Health care reform
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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

Health Care Reform

Dee FitzGerald


Terms of endearment

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


Health care reform

ACA

  • Passed in 2010

  • Staggered implementation

  • Court challenges

  • Target for repeal or major revision

  • Can not work independent of inclusion


Pre existing conditions

Pre-existing Conditions

  • One of two elements already in place

  • Popular desire – HIPAA

  • Minor insurance effect for large groups

  • Broad interpretation

  • Recidivism

  • Rescission


Exchanges in 2014

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)


Medical loss ratio

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


Rate review

Rate Review

  • WellPoint and the Individual Market

  • United Health and Medicare

  • Regulators and the Public


Hippa excepted plans

HIPPA-excepted Plans

  • The Delta Dental Story

  • What HIPAA was designed to fix

  • HIPAA and the electronic medical record


Essential therapy

Essential Therapy

  • What is Essential and Why?

  • Rehabilitation versus Habilative services

  • Who makes the interpretation?

  • Cross-state competition


Ten general categories and problem areas

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


Comprehensive major medical

Comprehensive Major Medical

  • The concept of rationing care

  • Medical choice


What does the future hold

What Does the Future Hold?

  • What is likely to happen and when?

  • What is unlikely to happen?

  • What might affect this group?


Questions www drdeekay com www deefitzgerald com

Questions?www.drdeekay.comwww.deefitzgerald.com


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