Contents of Obamacare - Part 9 - Women and Obamacare

Women and The Affordable Care Act (“Obamacare”). Erin Weir, the Manager of Health Care Access at “AgeOptions” an Oak Park, Illinois based Not-for-profit, says there are many reasons that women should be excited about Obamacare. Erin says that women visit the doctor more often than men and are usually the primary health care decision-makers in families. Women are less likely to get insurance from their jobs because they are often working part time or serving as family caregivers. They currently pay more for insurance premiums than men, and a greater share of their income is consumed by out-of-pocket health care costs. Women are more likely to lose their health insurance due to changes in marital status. Finally, access to health care is especially difficult for women of color, young women, and women in rural areas. Women’s Protections Against Pre-existing Conditions: Starting 2014, insurance companies can no longer deny coverage due to pre-existing conditions such as pregnancy, C-sections, cancers, domestic violence, or sexual assault. Prior law allowed them to do so. Consumer Protections for Women. Starting in 2014, insurance plans will no longer be able to discriminate against women by charging higher premiums due to gender. Women will also enjoy the immediate benefits of no lifetime limits on coverage and the upcoming benefit of no annual limits starting in 2014. Preventive Services for Women. Effective August 1, 2012, the law requires coverage of the following preventive services without a co-pay or deductible: annual well-women’s visits, gestational diabetes screening for women who are 24-48 weeks pregnant and high risk, HPV DNA testing (women 30 and over), sexually transmitted infection screening and counseling, including HIV, contraception and contraceptive counseling (excluding abortions), breastfeeding support and equipment, and interpersonal and domestic violence screening and counseling. Source: Erin Weir, “The ACA and Women”, Presentation at Chicago Bar Association, October 30, 2012. Agencies and Websites:Obamacare maintains an “Office of Women’s Health” within the federal Department of Health and Human Services, which is led by the “Deputy Assistant Secretary for Women’s Health”. In addition, the law maintains a “National Women’s Health Information Center”. Nancy C. Lee, MD, initially from the Center for Disease Control, is the Director, and the information center is at www.womenshealth.gov. The law also maintains an “Office of Women’s Health” within the Center for Disease Control (CDC). This office’s website is at www.cdc.gov/women.

Contents of Obamacare - Part 8 - The Donught Hole

Improving Medicare for Patients and Providers. New rules allow Physician Assistants to order post-hospital testing, allow funding for complex diagnostic testing such as genetic testing or cancer chemotherapy sensitivity assays, improved access for certified nurse mid-wife services, and extension of “hold harmless” provisions and other protections for small rural hospitals. Improving Payment Accuracy. This section includes adjustments to payment for Home Health Care, more modifications for rural care, hospice care payment modifications, procedures for reevaluation and modification of misvalued codes under the physician fee schedule, adjustments to payments for “power-driven wheel chairs”, payment rates for ambulatory cancer centers, and payment for biosimilar products (generic versions of biologicals). Medicare Advantage Payment (Part C): Covering someone on a Medicare Advantage plan used to cost 14% more than covering someone on the original Medicare. These payments are being reduced under the law which accounts for the savings in Medicare that are often referred to as “cuts” by Mitt Romney and his advocates. These savings to the government are actually being put back into the Medicare program. Medicare Part D (Prescription Drugs): The law phases out the “donut hole” by 2020. The “donut hole” was a coverage level in the original plan (signed into law by President George W. Bush) where seniors had to pay 100% of their costs for pharmaceuticals until their annual costs became so severe that they qualified for “catastrophic coverage”. Pharmaceutical manufacturers will now be paying 50% of the costs for brand name drugs purchased while the beneficiary is “in the donut hole”, and generic drugs will be offered with a 14% discount. Obamacare offers better prescription drug coverage for people with low incomes. Health Care System Delivery Research: The law directs the “Center for Quality Improvement and Patient Safety”, which is part of the” Agency for Healthcare Research and Quality”, to conduct studies and determine workable best practices for health care that can be promoted across the board to all providers. The center may identify certain health care programs that are particularly astute and successful in their delivery of services and develop methods for dissemination of such techniques nationwide. Grants are offered to conduct pilot projects for various health care delivery systems to determine the effectiveness and feasibility. The law promotes the availability of trauma care centers for all local areas. The law promotes grants to develop “patient decision aids” where patients, based upon their value system, provide input into the proper path for their own care; this includes the summaries of the risks and benefits of prescription drugs in a standardized format. NEXT: WOMEN AND OBAMACARE!

Contents of Obamacare - Part 7 - Linking Payment to Quality Outcomes

Improvements to Medicaid System: These include coverage for freestanding birth centers, more home health care, increased rebates for pharmaceuticals, coverage of drugs for smoking cessation, refusal to pay hospitals for treatment of hospital-acquired infections. Special Rules for Native Americans: Native Americans and Alaskans have no cost-sharing if they enrolled in a qualified state exchange and their income is less than 300% of the Federal poverty level. Maternal and Child Health Services: The states are to provide reports and the Federal government is to offer grants to enhance home visitation treatments for disadvantaged communities with higher than average levels of premature birth, child abuse, and other social problems. Postpartem Conditions: The act provides funding for the study and treatment of postpartum depression and psychosis. Personal Responsibility Education Programs: The act provides grants for innovative programs to promote individual responsibility in regards to sexual abstinence and birth control for the prevention of sexually transmitted diseases. Improving the Quality and Efficiency of Health Care: The preceding statement is the name of Title III of the Act. Subtitle A is called “Transforming the Health Care Delivery System” Linking Payment to Quality Outcomes Under the Medicare Program: This program pertains to five medical events: heart attacks, heart failure, pneumonia, surgical infections and hospital-acquired infections. Hospitals shall be given pay incentives for Medicare patients if they successfully treat and discharge the subject without a readmission. Likewise, payment to physicians will be based upon quality outcomes moreso that the number and cost of procedures that the MD performs. Hospitals shall be penalized in their payment amounts if their patients suffer from hospital-acquired infections. Intragency Working Group in Health Care Quality: The group contains senior executives from the Department of Health and Human Services , the Center for Medicare and Medicaid Services, the National Institutes of Health, the Center for Disease Control, Food and Drug Administration, Health Resources and Services Administration, Agency for Healthcare Research and Quality, Office of the Nation Coordinator for Health Information Technology, Substance Abuse and Mental Health Services Administration, Administration for Children and Families, Department of Commerce, Office of Management and Budget, Bureau of Federal Prisons, United States Coast Guard, National Highway Traffic Safety Administration, Federal Trade Commission, Social Security Administration, Department of Labor, United States Office of Personnel Management, Department of Defense, Department of Education, Department of Veterans Affairs, Veterans Health Administration, and “any other appropriate federal agency”. This “Justice League” of representatives from Federal agencies is supposed to coordinate activities to avoid duplication and maximize results for national health care priorities.

Contents of Obamacare - Part 6 - Individual Mandate

Individual Responsibility: Subtitle F, Part I, is ironically entitled “Individual Responsibility”. I say “ironically entitled” because Mitt Romney, who believes 47% of the US population takes no individual responsibility, wants to repeal this provision. This is the provision that was upheld by the United States Supreme Court. Under this provision, individuals are fined $750 on their personal tax return if they do not purchase minimal essential health care coverage during a calendar year. This is phased in at a rate of $95 for 2014 and $315 for 2015. If an individual goes one month without minimal coverage the fee is 1/12 of this amount. “Minimal Essential Coverage” includes Medicare, Medicaid, CHIP, Tricare, Veteran’s plans, and plans for Peace Corp volunteers. It also includes employer-sponsored plans, individual plans and grandfathered plans. Although the penalty is collected on your income tax form, the law expressly prohibits the Federal government from filing criminal charges against you if you don’t pay the penalty and also prohibits the IRS from filing liens and levies against your property to collect the fee. The US Supreme Court debated as to whether it was constitutional for the government to require you to purchase health insurance, and this provision was upheld under Congress’s taxing power. Beginning in 2014, your insurer will send you a formal notice of your coverage for tax purposes. Employers shall also be required to file a return regarding coverage of their employees and also to provide notice to their employees. Assisted Suicide: The law continues on with a prohibition of discrimination against individuals or health care entities on the basis that they refuse to implement assisted suicide, mercy killings or euthanasia. Expansion of Medicaid. The law initially required the states to expand Medicaid by offering it to anyone with an income of %133 of the federal poverty line but the United States Supreme Court struck down this requirement. It is now optional for the states. Children’s Health Insurance Plan (CHIPs): The law enhances funding for this federal program to assist the states in providing health insurance for Children.

Contents of Obamacare - Part 5 - Congress and Immigrants

The Federal Government may offer ONLY health care plans governed by Obamacare to the members of the US House of Representatives, the members of the US Senate, and their staff. ( I always thought such a provision, more than any other, would guarantee high quality health care plans in the system.) Can Illegal Immigrants enroll in an Obamacare plan? No, such plans are available only for lawful residents, i.e., citizens or lawful immigrants. Can prisoners enroll in an Obamacare plan? No. Does the False Claims Act apply to activities under Obamacare? Yes, this is the law that makes it a crime and imposes civil and criminal penalties for those who make false statements to the federal government or submit false claims. States May Opt Out of the Health Insurance Exchanges. If they do, the Federal government will establish the exchanges for them. Non-Profit Health Insurers. The law offers grants to encourage the formation of non-profit health insurers within the states and puts restrictions on what type of entities may operate as such. Multiple State Insurance Plans. States may agree to operate multistate plans. The law of the state where the plan is written shall control. Nationwide Insurance Plans. Nationwide plans are permitted under the law of the state when the plan was written. NEXT: THE HIGHLY CONTESTED INDIVIDUAL MANDATE MINIMAL ESSENTIAL COVERAGE (AS UPHELD BY THE UNITED STATES SUPREME COURT).

Contents of Obamacare - Part 4- Mental Health

Mental Health Parity. The Mental Health Parity Act (see my December 4, 1209 blog) applies to health care plans that are qualified under this law. This requires health plans that are governed by to offer equivalent levels of coverage for mental health and physical ailments. As stated in my October 23, 2012 blog (Contents of Obamacare - Part 2), one of the 10 essential benefits required of plans is described as "“mental health and substance use disorder services, including behavorial health treatment”. Not only do plans have to cover these services, the have to do so in a manner that is actuarially equivalent to coverage for physical ailments. Definitions: The law goes on to define various terms, such as group markets, individual markets, large employers and small employers. A large employer is one with 100 or more employees. A small employer is one with at least one employee and less than 100. The state can chose to define a small employer as 50 or less employees. Federal Grants to States for Health Benefit Exchanges. The law goes further to create Federal grants to the States to establish Health Benefit Changes in 2013. The Health Benefit Changes are to become self-funded in 2015 via user fees. Rewarding Quality Through Market-Based Incentives: The law’s strategy is to improve health care through quality reporting, effective case management, care coordination, chronic disease management, medication and care compliance initiatives, including the medical home model. It also includes the prevention of re-admission to the hospital for a prior condition through patient education and planning, discharge counseling and post-discharge enforcement. The law is designed to promote activities to improve patient safety and reduce medical errors through the appropriate us of “best clinical practice”, evidence based medicine, and health information technology. Finally, the law promotes the implementation of wellness and health promotion activities. Requirements for Hospitals. Hospitals are required to operate a patient safety evaluation system. Hospital discharge must include education and planning, a comprehensive discharge plan, and post-discharge enforcement of the plan. NEXT: DO THE PROVISIONS OF OBAMACARE APPLY TO THE MEMBERS OF THE HOUSE AND THE SENATE, and CAN ILLEGAL ALIENS BENEFIT FROM THE LAW?????

Contents of Obamacare - Part 3 - Abortion

Abortion: Obamacare is neutral on abortions in the sense that it adds no new federal requirements to cover abortions but does not disallow the coverage of abortions if no federal funds or federal risk is required for the coverage. However, it leans towards abortion in that it requires at least one plan in a state exchange to cover abortions and also requires at least one plan in a state exchange to refrain from covering abortions. Obamacare divides abortions into two subgroups: 1.) those for which federal funding is illegal as of 6 months prior to the start of the calendar year for the insurance plan, and 2.) those for which federal funding is allowed per the law as of 6 months prior to the start of the calendar year for the insurance plan. The states may cover abortions from the first subgroup (no federal funds allowed) but the law prohibits the federal government from providing any funding or accepting any insurance risk for such coverage. Effect of Obamacare of State and Federal Abortion Laws: The law attempts to have no indirect effect of its own on other abortion laws. In regards to the states, the law declares “Nothing in this Act shall be construed to preempt or otherwise have any effect on State laws regarding the prohibition of (or requirement of) coverage, funding, or procedural requirements on abortions, including parental notification or consent for the performance of abortion on a minor.” In regards to federal law, the statue declares, “Nothing in this Act shall be construed to have any effect on Federal laws regarding conscience protection, willingness or refusal to provide abortions, or discrimination on the basis of the willingness or refusal to provide, pay for, cover or refer for abortion or to provide or participate in training to provide abortion." In regards to Civil Rights law, the statute declares “Nothing…shall alter the rights and obligations of employees and employers under title VII of the Civil Rights Act of 1964."