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THE LATEST IN HEALTHCARE REFORM: INSURANCE EXCHANGES, ESSENTIAL HEALTH BENEFITS, PROPOSED REGULATIONS, AND OTHER ACA

THE LATEST IN HEALTHCARE REFORM: INSURANCE EXCHANGES, ESSENTIAL HEALTH BENEFITS, PROPOSED REGULATIONS, AND OTHER ACA DEVELOPMENTS. PANELISTS MELISSA D. BERRY CHARLIE LYNCH JAMES T. O’REILLY. THE LATEST IN HEALTHCARE REFORM PANELISTS.

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THE LATEST IN HEALTHCARE REFORM: INSURANCE EXCHANGES, ESSENTIAL HEALTH BENEFITS, PROPOSED REGULATIONS, AND OTHER ACA

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  1. THE LATEST IN HEALTHCARE REFORM: INSURANCE EXCHANGES, ESSENTIAL HEALTH BENEFITS, PROPOSED REGULATIONS, AND OTHER ACA DEVELOPMENTS • PANELISTS • MELISSA D. BERRY • CHARLIE LYNCH • JAMES T. O’REILLY

  2. THE LATEST IN HEALTHCARE REFORM PANELISTS Melissa D. Berry is a principal attorney editor with Thomson Reuters - Governance, Risk & Compliance. Melissa has been with the Thomson Reuters for 12 years and has worked on insurance compliance, health law and healthcare compliance products during that time. She currently leads Health Policy Tracking Service (HPTS) and oversees topic development as well as writing on Medicaid, FDA, medical malpractice/tort reform and healthcare reform subtopics. She is also a regular contributor to the Accelus blog (http://accelus.thomsonreuters.com/blog) on healthcare and insurance related topics and the Thomson Reuters Sustainability site (http://sustainability.thomsonreuters.com/) on various topics. Melissa is a graduate of the University of Akron School of Law and is licensed to practice in Ohio. She is also a member of the American Health Lawyers Association, AICP and Public Justice. MELISSA BERRY • MELISSA BERRY

  3. THE LATEST IN HEALTHCARE REFORM PANELISTS Charlie Lynch is a semi-retired attorney who does consulting work in the employee benefits field.  His areas of expertise are group life and health insurance, self-insured health plans and ERISA-related issues.  Before becoming a consultant, Charlie spent most of his career in the Law Department of the Metropolitan Life Insurance Company.  His most recent position there was as Associate General Counsel, specializing in group products and issues. He's a former AICP General Counsel and is currently the Mid-Atlantic Chapter's Regional Director.  He's also been a member of the AICP's Bylaws, Chapter Relations, Conference Planning and Nominating Committees.  In his spare time, Charlie's a docent at The Metropolitan Museum of Art in New York. Charlie has a Bachelor's degree in Economics from Boston College and earned his law degree at the Harvard Law School. • CHARLIE LYNCH

  4. THE LATEST IN HEALTHCARE REFORM PANELISTS Professor James T. O'Reilly teaches at the University of Cincinnati College of Law and its College of Medicine. His courses include Public Health Advocacy, Public Health Law, Food & Drug Law and other classes. His West treatise "Food & Drug Administration" was quoted by the U.S. Supreme Court with the words, 'The experts have written..." and other of his 45 texts have been cited and quoted by most federal appellate courts and many state supreme courts. He is active in health policy issues in Ohio and is a leader of the regional council of governments for the Cincinnati region. He was formerly Associate General Counsel for the Procter & Gamble Company and holds a JD from the University of Virginia and a BA cum laude from Boston College. • JAMES T. O’REILLY

  5. THE LATEST IN HEALTHCARE REFORM AGENDA • OVERVIEW OF AFFORDABLE CARE ACT (ACA) • INSURANCE EXCHANGES • ESSENTIAL HEALTHCARE BENEFITS • OTHER ACA DEVELOPMENTS TO WATCH • PROPOSED REGULATIONS TO WATCH • FINAL REMARKS

  6. THE LATEST IN HEALTHCARE REFORM PRINCIPAL LAWS • PATIENT PROTECTION AND AFFORDABLE CARE ACT (ACA) • HEALTHCARE AND EDUCATION RECONCILIATION ACT

  7. THE LATEST IN HEALTHCARE REFORM AFFORDABLE CARE ACT (ACA) PRINCIPAL OBJECTIVES • ACCESS • GUARANTEED ISSUE • GUARANTEED RENEWABILITY • “FAIR” PREMIUMS • NON-DISCRIMINATION • AFFORDABILITY

  8. THE LATEST IN HEALTHCARE REFORM HEALTH INSURANCE EXCHANGES • THE CONCEPT • TRANSPARENCY • COMPARISON SHOPPING • IMPLEMENTATION • POLITICAL CONSIDERATIONS • POSTPONEMENTS • THE COSTS

  9. THE LATEST IN HEALTHCARE REFORMHEALTH INSURANCE EXCHANGES KEY DATES • OPERATIVE DATE – 10/1/2013 • FORMS FILED AND APPROVED • MARKETING COMMENCES • EFFECTIVE DATE – 1/1/2014 • INDIVIDUAL & SMALL GROUP • PRACTICAL CONSIDERATIONS

  10. THE LATEST IN HEALTHCARE REFORMBY THE NUMBERS • 17 STATES + DC HAVE RECEIVED CONDITIONAL APPROVAL FROM HHS TO ESTABLISH STATE-BASED EXCHANGES • 7 STATES ARE PLANNING A FEDERAL-STATE PARTNERSHIP • 26 STATES ARE DEFAULTING TO THE FEDERAL EXCHANGE • THE DEFAULT DOES NOT MEAN THERE WILL BE UNIFORMITY ACROSS THE 26 STATES • STATES WILL BE INVOLVED IN PLAN CERTIFICATION AND OVERSIGHT FUNCTIONS, CONSUMER ASSISTANCE AND OUTREACH, AS WELL AS STREAMLINING ELIGIBILITY DETERMINATIONS

  11. THE LATEST IN HEALTHCARE REFORMSTATE DECISIONS • STATES RUNNING THEIR OWN EXCHANGES HAVE A NUMBER OF DESIGN AND FUNCTION DECISIONS TO MAKE: • CONSUMER ASSISTANCE AND IT SYSTEMS • MUST ALLOW CONSUMERS TO APPLY FOR AND ENROLL ONLINE, IN PERSON, BY PHONE, FAX, OR MAIL, AND PROVIDE CULTURALLY AND LINGUISTICALLY APPROPRIATE ASSISTANCE • HHS JUST RELEASED PROPOSED NAVIGATOR REGULATIONS TO CREATE STANDARDS RELATING TO CONFLICT-OF-INTEREST, TRAINING AND CERTIFICATION, FOR NAVIGATORS AND OTHER ASSISTANCE PERSONNEL

  12. THE LATEST IN HEALTHCARE REFORM MID-ATLANTIC JURISDICTIONS DISTRICT OF COLUMBIA • INDEPENDENT AUTHORITY OF THE DISTRICT GOVERNMENT • 11 MEMBER BOARD • THE EXCHANGE WILL CERTIFY QUALIFIED HEALTH PLANS IN THE EXCHANGE • Benchmark plan: GROUP HOSPITALIZATION AND MEDICAL SERVICES (CAREFIRST BCBS) - BluePreferred, PPO

  13. THE LATEST IN HEALTHCARE REFORM MID-ATLANTIC JURISDICTIONS STATE AGENCY OR OFFICE MARYLAND • INDEPENDENT STATE AGENCY • 2011 SB 182 (CHAP 1) AND 2011 HB 166 (CHAP 2) • 9 MEMBER BOARD • BOARD TO DECIDE ON PLANS INCLUDED • IN AUGUST 2012, LAUNCHED THE MARYLAND HEALTH CONNECTION, ITS OFFICIAL NAME, LOGO AND WEBSITE • BENCHMARK PLAN: CareFirst (BCBS)- HMO HSA Open Access • SIMILAR JURISDICTIONS: CA, KY, MA, NV, RI, TN, UT, & VT

  14. THE LATEST IN HEALTHCARE REFORM MID-ATLANTIC JURISDICTIONS STATE AGENCY OR OFFICE NEW YORK • GOV. ANDREW CUOMO (D) ESTABLISHED THE NEW YORK HEALTH BENEFIT EXCHANGE THROUGH AN EXECUTIVE ORDER 42 ON APRIL 12, 2012. • EXECUTIVE ORDER REQUIRES THE EXCHANGE TO BE FINANCIALLY SELF SUSTAINING BY 2015, AND TAKE ADVANTAGE OF THE FEDERAL FUNDS THAT ARE AVAILABLE THROUGH 2014. • NO FORMAL GOVERNING BOARD; STAKEHOLDER AND PUBLIC COMMENT THROUGH REGIONAL ADVISORY COMMITTEES. • THE DEPARTMENT OF HEALTH WILL HOUSE THE EXCHANGE. • BENCHMARK PLAN: Oxford, EPO

  15. THE LATEST IN HEALTHCARE REFORM MID-ATLANTIC JURISDICTIONS FEDERAL/STATE PARTNERSHIP DELAWARE • WILL PURSUE A STATE/FEDERAL PARTNERSHIP TO EXCHANGE ESTABLISHMENT IN THE STATE. • DELAWARE WILL RUN THE PLAN MANAGEMENT AND CONSUMER ASSISTANCE FUNCTIONS OF THE FEDERALLY FACILITATED EXCHANGE. • BENCHMARK PLAN: Highmark (BCBS of DE)- Simply Blue, EPO • SIMILAR JURISDICTIONS: AR, IL, IA, MI, NH, NC, & WV

  16. THE LATEST IN HEALTHCARE REFORM MID-ATLANTIC JURISDICTIONS DEFAULT TO FEDERAL EXCHANGE • NEW JERSEY • BENCHMARK PLAN: Horizon (BCBS)- HMO Access • PENNSYLVANIA • BENCHMARK PLAN: Aetna, POS • VIRGINIA • BENCHMARK PLAN: Anthem (BCBS)- KeyCare, PPO • SIMILAR JURISDICTIONS: AL, AK, AZ, FL, GA, ID, IN, KS, LA, ME, MO, MT, NE, ND, OH, OK, SC, SD, TX, WI, & WY

  17. THE LATEST IN HEALTHCARE REFORMOTHER STRUCTURES • QUASI-GOVERNMENTAL WITH A TWIST: • CT – PUBLIC INSTRUMENTALITY AND POLITICAL SUBDIVISION OF THE STATE, BUT NOT A DEPARTMENT, INSTITUTION OR AGENCY OF THE STATE • OR – “PUBLIC CORPORATION PERFORMING GOVERNMENTAL FUNCTIONS AND EXCERCISING GOVERNMENTAL POWERS” • NON-PROFIT ENTITIES: • CO, HI, MS (OPERATED THROUGH RISK POOL ASSOCIATION) • NM (SUBJECT TO OVERSIGHT AND AUDITING BY DOI) • PUBLIC/PRIVATE PARTNERSHIP: MN • PUBLIC/PRIVATE PARTNERSHIP SEPARATE FROM STATE: WA

  18. THE LATEST IN HEALTHCARE REFORM BEYOND EXCHANGES • STATE INSURANCE DEPARTMENTS • CONTINUED FUNCTIONS • RELATIONSHIP TO EXCHANGES

  19. THE LATEST IN HEALTHCARE REFORM ESSENTIAL HEALTH BENEFITS (EHBs) • THE CONCEPTS • CONSISTENCY • FLEXIBILITY • CORE BENEFITS • BENCHMARK PLANS • ACTUARIAL VALUE • QUALIFIED PLANS/ACCREDITATION • THE REGULATIONS

  20. THE LATEST IN HEALTHCARE REFORM ESSENTIAL HEALTH BENEFITS (EHBs) CATEGORIES (DEFINED IN ACA) • AMBULATORY PATIENT SERVICES • EMERGENCY SERVICES • HOSPITALIZATION • MATERNITY AND NEWBORN CARE • MENTAL HEALTH/SUBSTANCE ABUSE DISORDER SERVICES (INCLUDING BEHAVIORAL HEALTH SERVICES)

  21. THE LATEST IN HEALTHCARE REFORM ESSENTIAL HEALTH BENEFITS (EHBs) CATEGORIES (DEFINED IN ACA) • PRESCRIPTION DRUGS • REHABILITATIVE AND HABILITATIVE SERVICES AND DEVICES • LABORATORY SERVICES • PREVENTATIVE AND WELLNESS SERVICES/CHRONIC DISEASE MANAGEMENT • PEDIATRIC SERVICES (INCLUDING ORAL AND VISION SERVICES)

  22. THE LATEST IN HEALTHCARE REFORM INSURANCE DEPARTMENT APPROVALS • NON-EXCHANGE PRODUCTS • STATE MANDATES

  23. THE LATEST IN HEALTHCARE REFORM EHB RULEMAKING - FEDERAL • STANDARDS RELATED TO ESSENTIAL HEALTH BENEFITS, ACTUARIAL VALUE, AND ACCREDITATION (78 FR 12834-01 – FINAL RULE 2/25/2013) OUTLINES EXCHANGE AND ISSUER STANDARDS RELATED TO COVERAGE OF ESSENTIAL HEALTH BENEFITS AND ACTUARIAL VALUE.

  24. THE LATEST IN HEALTHCARE REFORM OTHER ACA ISSUES TO WATCH • HEALTH INSURANCE MARKET RULES; RATE REVIEW (78 FR 13406-01 – FINAL RULE 2/27/2013) • FAIR HEALTH INSURANCE PREMIUMS • GUARANTEED AVAILABILITY • GUARANTEED RENEWABILITY • SINGLE RISK POOLS • CATASTROPHIC PLANS

  25. THE LATEST IN HEALTHCARE REFORM OTHER ACA ISSUES TO WATCH • COMMONWEALTH FUND SURVEY SHOWING 22 STATES DO NOT HAVE AUTHORITY TO ENFORCE NEW REGULATIONS • HTTP://WWW.COMMONWEALTHFUND.ORG/PUBLICATIONS/FUND-REPORTS/2013/JAN/STATE-ACTION-2014-MARKET-REFORMS.ASPX • HTTP://WWW.MODERNHEALTHCARE.COM/ARTICLE/20130201/NEWS/302019902/MANY-STATES-LACK-AUTHORITY-ON-NEW-INSURANCE-RULES-REPORT

  26. THE LATEST IN HEALTHCARE REFORM OTHER ACA ISSUES TO WATCH • WHISTLEBLOWER PROTECTIONS (78 FED REG 13222/ACA SECTION 1558 – INTERIM FINAL 2/27/2013) • PROVIDES PROTECTIONS TO EMPLOYEES OF HEALTH INSURANCE ISSUERS OR OTHER EMPLOYERS WHO MAY HAVE BEEN SUBJECT TO RETALIATION FOR REPORTING POTENTIAL VIOLATIONS OF THE LAW’S CONSUMER PROTECTIONS (E.G., THE PROHIBITION ON DENIALS OF INSURANCE DUE TO PRE-EXISTING CONDITIONS) OR AFFORDABILITY ASSISTANCE PROVISIONS (E.G., ACCESS TO HEALTH INSURANCE PREMIUMS TAX CREDITS) • PENALTIES FOR VIOLATIONS

  27. THE LATEST IN HEALTHCARE REFORM PROPOSED REGULATIONS TO WATCH • MEDICARE PROGRAM; MEDICAL LOSS RATIO REQUIREMENTS FOR THE MEDICARE ADVANTAGE AND THE MEDICARE PRESCRIPTION DRUG BENEFIT PROGRAMS [78 FR 12428-01 PROPOSED 2/22/2013 – COMMENTS OPEN UNTIL 4/16/2013] • COVERAGE OF CERTAIN PREVENTATIVE SERVICES UNDER THE AFFORDABLE CARE ACT [78 FR 8456-01 – PROPOSED 2/6/2013]

  28. THE LATEST IN HEALTHCARE REFORM QUESTIONS

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