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Health Care Reform

Health Care Reform. Dee FitzGerald. Terms of Endearment. Personal Protection and Affordable Care Act Previous Conditions Exchanges Medical Loss Ratio Rate Review HIPPA-exception Plans Essential Therapy Comprehensive Major Medical Coverage. ACA. Passed in 2010 Staggered implementation

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Health Care Reform

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  1. Health Care Reform Dee FitzGerald

  2. Terms of Endearment • Personal Protection and Affordable Care Act • Previous Conditions • Exchanges • Medical Loss Ratio • Rate Review • HIPPA-exception Plans • Essential Therapy • Comprehensive Major Medical Coverage

  3. ACA • Passed in 2010 • Staggered implementation • Court challenges • Target for repeal or major revision • Can not work independent of inclusion

  4. Pre-existing Conditions • One of two elements already in place • Popular desire – HIPAA • Minor insurance effect for large groups • Broad interpretation • Recidivism • Rescission

  5. Exchanges in 2014 • Everyone must be enrolled in one of segments below • “Essential” benefits (still undefined) mandated for individual and small group market • Stand-alone dental will have opportunity to separately offer “essential” children’s dental inside, but not outside exchanges • HHS and States to determine rules of the exchange, and whether non-essential benefits can be sold there • Government • Programs • Medicare • Medicaid • CHIP • TRICARE • Veterans Large Group Plans (101+ lives) Individual or Small Group Plans (≤100 lives) Offered Outside Exchange Offered Inside Exchange Grandfathered Plans (Individual, Small or Large Group)

  6. Medical Loss Ratio • Set by regulation and law • Dictated by a business model • The dilemma of corporate bonuses • Shareholders versus the Public • Wall Street versus Main Street • Medical costs related to GNP • Disparity of medical costs by age

  7. Rate Review • WellPoint and the Individual Market • United Health and Medicare • Regulators and the Public

  8. HIPPA-excepted Plans • The Delta Dental Story • What HIPAA was designed to fix • HIPAA and the electronic medical record

  9. Essential Therapy • What is Essential and Why? • Rehabilitation versus Habilative services • Who makes the interpretation? • Cross-state competition

  10. Ten General Categoriesand problem areas • Ambulatory Patient Services • Varicose vein treatment • Emergency Services • Non-emergency care in ER • Hospitalization • Total hip replacement • Maternity & Newborn Care • Fertility treatments • Mental Health & Substance Abuse • Unlimited stay • Prescription Drugs • “lifestyle” drugs • Rehabilitative and HabilitativeServices & Devices • Unlimited physical therapy • Laboratory Services • Biometric testing, DNA markers • Preventive & Wellness Services & Chronic Disease Management • Nutritional counseling • Pediatric Services; including oral & vision care • braces

  11. Comprehensive Major Medical • The concept of rationing care • Medical choice

  12. What Does the Future Hold? • What is likely to happen and when? • What is unlikely to happen? • What might affect this group?

  13. Questions?www.drdeekay.comwww.deefitzgerald.com

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