Health insurance quotes care reform weekly

States with Republican governors kept up the pressure last week on Washington to give the states greater control over health care under the Patient Protection and Affordable Care Act (PPACA). Twenty-one Republican governors sent a letter to Health and Human Services (HHS) Secretary Kathleen Sebelius asking for greater authority over some provisions of health reform, including the ability to define "essential" health benefits and set minimum criteria for participating in insurance exchanges. They threatened not to run their own state-based exchanges if HHS does not act on their requests. Sebelius quickly responded with her own letter in which she reviewed the various options states have to reduce costs in their Medicaid programs, and she indicated she is continuing to review what authority she may have to "waive the maintenance of effort under current law." Senate bills have already been introduced to address the role of the states in health care reform, which is sure to ke ep the issue on the front burner. Visit Easy To Insure ME for more info

Federal

The House Committee on Ways & Means held a hearing last week on "The Health Care Law's Impact on Medicare and Its Beneficiaries," featuring testimony from CMS Administrator Donald Berwick, M.D., and CMS Chief Actuary Richard Foster. Berwick testified that the PPACA has had a positive impact on Medicare beneficiaries, noting that beneficiaries now have first-dollar coverage of key preventive benefits, additional assistance with prescription drug costs, and an annual wellness visit with the physician of their choice. In response to concerns noted by several committee members about the impact of funding cuts on Medicare Advantage, Berwick indicated that Medicare Advantage enrollment increased by 6 percent from 2010 to 2011. He suggested that the program is healthy and offers robust choices. Foster's testimony reiterated his prior projection that the PPACA will cause Medicar e Advantage enrollment to decline by about 50 percent by 2017 -- from a projected 14.5 million under the pre-PPACA law to 7.3 million under the new law. His testimony further explained that Medicare Advantage enrollees will experience "a large increase in out-of-pocket costs" and "less generous benefit packages" because PPACA will reduce rebates to Medicare Advantage plans, with the reduction in rebates reaching $1,500 per beneficiary by 2019.

The Administration last week issued favorable guidance with respect to student health coverage that will result in little disruption, if any, to this business until at least the 2012-2013 academic year. This guidance was announced in a Notice of Proposed Rule Making (rather than as an interim final regulation), which fortunately means that the rule is not effective immediately as has been the case with most regulations relating to PPACA reforms. The proposed student health rule would create a special class of individual cove rage for student health pursuant to a set of factors, e.g., written contract between school and insurer, coverage only for students and dependents, health status may not be used as a condition of eligibility. As Aetna has advocated, the impact would be delayed, as the rule (whenever finalized) would not be effective until policy years beginning on or after January 2012. Until then, student health is not subject to PPACA reforms. And, when effective, student health would be excepted from the current guaranteed issue and renewability provisions of PPACA. While it will be unclear for a while whether and how student health will be subject to the medical loss ratio (MLR) provisions of PPACA, we are encouraged by the fact that the proposed rule invites comments on whether student health should receive some sort of special accommodation (akin to the special rule for limited benefit plans) with respect to MLR, owing to the unique characteristics of the student health market.
States

ARIZONA: The industry-supported exchange bill was introduced last week under the sponsorship of the House Health Committee Chairman and the respective chairmen of the House and Senate Banking and Insurance Committees. The bill provides for a market-based mechanism; governance by a board with insurer representation; no dual regulation; and a conditional repeal provision. The first hearing will be held this week. In other news, Governor Jan Brewer appointed Don Hughes, former AHIP retained counsel, as Special Advisor for Health Care Innovation. Hughes will help direct state efforts to improve the cost-effectiveness and accessibility of health care. He will engage in strategic planning with a focus encompassing both public health care and Arizona's large private health insurance industry.

CONNECTICUT: A jointly held public hearing of the Public Health and Insurance and Real Estate Committees was scheduled for this week on two new health care bil ls. The first bill would establish the SustiNet Plan Authority, a quasi-public agency empowered to implement a public health care option. The SustiNet Plan is a health insurance program that consists of coordinated individual health insurance plans that provide health insurance products to state employees, Medicaid enrollees, HUSKY Plan, Part A and Part B enrollees, HUSKY Plus enrollees, municipalities, municipal-related employers, nonprofit employers, small employers, other employers, and individuals in Connecticut. The Authority is authorized, but not required, to begin offering SustiNet coverage to employees and retirees of non-state public employers, municipal-related employers, small employers, and nonprofit employers after January 1, 2012. Beginning on January 1, 2014, SustiNet will offer coverage to individuals and employers. Among other things, the bill directs the Authority to implement primary care case management and patient-centered medical homes for all SustiNet Plan members, establish a pay-for-performance system, and establish procedures to prevent adverse selection.

The Committees also will hear testimony on a bill to establish the Connecticut Health Insurance Exchange pursuant to PPACA. The exchange would be a quasi-public agency offering qualified health plans to individuals and qualified employers by January 1, 2014. The bill would establish a 13-member board of directors to manage the exchange. The exchange would have the authority to review the rate of premium growth within and outside the exchange in order to develop recommendations on whether to continue limiting qualified employer status to small employers. It also would have the authority to charge assessments or user fees to health carriers to generate funding necessary to support the operations of the exchange. The bill directs the exchange board to report to the legislature by January 1, 2012 on whether to establish two separate exchanges, one for the indi vidual market and one for the small employer market, or to establish a single exchange; whether to merge the individual and small employer health insurance markets; whether to revise the definition of "small employer" from not more than 50 employees to not more than 100; and whether to allow large employers to participate in the exchange beginning in 2017.

Aetna will submit comments on both bills through the Connecticut Association of Health Plans.

IDAHO: Draft legislation is circulating that would prohibit insurance companies and managed care organizations from refusing to contract with qualified providers solely because the provider: is not a member of a group, network or any other organization of providers contracting with the insurance company; or does not offer all of the services obtained through the group, network or organization of providers contracting with the insurance company. However, the provider may be required to comply with the practice standards and quality requirements of the contract specific to the services contracted. The bill generally is intended to impact insurers and managed care organizations. It does not contain an exclusion or exception for HIPAA-excepted benefits. As yet, the bill has not found a sponsor and has not been "introduced." While there remains a possibility that the bill could be introduced before the deadline for committee bill introductions, it is considered unlikely.

MINNESOTA: When the legislature convened the first half of its 2011-2012 biennium last month, Republicans controlled both legislative chambers for the first time since 1972. And, Republican lawmakers wasted little time introducing bills to repeal measures passed by the 2010 legislature to fund state medical assistance, general assistance medical care, and MinnesotaCare. In his first official act as Governor, Mark Dayton signed an executive order implementing early Medicaid expansion (to 133 percent of the federal poverty level) for Minnesota, which is expected to make 95,000 more state residents eligible. Minnesota's $188 million investment is expected to bring about $1.2 billion in matching federal funds. Governor Dayton also signed an executive order removing the ban on applications for federal PPACA-related grants. Minnesota is expected to receive an exchange planning grant soon. While Governor Dayton cleared the way for the state to seek grants for implementing federal health reform, it is unlikely that state legislators will be passing bills to implement the federal health reform law unless absolutely necessary. Other pending bills of interest include anti-PPACA legislation, a bill requiring guaranteed issue in the individual market, creation of a defined contribution program for childless adults with incomes at or above 133 percent of FPL (reduction from current level of 250 percent), the prohibition of dental plan fee schedules for non-covered services, and an autism c overage mandate. In addition, Governor Dayton named a new Commissioner of the Department of Commerce, Minneapolis attorney Michael Rothman.

NEVADA: The legislature convened on February 7 with a scheduled adjournment date of June 6. Governor Brian Sandoval will sponsor an exchange bill, although he opposes federal health care reform. His reasons include not wanting the federal government to take action in the state and the fact that the legislature will not meet in 2012. The Division of Insurance (DOI) has indicated that it will pursue federal reform measures, including external review. Other legislation of interest includes the establishment of a statewide health information exchange system and amending the requirements for reimbursement of out-of network services to comply with the PPACA.

TEXAS: Governor Rick Perry delivered his State of the State speech last week, which included plans to suspend the State Historical Commission and the Commission on th e Arts in addressing the state's $27 billion budget deficit. Speaking to a joint session of the legislature, Perry said the time has finally come to streamline state government. Perry's speech focused heavily on how strong the state's economy is, despite the deficit. According to Perry, Texas added more jobs in 2010 than any other state in the nation. That state-wide job growth occurred in the sectors of business, health care, manufacturing, hospitality, construction and energy. Perry's speech was highly critical of national politics, and he threatened to push back when Washington encroaches on states' rights. His budget proposal calls for cutting more than $2 billion in state spending on public education and another $2 billion in higher education, plus more than $2 billion in health and human services programs. Those cuts would come with much larger reductions in federal dollars, because states draw federal funding for programs such as Medicaid by spending state money.

VERMONT: Newly-elected Governor Peter Shumlin's focus has been on reducing the state's projected $100 million budget deficit. Proposals to deal with the deficit include changes to the administration of the state's Catamount program, changes to Catamount reimbursement, imposing an assessment on managed care organizations, increasing the provider tax on hospitals, and imposing an assessment on dentists. The legislature is also considering a number of bills that would create a single-payer, government-run health care plan and require rate reviews. The bills include:

Supported by the governor, H.B. 202 would establish Green Mountain Care and the Vermont Health Benefit Exchange, through which all state residents would be eligible for health benefits. After implementation of the Green Mountain single-payer system, private insurance companies would be prohibited from selling health insurance policies in that cover services also covered by Green Mountain Care.

H.B. 80 would create a single-payer health care system called Ethan Allen Health. If the secretary of Human Services obtains a waiver from the exchange requirement, private insurance companies will be prohibited from selling insurance policies in the state for coverage of services covered by Ethan Allen Health. But it would not prohibit individuals from purchasing supplemental health insurance covering services not already covered by Ethan Allen Health.

S.B. 57 would establish Green Mountain Care as a single-payer health care system, which will include coverage provided under a health benefit exchange, Medicaid, and Medicare.

H.B. 146 would establish a public health care coverage option called Green Mountain Care that would require Vermont residents to have health care coverage at least equivalent to the actuarial value of Green Mountain Care and would assess a financial penalty against those who fail to maintain such coverage. The bill would institute a candy and soft drink tax as well as a 10 percent payroll tax on all employers with more than four employees to fund Green Mountain Care.

S.B. 56 and H.B. 165 would amend current rate review procedures to require written approval from the commissioner before a health insurance policy can be issued and to require that all rate and form filings be filed electronically. Rate changes would require approval by the commissioner prior to implementation and notice to plan members of rate changes and a 30-day comment period.

H.B. 82 would require health insurers to disclose to the Department of Banking, Insurance, Securities, and Health Care Administration the fee schedules they negotiate with providers, and directs the department to post the information on its website.

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Health Insurance Reform Issues Student Health Insurance

With a law as complex as the Patient Protection and Affordable Care Act (PPACA), unintended consequences are always a concern. Last week The Wall Street Journal reported that the physician community is witnessing the emergence of a significant unintended consequence � since tax-advantaged flexible spending accounts can no longer be used to pay for over-the-counter medications without a prescription, under the law, many patients are now visiting their doctors expressly for the purpose of getting new prescriptions for the OTC medications. The change in the law was meant to discourage wasteful spending on some health products and raise revenue. Instead, critics say the provision is driving up health care costs. Unintended consequences of the health care reform law is an area of focus for Aetna insurance, and will continue to urge flexibility in the implementation process to help address potential unintended consequences.

Federal
In response to various requests for clarification (including from Aetna insurance), federal regulators last week issued a Question & Answer document that further refines the previous proposed rule on student health. In short, this clarification makes it clear that nothing from PPACA applies to student health plans until policy years beginning in 2012 or until academic year 2012-2013. The Q & A also clarified that the proposed regulation must be finalized to show what parts of the PPACA would apply to student health plans. This is welcome news in the college and university community. Aetna is communicating with its clients in a manner that is consistent with last week's clarification, though many schools were hearing conflicting advice from state regulators.

The House-passed continuing resolution includes language that would "prohibit the use of funds to pay any employee, officer, contractor, or grantee of any department or agency to implement the provisions" of the PPACA. In a letter to Finance Committee Chairman Max Baucus, HHS Secretary Kathleen Sebelius made several claims that, should the de-funding provisions in the resolution be enacted into law, seniors will lose access to Medicare Advantage plans and other services. Senate Republicans were quick to dispute these allegations stating, the scenarios the Secretary envisions are not allowed under Congressional rules, are not assumed by the Congressional Budget Office (CBO), and can be prevented by HHS. Senator Orrin Hatch and Ways and Means Committee Chairman Dave Camp also sent Secretary Sebelius a letter expressing their disappointment in what they called the letter's "baseless allegations," and expressing hope that "the urgency with which this letter was sent to Chairman Baucus is also being applied in answering a growing backlog of serious questions." The CBO also released a letter regarding the impact of the resolution, including the impact of the de-funding provisions on Medicare Advantage. The le tter shows the de-funding provisions would have a minimal MA budgetary impact of $5.7 billion over 10 years.

States
Governor Jan Brewer's Special Advisor on Arizona health insurance Health Care Innovations held a meeting last week with the state's major health insurers, including Aetna insurance, to discuss identifying IT gaps the state must address to develop the online product selection and enrollment mechanism for an insurance exchange. Social Interest Solutions, the organization that developed the enrollment form currently used by Medicaid applicants, provided a demonstration of that application process. Individual interviews will be conducted with the IT staff of each company to obtain recommendations for the new system.

The Real Estate Committee last week voted out a substitute prior-approval rate bill that retains all the problematic sections of the original bill. The sections of concern cover public hearings, new subpoena powers for the Att orney General and Connecticut health insurance Healthcare Advocate, multiple notice requirements, and new definitions of inadequate, excessive, and unfairly discriminatory. The only change is that the Commissioner would have to promulgate regulations to carry out the proposed public hearing process. The full contingent of Republicans and Rep. Linda Schofield (Dem.) voted against the bill, with Schofield stating that she was concerned the bill gets rid of any timeline under which the Department must act and would require public hearings, nonsensically, for group rates. She also said the bill would provide the Attorney General and Advocate with extraordinary subpoena powers. The Chairs indicated that the bill is a work in progress.

Florida health insurance Insurance Commissioner Kevin McCarty has disclosed that he will be submitting a medical loss ration (MLR) waiver request to HHS this week.

Georgia health insurance Insurance Commissioner Ralph Hudgens h as indicated he will be submitting an MLR waiver request to HHS within a week. Aetna insurance continues to work with the Chamber of Commerce and plan sponsors to help defeat legislation that would apply prompt-pay requirements to self funded plans, in violation of ERISA.

Oklahoma health insurance Last week State Rep. Mike Ritze, one of two doctors serving in the Oklahoma legislature, called on state officials to turn down $54 million that would be used to implement the new federal health care law. Shortly thereafter, Governor Mary Fallin joined other state leaders in announcing that Oklahoma will accept the grant to help design and implement the information technology infrastructure to operate an Oklahoma health insurance exchange. Fallin listed the creation of such an exchange as one of her top priorities in her State of the State address earlier this month. She and others announced their support for the grant after working with state agencies to ensure that no unworkable federal mandates were included.

Later in the week, the legislature continued taking steps forward to reduce the number of uninsured Oklahomans. House Speaker Kris Steele authored a bill that defines the membership and appointments to the Health Care for the Uninsured Board (HUB), which is designed to establish a system of counseling, including a website, to educate and assist consumers in selecting an insurance policy that meets their needs. The seven-member HUB consists of representatives from the Insurance Commissioner's Office, the Oklahoma Healthcare Authority, insurance companies, agents and also consumers. The purpose of HUB is to implement a market-based insurance exchange. The bill passed the House Public Health Committee at the end of the week and will proceed to the floor of the House.

Texas health insurance Legislators are wrestling with to what extent they should intervene in what residents eat, drink and breathe. In a state with some of the nation's highest obesity and diabetes rates, supporters of various proposals say they are trying to give Texans more ways to combat unhealthy decisions by others, as well as make good choices for themselves. The president of the Texas Medical Association testified last week in favor of a bill banning the sale of unhealthful drinks (sugary fruit juices, sodas, whole milk) to students during school hours. Other related bills would allow the state to raise taxes on sweet sodas and fine restaurants for not posting nutritional information.

About 30 percent of Texas schoolchildren are obese or overweight, according to the Texas Public School Nutrition Policy. And last month, Republican Comptroller Susan Combs released a report saying obesity cost Texas businesses $9.5 billion in 2009 � that could rise to $32 billion by 2030 due to the cost of health care services, absenteeism, decreased productivity and disability. Legislators will continue debate on these b ills until the session adjourns on May 31.

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