Historic changes Insurance coverage and reimbursement

1. Historic changes Insurance coverage and reimbursement ALAN M. FISHER, P.A. • 818 A1A North 601 Heritage Drive Suite 303 Suite 103 • Ponte Vedra Beach, Florida 32082 Jupiter, Florida 33458 • Tel: (904) 285-0070 Tel:(561) 743-0745 • Fax: (904) 245-1945 Fax: (561) 743-2414 Toll Free (888) 868-1926

2. Introduction • How Insurance coverage has changed from the Native Americans to the Affordable Care Act.

3. 500 years ago Ponce De Leon discovered “la Florida,” which at the time was all of North America, and declared it the sovereign territory of Spain. When he came to this country he discovered the miraculous health of the Indian population and believed that it had something to do with the water. Thus the legend of the Fountain of Youth was born.

5. Native American Healthcare • Medicine Men, as history has called them, were not only healers but the spiritual leaders of Native American tribes. • The Native American system covered all ailments and was a universal healthcare system.

7. St. Augustine – A Brief History • Roughly 50 years after the discovery of “la Florida” Pedro Menendez settled the city of St. Augustine at the behest of the Spanish King. • Pedro Menendez’s sister petitioned the Spanish King to provide free healthcare to the Native American population.

8. St. Augustine – A Brief History • Money was deducted from the salaries of the Spanish troops to pay for their medical treatment.

10. Spanish Military Hospital • When it was founded the hospital did not accept any private pay patients, only treating members of the Spanish military. • Doctors and pharmacists working at the hospital moonlighted to provide services to the townsfolk until they were caught and fined by the king.

11. Health Insurance before 1900 • Health Insurance in North America started during the Civil War as accident insurance.

12. Group Health Insurance Plans (1920-1930) • The Group Plans allowed hospitals to recover money that would have otherwise been written off due to tough economic times. The Great Depression made these Group Plans vital to recovering money.

13. Health Maintenance Organization (HMO 1933 - 1964) • Henry Kaiser formed the first major HMO starting in the 1940’s. Until the 1970’s the majority of HMO enrollees belonged to the Kaiser HMO.

14. Medicare (1965) • Prior to Medicare less than 50% of individuals over the age of 65 had health insurance. Due to increasing longevity and advances in medical care payment became a problem.

16. Important Moments in Healthcare

18. Affordable Care Act 2010 • General • Extending coverage for young adults. • Prohibition on denying coverage of children based upon pre-existing conditions. • Billing • Establishment of procedures for appealing insurance company claims decisions. • Reimbursement • Elimination of lifetime limits on insurance coverage. • Regulation of annual limits on insurance coverage. • Prohibition on Insurance companies from rescinding coverage.

19. Affordable Care Act 2011 • Reimbursement • Bringing Down Health Care Premiums • Overpayments to big insurance companies and strengthening Medicare Advantage.

20. Affordable Care Act 2012 • Reimbursement • CMS begins its readmission reduction program to reduce hospital readmissions at IPPS hospitals. The total payments received for a year will decrease progressively. IE 1% for the first year; 2% for the second (effective October 2013); and 3% for the third. • Change in payments to reflect quality outcomes. • Integrated Health Systems where the physicians will keep some of the money they save.

21. Affordable Care Act 2013 • Billing • Improvements to preventative health coverage. • Expansion of the authority to bundle payments.

22. Affordable Care ActThe Healthcare Market place (2014) • Insurers will only be able to vary rates based upon family size, geography, age, and tobacco use. • Directs insurers to provide coverage for, and accept all applicants who apply for coverage in the group and individual market. Barring certain limitations. • Directs that insurers maintain a single risk pool for the individual market, and a single risk pool for the group market unless a state merges those markets. • Codifies certain basic healthcare necessities that must be provided and establishes a ceiling on the cost of policies.

23. Affordable Care ActThe Healthcare Market place (2014)Essential Health Benefits • Ambulatory patient services • Emergency services • Hospitalization • Maternity and newborn care • Mental health and substance use disorder services, including behavioral health treatment • Prescription drugs • Rehabilitative and habilitative services and devices • Laboratory services • Preventive and wellness services and chronic disease management, and Pediatric services, including oral and vision care

24. Affordable Care Act (2014) • Billing • Prohibiting Discrimination Due to Pre-Existing Conditions or Gender • Increasing Access to Medicaid • Reimbursement • Eliminating Annual Limits on Insurance Coverage

25. Current Affairs • February 20, 2013 • HHS releases final rule regarding standards for health insurance . Effective 2014 • Medicaid Expansion. Effective 2014 • Florida? • What we know – Gov. Scott will accept. Florida Legislature is pursuing alternatives • Some Governors want Medicaid patients in the Exchange

26. Final Ruling • Final rule, 78 FR 12834, February 25, 2013—Patient Protection and Affordable Care Act - Standards Related to Essential Health Benefits, Actuarial Value, and Accreditation,(Feb. 28, 2013) • Appendix A: List of Essential Health Benefits Benchmarks • The purpose of this appendix is to list the EHB-benchmark plans for the 50 States, the U.S. territories (Puerto Rico, Guam, the U.S. Virgin Islands, American Samoa, and the Northern Mariana Islands) and the District of Columbia. As described in §156.100 of this regulation, each State may select a benchmark plan to serve as the standard for plans required to offer EHB in the State.64 HHS has also stated that the default base-benchmark plan for States, Puerto Rico and the District of Columbia that do not exercise the option to select a benchmark health plan would be the largest plan by enrollment in the largest product by enrollment in the State's small group market. The default base-benchmark plan for the territories other than Puerto Rico is the largest FEHBP plan by enrollment. As described in §156.110, an EHB-benchmark plan must offer coverage in each of the 10 statutory benefit categories. In the summary table that follows, we list the EHB-benchmark plans. Additional information on the specific benefits, limits, and prescription drug categories and classes covered by the EHB-benchmark plans, and state-required benefits, is provided on the Center for Consumer Information and Insurance Oversight (CCIIO) Web site (http://cciio.cms.gov/resources/data/ehb.html). • Florida Plan from largest small group product. • Blue Cross Blue Shield of Florida, Inc. BlueOptions PPO.

28. Florida Medicaid Effective 7/1/2013 • DRG’s • Goal – 88% of Cost

30. DRG’S • Benefit • LTAC • Rehab • Hurt • Rural • Children

33. Universal Healthcare… is it? • What does it really do? • It still won’t cover everyone.

34. The Issues on Coverage & Reimbursement still Remain • Medical Necessity • Pre Authorization • Pre Certification • Level of Care • Experimental Procedure • Authorization • Notification • Type of Coverage • Pre-Existing Condition • Annual Limits • Bundling

35. Questions and Comments?