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Transcript of University Health Services Student Services Building 100 W. Dean Keeton The Influence of Health...
University Health Services
Student Services Building100 W. Dean Keeton
The Influence of Health Insurance on College
Health:
Do you want to be In-Network?
ACHA 2014 Annual MeetingWednesday, May 28, 2014
University Health Services
Student Services Building100 W. Dean Keeton
Presenter
LeAnn Gutierrez, PhD, MBA
The University of Texas at Austin
Associate Director, Business and Ancillary Services
University Health Services
Student Services Building100 W. Dean Keeton
Objectives Discuss the influence of the Affordable
Care Act on college health
Identify alternative funding models Recognize important factors to consider
when shifting to insurance billing
University Health Services
Student Services Building100 W. Dean Keeton
Increased knowledge of key provisions of Affordable Care Act that can impact college health
Increased awareness about funding model alternatives and considerations
Understanding of key factors to consider for participation in insurance billing for a more informed decision-making process
What You Should Take Away Today
University Health Services
Student Services Building100 W. Dean Keeton
Affordable Care Act Overview
Background
Goals
Timeline
Key Provisions
University Health Services
Student Services Building100 W. Dean Keeton
BackgroundThe Affordable Care Act Becomes Law in March 2010 The law implements comprehensive
health insurance reforms Reforms scheduled from 2010 through
2015 Department of Health and Human
Services (HHS) issued a proposed regulation to ensure students enrolled in these plans benefit from important consumer protections in the ACA in February 2011
HHS issued final rule on March 21, 2012
(http://www.healthcare.gov/law/timeline/index.html)
University Health Services
Student Services Building100 W. Dean Keeton
Affordable Care Act Goals
Holds insurance companies accountable
Lowers health care costs
Guarantees more choice
Enhances the quality of care for all
Americans
(http://www.whitehouse.gov/healthreform/healthcare-overview)
University Health Services
Student Services Building100 W. Dean Keeton
Affordable Care Act Timeline: 2010
New Consumer Protections
Improving Quality And Lowering Costs
Increasing Access To Affordable Care
(http://www.healthcare.gov/law/timeline/full.html)
University Health Services
Student Services Building100 W. Dean Keeton
Student Health Coverage Goals
Ensure that students have access to coverage and benefits from the ACA’s Patient’s Bill of Rights
Treat student health insurance plans as individual market plans to extend all of the protections provided to enrollees in with several adjustments given plan uniqueness
Self-funded plans exempt Grandfathered plans exempt until 2014
(http://www.healthcare.gov/news/factsheets/2012/03/student-health-plans03162012a.htm)
University Health Services
Student Services Building100 W. Dean Keeton
2010 Key Provisions:New Consumer Protections
Prohibits denying coverage of children based on pre-existing conditions
Prohibits insurance companies from rescinding coverage
Eliminates lifetime limits on insurance coverage
Regulates annual limits on insurance coverage
Effective for health plan years beginning on or after September 23, 2010.Rule doesn’t apply to “grandfathered” individual health insurance policies.
(http://www.healthcare.gov/law/timeline/full.html)
University Health Services
Student Services Building100 W. Dean Keeton
2010 Key Provisions:Improving Quality and Lowering Costs
Providing small business health insurance tax credits
Offers relief to Seniors who hit Medicare prescription drug “donut hole”
Provides Free Preventative Care Cracks down on Fraud
University Health Services
Student Services Building100 W. Dean Keeton
2010 Key Provisions:Increasing Access to Affordable Care
Provides state-based programs for access to insurance with pre-existing conditions
Extends coverage for young adults Extends coverage for early retirees Rebuilds primary care workforce Holding insurance companies accountable
for unreasonable rate hikes Allows states to cover more residents for
Medicaid Increases payments to rural health care
providers Strengthens community health centers
University Health Services
Student Services Building100 W. Dean Keeton
2011 Key Provisions
Offers RX discounts to Seniors (Medicare) Provides Free Preventative Care to Seniors HHS Quality Improvement Plan Community care transitions program for
Seniors Proposal to extend life of Medicare Trust
Fund Increase access to services at
home/community Lowers health care premiums Addresses overpayments
University Health Services
Student Services Building100 W. Dean Keeton
2012 Key Provisions
Value-Based Purchasing Program (Medicare) Encourages Integrated Health Systems Reduces paperwork/administrative costs Understands and fights health disparities Provides options for new, voluntary options
for long-term care insurance
University Health Services
Student Services Building100 W. Dean Keeton
2013 Key Provisions
Improves preventative health coverage (Medicaid)
Expands authority to bundle payments Increases Medicaid payments for primary
care providers Provides additional funding for CHIP
University Health Services
Student Services Building100 W. Dean Keeton
2014 Key Provisions
Prohibits discriminations (pre-existing/gender)
Eliminates annual limits on coverage Ensures coverage for participants on clinical
trials Tax Credits for individuals between 100-44%
FPL Establishes affordable insurance exchange Increases access to Medicaid Promotes individual responsibility Ensures free choice
University Health Services
Student Services Building100 W. Dean Keeton
Student Insurance Coverage Special Timelines
Annual Limits on essential health benefits
No less than $100,000 for policy years beginning on or after 7/1/12 but before 9/23/12
$500,000 for policy years beginning on or after 9/23/12 but before 1/1/14
No annual limits as of 1/1/14 Medical Loss Ratio-changes to
methodology for reporting and rebates only in 2013
Notice Requirement until 2014
(http://www.healthcare.gov/law/timeline/full.html)
University Health Services
Student Services Building100 W. Dean Keeton
Plan Design Differences as a result of ACA & New Vendor Administration of ACA in 2012
Benefit 11-12 Plan 12-13 ACA Change -New Plan
Dependent EligibilityUnmarried children not self -supporting
All children up to age 26
Routine STI Testing Under Health Center Charges ($500 maximum and $25 copay)
Now covered at 100%
Allergy Medicines and Prescriptions for STI treatment
$1,300 maximum prescription benefit
$1,300 limit removed
Inpatient Psychotherapy Covered up to 30 day maximumCovered as any other sickness (30 day limit removed)
Medical Emergency Benefits, $75 Copay
Covered up to $1,000 $1,000 limit removed
Flu Shot Benefit Covered at 80% up to $20 Now covered at 100% (no maximum)
Benefits for HPV and Cervical Cancer Screening (under X-rays and Labs)
Covered at 80% up to $75 Now covered at 100% (no maximum)
PrescriptionsCovered up to $1,300, with copays
Limit of $1,300 removed. Birth Control covered at 100%
Outpatient PsychotherapyLimited to 20 visits per year, daily limits of $65 per day individual/$20 for group visits
20 visit limit removed, paid as any other sickness, internal limits removed
Ambulance Services $300 maximum $300 limit removed
Alcohol/Drug AbusePreviously covered under mental health with limits
Covered without daily limits
Wellness Benefit/ Routine Preventive (including immunizations)
Paid at 100% in network and 60% out-of-network, to $500 maximum
Now paid at 100% (no maximum)
University Health Services
Student Services Building100 W. Dean Keeton
Key ACA Factors Influencing College Health
Provides Free Preventative Care Pre-existing conditions (For Children until 2014)
Extends coverage for young adults (All Plans, Except for one temporary exception until 2014)
Eliminates lifetime limits on insurance coverage (All Plans)
Regulates annual limits on insurance coverage (Not required for grandfathered plans until 2014)
Access to state/federal exchange plans
University Health Services
Student Services Building100 W. Dean Keeton
UT at Austin Insurance Claim Volume
Trends
Per month Per year
3,000 36,000
Per month Per year
4,200 50,400
2012 – 2013
Per month Per year
3,500 42,000
2011 – 20122010 – 2011
2013 - 2014 thru 4-13
Per month Per year
4,500 36,456
University Health Services
Student Services Building100 W. Dean Keeton
UT at Austin Insurance Utilization Trends
Students using insurance at UHS
Students not using insurance at UHS
63% 37%
Students using Insurance at UHS
Students not using insurance at UHS
66% 34%
2012 - 2013
Students using insurance at UHS
Students not using insurance at UHS
69% 31%
2010 - 2011 2011 - 2012
University Health Services
Student Services Building100 W. Dean Keeton
UT at Austin Insurance Payor Trends
2010 -2011 Payors
%
BCBS 44%Aetna 11%SHIP 22%United HealthCare 10%Other 13%
2011 - 2012 Payors
%
BCBS 46%Aetna 12%SHIP 15%United HealthCare 12%Other 15%
Insurance Payor Mix
2013 - 2014 thru 4-14 Payors
%
BCBS 52%SHIP 20%United HealthCare 12%Aetna 8%Other 8%
2012 -2013 Payors
%
BCBS 44%Aetna 11%SHIP 14%United HealthCare 16%Other 15%
University Health Services
Student Services Building100 W. Dean Keeton
Alternative Funding Models Faculty and Staff Services
Ancillary services or self-supporting arm (physical therapy)
Flu shot campaigns, Travel services
Explore Potential Campus Partnerships
Summer programs
Research support (example: lab)
Physical exam clinics for club sports
Visiting scholars, post-docs, ESL
In-Network Status with insurance payors
University Health Services
Student Services Building100 W. Dean Keeton
Considerations for Insurance Billing
HIPAA Compliance
Clinical Documentation
Coding: CPT, HCPCS, ICD-9/ICD-10
Contracting: credentialing, NPI, CAQH, referrals
Charges Structure: charges philosophy, discounts, co-pays, ancillary reimbursement
Financial
patient collections and revenue potential
Expenses related to third-party filing
University Health Services
Student Services Building100 W. Dean Keeton
Charges Philosophy UHS charges for services
Provider encounters, minor procedures, lab tests, x-rays, medications, supplies, immunizations, nutrition services, and physical therapy
Charges based on 150% Allowable Medicare Fee Schedule (in some exceptions cost is used)
Miscellaneous/Administrative Charges: missed appointments, after-hours, medical records release, service extension fees
Discounts
Insurance contractual adjustments
Self-pay amounts: students and faculty/staff
University Health Services
Student Services Building100 W. Dean Keeton
Appointment Scheduled
Check-In-Registration
into EHR-Insurance information-Reason for
visit
Patient Encounter
-What's Wrong-Plan of Action-EHR
Documentation
-EHR CodingClaim Filing/Billing
-Charges review and
post-Claim
Submission-
Clearinghouse for errors-Claim goes
to payer
Claim Payment or
Denial-Payment
posted and processed
-Denial appealed
Claim Appeals
Processing-
Documentation reviewed
and submitted
for reconsiderat
ion-Claim re-files and
processes
Patient responsibility-Collect from patient in C/I
or Bursar
Claim Lifecycle
University Health Services
Student Services Building100 W. Dean Keeton
Questions?
University Health Services
Student Services Building100 W. Dean Keeton
Thank You!
University Health Services
Student Services Building100 W. Dean Keeton
References
ACHA. Health Care Reform FAQ. Retrieved from http://www.acha.org/Topics/Health_Care_Reform/FAQs_for_IndividualCoverageClassification.cfm.
Healthcare.gov. (2011). Affordable care index. Retrieved from http://www.healthcare.gov/law/timeline /index.html.
Healthcare.gov. (2011). Glossary. Retrieved from http://www.healthcare.gov/glossary/d/donuthole.html.
Healthcare.gov. (2011). Preventative services. Retrieved from http://www.healthcare.gov/news/ factsheets/2010/07/preventive-services-list.html.
University Health Services
Student Services Building100 W. Dean Keeton
References
Healthcare.gov. (2012). Student Health Plans. Retrieved from http://www.healthcare.gov/news/ factsheets/2012/03/student-health-plans03162012a. html.
The White House. (2011). The affordable care act. Retrieved from http://www.whitehouse.gov/healthreform /healthcare-overview.