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