2010 PSOW Conference - Healthcare Reform

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Transcript of 2010 PSOW Conference - Healthcare Reform

  • Healthcare ReformHow Will it Impact You?

  • About Your PresenterJerry Miller, NREMT-PCEO/President of LifeQuestJerry Miller has been actively involved in the EMS and Fire industry for 31 years

  • TodayAmbulance Impact Background & Major Points As an Employer

  • TodayFraud & Abuse Quality Patient Care Funding Q&A

  • BackgroundPatient Protection & Affordable Care Act(PPACA)Became law 3/23/2010

    Healthcare & Education Affordability ReconciliationFixes & CorrectionsBecame law 3/30/2010

  • Background21 states have filed Federal LawsuitsMay be Dismissed VirginiaMay have a Case At Issue:Can the Feds force Healthcare?

  • BackgroundIs it a tax or isnt it a tax? Argument Restricts Personal and Economic Freedoms

  • BackgroundWill likely go to the Supreme CourtMoving to strike down entire billFeds moving forward with implementation

  • Ambulance Impact

  • The Good NewsExtends MIPPA PaymentsThrough December 31, 20102% Urban Ground3% Rural Ground22.6% Super Rural GroundAir Ambulance Rural remains the same as they were 12/31/2006

  • The Good NewsRetroactive to January 1st, 2010 Carriers were supposed to begin reimbursement July, 2010

  • The Bad NewsProductivity AdjustmentEffective beginning of 2011Already applies to other providers, applicable to everyoneEnsure Medicare Sustainability

  • The Bad NewsAssumes efficiency each yearReduces CPI annual updatesAllows for negative fee schedule updates

  • The Bad NewsWhat is it?10 year moving average Fee schedule amount subject to the 10 year moving average

  • The Bad News2010 Negative CPI, however 0% increase PPACA would have likely been negative increase

  • The Bad NewsExample: CPI = 1% Productivity Adjustment = -1.5% Annual Increase = -0.5%

  • The Bad NewsProductivity FactorDifficult for EMS to provide more cost effective careCost of equipmentCost of ambulancesCost of operationsCost of fuelCost of SuppliesImpact on Patient Care

  • The Not So Bad NewsAmerican Ambulance AssociationAdvocatesCongressExclude EMS???

  • Background & Major Points

    Pilot ProgramsHHS (Four competitive grants)Innovative models of regionalized, comprehensive and accountable emergency care and trauma systems.States, Partnership of States, or Indian Tribes

  • Background & Major Points

    StatesRegionalizationRegionalization discussions not new to WisconsinMust be consistent region wide management system

  • Background & Major PointsCoveragePlan to cover 32 million uninsured16 million State exchanges16 million through Medicaid expansion

  • Background & Major PointsEstimated 23 million will still be uninsured How it happens:Coverage mandates for individuals, employers and states

  • Individual MandateMost people (legal) must have health coverage by 2014 Penalties for Individuals2014 - $95.00 or 1% of taxable income2015 - $325.00 or 2% of taxable income2016 - $695.00 or 2 % of taxable income

  • Individual MandateIndividual Mandate Exemptions:Financial HardshipReligious Objections 2014 - Must Prove Coverage Will impact tax returns

  • Credits & Cost SharingEligible:Meet Income limitsEmployees w/o sufficient coverage or pay share exceeding 9 % of incomeLegal Immigrants during first 5 years - no Medicaid

  • Credits & Cost SharingTax Credits Income between 133-400% FPL Cost Sharing Reduce Out of Pocket

  • Expansion of Medicaid2014 States expand Medicaid to cover those under 65 with incomes up to 133% of FPL Mandates automatic enrollment of new eligibles

  • Expansion of Medicaid2014 2016: States receive Federal Funding for new eligibles 100% 2020 + : States receive Federal Funding for new eligibles 90%

  • Expansion of MedicaidEmployer:Large employers must offer coverage starting 2014

  • AmbulanceMore good news: 32 million covered under insuranceBetter than nothing Down Side:Low reimbursement rates

  • AmbulanceWe must start now to increase Medicaid rates Grass Roots:LitigationOther

  • AmbulanceIncrease use of Ambulance System Increase abuse of Ambulance System?? Community Paramedic Programs?

  • OptionsHealth Insurance ExchangesPurchasing OptionsState Exchanges (2 types)American Health Benefit Exchanges No employer coverageSmall Business Health Options ProgramSmall employers up to 100 employees

  • DetailsFour Categories/Plans (Bronze-Platinum)Catastrophic Plan/Under 30 (Option)(Out of Pocket) Expense is limited by annual income

  • DetailsExchange Rules:Strict MarketingContract w/ providersAccreditedUniform Enrollment

  • DetailsAmbulanceMore affordable for small services50 FTEs or lessSave MoneyIncrease reimbursement potential

  • DetailsHigh Risk PoolThose with pre-existing conditions Effective 6/21/2010 Wisconsin Health Insurance Risk Sharing Plan (HIRSP)

  • New RulesNo prior authorization for emergency services Prudent lay person (definition)

  • New RulesNo lifetime caps after 9/23/2010 No withdrawing coverage except in cases of fraud

  • New RulesCoverage for adult children up to age 26Wisconsin Age 27Any insurers current

  • New RulesNo exclusion for preexisting conditionsChildren 9/23/2010, all others 1/1/2014Process for reviewing increases for 2010No annual limits/plans - 2014Eliminate waiting periods for coverage over 90 days.

  • New RulesExisting plans grandfathered except:Coverage up to age 27Elimination of waiting periodsLifetime and Annual capsPre-existing conditions

  • Medicare AdvantageRestructure paymentsPlus 14% - Gone Phase in 3 6 years starting 2011 Medicare advantage align with fee for service

  • Medicare AdvantageHigh ratings = Bonus

  • Medicare AdvantageStill capped at 12-14% (Current) Penalties Poor Performance

  • Medicare Advantage: AmbulanceWatch your rates Need to cover losses Only mandatory reduction = productivity adjustment

  • Employer Mandates2014 50 or more FTEs must offer coverage to FTEs/dependentsFTEs = Average 30 hours per weekNo requirement for PT EmployeesMight see more PT employees

  • Employer MandatesPenalties:50 or more FTEs no coverage$2000/FTE not including first 3001/01/2014

  • Employer MandatesUnaffordable Coverage50 or more FTEs can not cost more then 9.5% of household income - if employee opts outLesser of $3,000/FTEs or$2,000 for all FTEs

  • Employer Mandate

    Free Choice VoucherEmployee less than 400% FPL & pay 8-9.8% of income for Ins Employer must offer free choice voucherEnables employee to purchase from exchangeVoucher must equal amount employer would have contributed

  • Employer MandatesFree Choice VoucherApplies to all employersExcess cost Employee KeepsTax Deductible

  • Employer MandatesEmployer/200 FTEs must automatically enroll FTEs Give employee opt out option

  • Employer Mandates3/1/2013 Must provide written notice of:ExchangesEntitlement, Credits/SubsidiesTax ImplicationsFinancial Impact

  • Employer MandatesW-2 Reporting1/1/2011- Must report value of all Medical, Dental, Vision and Supplemental insurance coverage on W-2

  • Employer Mandates2014 Employers w/ 50 or more employees file information returnReport coverage offered and statusFlexible Spending account2013 Contribution reduced to $2500/per yearPrescription Required for OTC meds using FSA funds

  • Employer OptionsSmall Employers50 or less FTEs exempt from penaltiesNo duty to provide coverage2014 Can purchase coverage from small business exchange

  • Employer OptionsTax Credits25 or less FTEs and average annual wage of 50K or less Must contribute at least 50% of premium

  • Employer OptionsSmall Employers2010-2013 25 or less FTEs = 35% tax credit of their contribution into premium2014 Employers with 25 or less FTEs = 50% credit for employers that purchase through exchange

  • Employer Options10 or less FTEs and average annual wage of less than $25K eligible for full credit of premium amount paid by employer

  • Employer OptionsSmall EmployerWellness ProgramGrants available for establishing wellness programs (up to 5 years/ 2011-2015)Profit or Non-ProfitLess than 100 employees who work 25 hours or moreDid not provide wellness program before 3/23/10

  • Employer OptionsAmbulanceSmall ServicesBenefit from tax breaks and grantsSome increased reportingBetter Healthcare coverage of EMS Staff/Recruitment

  • Here It ComesFraud350 million over ten years for fraud and abuse.

  • Claim FilingMust be submitted 1 calendar year after date of service Medicare MAC creating edits to catch late filing Claims over 1 year automatically denied

  • Anti-KickbacksClarificationPerson need not have actual knowledge of this sectionOr Specific intent to commit a violation or specific intent to commit a violation

  • Anti-KickbackMust still prove defendant knew conduct was unlawful

  • OverpaymentsNew:Must provide system to identify overpayments along with written notificationMust report and return 60 days after overpayment identified Hospital cost based report is due

  • OverpaymentMust return government money within 60 days

  • False StatementsKnowingly making false statements, omissions or misrepresentation of a factMay cause exclusion from federal programs

  • PenaltiesFalse statement and claims for paymentKnowingly making false record or statement $50K per false statement or record

  • PenaltiesIntentional delay of