Home > Archives for 2012
Wednesday, November 14, 2012
Friday, November 9, 2012
Sunday, November 4, 2012
Monday, October 29, 2012
Saturday, October 27, 2012
Monday, October 22, 2012
Image Credit: Zawezome, on Flickr
Friday, October 19, 2012
Wednesday, October 17, 2012
Thursday, October 11, 2012
Tuesday, September 18, 2012
You might want to think about a United Healthcare Medicare plans for those who have recently flipped 65 and so are just turning out to be eligible for Medicare insurance. You might presently always be enrolled in a Medicare health plan yet are not content and wish to alter suppliers. You could be in times where you proceed to a whole new spot as well as are unable to obtain insurance coverage through your old strategy. You may be considering a new Medicare health plan in case you are concerned about receiving coverage on your medications.
United Healthcare Medicare plans likewise incorporate supplement insurance. This insurance policy helps you deal with the expenses accrued in Medicare medicare part a as well as part B expenditures. The particular unique needs programs are only for those with selected health conditions and also existence scenarios and are not available for common sign up.
Monday, September 17, 2012
Friday, September 14, 2012
Wednesday, September 12, 2012
Monday, September 10, 2012
It is a known fact that in the past women experience difficulty in accessing health insurance more than their male counterpart. They were made to pay more because of their gender thereby making it impossible for a lot to be covered. If they are pregnant or require an operation during delivery or suffer domestic abuse, they are often denied coverage. Now, American women can heave a sigh of relief because of the benefits coming their way through the health act.
The current law was enacted to be effective in phases. Some have taken off while some will be fully effective in 2014.
Daily Cleansing- This is the number one acne remedy. It is important to find a gentle face cleanser that works well with your skin type. Regular deodorant soaps or body washes should never be used on the face or effected area. They will strip the skin of its moisture and make matters worse. After cleansing, use a mild moisturizer. It is essential to do this twice a day.
Friday, September 7, 2012
In an August 27 letter to Deputy Assistant to the President for Health Policy Jeanne Lambrew, ERIC expressed concern that the executive branch agencies might inappropriately interpret the ACA to require employers to offer dependent coverage regardless of whether the dependent coverage is affordable or sufficiently valuable. ERIC argued that this interpretation is not consistent with the statute and would have significant negative effects on the nation’s large employers without producing a meaningful increase in dependent coverage.
“We urge the President to support regulations or other guidance clarifying that employers are not obligated to offer dependent coverage and are not liable for a shared responsibility penalty if they decline to cover dependents,” said ERIC President & CEO Scott Macey and Senior Vice President for Health Policy Gretchen Young.
ERIC’s letter explains that, although the shared responsibility provisions refer to health coverage for full-time employees and their dependents (the latter being referred to in a parenthetical), the penalties are based solely on the number of an employer’s full-time employees: dependents do not enter into the penalty calculation. An employer that offers affordable health coverage to all of its full-time employees is not subject to any shared responsibility penalty, regardless of whether the employer offers dependent coverage.
“If Congress had intended to create a dramatic new mandate that penalized employers for failing to offer dependent coverage, Congress would have done so much more directly (and more effectively) than the statute achieves with its parenthetical reference to dependents,” Macey and Young wrote. ERIC believes that the reference to dependents in the shared responsibility provisions is merely a drafting error (resulting from the legislative confusion during the passage of the ACA), one that should be corrected in agency guidance, they added.
The letter also warns that, while some commenters have suggested that the statute should be interpreted to require employers to offer dependent coverage on an employee-pay-all basis, a mandate to offer unsubsidized dependent coverage would impose substantial burdens and costs on the employer without increasing the dependents’ access to affordable health coverage.
ERIC contends that this suggestion misperceives the administrative burden that an employer must bear if it introduces dependent coverage, even on an employee-pay-all basis, and that such a mandate would not accomplish ACA’s central goal, which is to increase access to affordable health coverage.
“In fact, an employer might do its low-income employees a disservice by offering unsubsidized dependent coverage, since the availability of the coverage might make the employee ineligible for premium tax credits and other financial assistance with respect to the dependent,” ERIC argues.
For more information, visit http://www.eric.org.
Wednesday, September 5, 2012
Notice 2012-58 describes safe harbor methods that employers may use (but are not required to use) to determine which employees are treated as full-time employees for purposes of the ACA-added shared employer responsibility provisions of Code Sec. 4980H. Specifically, the administrative guidance in Notice 2012-58 modifies and expands on previous guidance and includes a safe harbor method that employers may apply to specified newly-hired employees.
Beginning Jan. 1, 2014, Code Sec. 4980H provides that an applicable large employer (generally, an employer who employed at least 50 full-time employees, including full-time equivalent employees, on business days during the preceding calendar year) is subject to an assessable payment if either of the following situations exists:
1. the employer fails to offer its full-time employees (and their dependents) the opportunity to enroll in minimum essential coverage under an eligible employer-sponsored plan and any full-time employee is certified to receive a premium tax credit or cost-sharing reduction; or
2. the employer offers its full-time employees (and their dependents) the opportunity to enroll in minimum essential coverage and one or more full-time employees is certified to receive a premium tax credit or cost-sharing reduction (generally because the employer’s coverage either is not affordable or does not provide minimum value).
Coverage under an employer-sponsored plan is considered affordable to a particular employee if the employee’s required contribution (within the meaning of Code Sec. 5000A(e)(1)(B)) to the plan does not exceed 9.5 percent of the employee’s household income for the taxable year. Code Sec. 4980H(c)(4) provides that a full-time employee with respect to any month is an employee who is employed on average at least 30 hours of service per week.
Safe harbor method. The safe harbor method described in a previous notice provides employers the option to use a look-back measurement period of up to 12 months to determine whether new variable-hour employees or seasonal employees are full-time employees, without being subject to a payment under Code Sec. 4980H for this period with respect to those employees. An employee is a variable-hour employee if, based on the facts and circumstances at the date the employee begins providing services to the employer (the start date), it cannot be determined that the employee is reasonably expected to work on average at least 30 hours per week.
In addition, the safe harbor:
- gives employers the option to use specified administrative periods (in conjunction with specified measurement periods) for ongoing employees (generally an employee who has been employed by the employer for at least one complete standard measurement period, a defined time period of not less than three but not more than 12 consecutive calendar months, as chosen by the employer) and certain newly hired employees;
- facilitates a transition for new employees from the determination method the employer chooses to use for them to the determination method the employer chooses to use for ongoing employees; and
- provides employers reliance, at least through the end of 2014, on the guidance in Notice 2012-58 and on the following approaches described in prior notices:
- for ongoing employees, an employer will be permitted to use measurement and stability periods of up to 12 months;
- for new employees who are reasonably expected to work full-time, an employer that maintains a group health plan that meets certain requirements will not be subject to an assessable payment under Code Sec. 4980H for failing to offer coverage to the employee for the initial three months of employment; and
- for all employees, an employer will not be subject to an assessable payment under Code Sec. 4980H(b) for an employee if the coverage offered to that employee was affordable based on the employee’s Form W-2 wages reported in Box 1 (often referred to as the affordability safe harbor).
Seasonal employees. Code Sec. 4980H(c)(2)(B) generally provides that if an employer’s workforce exceeds 50 full-time employees for 120 days or fewer during a calendar year, and the employees in excess of 50 who were employed during that period of no more than 120 days were seasonal employees, the employer would not be an applicable large employer. A seasonal worker is a worker who performs labor or services on a seasonal basis, such as during the summer or the winter holiday season.
This guidance is intended to encourage employers to continue providing and potentially to expand group health plan coverage for their employees by permitting employers to adopt reasonable procedures to determine which employees are full-time employees without becoming liable for a payment under Code Sec. 4980H; to protect employees from unnecessary cost, confusion, and disruption of coverage; and to minimize administrative burdens on the Affordable Insurance Exchanges (Exchanges).
Limited waiting period. Simultaneously with the issuance of Notice 2012-58, the Departments issued Notice 2012-59, which provides guidance under Public Health Service Act (PHSA) Sec. 2708. PHSA Sec. 2708 provides that, for plan years beginning on or after Jan. 1, 2014, a group health plan or group health insurance issuer shall not apply any waiting period that exceeds 90 days. Other conditions for eligibility under the terms of a group health plan are generally permissible under PHSA Sec. 2708, unless the condition is designed to avoid compliance with the 90-day waiting period limitation.
A “waiting period” is defined as the period that must pass before coverage for an employee or dependent who is otherwise eligible to enroll under the terms of the plan can become effective. For this purpose, being eligible for coverage means having met the plan’s substantive eligibility conditions (such as being in an eligible job classification or achieving job-related licensure requirements specified in the plan’s terms).
If, under the terms of a plan, an employee may elect coverage that would begin on a date that does not exceed the 90-day waiting period limitation, the 90-day waiting period limitation is considered satisfied. Accordingly, a plan or issuer will not be considered to have violated PHSA Sec. 2708 merely because employees take additional time to elect coverage.
Variable hour employees. If under a group health plan an employee’s eligibility is based on the employee regularly working a specified number of hours per period (or working full time), and it cannot be determined that a newly hired employee is reasonably expected to regularly work that number of hours per period (or work full time), the plan may take a reasonable period of time to determine whether the employee meets the plan’s eligibility condition. The eligibility condition may include a measurement period that is consistent with the timeframe permitted for such determinations under Code Sec. 4980H, whether or not the employer is an “applicable large employer” subject to Code Sec. 4980H.
Unless a waiting period that exceeds 90 days is imposed after a measurement period, the time period for determining whether such an employee meets the plan’s eligibility condition will not be considered to be designed to avoid compliance with the 90-day waiting period limitation if coverage is made effective no later than 13 months from the employee’s start date, plus, if the employee’s start date is not the first day of a calendar month, the time remaining until the first day of the next calendar month.
Employers, plans and issuers may rely on the compliance guidance in Notice 2012-59 at least through the end of 2014.
All employees, whether full time, part-time, or variable hour, who are not offered the opportunity to enroll in health insurance by their employer will be eligible to receive premium tax credits and cost-sharing reductions for Exchange coverage if they meet other conditions for receipt of these credits, the Departments asserted.
Comments. Comments on either notice may be submitted by September 30 to the specified addresses, referring to the applicable notice. For Notice 2012-58, send comments electronically to Notice.email@example.com, or via regular mail to CC:PA:LPD:PR (Notice 2012-58), Room 5203, Internal Revenue Service, P.O. Box 7604, Ben Franklin Station, Washington, DC 20044. For Notice 2012-59, send comments electronically to firstname.lastname@example.org; or via regular mail to Office of Health Plan Standards and Compliance Assistance, Employee Benefits Security Administration, Room N-5653, U.S. Department of Labor,
Monday, September 3, 2012
Friday, August 31, 2012
These experts insist that to effectively contain health care costs, strategies must target drivers of both the level and growth of costs and the role of medical prices and quantity of services; and eliminate administrative costs that do not improve health status and outcomes. The United States spends nearly $360 billion a year on administrative costs, accounting for 14 percent of excessive health spending.
“Although these solutions are not intended to be exhaustive, they have the greatest probability of both being implemented and successfully controlling health costs,” the report noted, emphasizing that it would be most effective to implement as a package the following recommended solutions.
• Negotiate uniform payment rates to apply to all payers and providers in a state; install an independent council to enforce a global spending target with growth per person limited to the average growth in wages. States will publicly report measured of quality, access, and costs with bonuses to be paid to high performing providers and payment rates adjusted for quality.
• Use payment alternatives to fee-for-service with fixed bundled payments for all the services and care a patient needs, including related rehabilitation and follow-up care for 90 days after discharge. Begin implementation as soon as possible using the bundles for 37 cardiac (heart) and orthopedic procedures used in the Medicare Acute Care Episode program.
• Implement competitive bidding for all medical equipment and devices, laboratory tests, radiological diagnostic services, beginning with Medicare and health insurance exchanges negotiating for private payers and state employee plans.
• Health insurance exchanges should offer tiered products based on high quality and low cost providers tied to reduced cost-share for insureds who use the high quality providers.
• Simplify administrative systems by electronic exchange of eligibility and claims information; use a single standard physician credentialing system; electronically provide monthly explanation of benefits statements; implement electronic health records integrating clinical (test orders, for example) and administrative tasks (billing, prior authorization, and payments).
• Require full transparency in medical provider pricing, including out-of-pocket costs, quality of care, and patient volume; prohibit “gag clauses” (which forbid contracted providers from disclosing to patients the discounts negotiated with insurers) on price information. Have state insurance department and health insurance exchanges collect, audit, and publicly report pricing and claims data.
• Expand use of non-physician providers such as advance practice nurses or nurse practitioners.
• Expand to private sector payers the Medicare ban on physician self-referral to facilities in which they or their families have a financial interest.
• Reduce costs of defensive medicine by providing a “safe harbor” for providers who use qualified health information technology and evidence-based clinical practice guidelines.
In conclusion, the NEJM article states, “These are the types of large-scale solutions that are necessary to contain health costs. Although many in the health industry perceive that it is not in their interest to contain national health spending, it is a fact that what cannot continue will not continue….Americans therefore face a choice. Payers could simply shift costs to individuals. As those costs become more and more unaffordable, people would severely restrict their consumption of health care and might forgo necessary care.
“We present alternative strategies to contain national health spending that allow Americans to access necessary care. Our approach addresses the system as a whole, not just Medicare and Medicaid. It is the path to rising wages, a sustainable federal budget, and the health system that all Americans deserve.”
Wednesday, August 29, 2012
Most recently, the Centers for Medicare and Medicaid Services (CMS) announced a final rule expected to save time and money for physicians and other health care providers by establishing a unique health plan identifier (HPID) and a data element that will serve as an “other entity” identifier (OEID) for entities that are not health plans, health care providers, or individuals, but that need to be identified in standard transactions. The rule also specifies the circumstances under which an organization-covered health care provider, such as a hospital, must require certain non-covered individual health care providers who are prescribers to obtain and disclose a National Provider Identifier (NPI). The final rule is scheduled to be published in the September 5 Federal Register.
The adoption of the HPID implements an administrative simplification provision of the ACA, and one of a series of changes required to cut red tape in the health care system. The measure is projected to save up to $6 billion over ten years. Currently, when a health care provider bills a health plan, that plan may use a wide range of different identifiers that do not have a standard format. As a result, health care providers run into a number of time-consuming problems, such as misrouting of transactions, rejection of transactions due to insurance identification errors, and difficulty determining patient eligibility. The final rule will simplify these processes.
Future administrative simplification rules enacting HIPAA will address adoption of:
• a standard for claims attachments;
• operating rules for claims attachments; and
• requirements for certification of health plans’ compliance with all HIPAA standards and operating rules.
“These new standards are a part of our efforts to help providers and health plans spend less time filling out paperwork and more time seeing their patients,” said Health and Human Services Secretary Kathleen Sebelius.
The rule also makes final a one-year proposed delay—from Oct. 1, 2013, to Oct. 1, 2014—in the compliance date for use of new codes that classify diseases and health problems. These code sets, known as the International Classification of Diseases, 10th Edition diagnosis and procedure codes (ICD-10) will include codes for new procedures and diagnoses that improve the quality of information available for quality improvement and payment purposes.
This rule is the fourth administrative simplification regulation issued by HHS under the ACA, including the following with anticipated savings over ten years:
• On July 8, 2011—Operating rules for two electronic health care transactions to make it easier for health care providers to determine whether a patient is eligible for coverage and the status of a health care claim submitted to a health. Savings from this measure could be up to $12 billion.
• On Jan. 10, 2012—Standards for the health care electronic funds transfers (EFT) and remittance advice transaction between health plans and health care. Savings could be up to $4.6 billion.
• On Aug. 10, 2012—An IFC that adopted operating rules for the health care EFT and electronic remittance advice transaction. Savings are anticipated to be up to $4.5 billion.
The regulation is effective November 5. Health plans, excluding small health plans, are required to obtain HPIDs two years after the effective date, in 2014. Small health plans are required to obtain HPIDs three years after the effective date, in 2015. All covered entities are required to use HPIDs where they identify health plans that have HPIDs in standard transactions four years after the effective date, in 2016.
Covered entities have 180 days from the final regulation’s effective date to comply with the additional NPI requirement.
Monday, August 27, 2012
Proper screening is essential to ensure that the person you choose has, not only the skills to provide excellent care, but also the right personality for the job. Consider these tips and hints and you will find that hiring an in-home heath care provider does not have to be stressful.
1. Evaluate Your Loved One's Needs
While some older adults just need assistance with basic living skills, others have additional health care needs that require a special skill set. Therefore, it is necessary to make a list of all of the duties that an in-home health care professional will need to provide so you can narrow down the list of candidates early on. If you are hiring through an agency, give them as much information from the start so they can match you up with someone who possesses all of knowledge and capabilities to give the best care possible to your loved one.
If your home health care worker will be assisting with bathing or dressing, it is important to discuss this with your loved one to make sure that they are comfortable with the gender of the companion. Women or men may become embarrassed when opposite gendered health care workers assist them with personal care and this may cause bath time to become stressful.
2. Speak With Local Experts
Before you go to the yellow pages or check out the classifieds for home heath aids, speak with neighbors, doctors, and elder care providers locally who can give you some recommendations and advice. Find out where other families have found in-home help and have them tell you about their experience. An administrator at a local nursing home may also have some suggestions for you on where to locate the best care giver. Support groups are a wealth of information, as well.
3. Create a Job Description
When you are ready to begin speaking with applicants and conducting interviews, start by writing a job description. The job duties can serve as talking points for your interview and also give the applicants a clear picture of what will be required of them.
4. Prepare Interview Questions
If you are not experienced at conducting formal interviews, you will benefit greatly by having a prepared list of questions. It will help you stay in control of the interview, not miss any key points, and make the best use of your time. Write it all down.
5. Outline an Employment Contract
Even if the person you select comes highly recommended and you and your family really hit it off with them, make sure to remain professional. This includes having them sign a contract that outlines your expectations, their duties, as well as boundaries. You can then refer back to the contract should a situation arise in the future. Often Home Health Agencies prepare the contracts themselves. Be sure to read them carefully and add anything that you wish to be included.
6. Personally Screen Candidates
Since the person you hire will be spending time alone with your parent or loved one, it is essential that you approve them yourself. Having an agency just send someone over is not acceptable in this situation. Even if they can paint a picture of a candidate's qualifications, because the job of health care provider is so intimate, personality is equally as important. If your loved one is able to participate in the interview, that is ideal. Regardless, they should spend some time together to make sure that they click.
7. Conduct a Background Check
Do not trust your intuition. When you think that you have found the person you want to hire, do conduct a background check to make sure that the person you hire does not have a questionable past.
8. Check References
Even if this is their first job in the field of health care, every applicant should be able to provide references. Ideally, these should come from past employers. Otherwise, professors, internship supervisors, and personal references can also be used.
9. Protect Your Home and Family
Since the health care provider you hire will most likely have free access to your home, possessions, and family members, find out if they are bonded. It they are not bonded themselves, find out if the agency that you hired them from is. Remember not to leave credit cards, checkbooks and personal papers in unsecured areas.
10. Stay Involved
Your job is not over once the contract is signed and employment has begun. The more of a presence you have in your loved one's life the better. Even if you can not be there in person, scheduling telephone meetings can let the health care provider know that you are involved and on top of things. Ask for progress reports and find out if there are any difficulties. Since the health care provider is around your loved one the most, they can give you the best information about their physical health as well as their state of mind.
One way to stay involved is to use a caregiver's organizer (which we just happen to offer on our website). The Caregiver's Companion is an organizational tool that has sections for personal information, family history, medications and side effects, medical appointments, and home health care workers notes. I hate selling, but this IS a very good tool in my opinion.
Shelley Webb has been a registered nurse for almost 30 years, with experience in the fields of neonatal intensive care, dialysis, case management and elder care. When her father came to live with her in 2005, the advantages of her medical experience became clear. Due to his dementia and congestive heart failure, her father was not able to care for himself alone any longer and so she took over these duties.
Having experienced the helplessness, frustration, overwhelm and even loneliness that care giving for an aging parent brings, Shelley is well aware of the emotional and educational support that caregivers need and so she began The Intentional Caregiver web site. With its weekly newsletter, daily news updates and monthly audio interviews of experts in elder care and supporting services, Shelley strives to encourage and educate caregivers so that they can be empowered to provide the best possible care for themselves while caring for their aging loved one(s).
The reason Sister Kenny, and her struggles with the established order of medicine, is brought to mind is that licensed medical doctors all too often behave like members of a closed-shop union. In such an environment, no one is allowed to do work that is perceived as encroaching on their specialty, without consequent castigation and sanction. And, they vigorously lobby for laws to protect them from perceived interlopers.
In Sister Kenny's case, she struggled for years to get her therapeutic methods accepted, even in the face of observable success, and admiring testimonials from patients. The medical profession cast aspersions on her methods and her person, largely because she wasn't an accredited practitioner (only a nurse), and her methods contradicted generally accepted treatment standards.
In today's contentious health care environment, alternative treatments are greatly frowned upon, and their practitioners ridiculed. Ask licensed doctors what they think of acupuncture, chiropractic, aroma or muscle activation therapy, and they will almost always turn up their noses. In fact, they have convinced the insurance industry that these methods are nothing more than palliatives bordering on quackery. Thus, patients are channeled into much more expensive surgical and drug treatments that often times provide no relief.
This is not to say that there aren't quacks hovering around the practice of alternative medicine, just as there are quacks who are licensed to practice the approved variety. It is also not claimed that there alternative methods for all sicknesses or diseases. But it is also true that in most professions, wherever there is a buck to be made, a surfeit of willing hands will extend to accommodate. We see desperately sick people try all sorts of last gasp treatments, especially after traditional medicine has given up on them. And these alternative methods seldom work.
However, in the less well defined areas of pain management, due to a variety of causes, modern medicine has proven to be quite fallible. Countless thousands of people suffer through painful days of agony with only the promise of relief provided by dangerous drugs. Doctors prescribe many unproven medications because their pharmaceutical rep told them this was the cutting edge drug du jour for pain management. Big Pharma and the medical profession work hand and glove to push their latest (and expensive) drug on suffering patients. And since only licensed doctors can dispense them, this conduit is exploited by both parties. Why there might even be a financial incentive for the prescribing doctor. Heavens!
Because of the built-in aversion to examining or even testing alternative therapies, the healthcare system is saddled with more expensive, "accredited" treatments that push the insured patients in that direction.
Even though back surgery has been shown to be less than 50% effective, and much less costly alternative therapies have proven efficacious, they are ignored. Worse, just as in Sister Kenny's case, they are scoffed at by the establishment. Such are the ironic side-effects of our costly for-profit health care system.
As another example of padding the bottom line is a practice that is becoming more common. Doctors are increasingly insisting on patients coming in for an office visit just to renew a prescription. Admittedly for some drugs it is necessary to monitor side effects (another indication of how dangerous some of them are), but in many cases it is totally unnecessary. As cuts in Medicare go into effect (which will increase, rather than cut costs), doctors will seek more ways to supplement their income. Once a professional is used to a certain level of earnings (no matter the discipline), it's hard to accept less. Doctors are no exception.
So, the bottom line is that there just might be ways to improve both the costs of health care and the patients' welfare by researching and approving alternative therapies. Sadly, that's not even on the table for discussion.
Raff is an author who took early retirement from a career in the computer industry to pursue a writing career. He has two non-fiction books in print. Information about him and his work may be found at http://www.raffellis.com
According to the U.S. Department of Health and Human Services (HHS), Exchanges will level the health insurance playing field, so that small businesses will have a better choice of plans and insurers at a lower cost, the way larger employers do now. These competitive health insurance marketplaces will make purchasing health insurance easier and more understandable and offer consumers and small businesses increased competition and choice, HHS said.
In addition, small employers will be eligible to receive tax credits for coverage purchased for employees through the Exchange. And, consumers will be able to learn if they are eligible for tax credits and cost-sharing reductions, or other health care programs like the Children’s Health Insurance Program.
This latest round of awards will give states additional resources and flexibility to establish an Exchange. On August 23, California, Hawaii, Iowa, and New York were awarded Level One Exchange Establishment grants, which provide one year of funding to states that have begun the process of building their Exchange. Connecticut, Maryland, Nevada, and Vermont were awarded Level Two Establishment grants, which are provided to states that are further along in building their Exchange and offers funding over multiple years.
Previously, 49 states, the District of Columbia and four territories received grants to begin planning their Exchanges. With the new grants, 34 states and the District of Columbia also have received Establishment grants to begin building their Exchanges.
In June 2012, HHS announced an initiative to provide states with ten additional opportunities to apply for funding to establish a state-based Exchange, state Partnership Exchange, or to prepare state systems for a Federally-facilitated Exchange. States can apply for Exchange grants through the end of 2014, and may use funds during the initial start-up year. This schedule ensures that states have the support and time necessary to build an Exchange that best fits the needs of their residents.
Friday, August 24, 2012
The PPACA generally requires states to establish American Health Benefit Exchanges by January 1, 2014. If a state decides not to establish an exchange for its residents, HHS will operate a federally facilitated exchange (FFE). Qualified taxpayers will be able to purchase health insurance coverage through the exchanges. Some taxpayers may be eligible for the Code Sec. 36B premium assistance tax credit to help them obtain coverage. The Treasury and the IRS have issued guidance on the Code Sec. 36B tax credit (I.R.B. 2012-24).
HHS officials said that, through the exchanges, individuals will be able to learn if they are eligible for programs to make insurance more affordable, such as eligibility for the premium assistance tax credit, or health programs such as Medicaid and the Children’s Health Insurance Program (CHIP). HHS is aiming for real-time determinations of eligibility for coverage, the officials said.
Federal agencies are planning a "data services hub" to facilitate the exchange of information, the officials said. An inter-agency task force is currently meeting to develop the parameters of the hub. "There is an incredible amount of complex work going on," one official said.
Wednesday, August 22, 2012
Similarly, HHS will not enforce the requirement that non-federal governmental plans provide contact information for the EBSA or a state department of insurance. This safe harbor is applicable as long as such a plan provides contact information for member assistance provided by any third-party administrator or health insurance issuer that is hired by or contracts with the plan, and, if available, consumer assistance offered directly by the plan such as applicable member services, employee services, human relations or fiscal or personnel department, or consumer support services, if applicable.
Notice requirement. PHSA Sec. 2719 requires that non-grandfathered group health plans and health insurance issuers offering non-grandfathered group or individual health insurance coverage have an effective internal claims and appeals process. PHSA Sec. 2719(a)(2)(A) requires that such plans and health insurance issuers in the group market provide an internal claims and appeals process that initially incorporates the procedures of 29 CFR 2560.503-1 (the Department of Labor claims procedure regulation) and update such procedures in accordance with any standards established by the Secretary of Labor for such plans and issuers.
The Department of Labor claims procedure regulation clarifies the manner and content of notification of benefit determinations, which include certain disclosures. Among these required disclosures is a statement of the claimant’s right, under ERISA Sec. 502(a), to bring a civil action following review of an adverse benefit determination. ERISA Sec. 502(a) permits a plan participant or beneficiary to bring a civil action, among other purposes, “to recover benefits due to him under the terms of his plan, to enforce his rights under the terms of the plan, or to clarify his rights to future benefits under the terms of the plan.”
In addition, the Departments of the Treasury, Labor, and HHS have provided model notices for adverse benefit determinations. The model notices outline information that must be provided to claimants, including contact information for EBSA or a state’s department of insurance, as well as contact information for a consumer assistance program established under PHSA Sec. 2793 if one is available in that state.
Private right of action not available. The private right of action under ERISA Sec. 502(a) is not available to participants or beneficiaries of non-federal governmental plans, and the EBSA does not provide services to these participants or beneficiaries. In some cases, state departments of insurance do not provide services to these participants or beneficiaries. However, PHSA Sec. 2722(a) requires that non-federal governmental plans comply with the requirements found in the Department of Labor’s claims procedure regulation and the rules implementing PHSA Sec. 2719, including providing information on the private right of action under ERISA Sec. 502(a), and the information contained in the model notices. HHS indicates that complying with these requirements would place non-federal governmental plans in the difficult position of providing inaccurate information to participants or beneficiaries.
Consumer assistance program. In states that do not have a consumer assistance program, non-federal governmental plans that seek to take advantage of this safe harbor must provide the contact information for HHS’ Health Insurance Assistance Team (HIAT). The contact information for HIAT is 888-393-2789.
Other requirements still apply. This guidance does not provide non-federal governmental plans with relief from any other requirements of the PHSA, including the requirement that they provide all other notices required by the Department of Labor claims procedure regulation. Furthermore, to the extent that a non-federal governmental plan purchases a fully-insured health insurance policy for its participants or beneficiaries, or to the extent that state departments of insurance provide services to these participants or beneficiaries, HHS expects that participants and beneficiaries will receive the required contact information for the state department of insurance (or any other applicable state department).
Monday, August 20, 2012
IRS Commissioner Douglas H. Shulman testified that "important progress on implementation has been made." In response to questioning from Rep. Danny Davis, D-Ill., Shulman said that the IRS will not have access to private health care information and will only get "barebones information. The IRS’s role has been way overstated. The IRS won’t have access to health care information except for the fact of coverage." The information provided will include whether the taxpayer has coverage, how many months the taxpayer has had coverage, and the identity of the insurer, Shulman indicated.
Shulman said that 92 percent of the IRS’s budget request for PPACA implementation for fiscal year 2013 is for operations support, information technology and operations investments. Shulman denied reports that the IRS will be hiring 16,000 agents to verify health insurance coverage and to enforce the health care law. "Generally, revenue agents…would not work on resolving these types of issues. Typically, these issues are addressed and resolved through written correspondence," he said.
Communication, education needed. IRS National Taxpayer Advocate Nina Olson told the committee that "the IRS has made significant progress toward ACA implementation," but "there remain significant concerns." Olson said a top IRS priority should be "communication and outreach to the many Americans who will not interact with the IRS on health insurance for the first time. In particular, these taxpayers may need education on the method by which the premium assistance tax credit is advanced to insurers and later reconciled with their tax returns. Finally, channels must be open for taxpayer referrals where another agency [such as the Department of Health and Human Services] makes a determination that the IRS must execute, and vice versa."
Olson testified that "certain ACA provisions have tax consequences that require Americans to understand their role beyond traditional return-filing at year-end. In particular, taxpayers at certain income levels may qualify for a premium assistance tax credit advanced by the government to their insurer. If their income at year-end turns out to be more than anticipated, the credit may be less than the amount advanced, and the IRS may recover the excess as a tax. To avoid receiving an excess, taxpayers may need to update information if their income or other relevant circumstances change. In effect, the premium assistance tax credit requires not only an initial application and a year-end tax return but ongoing updates on major life changes throughout the year. Because this updating role will be new, education of taxpayers is necessary to avoid unexpected tax consequences."
Former IRS Commissioner Mark W. Everson, vice-chairman of alliantgroup, L.P., Houston, Tex., stated that the need for the updating and timely provision of information will be new for taxpayers. Everson expressed concern that there will be "new players" handling tax-related information, such as exchanges, state governments and insurers, and that it will be challenging for these actors to protect against the improper disclosure of information.
Premium assistance tax credits questioned. Rep. Scott DesJarlais, R-Tenn., and other members of the committee questioned whether the IRS had exceeded its authority by providing for the premium assistance tax credit when taxpayers obtained affordable insurance through an exchange established by the federal government, as opposed to state governments. Shulman defended the IRS regulatory process and the Service’s reliance on career attorneys to draft proper regulations. The committee also heard from Michael Cannon, director of health policy studies, Cato Institute, Washington, D.C., who testified that premium assistance tax credits are not available through federal exchanges, and Prof. Timothy Jost, Washington and Lee University, Lexington, Va., who disagreed with Cannon.