PPACA: The Insurance Agent's Guide to the Next 12 Months

As the New Year dawns, a new set of PPACA provisions prepares to kick in. Whether you support reform or not, and whether the courts turn down all or parts of it or not, here's what you may have to look forward to in the coming 12 months:

Deadline: Jan. 1, 2011

• Insurers bound to minimum medical loss ratio requirements. As of this week, health plans will be required to spend 85 percent of large group premiums on clinical services and quality; for those in the small group market, the percentage must be 80 percent. The requirement to report medical loss ratios was effective in 2010, and insurers must begin providing rebates beginning Jan. 1.
• Medicare drug coverage gap closes. Pharmaceutical manufacturers must provide a 50 percent discount on brand-name prescriptions filled in the Medicare Part D coverage gap beginning in 2011. Federal subsidies for generic prescriptions filled in the Medicare Part D coverage gap are now being phased in, as well.
• Some health care professionals get a bonus. Primary care service providers and general surgeons practicing in shortage areas will begin receiving a 10 percent Medicare bonus payment. The phased-in payments are scheduled to become fully functional by Dec. 31, 2015.
• Medicare covers clients' preventive care costs. Now, when beneficiaries seek A or B-rated Medicare-covered preventive services that are recommended by the U.S. Preventive Services Task Force, they pay nothing. It also waives the Medicare deductible for colorectal cancer screening tests and authorizes Medicare coverage for a personalized prevention plan, including a comprehensive health risk assessment. Covered services include bone mass measurement, the hepatitis B shot, breast cancer screening, medical nutrition therapy, and smoking cessation sessions.
• Center for Medicare and Medicaid Innovation opens doors. This new center is meant to test new payment and delivery system models that reduce costs while maintaining or improving quality.
• More beneficiaries pay more Medicare premiums. The income threshold for income-related Medicare Part B premiums are frozen at 2010 levels through 2019, which should result in more people paying income-related premiums. In addition, the Medicare Part D premium subsidy is frozen for individuals with incomes over $85,000 and couples with income over $170,000.
• Changes come to Medicare Advantage plans. Payments to private Medicare Advantage plans have been restructured, with phased-in payments set at increasingly smaller percentages of Medicare fee-for-service rates. In addition, 2011 payments are frozen at 2010 levels, and Medicare Advantage plans are prohibited from imposing higher cost-sharing requirements for some Medicare-covered benefits than required under the traditional fee-for-service program.
• Medicaid Health Homes emerge as an option. This new Medicaid state option allows certain Medicaid enrollees to designate a provider as a health home, and provides states that implement the option with 90 percent federal matching payments for two years for health home-related services.
• Medicaid explores chronic disease prevention. States will begin receiving three-year grants to develop programs that provide Medicaid enrollees with incentives to participate in comprehensive health lifestyle programs and meet certain health behavior targets.
• CLASS Act starts collecting premiums. If they don't opt out, employees may begin paying premiums into the national, voluntary long term care insurance program. Consumers can choose to opt out of this program if offered at work; the Department of Health and Human Services is scheduled to determine benefit amounts in 2012.
• Quality Improvement Strategy draft due to Congress. The Secretary of Health and Human Services will develop a national quality improvement strategy, to be updated annually, that includes recommendations on improving health care service delivery, patient health outcomes, and the overall health of the population.
• Changes to tax-free savings accounts kick in. As of the first of the year, over-the-counter drugs not prescribed by a doctor cannot be reimbursed through a health reimbursement account or a health flexible spending account, nor can they be reimbursed on a tax-free basis from an HSA or Archer Medical Savings Account. In addition, the tax on distributions from an HSA or Archer MSA not used for qualified medical expenses will be increased to 20 percent of the amount used.

Deadline: Fiscal year 2011

• Funding authorized for wellness program grants. Under this provision, small employers establishing wellness programs will receive grants for up to five years.
• Funding appropriated for Teaching Health Centers. This funding will be available for five years for community-based, ambulatory patient care centers that operate primary care residency programs.
• Funding authorized for medical malpractice grants. This sets aside $50 million for five-year demonstration grants awarded to states to develop, implement, and evaluate alternatives to current tort litigations.

Deadline: March 23, 2011

• Funding for health insurance exchanges. Here, grants will start going out to states to help them plan for the establishment of American Health Benefit Exchanges and Small Business Health Options Program Exchanges, which facilitate the purchase of insurance by individuals and small employers. Enrollment is scheduled to begin Jan. 1, 2014.
• Nutritional labeling kicks in. This requires disclosure of the nutritional content of standard menu items at chain restaurants and food sold from vending machines.

Deadline: July 1, 2011

• Medicaid stops paying infection-prone hospitals. Medicare already turns down hospitals seeking payments for extra care given in cases of preventable infections and medical errors. Now, Medicaid will do the same.
• Graduate Medical Education gets a boost. This increases the number of Graduate Medical Education training positions by redistributing currently unused slots and promotes training in outpatient settings.

Deadline: Oct. 1, 2011

• Funding available for Medicare Independent Payment Advisory Board. Scheduled to hand down its first recommendations by Jan. 15, 2014, the 15-member board will submit legislative proposals containing recommendations to reduce the per capita rate of growth in Medicare spending if spending exceeds targeted growth rates.
• Medicaid gets in the long term care game. Creates the State Balancing Incentive Program in Medicaid to provide enhanced federal matching payments in order to increase non-institutionally based long term care services. Also establishes the Community First Choice Option in Medicaid to provide community-based attendant support services to certain people with disabilities.

SOURCE: The Henry J. Kaiser Family Foundation Health Reform Source