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
MELISSA BERRY
MELISSA BERRY
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.
2
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 LYNCH
Charlie has a Bachelor's degree in Economics from Boston
College and earned his law degree at the Harvard Law
School.
3
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
4
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
5
THE LATEST IN HEALTHCARE REFORM
PRINCIPAL LAWS
• PATIENT PROTECTION AND AFFORDABLE CARE ACT
(ACA)
• HEALTHCARE AND EDUCATION RECONCILIATION ACT
6
THE LATEST IN HEALTHCARE REFORM
AFFORDABLE CARE ACT (ACA)
PRINCIPAL OBJECTIVES
• ACCESS
 GUARANTEED ISSUE
 GUARANTEED RENEWABILITY
 “FAIR” PREMIUMS
 NON-DISCRIMINATION
• AFFORDABILITY
7
THE LATEST IN HEALTHCARE REFORM
HEALTH INSURANCE EXCHANGES
• THE CONCEPT
 TRANSPARENCY
 COMPARISON SHOPPING
• IMPLEMENTATION
 POLITICAL CONSIDERATIONS
 POSTPONEMENTS
• THE COSTS
8
THE LATEST IN HEALTHCARE REFORM
HEALTH 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
9
THE LATEST IN HEALTHCARE REFORM
BY 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
10
THE LATEST IN HEALTHCARE REFORM
STATE 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
11
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
12
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
13
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
14
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
15
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
16
THE LATEST IN HEALTHCARE REFORM
OTHER 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
17
THE LATEST IN HEALTHCARE REFORM
BEYOND EXCHANGES
• STATE INSURANCE DEPARTMENTS
 CONTINUED FUNCTIONS
 RELATIONSHIP TO EXCHANGES
18
THE LATEST IN HEALTHCARE REFORM
ESSENTIAL HEALTH BENEFITS (EHBs)
• THE CONCEPTS
 CONSISTENCY
 FLEXIBILITY
 CORE BENEFITS
 BENCHMARK PLANS
 ACTUARIAL VALUE
 QUALIFIED PLANS/ACCREDITATION
• THE REGULATIONS
19
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)
20
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)
21
THE LATEST IN HEALTHCARE REFORM
INSURANCE DEPARTMENT APPROVALS
• NON-EXCHANGE PRODUCTS
• STATE MANDATES
22
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.
23
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
24
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/F
UND-REPORTS/2013/JAN/STATE-ACTION-2014-MARKETREFORMS.ASPX
 HTTP://WWW.MODERNHEALTHCARE.COM/ARTICLE/2013020
1/NEWS/302019902/MANY-STATES-LACK-AUTHORITY-ONNEW-INSURANCE-RULES-REPORT
25
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
26
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]
27
THE LATEST IN HEALTHCARE REFORM
QUESTIONS
28