Major ObamaCare Regulations Issued Last Week

The regulatory heart and soul of the Affordable Care Act was issued by CMS last week. Proposed rules regulating health insurance markets, including coverage for essential health benefits, pre-existing conditions and expanding employment-based wellness programs were made public last Wednesday. Starting in 2014,  health insurance issuers in the individual and small group markets would only be allowed to vary premiums based on age (within a 3:1 ratio for adults), tobacco use (within a 1.5:1 ratio and subject to wellness program requirements in the small group market), family size, and geography. All other factors – such as pre-existing conditions, health status, claims history, duration of coverage, gender, occupation, and small employer size and industry – would no longer be able to be used by insurance companies to increase the premiums for those seeking insurance. Click here for a CMS summary. Click here to read the 131-page rule.

Insurance Exchange and Essential Health Benefit Proposed Rules Released

Click here to review the actual 119-page proposed rule that outlines Exchange and issuer standards related to coverage of essential health benefits and actuarial value. (This proposed rule also proposes a timeline for qualified health plans to be accredited in federally-facilitated Exchanges and an amendment which provides an application process for the recognition of additional accrediting entities for purposes of certification of qualified health plans.) As many as 30 or more states may refuse to run their own exchanges and have the feds run them instead. Click here for that update.

Regarding Essential Health Benefits, the law ensures that health plans offered in the individual and small group markets, both inside and outside of Affordable Insurance Exchanges, offer a core package of items and services, known as “essential health benefits” (EHB). Click here for further details from CMS. Click here for a good summary from the New York Times.  EHB must include items and services within at least the following 10 categories:

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.

Rules Would Expand Workplace Wellness Programs

The proposed rules also continue to support workplace wellness programs, including “participatory wellness programs” that generally are available without regard to an individual’s health status. These include programs that reimburse for the cost of membership in a fitness center; that provide a reward to employees for attending a monthly, no cost health education seminar; or that provides a reward to employees who complete a health risk assessment without requiring them to take further action. The rules also outline amended standards for nondiscriminatory “health-contingent wellness programs,” that generally require individuals to meet a specific standard related to their health to obtain a reward. Click here for a summary and to read the actual rules.

NOTE: More detailed and easy to read summaries prepared by our policy team will be emailed to our clients later this week.

House GOP Planning Significant ObamaCare Scrutiny

Maybe Obamacare can’t be repealed, but it can be scrutinized at every turn by the GOP-controlled House of Representatives, according House Speaker John Boehner. The House oversight committees are apparently planning to step up their review of the Affordable Care Act. Click here for the story.

Cost to Fix Physician Payment Cut for 1-Year Increases: CBO

The cost of preventing the cuts in physician payments for one year just got a lot more expensive, according to a CBO analysis released last week. A one-year delay in the 26.5% Sustainable Growth Rate cut will cost $25.2 billion.  That’s up $7 billion from earlier CBO estimates. Many in Congress are pushing for a one-year fix to be implemented before January. However, the price of stopping the cuts for two years is lower than previous estimates. It’s now at $41.5 billion. The 10-year, or permanent repeal, cost is now at $243.7 billion. Click here for the story.

Hospitals Continue Selling Bundled Payment Deals to Employers

Employers and employees continue to save money by buying bundled surgery services directly from hospitals, according to a report last week in the LA Times. For example, At Kroger, 21 patients have traveled for surgery this year, and none have experienced complications or been readmitted to the hospital, said the company’s vice president for employee benefits. Kroger pays about $30,000 on average for those knee and hip replacement surgeries, 15% less than what it pays at other hospitals. Click here for the story. Meanwhile, the Cleveland Clinic finalized a surgery deal with Boeing last month, according to press reports. Boeing’s deal with top-rated Cleveland Clinic means about 83,000 managers, some retirees and family members can get a big cost advantage on heart procedures, as well as free travel and lodging. Click here for the report in the Seattle Times.

Patients with Online EMR Access Use More Services: JAMA

Patients with online access to their medical records and secure e-mail communication with clinicians had increased use of clinical services, including office visits and telephone encounters, compared to patients who did not have online access, according to a study last week in the Journal of the American Medical Association. Click here to read a good summary.

Deadline This Week for EHR Incentive Payment Registration, Attestation

Hospitals that want a Medicare EHR Incentive Program payment for fiscal year 2012 have until Nov. 30 to complete their online registration and attestation through the CMS website. To receive an incentive payment, a hospital must use certified EHR technology, meet the Meaningful Use criteria and submit the required quality measurement data generated by certified EHR technology to CMS. If a hospital is attesting to Meaningful Use for the first time, it must report on a continuous 90-day period that ended on or before Sept. 30. If a hospital is attesting to Meaningful Use for the second time, the reporting period covers all of FY 2012. Click here for more from CMS.

Researchers: Medicare Patients Getting Too Many Diagnostic Tests

Are Medicare patients getting too many repeat diagnostic tests, including medical imaging scans? A study of nearly 750,000 patients published last week in the Archives of Internal Medicine suggests this is the case. The researchers discovered that one-third to one-half of the tests were repeated within three years, despite the fact that repeat testing for these exams is not routinely anticipated. Click here for the story.

U.S. Task Force Calls for Routine HIV Testing for Most Americans

The U.S. Preventive Services Task Force last week called for routine HIV testing for all Americans aged 15 to 65, expanding its 2005 recommendation that included only high-risk individuals. The draft recommendation was prompted by studies showing major health benefits of early HIV treatment.  Click here to see the Task Force recommendation. Click here for the report in USA Today.