HISTORIC CHANGES INSURANCE COVERAGE AND REIMBURSEMENT

ALAN M. FISHER, P.A.818 A1A North 601 Heritage Drive Suite 303 Suite 103Ponte Vedra Beach, Florida 32082 Jupiter, Florida 33458Tel: (904) 285-0070 Tel: (561) 743-0745Fax: (904) 245-1945 Fax: (561) 743-2414

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Introduction

How Insurance coverage has changed from the Native Americans to the Affordable Care Act.

500 years ago Ponce De Leon discovered “la Florida,” which at the time was all of North America, and declared it the sovereign territory of Spain. When he came to this country he discovered the miraculous health of the Indian population and believed that it had something to do with the water. Thus the legend of the Fountain of Youth was born.

Native American Healthcare

Medicine Men, as history has called them, were not only healers but the spiritual leaders of Native American tribes.

The Native American system covered all ailments and was a universal healthcare system.

St. Augustine – A Brief History

Roughly 50 years after the discovery of “la Florida” Pedro Menendez settled the city of St. Augustine at the behest of the Spanish King.

Pedro Menendez’s sister petitioned the Spanish King to provide free healthcare to the Native American population.

St. Augustine – A Brief History

Money was deducted from the salaries of the Spanish troops to pay for their medical treatment.

Spanish Military Hospital

When it was founded the hospital did not accept any private pay patients, only treating members of the Spanish military.

Doctors and pharmacists working at the hospital moonlighted to provide services to the townsfolk until they were caught and fined by the king.

Health Insurance before 1900

Health Insurance in North America started during the Civil War as accident insurance.

Group Health Insurance Plans (1920-1930)

The Group Plans allowed hospitals to recover money that would have otherwise been written off due to tough economic times. The Great Depression made these Group Plans vital to recovering money.

Health Maintenance Organization (HMO 1933 - 1964) Henry Kaiser formed the first major HMO

starting in the 1940’s. Until the 1970’s the majority of HMO enrollees belonged to the Kaiser HMO.

Medicare (1965)

Prior to Medicare less than 50% of individuals over the age of 65 had health insurance. Due to increasing longevity and advances in medical care payment became a problem.

Important Moments in Healthcare

Affordable Care Act 2010

General Extending coverage for young adults. Prohibition on denying coverage of children based

upon pre-existing conditions. Billing

Establishment of procedures for appealing insurance company claims decisions.

Reimbursement Elimination of lifetime limits on insurance coverage. Regulation of annual limits on insurance coverage. Prohibition on Insurance companies from rescinding

coverage.

Affordable Care Act 2011

Reimbursement Bringing Down Health Care

Premiums Overpayments to big insurance

companies and strengthening Medicare Advantage.

Affordable Care Act 2012

Reimbursement CMS begins its readmission reduction program

to reduce hospital readmissions at IPPS hospitals. The total payments received for a year will decrease progressively. IE 1% for the first year; 2% for the second (effective October 2013); and 3% for the third.

Change in payments to reflect quality outcomes.

Integrated Health Systems where the physicians will keep some of the money they save.

Affordable Care Act 2013

Billing Improvements to preventative health

coverage. Expansion of the authority to bundle

payments.

Affordable Care ActThe Healthcare Market place (2014)

Insurers will only be able to vary rates based upon family size, geography, age, and tobacco use.

Directs insurers to provide coverage for, and accept all applicants who apply for coverage in the group and individual market. Barring certain limitations.

Directs that insurers maintain a single risk pool for the individual market, and a single risk pool for the group market unless a state merges those markets.

Codifies certain basic healthcare necessities that must be provided and establishes a ceiling on the cost of policies.

Affordable Care ActThe Healthcare Market place (2014)

Essential Health Benefits

Ambulatory patient services Emergency services Hospitalization Maternity and newborn care Mental health and substance use disorder services,

including behavioral health treatment Prescription drugs Rehabilitative and habilitative services and devices Laboratory services Preventive and wellness services and chronic

disease management, and Pediatric services, including oral and vision care

Affordable Care Act (2014)

Billing Prohibiting Discrimination Due to Pre-Existing

Conditions or Gender Increasing Access to Medicaid

Reimbursement Eliminating Annual Limits on Insurance

Coverage

Current Affairs

February 20, 2013 HHS releases final rule regarding standards for

health insurance . Effective 2014 Medicaid Expansion. Effective 2014

Florida? What we know – Gov. Scott will accept. Florida

Legislature is pursuing alternatives

Some Governors want Medicaid patients in the Exchange

Final Ruling Final rule, 78 FR 12834, February 25, 2013—Patient Protection and

Affordable Care Act - Standards Related to Essential Health Benefits, Actuarial Value, and Accreditation,(Feb. 28, 2013)

Appendix A: List of Essential Health Benefits Benchmarks The purpose of this appendix is to list the EHB-benchmark plans for the 50 States, the

U.S. territories (Puerto Rico, Guam, the U.S. Virgin Islands, American Samoa, and the Northern Mariana Islands) and the District of Columbia. As described in §156.100 of this regulation, each State may select a benchmark plan to serve as the standard for plans required to offer EHB in the State.64 HHS has also stated that the default base-benchmark plan for States, Puerto Rico and the District of Columbia that do not exercise the option to select a benchmark health plan would be the largest plan by enrollment in the largest product by enrollment in the State's small group market. The default base-benchmark plan for the territories other than Puerto Rico is the largest FEHBP plan by enrollment. As described in §156.110, an EHB-benchmark plan must offer coverage in each of the 10 statutory benefit categories. In the summary table that follows, we list the EHB-benchmark plans. Additional information on the specific benefits, limits, and prescription drug categories and classes covered by the EHB-benchmark plans, and state-required benefits, is provided on the Center for Consumer Information and Insurance Oversight (CCIIO) Web site (http://cciio.cms.gov/resources/data/ehb.html).

Florida Plan from largest small group product. Blue Cross Blue Shield of Florida, Inc. BlueOptions PPO.

Florida Medicaid Effective 7/1/2013

DRG’s Goal – 88% of Cost

DRG’S

Benefit LTAC Rehab

Hurt Rural Children

Universal Healthcare… is it?

What does it really do? It still won’t cover everyone.

The Issues on Coverage & Reimbursement still Remain

Medical Necessity Pre Authorization Pre Certification Level of Care Experimental Procedure Authorization Notification Type of Coverage Pre-Existing Condition Annual Limits Bundling

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