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Federal Health Care Reform

Update

1Q11 Medical Office WEBINAR

March 30, 2011

Kathy C. Nixon, CMA (AAMA), CPC Provider Network Manager (Virginia) Provider Engagement & Contracting

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WELCOME !

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Disclaimer

The information contained in this WEBINAR was current at the time it was published or uploaded. Due to the evolving nature of this subject matter, this information may be subject to change. Anthem will continue to communicate updates on an ongoing basis via our provider newsletters and web portals.

Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. Anthem Blue Cross and Blue Shield and its affiliated HMO, HealthKeepers, Inc., are

independent licensees of the Blue Cross and Blue Shield Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.

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Note: This presentation is not intended to advise you on how to comply with PPACA or its related regulations. This presentation is not intended to offer legal advice. For specific questions, please consult with your counsel or benefits advisor.

Today’s Agenda (March 30, 2011)

▪ What is Health Care Reform?

▪ Our Approach to Implementation

▪ Key Provisions for 2010-12 and Beyond

• Group / Individual / Medicare

▪ Spotlight on Preventive Care

▪ How to Stay Informed

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Note: This presentation is not intended to advise you on how to comply with PPACA or its related regulations. This presentation is not intended to offer legal advice. For specific questions, please consult with your counsel or benefits advisor.

ACRONYMS related to Health Care Reform

▪ ACIP Advisory Committee on Immunization Practices

▪ CDC Centers for Disease Control & Prevention

▪ CLASS Community Living Assistance Services & Supports Act

▪ FSA Flexible Spending Account

▪ HCR Health Care Reform

▪ HHS U.S. Department of Health & Human Services

▪ HRSA Health Resources & Services Administration

▪ PPACAPatient Protection & Affordable Care Act

▪ USPSTF United States Preventive Services Task Force

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What is Health Care Reform?

HHS Issues Interim Final Regulations

Implementation Begins

HHS Finalizes Regulations

The Patient Protection & Affordable Care Act or “PPACA,” which was

signed into law by President Obama on March 23, 2010

How is it being Implemented?

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Our Approach to Implementation

PUT OUR CUSTOMERS AND MEMBERS FIRST

▪ Our mission:• Improve the lives of the people we serve

and the health of our communities

▪ Our implementation strategy:• Adjust policies and procedures with the

best information available at the time• Implement appropriately and consistently

across business units• Communicate aggressively

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• Rate review• Rescission requirements• Early retiree reinsurance• Tax credits for small employers• Dependents to age 26• No pre-ex exclusions for children• No lifetime limits• Restrictions on annual limits• Coverage of recommended

preventive services*• Patient protections (PCP selection,

OB-GYN access, ER services)*

• Consumer appeal process*• No benefit differences by employee

salary*

• Reporting cost of health coverage on employees‘ W-2s

• Minimum medical loss ratios

• Grants for small employer wellness programs

• Prescription required for OTC drug reimbursement

• Increased tax on nonqualified HSA disbursements

• CLASS program developed (enrollment date TBD)

• Uniform coverage summaries

• Standard terms and conditions

• FSA contributions limited to $2,500/year

• Tax exclusion for Medicare Part D retiree drug subsidy payments eliminated

• Quality initiative reporting

• Employer mandate (with auto-enrollment)

• Expands small group to 1-100

• Insurance exchanges for small group

• New product framework for small group

• Free choice vouchers• Increased small

business tax credit• No annual limits• Essential Health

Benefits mandates

*Required for non-grandfathered, but plans may choose to implement for grandfathered

Key Provisions: GROUP Health Plans

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• Rate review• Rescission requirements• Dependents to age 26• No lifetime limits• Restrictions on annual limits*• No pre-ex exclusions for

children*• Coverage of recommended

preventive services*• Patient protections (PCP

selection, OB-GYN access, ER services)*

• Consumer appeal process*

• Minimum medical loss ratios

• Prescription required for OTC drug reimbursement

• Increased tax on nonqualified HSA disbursements

• Uniform coverage summaries

• Standard terms and conditions

• Quality initiative reporting

• Individual mandate• Insurance exchanges• New product

framework• Premium subsidies

and tax credits for low-income individuals

• No annual limits• Individual health

plans “guaranteed issue”

• No health status rating

• Essential Health Benefits mandates

Key Provisions: INDIVIDUAL Market

*Required for nongrandfathered, but plans may choose to implement for grandfathered

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• $250 rebate to offset the Medicare Part D “donut hole”

• Reductions to Medicare Advantage program payments, which may result in reduced benefits and/or increased member cost-sharing

• No more cost-sharing for preventive services

• Discounts on prescriptions in the Medicare Part D “donut hole”

• Subsidies for brand-name prescriptions filled in the Medicare Part D “donut hole”

• Medicare provider payment changes

• Pilot programs such as bundled payments for an episode of care

• Medicare Advantage plan minimum medical loss ratios

Key Provisions: MEDICARE

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Plans Not Impacted by HCRIn general, these plans are exempted from health care reform:

▪ Retiree-only plans with no active employees ▪ Short-term health insurance plans▪ Most dental and vision plans (unless built into a basic

health plan)▪ Long-term care insurance▪ Medigap (Medicare Supplemental)▪ EAP (Employee Assistance programs)

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Update on 2010 Provisions

Grandfathering

• Allows groups to keep the health plan they had when HCR was passed if they make no changes after March 23, 2010

• EXAMPLE: Plans will lose their grandfathered status if they decrease benefits or increase member cost share (deductible or co-insurance), or copays if over a certain amount

• We are reviewing our plans to determine which plans we consider grandfathered and are notifying them as required by law

• Newly insured plans sold after March 23, 2010, are NOT grandfathered

• Federal law doesn’t require us to continue offering a product just because it’s a grandfathered plan; however some states restrict a payer’s ability to close out books of business

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Update on 2010 Provisions (continued)

Dependent Coverage to Age 26

No Lifetime Dollar Limits on Essential Health Benefits

Restricted Annual Dollar Limits on Essential Health Benefits

• Implemented early for many plans• Business decision to include vision and dental, as well as pharmacy• Parents can enroll dependents at their next open enrollment after September 23,

2010, (for group) or during a one-time enrollment period (for Individual)

• Implemented for all grandfathered and non-grandfathered group and Individual plans starting September 23, 2010

• Those who previously reached their lifetime maximum may re-enroll

• Business decision to not administer restricted annual limits on essential health benefits

• We’re providing data for employers who want to apply for a waiver

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Update on 2010 Provisions (continued)

Essential Health Benefit Categories per HHS

• Ambulance• Ambulatory surgical services• Emergency services• Hospitalization• Maternity and newborn care• Mental health and substance

use disorder services, including behavioral health treatment

NOTE: PPACA includes provisions that eliminate lifetime $ limits and restrict annual $ limits for essential health benefits; Effective upon renewal on or after September 23, 2010, this applies to medical and pharmacy benefits only. Regulations to fully define essential health benefits have not yet been issued, and good faith compliance is required until we receive detailed regulations from HHS.

• Prescription drugs• Rehabilitative and habilitative services

and devices• Laboratory services• Preventive and wellness services• Chronic disease management• Pediatric services, including oral and

vision care

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Update on 2010 Provisions (continued)

Preventive Care

Patient Protections

• We’ve reviewed the USPSTF/HRSA/ACIP recommendations to determine services we are required to cover

• We’ve updated non-grandfathered plans to cover preventive services with no member cost sharing

• Some grandfathered plans may voluntarily implement this provision; we chose to include this coverage in some grandfathered plans

• Give consumers more flexibility in choosing a primary care doctor and accessing OB-GYN services

• Insurers must cover out-of-network emergency medical care received in an ER; copays and coinsurance for these services cannot exceed those required for in-network emergency care

• We chose to include these provisions in all plan offerings, even though they aren’t required for grandfathered plans

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Preventive Care

Who, What, When, Where ?

• Anthem (VA) already had a Preventive Services list, which was expanded to include the HCR compliant preventive services effective September 17, 2010

• Grandfathered plans are not required to implement the new HCR Preventive Care provision if they retain the preventive coverage they already have

• Non-grandfathered plans are required to include it with no member cost-sharing; however, the change from cost-share to no cost-share does not occur until the renewal date for existing policies --- this is not “One Size Fits All”

• Verification of eligibility and benefits for every patient is key to determining correct member cost share; use of Point of Care is even more critical to provider practices

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POINT of CARE Benefit ScreenPoint of CareEXAMPLE:

HMO “Jane Doe”Benefit Screen

NOTE:PCP OV Copay $25

PCP OV (Preventive)is $0

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POINT of CARE Benefit ScreenPoint of Care

EXAMPLE(continued)

Select PREVENTIVE from dropdown box

and VIEW; NOTE:

$0 copay and 0% coinsurance

for allPreventive

Services

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Navigating Anthem’s Provider Portal▪ Provider information regarding HCR is featured in our

Network Update bi-monthly provider newsletters

▪ HCR articles specific to providers are also being posted to a dedicated HCR section of our website

▪ The following are screen prints taken from the Virginia open provider portal of www.anthem.com

• Codes for Preventive Services

• Where to Find Updates on-line

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www.anthem.com

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Virginia; then Enter

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HORIZONTAL Navigation

VERTICAL Navigation

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Provider Home; Preventive Codes

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HCR- VA Preventive Care Code List

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Notice TABS at bottom of screen for ease in

finding code(s)

by category

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Provider-

The“DIAG Codes”tab is

currentlythe last tab

of this listing;however, weplan to add a“Modifiers”tab at our

next revisionto include

“PT” and “33”

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HEALTH CARE REFORMProvider-centric information being

Posted “prn” by corporate Provider Communications –

Please check here periodicallyFor the latest addition

to this “library”.

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NEW!HCR Articlefor March

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NEW WAY TO RECEIVEANTHEM NEWS!

Requires you to register on-line to receive “prn” time-sensitive

e-mails of importance for providers.

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NEW!Please Sign-Up

TODAY!

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You!

CONCLUSION This concludes our WEBINAR program for the 1st quarter of 2011. We hope you found the information helpful and that your time today was well spent.

If you wish to comment about your experience today and/or ifyou have questions specifically regarding today’s topic, please submit an e-mail with “Anthem 3/30/11 Webinar: HCR” in the subject line to: kathy.nixon@anthem.com

(Remember to include your detailed contact information.)

Thank You!

Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. Anthem Blue Cross and Blue Shield and its affiliated HMO, HealthKeepers, Inc., are

independent licensees of the Blue Cross and Blue Shield Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.