Guidance on Essential Health Benefits from HHS/CMS – Healthcare reform under PPACA
Posted December 28, 2011 by PHaynes
Essential Health Benefits (“EHB”) is a set of health care service categories that must be covered by certain plans, starting in 2014*. Starting with plan years or policy years that began on or after September 23, 2010, health plans can no longer impose a lifetime dollar limit on spending for these services. All plans, except grandfathered individual health insurance policies, must phase out annual dollar spending limits for EHB services by 2014.
Centers for Medicare and Medicaid Services (CMS), a department of HHS (U.S. Department of Health & Human Services), has an office called The Center for Consumer Information and Insurance Oversight (CCIIO). Strangely, in a move that some critics have called “deft” and others suggest is a “detour” CMS-CCIIO issued a “Benefits Bulletin” on Friday, December 16, 2011, called “Giving States Additional Flexibility to Implement Health Reform.”
For HHS & CMS to issue “guidance” in this way is strange to say the least. Perhaps the Administration is looking to take some pressure off of HHS. The recent backlash, as a result of the guidance calling for birth control to be a covered preventive benefit (starting January 1, 2013) may suggest that HHS is looking to defer to states to define EHB. Whereas the input from the Institute of Medicine (IOM) suggested that the HHS adopt typical small employer coverages as a model for “essential benefits”, here, the HHS is suggesting that each State and the District of Columbia determine what is essential and balance that with issues of effectiveness and cost. The current categories that EHB includes are:
- 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
Public input is welcome on this intended approach. Please send comments on the bulletin (by January 31, 2012)to: EssentialHealthBenefits@cms.hhs.gov.
* PPACA requires that fully-insured small group and individual health plans on and off the Exchange must cover essential health benefits beginning January 1, 2014. PPACA also mandates that plans of all sizes that cover benefits designated as Essential Health Benefits, including self-funded plans, must cover these benefits with no annual limits or lifetime maximums.
Government Links
Reaction
- Washington Post: Kathleen Sebelius’s health-care muddle
- LA Times: A detour on health reform
- American Medical News: IOM panel: Insurance exchanges will fail unless cost factor is faced
Open Enrollment Effectiveness & Compliance Slides
Posted December 16, 2011 by Megan DiMartino
We recently hosed an educational webinar conducting a “Postmortem” of 2012 Open Enrollment effectiveness and compliance strategies. Expert speaker, Attorney Patrick Haynes reviewed Communication and Enrollment strategies and walked Employers and Plan Sponsors through a checklist of Open Enrollment and compliance requirements. The webinar covered a variety of important issues, including:
* Required ERISA, PPACA, and HIPAA notices
* Compliance with State Insurance Mandates
* Proper electronic signature and election methods
* Making Open Enrollment available to all similarly situated plan participants
* What constitutes a Qualifying Event
Popular Group Health & Benefits Administration Blogs
Posted December 13, 2011 by Megan DiMartino
We’ve been blogging for several months now at AP Benefit Advisors about group health, compliance, benefits administration, employee communications, and other issues highly relevant to business operation in the 21st century. Moving into 2012, we thought it would be a good idea to share some of our more popular blogs to gain some perspective on where we’ve been, and where we’re going.
Webinar: 2012 Open Enrollment Effectiveness and Compliance Review
Posted December 8, 2011 by Megan DiMartino
Join us for this complimentary, educational webinar as we conduct a “Postmortem” of your 2012 Open Enrollment effectiveness and compliance strategies. Expert speaker, Attorney Patrick Haynes will review Communication and Enrollment strategies, and walk Employers and Plan Sponsors through a checklist of Open Enrollment and compliance requirements. Highlights of the webinar will include:
- Required ERISA, PPACA, and HIPAA notices
- Compliance with State Insurance Mandates
- Proper electronic signature and election methods
- Making Open Enrollment available to all similarly situated plan participants
- What constitutes a Qualifying Event
Date & Time: Thursday, December 15, 2011 @ 12:00 PM – 12:30 PM EST
System Requirements: Windows® 7, Vista, XP, 2003 Server, or Mac OS® X 10.5 or newer
Space is limited; reserve your Webinar seat now at: https://www1.gotomeeting.com/register/714366137
Employee Health Improvement Strategies
Posted December 5, 2011 by Megan DiMartino
Increasingly, employers are looking to data analysis and predictive modeling to identify and understand the health factors driving the cost of their health benefits program. With approximately 75% of health care cost attributable to people with chronic diseases, and the extensive body of evidence attributing chronic disease to lifestyle factors such as smoking, poor eating habits and physical inactivity, these same employers are actively seeking ways to promote positive changes in employees’ lifestyles by helping them reduce their health risk factors.
Utilizing our claims data warehouse, we store, access and analyze your claims history to assess the risk factors that affect your company and to develop customized solutions based on your population. In addition, we identify large open claims and emerging claims in order to monitor medical management intervention and manage the reinsurance risk. By taking an in-depth look into your employee health population management, we are able to identify your company’s risks, and potential areas of saving.
From there, we will develop a strategy to bring wellness and health improvement to your workplace. Our consultants will work with you to document program specifics, develop the right communications strategy and identify potential vendors that best meet your needs. We’ll help you devise the right employee incentive programs to encourage more participation, drive changes in employee behavior, and measure the program’s return on investment.
