Washington could wind up running more health exchanges: official

Reuters – 17 hrs ago


WASHINGTON (Reuters) – The U.S. government could have to run more state health insurance exchanges than expected under President Barack Obama’s healthcare law, if U.S. states pursuing their own marketplaces cannot complete them on time, a senior official said on Thursday.

The Obama administration has given 17 of the 50 states conditional approval to set up online exchanges where working families would purchase private plans at subsidized rates. The remaining 33 states will all have federally run markets, at least in the early years of the coming reform era.

But Gary Cohen, who spearheads exchange implementation for the U.S. Department of Health and Human Services, said some of the approved states face hurdles that could require Washington to step in with federal exchanges before open enrollment starts on October 1.

“I’m absolutely confident that every state will have an exchange that will be functioning and ready,” said Cohen, who declined to elaborate on the number or identity of states that could be in for difficulties.

“The type of exchange may be different,” he told reporters. “(But) there will be an exchange of one kind or another in every state.”

Obama’s Patient Protection and Affordable Care Act requires Washington to provide an exchange in any state that cannot or will not set up their own.

The exchange initiative is expected to insure 26 million Americans, many of whom currently have no coverage, according to the nonpartisan Congressional Budget Office. A planned expansion of the Medicaid program for the poor is likely to cover another 12 million people.

Both the exchanges and the Medicaid expansion are due to begin providing coverage on January 1, 2014.

Republicans and other healthcare reform critics have warned of potential problems for states, saying the administration has been slow to release rules governing implementation.

Many states also held off on implementation in 2012 until after the law survived a U.S. Supreme Court ruling in June and last November’s Republican presidential election challenge to Obama’s re-election.

Cohen said the main hurdles for states are development of information technology systems for applicant enrollment eligibility and continued legal and political challenges from reform opponents.

“The biggest challenges are for states that started later. Obviously, they have less time,” he said.

New Mexico and Idaho, two of the few Republican-led states to move toward establishing their own marketplace, are still awaiting final approval from their respective legislatures.

But even in Connecticut, one of the first states to embrace the healthcare exchange model, media reports have described implementation problems linked to vague or changing federal guidance.

(Reporting by David Morgan; editing by Matthew Lewis)


Article Link: http://news.yahoo.com/washington-could-wind-running-more-health-exchanges-official-220411060–finance.html


Charity Spotlight: Passport Health Plan CEO, Mark Carter

Charity Spotlight: Passport Health Plan CEO, Mark Carter

Debra Childers
pg. 45, March 2013

Mark Carter came to Passport Health Plan as interim CEO in the wake of a critical state audit revealing the plan was in jeopardy. He put in place internal controls and made some fixes he terms “easy.” The reason he stayed, however, was the story of one person’s need and one employee’s generous response. The Courier-Journal ran a story of a woman with unmet health-care needs. She was one of the many vulnerable members of our society who lacks access to healthcare and whose needs are most often neither seen nor heard by the more fortunate.

But not this time. A Passport employee read the story and tracked down the woman in need. Although she was not eligible for Medicaid and Passport, her guardian angel was able to connect her to other social services agencies. Carter discovered that this “above-and-beyond” effort was the essence of the Passport culture. That began his “attraction to Passport,” and four months later, despite the comple-tion of his goals during an interim role at Passport, he decided to stay.

“I feel a compelling personal desire to do something meaningful in our com-munity. My best opportunity to serve is right here, right now.” Though many are aware of Passport in our community, few understand the one-of-a-kind health care network that serves over 100,000 children, and Medicaid-dependent adults in Kentucky.

Carter’s confidence in the vision and mission of Passport is supported by a unique business model. Sponsored by a group of compassionate physicians that assumes 51% of the financial risk, Passport has provided a consistent, provider-sponsored, community-based Medicaid health plan for more than 15 years. The plan employs over 230 individuals and offers a large provider network, including approximately 914 primary care physicians, 3,977 special-ist physicians, and all hospitals in the 16-county region it serves—all of whom are dedicated to improving the health and quality of life of Passport members. In addition to working closely with local providers, Passport also works with area health departments and social service agencies to promote events that support healthy living such as Healthy Hoops Kentucky, a program for children living with asthma, and the 2013 March of Dimes’ Walk for Babies. 

Carter’s work day begins at 5:00 with a vigorous encounter on his treadmill, and with the demands of Passport and his many philanthropic commitments, it doesn’t conclude until around 8 pm. Yet he says that his enduring marriage to wife Kellie keeps him centered and balanced. Mental and emotional renewal come from his family retreat on Lake Cumberland, enjoying his three children and four grandchildren, piloting his sin-gle-engine Beach Bonanza, and listening to old style country music.

Volunteering his time on behalf of the American Heart Association, Carter served as President of the 2013 Heart Ball Gala, which raised over $515,000! His philanthropic energies line up with his professional choices. The Heart Association has a “Big Goal of reduc-ing heart disease by 20% in 2020,” and Carter says that “gets his motor running.”

“When I leave here, ten years from now, I want to point to real improvements in the health status of Kentuckians. Obesity and diabetes threaten our population. Many of them are children, whose lives are just start-ing out. The implications are daunting. If we want a vibrant economy, we must have a very productive workforce. The choices we make now affect our health status as these young people grow up to live and work in their 40s and 50s. We are small and nimble with close con-nections to our providers. Together we make a difference.”  

—Debra Childers


As Affordable Care Act Expands Coverage for Children’s Mental Health Services, New Report Exposes Barriers and Opportunities

George Washington University Study Reveals Promising Practices, Partnerships

WASHINGTON, March 6, 2013 /PRNewswire/ — With the Patient Protection and Affordable Care Act aiming to expand coverage for critical mental health services, a newstudy by children’s health policy experts at the George Washington University Center for Health and Health Care in Schools (CHHCS) shows that meaningful improvements will also require state and local  governments to address the systemic impediments that lead to significant shortfalls in care.

“The children’s mental health system is as fragile as the at-risk youth it is intended to serve,” said Julia Graham Lear , PHD, a senior advisor and founder of CHHCS and the co-author of the study, Improving Access to Children’s Mental Health Care: Lessons from a Study of Eleven States. “The system is racked not only by chronic funding shortages but also by significant challenges and disconnects between the many institutions that serve children and families. This analysis, however, highlights ways in which policymakers, advocates and service providers must work together to elevate children’s mental health on the public agenda and seek comprehensive solutions to addressing this critical public health need,” she added.

While the Affordable Care Act creates a unique opportunity to expand mental health services for children, Donna Behrens, RN , MPH, associate director of CHHCS and lead author of the paper, comments that “the underdeveloped state of children’s mental health services across the United States imperils the potential success.”  She adds, “Unlike children’s physical health services for which there is a robust private and publically funded functioning system, management and delivery of mental health services is much less well developed or coherent.”

Fewer than 10 percent of children identified as needing mental health services get them within three months of recommendation, and fewer than half of those diagnosed with a serious emotional disorder ever get treatment from an appropriate mental health clinician.  “While lawsuits have driven some states to improve treatment services for young people, critical prevention programs and services are sporadic at best,” said Olga Acosta Price , PhD, study co-author and Director of CHHCS.


Bright Spots for Children’s Mental Health Services

With a grant from the Robert Wood Johnson Foundation, CHHCS researchers identified promising practices at the state level intended to increase access to children’s mental health programs and services.  They interviewed 47 individuals from governors’ offices, state mental health agencies, education and health departments and child advocacy organizations in Arizona, Connecticut, Florida, Georgia, Massachusetts, Minnesota, New Mexico, North Carolina, Oregon, Texas and West Virginia to hone in on the most pressing challenges and promising strategies to improve mental health and well-being for America’s children. 

Five of the eleven states offered bright spots of positive state strategies: 

  • West Virginia has implemented a statewide system that addresses prevention, early intervention and treatment and uses schools as an access point for reaching and serving children.
  • Connecticut has demonstrated the value of making emergency psychiatric services available via schools.
  • Massachusetts has expanded children’s access to mental health screenings through statewide health care reform. 
  • Minnesota is working to overcome professional shortages in rural areas through tele-psychiatry. 
  • North Carolina has demonstrated the power of partnerships between mental health professionals and physical health providers to elevate the need for children’s mental health services on the policy-making agenda.


Prescription for Action

Price noted the opportunities for schools and community mental health providers to work together in ensuring delivery of children’s mental health services.  “Successful partnerships are developing among those addressing the needs of children with diagnosed illnesses and disorders and those who working to ensure meaningful, evidence-based prevention and early intervention programs for all children,” Price said.

Lear, who has deep expertise in school-based health programs to promote children’s well-being, recommends states assess where progress has been made and what partners are moving the agenda forward.  In addition, state leaders need to explore which alliances prove enduring and effective and what confluence of events or interests can lead to overall success. 

This study is the second in a series by CHHCS that reports on strategies to strengthen and sustain children’s mental health services and prevent the onset of problem behaviors.  The first study, Developing a Business Plan for Sustaining School Mental Health Services, examines three case studies in which local communities partnered with state agencies to finance school-connected services. 


About the Center for Health and Health Care in Schools

The Center for Health and Health Care in Schools is a nonpartisan resource center at George Washington University’s School of Public Health and Health Services that builds on a 20-year commitment to achieve better health outcomes for children and adolescents through school-connected health programs and services. CHHCS’s web site, www.healthinschools.org, provides up-to-date information for health professionals, educators and families to assist in promoting the health of children through school-connected programs. 


Libby Simmons 
317- 454-8031

SOURCE Center for Health and Health Care in Schools

Link: http://www.prnewswire.com/news-releases/as-affordable-care-act-expands-coverage-for-childrens-mental-health-services-new-report-exposes-barriers-and-opportunities-195645121.html

Language barriers part of health exchange outreach

As health exchanges are implemented, language barriers become more of an issue in Washington and Oregon.

The Columbian

By Donna Gordon Blankenship, Associated Press

Monday, March 4, 2013


Source: The Associated Press

SEATTLE — A visit to a health clinic in Seattle’s International District, where patients speak more than 50 different languages, illustrates a challenge Washington faces as it launches its new health insurance exchange as part of the federal Affordable Care Act.

Officials have to overcome a language barrier with many people to get them to participate, a situation many who provide health services are familiar with.

“If the patient doesn’t understand and the provider doesn’t understand, you have great cause for problems,” said Teresita Batayola, CEO of International Community Health Services, which has four clinics around Seattle. Everyone on their medical staff speaks at least one language other than English. “Seattle happens to be very much an international gateway.”

The ICHS website is translated into four languages — Chinese, Korean, Vietnamese and Tagalog — and signage around the clinics is offered in multiple languages as well as symbols.

According to U.S. Census figures, nearly half a million Washington residents over age 5 speak a language other than English and say they don’t speak English very well.

More than 200,000 say Spanish is their primary language, but another 150,000 say they speak an Asian or Pacific Islander language, with Chinese, Korean, Tagalog and Russian the next most popular languages.

In all, people in Washington who don’t speak English well speak more than 150 different languages, not including dialects, according to the Census.

State officials estimate about 1 million Washington residents are uninsured, or about one in seven people who live in the state. About a third of them will likely become eligible for free health insurance under Medicaid if the Legislature votes to join the federal expansion program. The rest will be targeted by the state’s new health insurance exchange.

Reaching people like the users of the International District clinic — where only about 14 percent of the patients have private insurance — will be a challenge, acknowledged Michael Marchand, spokesman for Washington’s health plan finder.

The Affordable Care Act requires that Washington’s Health Benefit Exchange build relationships with local groups to help with outreach and assist people who need help signing up for insurance.

The Health Benefit Exchange will be asking groups to apply to be navigators and be paid to help people in their community navigate the exchange.

Chan Lai Ly came into the International District health clinic on Friday for a regular checkup for his diabetes. The 63-year-old exchanged information in both Chinese and Vietnamese with a medical assistant and a physician’s assistant.

Ly and his wife immigrated to Seattle two years ago from Ho Chi Minh City, Vietnam, to live near their children. When asked what he would do if he wasn’t able to get medical help in a language he understood, Ly shrugged his shoulders and said he would “give up.”

Marchand expects the navigator grants will go to larger community groups that will subcontract with organizations like International Community Health Services to reach specific populations.

The website for the insurance marketplace will launch in October in both English and Spanish, the most popular language in Washington other than English.

Developers of the website are still working on how they will let non-English speakers know they can get help on the telephone or in person in other languages.

And language barriers are not the only obstacle to getting everyone in Washington to sign up for health insurance.

“Part of the challenge is getting people to embrace change. Change is a difficult thing. There’s no way to really sugarcoat it,” Marchand said.

In Oregon

Oregon’s health insurance exchange will have staff who speak Spanish, Russian and Vietnamese to help explain and market the service that’s expected to provide health coverage to thousands of Oregonians.

The exchange will help the uninsured get access to health coverage once the federal health care overhaul requires most Americans to have insurance beginning next year.

But the state faces cultural and linguistic challenges in trying to educate limited-English speakers and hard-to-reach populations.

The exchange will be called Cover Oregon. Spokeswoman Lisa Morawski says staff will use an interpretation service to reach people who speak other languages. Cover Oregon also is partnering with insurance agents and community organizations to reach non-English speakers.

Article Link: http://www.columbian.com/news/2013/mar/04/language-barriers-part-of-health-exchange-outreach/

Obama Asks Health Plans to Report Rising Rates

By ROBERT PEAR | nytimes.com

Published: March 3, 2013


WASHINGTON — The Obama administration says it will require health insurance companies to report all price increases, no matter how small, to the federal government so officials can monitor the impact of the new health care law and insurers’ compliance with it.

Under current rules, the federal government requires insurers to report information on rate increases of 10 percent or more. New rules being issued by the administration will extend this requirement to all rate increases for all health plans sold to individuals, families and small businesses — a total of 60 million people.

Federal health officials said they needed the additional data to monitor trends in premiums as major provisions of the law take effect and more people buy insurance.

“The purpose of this policy is to identify patterns that could indicate market disruption, which could occur given the additional standards that apply” to insurance starting next year, the administration said in a justification of the rules adopted by Kathleen Sebelius, the secretary of health and human services.

Under the new law, Ms. Sebelius said, she is supposed to “monitor premium increases of health insurance coverage” inside and outside the regulated state-level markets known as insurance exchanges.

Consumer advocates welcomed the new reporting requirements, saying they would enhance the ability of insurance regulators and the public to scrutinize rate increases.

Insurers object to the requirements. The federal government “is creating a hugely burdensome and expensive reporting system” that duplicates what most states already require, the Blue Cross and Blue Shield Association said.

The reporting requirements generally apply to rate increases sought after the beginning of next month.

A fierce debate has erupted over the impact of Mr. Obama’s health care law. Insurers and employers predict that it will drive up premiums, especially for healthy people under the age of 35. The White House disputes that prediction and says that many factors will lead to lower prices.

The law guarantees coverage for people regardless of pre-existing conditions, prohibits insurers from charging women more, and limits their ability to charge higher rates to older people.

Insurers now often divide consumers into groups. Premiums are often higher and rise faster for less healthy individuals and groups.

By contrast, the new law requires insurers to pool the claim costs of all their customers when setting rates in the individual market in a state. 

Likewise, insurers must consider the claims histories of all their small-business customers when setting rates for them. Premiums for each product are supposed to reflect the combined experience of all products in the market.

Federal health officials said they needed to know the prices of all insurance products so they could determine whether insurers were complying with these requirements.

If an insurer wants to increase rates for any product, it “must submit a rate filing justification for all products” in the same market, the rule says. “Products can no longer be reviewed as completely unique,” but must reflect the experience of the entire market.

Julia T. Philips, a health actuary who works for the Minnesota insurance commissioner, called this one of the law’s most important consumer protections. Minnesota has had a similar requirement for 20 years, she said, and consumers have benefited.

Insurers say that policies sold under the new federal law will be more comprehensive and more expensive than what many people have now.

The White House says the fears of “rate shock” are overblown. Consumers can move from expensive health plans to more efficient, lower-cost plans, the administration says. It says critics who focus on premiums do not take account of other provisions of the law that limit how much consumers will spend out of their own pockets for health care.

In addition, the administration predicts that people gaining insurance will, on average, be younger and healthier than those who already have it, and this would tend to hold down premiums. Finally, it says, even if premiums increase significantly, lower-income people will be able to get federal subsidies to help defray the cost.

Carmen L. Balber, the director of the Washington office of Consumer Watchdog, a nonprofit advocacy group, said: “We applaud the administration for the new reporting requirements. This is a huge step forward.” But she added: “There’s a loophole. In 10 to 15 states, insurance commissioners have no power to reject unreasonable rate increases.”

Representative Jan Schakowsky, Democrat of Illinois, said she would introduce a bill to provide the secretary of health and human services with power to deny or modify rate increases found to be excessive or unjustified. 


Article Link: http://www.nytimes.com/2013/03/04/us/obama-to-require-reports-on-health-insurance-prices.html?_r=0

Medicare Pay to Shrink 2% as Sequester Looms on Friday

By: Robert Lowes

Feb 27, 2013



Unless a Congressional miracle occurs, Medicare reimbursement for physicians will decrease by 2% as $85 billion worth of automatic, across-the-board budget cuts called sequestration take effect on March 1 for the current fiscal year.

Organized medicine is complaining not only about reduced pay, which could push struggling medical practices further into a hole, but also about the deleterious effect of even larger budget cuts in store for federal agencies such as the Centers for Disease Control and Prevention, the US Food and Drug Administration, and the National Institutes of Health.

“Many physicians are worried about what will happen to the fundamental infrastructure of healthcare,” American College of Physicians (ACP) President David Bronson, MD, told Medscape Medical News. “And they’re concerned about a dysfunctional Congressional system that’s not getting people’s problems solved.”

President Barack Obama has invited Congressional leaders to meet with him on Friday to negotiate a deal to retroactively replace sequestration with a more discriminating deficit reduction deal that does not halt cancer research, furlough air traffic controllers, reduce fighter jet maintenance, and force children out of Head Start. The medical profession witnessed such postdeadline remedies in 2010 in the form of legislation that erased massive Medicare pay cuts required by the program’s notorious sustainable growth rate (SGR) formula.

The scheduled 2% reduction in Medicare reimbursement to physicians and other providers presumably would apply to all services rendered, beginning Friday. A spokesperson for the Centers for Medicare and Medicaid Services (CMS) told Medscape Medical News yesterday that the agency had no comment at this time on how the pay cut would be implemented.

When SGR-triggered pay cuts have loomed on the horizon in the past, CMS has informed physicians that Medicare administrative contractors (MACs) cannot pay electronic, error-free claims any sooner than 14 working days. This time lag allows MACs to sit on claims temporarily instead of processing them at a new, reduced rate. Likewise, lawmakers have 14 working days to nullify a Medicare pay cut so that MACs can process suspended claims at the old rate.

In the sequester crisis set to erupt on March 1, MACs would be forced to pay post–March 1 claims at the new reduced rate if Congress does not undo sequestration within the first 14 working days of March. If lawmakers forge an agreement afterward, MACs would reprocess the claims at the old rate.

A retroactive solution to sequestration could, in fact, come late this month, when a so-called continuing appropriations resolution expires March 27 and forces lawmakers to pass a new resolution to continue funding government operations. That legislation conceivably could apply a cure to the sequester.


2% Cut Comes on Top of Rising Medical Practice Costs

The sequester is all but certain to happen because Congressional Democrats and Republicans are just as stalemated on how to shrink the budget deficit in 2013 as they were in 2011, when the current sequester was born.

That year, Congress passed the Budget Control Act, which charged a bipartisan committee to propose at least $1.2 trillion in deficit reduction over the course of 10 years for lawmakers to approve. Under the act, failure to achieve this goal would trigger an equal level of sequestration beginning January 1, 2013, that would apply to defense as well as domestic spending. Medicare benefits, Social Security, and Medicaid are off-limits.

The idea behind sequestration was that the prospect of blind cuts to the armed services and social service programs such as Head Start would pressure conservative and liberal lawmakers alike to reduce the budget deficit in a more thoughtful, less painful way.

The pressure did not work. The bipartisan committee could not reach a deal, in part because Democrats and Republicans deadlocked on the issue of tax increases. Congress partly came around last December in its fiscal-cliff legislation, when it agreed to preserve the Bush-era tax cuts for everyone except the ultra-affluent. That legislation, the American Taxpayer Relief Act, also delayed a 26.5% Medicare pay cut until January 1, 2014, and sequestration was delayed until March 1 of this year.

Glenn Stream, MD, who chairs the board of directors of the American Academy of Family Physicians (AAFP), told Medscape Medical News that the 2% reduction in Medicare reimbursement required by sequestration poses more of a threat to medical practices than one might imagine.

“This is not about reducing a physician’s income, but revenue to the practice,” said Dr. Stream. “For practices with a high percentage of Medicare patients that are already struggling financially, even a 2% cut could make the difference between being a viable business or not.”

Similar to others, the ACP’s Dr. Bronson notes that the cut will occur even as medical practice expenses are expected to increase 3%. “So it’s a functional 5% cut,” said Dr. Bronson.

Sequestration will take an even bigger toll elsewhere in the federal government, reducing outlays during the remaining 7 months in fiscal 2013 by roughly 9% for domestic programs and roughly 13% for the military, according to the Obama administration.

The administration has ticked off a number of blows that sequestration would deliver to the nation’s health:

  • The National Institutes of Health would be forced to postpone or stop scientific projects and decrease the number of new research grants by the hundreds.
  • New drug approvals would slow down in a budget-whacked US Food and Drug Administration.
  • Cuts at the Centers for Disease Control and Prevention could result in 400,000 fewer HIV tests.

The AAFP’s Dr. Stream also worries about the effect of sequestration on federal programs that fund family medicine education.

“Everyone recognizes that the status quo can’t go forward, that we must carefully balance revenue and spending,” said Dr. Stream. “But sequestration is such a blunt instrument to implement that. We need to be strategic and prioritize our spending.”


Article Link:



Health insurance plans in Kentucky move forward

Written by: Logan Bayan

Written on: February 23, 2013



Kentucky establishes new agency to manage health insurance exchange

While many states throughout the U.S. have decided to abandon their efforts concerning a health insurance exchange, Kentucky is one of the few that has decided to build and operate its own. State officials chose for the state to run its own exchange in the hopes that it will better address some of the health insurance concerns that are specific to Kentucky residents. State officials have now formed the Office of the Kentucky Health Benefits Exchange, a new agency that will oversee the operation of the state’s health insurance exchange program.


Agency boasts of $40 million annual budget

This agency will boast of 30 employees, but several hundred contract workers and insurance agents throughout the state. This agency is notably different from others in the state, largely because of its annual budget, which comes in at nearly $40 million. These funds cover the operational costs of the state’s health insurance exchange and the administrative costs of the agency itself, with surplus to account for any catastrophic issues that the exchange may experience in the future.


Health insurance to be accessible to 600,000 people

State officials expect that the exchange system will help more than 600,000 residents throughout the state gain access to health insurance coverage. Many of these people do not have insurance currently, and Kentucky officials believe that this is primarily due to the high costs of coverage for some individuals and families. Kentucky officials aim to address these issues through the exchange. Much of the initial funding that is required for the exchange to take form is being provided by the federal government.


Health insurance exchange to help boost state revenue

The state will impose a 1% fee on all health insurance policies sold through the exchange. This will account for some $50 million in annual revenue for the state. The federal government plans to impose a 3% fee on insurance policies it sells through exchanges it operates throughout the country. State officials have noted that another reason the state has chosen to operate its own health insurance exchange is to avoid potentially paying to help cover the costs of federal exchanges that are being built elsewhere in the U.S.


Article Link: http://www.liveinsurancenews.com/health-insurance-plans-in-kentucky-move-forward/8520189/


Health Insurance Exchanges Bring Concerns of IT Disruptions: Survey

By Brian T. Horowitz  | Posted 2/25/2013


Insurers want to implement federally mandated health insurance exchanges, but they worry about IT infrastructure headaches, an Edifecs survey revealed.

Health insurers are embracing the move toward health insurance exchanges, yet they’re concerned about IT infrastructure changes, according to a Feb. 20 report by Edifecs, a health care IT software company.

The Obama administration’s Affordable Care Act calls for states to implement the exchanges, referred to as HIXes, by October 2013 or have the federal government implement them on their behalf. The Web-based exchanges allow small businesses or uninsured individuals to purchase health insurance.

Edifecs—which based its study on interviews with 125 senior health care professionals at the 2013 Healthcare Mandate Summit Feb. 4 to 6 in Austin, Texas—found that 95 percent of respondents plan to participate in an HIX, and 80 percent will join in 2014.

However, 88 percent of respondents are concerned about disruptions to their current IT enrollment infrastructure and processes when they join an exchange. Insurers will have to create new business processes and integration points rather than simply add new data from individuals and small businesses, according to Jamie Gier, vice president of corporate marketing at Edifecs.

“It goes beyond simple data feeds,” Gier told eWEEK in an email. “Beyond integrating their systems with federal and/or state exchanges, insurers will need to reconcile their detailed member records with those maintained by the exchange on at least a monthly basis.”

Insurers must manage and reconcile their membership records between their own insurer systems and HIXes, said Gier. This cross-checking of data will confirm eligibility and credit premiums, as well as ensure correct payments, said Gier.

In the survey, insurers also voiced concerns about a lack of time for sufficient testing of the exchange systems, said Gier.

“We are now less than eight months from the Oct. 1, 2013, deadline for exchanges to start offering enrollment,” Gier noted. “Many systems have yet to be set up, and all must be tested across multiple scenarios.”

A lack of comprehensive testing of IT systems could lead to major disruptions for the carriers and the exchanges. In fact, HIX health plans go into effect Jan. 1, 2014, and qualified health plans, benefit tiers and payment contracts must be entered and integrated with insurers’ IT systems by then, said Gier.

Many states will also have to overhaul their existing IT systems to comply with the Affordable Care Act, the survey revealed.

Ninety-three percent of respondents said they wanted more input in how the exchanges will be built. In addition, 69 percent said the information received from exchanges to date was either “poor” or “very poor.”

A lack of common data interoperability could be a problem as insurers transmit and receive information in the exchanges, Gier suggested.

Of respondents, 39.7 percent were “somewhat concerned” and 35.3 percent were “very concerned” about being able to support multiple formats from different exchanges. In addition, 96 percent of respondents were concerned about data formats changing over time.

“These formats will likely change as each exchange fixes issues and improves business processes,” said Gier. “Insurers will need flexible IT systems to accommodate the changes.”

Insurers participating in more than one exchange face additional data-transfer challenges. More than 30 percent of survey respondents intend to participate in three to five exchanges, according to Gier.

Meanwhile, doctors could face payment delays if insurance exchange data doesn’t match up.

“In the HIX model, that goal is more difficult to achieve because insurers have to work with the exchange and the federal government to reconcile and verify information,” Gier noted.

Still, the Web-based exchanges will bring fewer unpaid bills for doctors, said Gier.

She noted that low or unpredictable data quality will also be a challenge in HIXes.

“Health plans will need to carefully examine membership/enrollment updates coming from state exchanges,” said Gier. “Each state is at varying stages of HIX adoption and will have their own transaction formats, member identifiers and process flows.”

Brian T. Horowitz is a freelance technology and health writer as well as a copy editor. Brian has worked on the tech beat since 1996 and covered health care IT and rugged mobile computing for eWEEK since 2010. He has contributed to more than 20 publications, including Computer Shopper, Fast Company, FOXNews.com, More, NYSE Magazine, Parents, ScientificAmerican.com, USA Weekend and Womansday.com, as well as other consumer and trade publications. Brian holds a B.A. from Hofstra University in New York.

Follow him on Twitter: @bthorowitz

Article Link: http://www.eweek.com/enterprise-apps/health-insurance-exchanges-bring-concerns-of-it-disruptions-survey/


U.S. sets final rule for insurance exchange coverage


Posted on chicagotribune.com

2:47 PM CST, February 20, 2013


The Obama administration on Wednesday issued its long-awaited final rule on essential health benefits that insurers must offer consumers in the individual and small-group market beginning in 2014 under health care reform.

A cornerstone of President Barack Obama’s plan to enhance the breadth of health care coverage in the United States, the mandate allows the 50 U.S. states a role in identifying benefit requirements and grants insurers a phased-in accreditation process for plans sold on federal health care exchanges.

Wednesday’s rule included few changes from previous administration proposals, which could help states and insurers as they prepare for new online state health insurance marketplaces, known as healthcare exchanges, scheduled to begin enrolling beneficiaries for federally subsidized coverage on Oct. 1.

“The administration has been consistent in its approach to essential health benefits for more than a year, and that continued today. It’s good news for states and insurers because it means they don’t have to make any changes,” said Ian Spatz, a senior health care adviser at the consulting firm Manatt Health Solutions.

The exchanges are expected to cover as many as 26 million people within 10 years and seem likely to dominate individual and small group insurance markets. Another 12 million people are expected to receive health care coverage through an expansion of the Medicaid program for the poor, according to the nonpartisan Congressional Budget Office.

Obama’s Patient Protection and Affordable Care Act sets out 10 benefit categories that must be covered by most plans at the same level as a typical employer plan. The categories range from hospitalization, prescription drugs and maternity and newborn care.

Insurers including UnitedHealth Group Inc., Aetna Inc. and Cigna Corp. will use the government’s final word on these required benefits as they design plans and set premiums before the exchange launches. They have each said they will sell plans on some of the exchanges, but have not yet committed to which ones.

UnitedHealth, the largest insurer, said it is still reviewing the new rule. The company said the exchange insurance plans will essentially be a new type of coverage.

“In the long term, we are expecting and preparing for an ‘exchange’ category of coverage to become established as a new benefit category between Medicaid and the traditional commercial benefits markets,” spokesman Daryl Richard said.

The Department of Health and Human said the rule would mean greater access to mental health and substance abuse services by requiring parity with other health care benefits. HHS estimated that 62 million Americans would gain mental health coverage, an issue that has risen in importance after a string of mass shooting including last year’s elementary school massacre in Newtown, Conn.

The final rule preserved the state role in determining how the requirements are met by selecting their own benchmarks from plans sold within their respective borders. Most states opted for their home market’s largest small-group plan.

HHS kept to the benchmark rule despite objections from consumer groups who claimed that some of the selected plans were not comprehensive enough and argued for a single, uniform federal package.

But HHS officials found that maintaining states as primary regulators of state insurance markets would keep benefit offerings more in line with services typically offered through employer-sponsored plans in each state.

“The states continue to maintain their traditional role in defining the scope of insurance benefits and may exercise that authority by selecting a plan that reflects the benefit priorities of that state,” HHS said in the rule.

The administration also gave insurers the chance to phase-in requirements for plans sold on federally facilitated exchanges and denied requests from groups that wanted to exempt low-cost community health plans and Medicaid managed-care plans from the accreditation process.


Copyright © 2013, Reuters


Article Link: http://www.chicagotribune.com/business/breaking/chi-us-sets-final-rule-for-insurance-exchange-coverage-20130220,0,7203591.story 


What does the Affordable Care Act mean for you?

February 20, 2013 12:00 am  •  Christine Bryant Times Correspondent nwtimes.com

These next two years are important years in health care, with several provisions of the Patient Protection and Affordable Care Act taking effect.

Although several features have already been implemented, including prohibiting insurance companies from denying coverage to children based on pre-existing conditions and eliminating lifetime limits on insurance coverage, there’s a lot still to watch for in 2013.


Medicaid expansion

In a little less than a year, on Jan. 1, 2014, Americans younger than 65 whose family income is less than 133 percent of the poverty level will be eligible to enroll in Medicaid as part of a new initiative.

States will receive 100 percent federal funding for the first three years to support the expanded coverage, followed by 90 percent federal funding after the first three years.

The catch – states can choose whether they want to participate and accept the additional funding.

Several states have said yes so far, including Illinois. Indiana, however, remains undecided.

About half of the uninsured who want medical coverage under the Affordable Care Act will do so under Medicaid, and several Democrat lawmakers have called for Indiana to expand Medicaid under the act.

Gov. Mike Pence, who opposed the Affordable Care Act as a congressman, has not yet included money for the Medicaid expansion in his budget, saying it would cost too much money.

Dr. Alex Stemer, president of Franciscan Medical Specialists, says opting in would open Medicaid to thousands of families who couldn’t otherwise afford health coverage.

“I think it would be a misfortune for Indiana to decline it because it would bring a lot of healthcare dollars primarily to indigent neighborhoods, like Gary, East Chicago and Hammond,” he said.

Watch this year for Indiana to decide whether to participate in the Medicaid expansion.


Medicare payments

In the meantime, as of Jan. 1 this year, the Affordable Care Act requires states to pay primary care physicians Medicare payment rates for Medicaid patients. In other words, Medicaid payments to physicians will look more like Medicare payments.

The increase is fully funded by the federal government, and allows Medicaid patients to have more choices in which doctors they see because more doctors will now be willing to accept Medicaid.

While this may be beneficial to Medicaid patients, patients with private insurance may have more difficulty getting in to see their primary care physician in a timely manner, Stemer said.

This initiative is meant to keep more Medicaid patients from having to go the emergency room for medical help, but if a patient cannot get in to see his primary care physician, he may have to turn to the emergency room regardless, he said.


Health insurance exchanges

Beginning in 2014, if your employer doesn’t offer insurance and you aren’t on Medicaid, you must buy insurance in what is called the Health Insurance Marketplace – a health insurance exchange that is tightly regulated and offers citizens various plans from which to choose based on their needs.

No one can be turned down, and people who make between 133 and 400 percent of the federal poverty line will receive subsidies in the form of tax credits to help defer the cost.

States have the option on whether to form local exchanges, and if they choose not to, the federal government will.

Gov. Pence has said in the past he has opted to allow the federal government to run the state’s exchange.

If someone who can afford basic health insurance but chooses not to get it, he must pay a fee to help offset the costs of caring for uninsured Americans. If someone cannot afford it, he will be eligible for an exemption.


The cost

In 2012, employees paid a 1.45-percent tax for Medicare, but this year, if you earn more than $200,000, that tax goes up by 0.9 percent.

The Affordable Care Act also creates a new, 3.8-percent tax on investment income.

Some might also see an increase in their premiums, Stemer warns, because more people of various conditions will be covered.

“I don’t think health insurance is going to be cheaper, and a policy may cost more than last year,” he said. “There is a shift in covering those without preexisting conditions to those with preexisting conditions.”

Stemer also said the cost of medications will not decrease because that health care cost is not part of the Affordable Care Act.

“The U.S. government cannot negotiate those prices, so if the companies choose to raise those prices, the cost of health care for families will go up,” he said.

However, the increase in availability of generic drugs has helped alleviate many of those concerns, he said.

Stemer said there are still many uncertainties of how this act exactly will affect families – and it may differ for each individual family.

Many will benefit from this act, he said, but those who are healthy and rarely seek medical care may not benefit.

“We have a program with a lot of unknowns because it’s never been done before here,” he said.


Article Link: http://www.nwitimes.com/niche/get-healthy/health-care/what-does-the-affordable-care-act-mean-for-you/article_8db8e9e1-8a53-53b9-bb08-fec99d1c54cc.html