essential health benefits. Requires coverage of specified preventive health services without cost sharing by patients. Prohibits plans from requiring a referral for OB/GYN care. Prohibits plans from retroactively cancelling coverage except for fraud. 8

9 Physician Payment Sunshine Act ACA directed final rule Final rule published February 1, 2013 Data collection begins August 1, 2013 thru December 2013 Must be reported to CMS by March 31, 2014 Released to the public by September 30, 2014, June 30 in subsequent years. 9

10 Sunshine Act (con t) National Physician Payment Transparency Program Examples of Reportable Transfers of Value Medically relevant gifts In-service meals (i.e., drug rep lunches) Meals provided at a speaker program Travel costs Fee for service arrangements (consultant, speaker advisory, board member, clinical trial investigator) Grants Ownership and investment interests 10

11 Sunshine Act (con t.) Open Payments: Reporting exceptions Payments of less than $10 unless payments exceed $100 annually Educational materials and items Discounts and rebates Samples 11

12 Sunshine Act (Cont d) Physicians have 45-days to review manufacturer and GPO information Manufacturer/GPOs have 15-days to submit corrections If a dispute continues, public information will be marked as disputed Manufacturers/GPOs will be audited by CMS 12

13 Medicaid PCP Enhanced Payment Effective January 1, 2013 payment applicable to calendar years 2013 and 2014 Mandated by Affordable Care Act Limited to primary care specialties and subspecialties 13

14 Medicaid PCP Enhanced Payment Effective January 1, 2013 Medicaid will be paid at Medicare rates for 2013 & 2014 Physicians must be board certified in one of the following specialties/subspecialties of Family Medicine, General Internal Medicine and Pediatric Medicine Eligible codes include Evaluation & Management & Vaccine Administration OR At least 60 percent of MA services billed are Evaluation and Management or Vaccine Administration Codes 14

15 Medicaid PCP Enhanced Payment Send Documentation to: and include PCP in subject title Fax: and Include PCP in fax cover sheet Mail: DPW/OMAP/BFFSP Attention: Provider Enrollment/PCP PO Box 8045 Harrisburg, PA

16 Medicaid PCP Enhanced Payment Additional Resources: PAMED Website Medical Assistance Bulletin Tutorial for completing Attestation Questions can be submitted: Attestation form ents/document/p_ pdf 16

17 Medicaid PCP Enhanced Payment Managed Care Health Choices Capitation rates are currently under review with a CMS contractor Deloitte Health Care Consulting Services Rates will be determined at a later date - no date has been announced Vaccine rates under both Fee-for-Service and managed care are not yet determined 17

18 Medicaid Expansion Pennsylvania has not yet made a decision Numerous studies have been conducted to determine impacts including RAND, Pennsylvania Economy League, and the Pennsylvania Independent Fiscal Office Whether Pennsylvania expands or not there will be impacts 18

19 Medicaid Expansion (Cont d) Without expansion approximately 175,000 adults and children would receive coverage Woodwork effect Elimination of the asset test Medicaid MCO lives CHIP program 19

20 Physician Compare Website Provides info on Medicare physicians and other EPs currently participating in PQRS and erx programs In 2013 CMS lays out frame work for expanding the website by collecting data on: Physician quality Efficiency Patient experience of care CMS will begin posting data in 2014 on groups 100+ Individual EPs posted by 2015 Physicians will have 30 days to preview quality data before posted on Physician Compare 20

21 Health Insurance Exchanges The 2010 Affordable Care Act (ACA) calls for the creation of a Health Insurance Exchange (HIE) in every state by 2014 States can choose to operate their own exchange, a partnership exchange with feds or a federally facilitated exchange run by federal government 21

22 Health Insurance Exchanges Purpose: Make insurance more affordable and easier to purchase for small business and individuals Promote competition and choice Easy enrollment and comparison of costs and benefits 22

23 Exchange Contracting Tying arrangements All Product Clauses (a) New Benefit Programs. Insurer may develop new Benefit Programs (e.g., Medicaid Benefit Programs) and provider shall participate in such new Benefit Programs to the extent evidenced by a written Amendment to this Agreement. Contract amendments- insurer is amending your participation agreements with respect to reimbursement for covered services provided to Product members. PA Fair Care 23

24 ACA Tax Penalties $95 in 2014 $325 in 2015 $695 in 2016 After 2016 penalty increased by a cost of living adjustment 24

25 QHP Benefit Tiers Bronze Plan 60% actuarial value Silver Plan 70% actuarial value Gold Plan 80% actuarial value Platinum Plan 90% actuarial value 25

26 Essential Health Benefits Ambulatory patient services Emergency services Hospitalization Maternity and newborn care Mental health and substance abuse disorder services Prescription drugs Rehabilitative and habilitative services and devices Laboratory services Preventive and wellness services including chronic disease management Pediatric oral and vision care (can adopt pediatric dental and vision covered under the Federal Employees Dental and Vision Insurance Program or the state s CHIP). 26

27 Premiums Insurers set premiums based on new criteria - age, tobacco use, geographic area and individual vs. family enrollment--only factors insurers will be able to use to set premiums, other current factors such as health status, previous use of services, gender will no longer be allowed A new tax on premiums - proposed at 3.5 percent of premiums Requirements that insurance plans cover more health care - elimination of pre-existing conditions Use age band rating of 3:1 rather than 5:1 27

28 Health Insurance Exchanges Five Core Functions of Exchanges Eligibility Enrollment Plan management Consumer assistance Financial management 28

29 Exchange Eligibility Single application: online, mail, phone, in person. Required to determine eligibility for federal subsidies. Determine access to coverage through employer makes individual ineligible for premium assistance. Must screen to determine if eligible for Medicaid or CHIP. If eligible for federal subsidies, Medicaid or CHIP, exchange must assist them to enroll in a plan. 29

30 Enrollment Estimated mean number of participants in Pennsylvania is 2.1 million. A digital link (federal data hub) will provide real-time access to the database of seven federal departments and agencies to verify a range of details including the incomes and citizenship status of applicants. 30

31 Plan Management Exchanges must certify that plans for purchase are qualified. Plans must offer essential health benefits. Collect and review health plans rates and benefit information. Regulate health plan marketing. Assign quality ratings to plans. Oversight of plans in tandem with state insurance departments and federal regulators. 31

32 Exchanges Must Provide Consumer Assistance In-person assistance. Maintain website and call center. Conduct outreach and education. Navigator program to help individuals and small employers understand their options. 32

33 Financial Management by Exchanges Accounting, auditing and reporting. May collect premiums directly, serving as electronic pass-through to health plans. Financially self-supporting by January 2015 revenues through fees from health plans or other means. 33

34 Exchange Contracting QHPs 90-day grace period for non-payment of premiums QHP suspension of provider payments after member delinquent more than one month Plan can terminate coverage after three months of non-payment of premium and deny all pending claims Physician would have to collect payment for all outstanding claims 34

35 Administrative Simplification-Operating Rules Section 1104 of the ACA defines operating rules as the necessary business rules and guidelines for the electronic exchange of information that are not defined by a standard or its implementation specifications. Three critical dates for implementation of ACA mandated operating rules for HIPAA covered entities. 1. January 1, 2013 CAQH CORE enforcement date extension March 31, eligibility & claims status transactions 35

36 Administrative Simplification-Operating Rules (con t) 2. January 1, electronic fund transfer and claim payment/remittance advice transactions 3. January 1, 2016 health claims or equivalent encounter information, health plan enrollment/disenrollment, health plan premium payment, referral certification and authorization transactions 36

37 PAMED Member Contact Pennsylvania Medical Society Division of Practice Economics & Payer Relations