Adam S. Levine , M.D., J.D.

1. Making Better Alphabet Soup(ACA, ACO, PIP, HIPAA, Medicaid Expansion):Applying Rapidly Changing Ingredients to Facilitate Better Digestion • Adam S. Levine, M.D., J.D.

2. Tonight’s Recipe • Introduction • Goals • Alphabet Soup • Some Thoughts & Questions

3. Tonight • ACA - Patient Protection & Affordable Care Act • ACO - Accountable Care Organizations • PIP - Personal Injury Protection • HIPAA - Health Ins. Portability & Accountability Act • Medicaid Expansion

4. Objectives • Brief Overview • Review the Impact of Recent Changes in Federal & State Health Law on Practice • Make Some Compliance Suggestions • Avoiding Pitfalls

5. ACA • Patient Protection & Affordable Care Act (providing everybody with basic healthcare security) • Expand Guarantee Health Insurance Coverage • Positively Influence the Cost Curve for Savings • Decrease rate of increase in healthcare spending • 18% GDP (2.6 trillion dollars)

6. pre - ACA & Health Insurance • HIPAA Came First • Changes Basic Health Insurance Rules • Actuarial Tables, Premiums & Loss Ratios • Spread & Manage Risk • Prevention >>> Treatment

7. ACA • Health Insurance to Promote Health & Wellness • Rewards, Penalties, & Incentives • No Direct Regulation of Health Care Cost (SLOW spending by managing disease)

8. 95% of Health Care Expenditures are Spent in the First and Last Year of Life

9. Mortality & Chronic Disease (2007)

10. ACA Incentives • Smoking Cessation • Weight Control • Lower Cholesterol • Lower Blood Pressure • Avoid Diabets

11. ACA Controversy • Federal Requirements & State Interpretations • Section 2706 - Non Discrimination Against Providers Working Within Their Scope of Practice

12. ACA in Practice • Health Insurance Exchanges • Health Homes • Reward Quality Care • Innovation Center - test different payment models such as ACOs

13. ACO • Accountable Care Organizations • Voluntary Health Provider Groups Providing Coordinated Care to: • Improve quality and prevent errors • Reduce service duplication • Share in savings!

14. Medicare Shared Savings ACO Program • Fee for Service Model • Accountability, Coordinated Care, Infrastructure and Care Process Investment • Quality Measures & Performance Standards • Physician Quality Reporting System incentive payments

15. Advance Payment Models • Physician-based and Rural Providers Providing High Quality Care with a significant number of Medicaid beneficiaries and <50 million in revenue if no inpatient facility (<80 with) • Upfront Fixed Payment • Upfront Variable Payment (# beneficiaries) • Monthly Variable Payments (# beneficiaries)

16. ACO How-To • Complex Application Process • Different Application Time-frames/requirements

17. PIP • No-Fault 1971 & Personal Injury Protection • 2012 PIP Act • Limitation of Coverage Benefits & EMC • 14 Days, $10,000.00 or $ 2,500.00 • No Massage No Acupuncture Limited Chiropractic

18. 2012 PIP Lawsuit • State - Federal - State • Temporary Injunction • Vacation of Stay • Pending in Trial Court • Pending in Appellate Court

19. HIPAA • Health Insurance Portability & Accountability Act of 1996 • Improve access to health care and insurance • Decrease insurance exclusions • Increase insurance portability • Standardize health information and coding • Improve efficiency • m

20. Protected Health Information &Individually Identifiable Health Information

21. IIHI • Data Created or Received by Health Provider • Past, Present, or Future • Diagnosis • Evaluation & Treatment • Payment

22. Health Providers • Health Care Providers • Health Care Clearinghouses • Health Insurers • Employee Group Plans (>50) • Business Associates (BA Agreement)

23. HIPAA • Statutory & Administrative Rules Change 2009/2010 • Old Model - Covered Entity Liable, BA not • New Model - Everyone Liable (CE + BA)

24. Breach Reporting • Report Data Breaches Resulting in Significant Risk of: • Financial Harm • Reputational Harm • Other Harm • Breach <500 persons, BA to CE to HHS • Breach >500 persons, BA + CE to HHS

25. Civil & Criminal Penalties • No Private Cause of Action • HHS or State Attorney General may sue • If not willful neglect, OCR may waive/reduce

26. Civil Penalties

27. Criminal Penalties

28. Corporate Compliance • Assign Responsible Party • Look at the Rule: (45 C.F.R. §164) • Maintain Written Policies • Complaince Checklists and Business Associate Agreements • Regular Training • Self Reporting & Response • Documentatiion

29. Records Access • Consumer Control of Medical Records • Statutory Access - Federal Preemption • Exceptions

30. Medicaid Expansion • Supposed to Increase Medicaid Availability • $51 Billion Dollars (Federal) over 10 years • Unlikely in 2013 (Florida)

31. Medicaid Expansion and CMS • Don’t Ignore CMS - think single payor! • 80% of Floridians Possess Health Insurance • Of these 80% Floridians with Insurance • Medicare insures 19% • Medicaid insures 18%

32. Medicaid • Current • If Pregnant, Disabled, Dependent Children • <200% Poverty Level • ACA • All adults < age 65 • <138% Poverty Level

33. 2013 Poverty Guidelines

34. Interesting Results Without Expansion • All Immigrants* <400% Poverty Level • Family of 4 making < $94,200 • Citizens <100% Poverty Level • Family of 4 making < $23,500 *Legal immigrants must wait 5 years for Medicaid

35. Looking Forward • ACA - Watch HHS & Florida Carefully • ACO - A Good Time to Join or Create One • PIP - Make Sure You Get What You Pay For • HIPAA - Protect IIHI • MedicaidExpansion - Follow This Topic

36. Adam S. Levine • aslevine@msn.com • (727) 512 - 1969 [Cell]