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Health Insurance Reform & Rehabilitation Coverage

Presenter: Theresa Morgan, Legislative Director Powers, Pyles, Sutter, and Verville, PC

January 24, 2014

Health Care Reform Overview

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Massive overhaul of the health insurance market and health care delivery in the U.S.

Insurance market reforms implemented using the existing state by state system Consumers purchase plans offered in in their state, not a

national plan States select benchmark plan States retain enforcement authority

Health Insurance Market Reforms

Share the costs:

ACA Strategy for Expanding Coverage

Large Employers provide insurance or pay finesIndividuals

purchase insurance or pay fines

Universal Coverage

Feds and States Expand Medicaid to 133 percent of poverty line, regardless of beneficiary’s health status (voluntary)

Feds help individuals pay premiums up to 400 percent of FPL

Insurance companies must guarantee issue (cannot deny coverage to because of costly pre-existing conditions)

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Reforms in Effect Prior to October 1 Ban on pre-existing condition denials for children Young adults can stay on parents’ insurance plans

until 26 No lifetime monetary caps on essential health

benefits (EHBs) Significant premium increases subject to state and

federal review Medical loss ratio requirements Coverage of preventive services without cost-sharing

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Additional Requirements: 2014

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Non-grandfathered plans can no longer deny or rescind coverage for adults based on condition, disability, health status or age

Insurers prohibited from designing discriminatory benefit packages or setting price based on health status of participants

Annual coverage caps on EHB prohibited Mental health parity applies to qualified health plans

(QHPs)

Grandfathered Plans

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Some plans that were in existence before March 23, 2010, are exempted from compliance with the Affordable Care Act’s coverage requirements Plans that were created after March 23, 2010

are never considered grandfathered Plans that make significant changes to their

cost-sharing or coverage structures after March 23, 2010 will lose their grandfather status

Health Insurance Exchanges

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Exchanges States can establish new Marketplaces (Exchanges) through

which issuers offer approved plans for purchase by individuals and small groups (17, including DC)

States can partner with the Feds to operate an Exchange (7) States can abdicate all Exchange authority to Feds (27)

Benefit Design States can base plan benefits on existing benchmark in the

state Medicaid Expansion

Choose to expand or not Select Medicaid Benchmark

What is the State’s Role?

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State insurance commissioners and department of health play significant enforcement and oversight role of qualified health plans (QHPs)

In each state, the authority can lie in different offices

State Oversight Role

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The Federal Marketplace is very large, causing massive implementation challenges

• Healthcare.gov struggles to stay live• Oversight of all plans within 27 states a challenge• State laws still apply• Transparency of coverage in federal marketplace a

challenge

Health Insurance Marketplace (con’t)

Rehabilitation as Essential Health Benefit

What Benefits Are Covered?

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Ten categories of EHBsEmergency services HospitalizationMaternity and newborn careMental health and substance abuse disorders, including behavioral health treatmentPrescription drugsRehabilitative and habilitative services and devicesLaboratory services Preventive care and wellness services and chronic disease management (Medicare, Medicaid and private will cover preventive care without co-pays)Pediatric services, including oral and vision care

Defining Essential Health Benefits

Federal regulations do not mandate specific services and devices which must be covered under the benefit

Some states have legislated or regulated definitions and scope of coverage

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Benchmark Plan Coverage

Plans operating in an exchange must provide benefits substantially equal to those provided in their state’s benchmark plan

Once a plan has been certified to meet the requirements, the plan is a “qualified health plan”

Although monetary annual and lifetime caps are prohibited, plans can substitute benefits within the category, place visit limits on the benefits, and use other “utilization management techniques”

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26 states have decided to implement expansion to new eligibility group in 2014

Because 24 states not moving forward at this time, number of uninsured will decrease at a slower pace, with 3 million more people uninsured in 2022 than with mandatory expansion

All existing Medicaid benchmark and benchmark equivalent plans (now called Alternative Benefit Plans (ABPs)) must cover EHBs, regardless of whether the state chooses expansion

Medicaid Expansion

State Examples

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States Covering ≥20 Outpatient Rehab Visits Per Year

New York (60 visits per condition per lifetime) Texas (35 visits per year) Pennsylvania (30 visits per year combined for PT/OT, 30

visits per year for ST) New Jersey (30 visits per year for PT/OT) Florida (35 visits per benefit period) Ohio (20 visits per year per specialty) Michigan (30 visits per year) Virginia (30 visits per year) Unknown

California Illinois

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New York

Benchmark Plan: Oxford Health Insurance Oxford EPO http://www.cms.gov/CCIIO/Resources/Data-Reso

urces/Downloads/new-york-ehb-benchmark-plan.pdf

Exchange Origin: State-based Decision on Medicaid Expansion:

Implementing Expansion in 2014

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New York Rehab Coverage

Inclusions

Sets habilitative services at modified parity with rehabilitative services

Home health services (40 visits per year)

Skilled nursing facility (200 days per year)

Outpatient rehabilitation services (short-term PT, ST, OT) (60 visits per condition per lifetime)

1 consecutive 60 day period per condition per lifetime in a rehabilitation facility

Exclusions

Long-term/custodial nursing home care not covered

Private-duty nursing not covered

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California

Benchmark Plan: Kaiser Foundation Health Plan Small Group HMO 30 (ID 40513CA035) https://www.statereforum.org/sites/default/files/ca_

kaisersmallgrouphmo.pdf Exchange Origin: State-based Decision on Medicaid Expansion:

Implementing Expansion in 2014

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California Rehab Coverage

Inclusions

Physical, occupational and speech therapy--$30 per day copayment in out-patient setting and $400 per day copayment in in-patient setting

Outpatient rehabilitation services

Home health services (up to 100 visits per calendar year) with no charge

Skilled nursing facility care (up to 100 days per benefit period) with no charge

Exclusions

Services provided by any non-licensed health care professional not covered

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Texas

Benchmark Plan: Blue Cross Blue Shield of Texas BestChoice PPO RS26 http://www.cms.gov/CCIIO/Resources/Data-Resou

rces/Downloads/texas-ehb-benchmark-plan.pdf Exchange Origin: Federally-facilitated Decision on Medicaid Expansion: Not Moving

Forward at this Time

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Texas Rehab Coverage

Inclusions

Home health care services (60 visits per year)

Skilled nursing facility (25 days per year)

Outpatient rehabilitation services (35 visits per year)

Habilitation services (35 visits per year)

No limit to rehabilitation/habilitation for children with autism

Exclusions

Long-term/custodial nursing home care is not covered

Private-duty nursing is not covered

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Pennsylvania

Benchmark Plan: Aetna HMO PA POS Cost Sharing 34 1500 Ded http://www.cms.gov/CCIIO/Resources/Data-Reso

urces/Downloads/pennsylvania-ehb-benchmark-plan.pdf

Exchange Origin: Federally-facilitated Decision on Medicaid Expansion: Seeking to

Move Forward with Expansion Post-2014

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Pennsylvania Rehab Coverage

Inclusions Skilled nursing facility (120

days per year) Outpatient rehabilitation

services (30 visits per year combined for PT/OT, 30 visits per year for ST)

Large group insurers must cover habilitation services for autism

Exclusions

Long-term/custodial nursing home care not covered

Other habilitation services not covered

Private-duty nursing not covered

Precertification required for home health care services, hospice services, and skilled nursing facilities or else benefits will be reduced 50%

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Illinois

Benchmark Plan: Blue Cross Blue Shield of Illinois BlueAdvantage Entrepreneur PPO https://www.statereforum.org/sites/default/files/il

_ehb_benchmark_blueadvantage_entrepreneur.pdf

Exchange Origin: Federally-facilitated partnership

Decision on Medicaid Expansion: Implementing Expansion in 2014

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Illinois Rehab Coverage

Inclusions

Limited benefits for cardiac rehabilitation maximum 36 outpatient treatment sessions within 6 month period and only available in BCBS approved programs.

Rehab/habilitative treatment programs for autism spectrum disorder.

Habilitative services covered for persons with congenital, genetic or early acquired disorders, treatment must be medically necessary not investigative or therapeutic.

Exclusions

Hospitalization, services, supplies if BCBS decides they are not medically necessary

Definition of some therapy services excludes treatment for acquiring function

Some speech therapy services except for autism

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New Jersey

Benchmark Plan: Horizon HMO Access HSA Compatible http://www.cms.gov/CCIIO/Resources/Data-Reso

urces/Downloads/new-jersey-ehb-benchmark-plan.pdf

Exchange Origin: Federally-facilitated Decision on Medicaid Expansion:

Implementing Expansion in 2014

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New Jersey Rehab Coverage

Inclusions Habilitations as provided through

rehabilitation services are covered (30 visits per year)

Outpatient rehabilitation services require pre-approval, separate from home health care services

Private-Duty nursing covered as part of home health benefits only (60 visits per year)

Home health care services requires pre-approval

Physical and occupational therapy (30 visits per year)

Speech and cognitive therapy (30/yr) Separate limits for DD/Autism

Exclusions

Long-term/custodial nursing home care

Home health care services furnished to family members

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Florida

Benchmark Plan: Blue Cross and Blue Shield of Florida BlueOptions 5462 http://www.cms.gov/CCIIO/Resources/Data-Resourc

es/Downloads/florida-ehb-benchmark-plan.pdf Exchange Origin: Federally-facilitated Decision on Medicaid Expansion: Not Moving

Forward at this Time

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Florida Rehab Coverage

Inclusions

Home health care services are covered limited to 20 visits per benefit period

Skilled nursing facility care covered limited to 60 days per benefit period

Outpatient rehab services covered limited to 35 visits per patient per benefit period

Speech therapy is covered for child cleft lip and cleft palate

Covered outpatient therapies include cardiac, occupational, physical, speech, massage therapies in home health care, hospital and skilled nursing facility setting

Exclusions

Speech therapy provided for diagnosis of developmental delay is excluded.

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Michigan

Benchmark Plan: Priority Health PriorityHMO 100 Percent Hospital Services Plan https://www.statereforum.org/sites/default/files/m

ichigan_2012-priorityhmo-coc.pdf Exchange Origin: Federally-facilitated

partnership Decision on Medicaid Expansion:

Implementing Expansion in 2014

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Michigan Rehab Coverage

Inclusions Cardiac and pulmonary rehab, physical and occupational therapy

(including spinal manipulations by chiropractor and all manipulations by osteopathic physicians), speech therapy for treatment of medical diagnoses, biofeedback for treatment of medical diagnoses when medically necessary.

Breast cancer rehabilitation services must be covered Short term rehab medicine services covered if treatment is provided for

illness, injury or congenital defect for which you have received corrective surgery, they are provided in outpatient setting or at home, you cannot receive these services from any federal or state agency or any local political subdivision, including school districts, treatments result in meaningful improvement in your ability to do important day-to-day activities within 90 days of starting, a participating physician refers, directs and monitors services

Outpatient rehabilitation services (30 visits per year, applies to all rehab services)

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Michigan Rehab Coverage

Exclusions Therapy not covered if there has not been meaningful improvement

within 90 days of starting, therapies not covered for DD and cognitive disorders (including PT, OT, ST, and cognitive and sensory integration therapy)

Cognitive rehabilitative therapy not covered, craniosacral therapy, prolotherapy, rehab services obtained from non-Health professionals (including massasge therapists), relational, eduacational and sleep therapy, strength training and exercise programs, summer programs meant to maintain physical condition or developmental status during periods when school programs unavailable, visual training and sensory integration therapy, vocational rehab, services outside the scope of practice of provider, therapy to maintain physical condition for chronic condition (including CP and DD), therapy to correct impairment not due to illness, injury or congenital defect

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Ohio

Benchmark Plan: Community Insurance Company (Anthem BCBS) Blue 6 Blue Access PPO Medical Option D4 Rx Option G http://www.cms.gov/CCIIO/Resources/Data-Reso

urces/Downloads/ohio-ehb-benchmark-plan.pdf Exchange Origin: Federally-facilitated Decision on Medicaid Expansion:

Implementing Expansion in 2014

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Ohio Rehab Coverage

Inclusions

Home health care (100 visits per year)

Skilled nursing facilities (90 days per year)

Outpatient rehabilitation services (20 visits per year for each specialty)

Inpatient rehab facilities including physicians (60 days per year)

Habilitation for children with autism is covered

Exclusions Other habilitation services not covered

Long-term/custodial nursing home care not covered

Home health care services do not include food, physician charges, family member services, non-employee helpers

SNF custodial care is not covered, except as part of hospice care

Outpatient rehabilitation services does not include maintenance therapy to delay or minimize muscular deterioration in patients suffering from a chronic disease or illness; repetitive exercise to improve movement, maintain strength and increase endurance (including assistance with walking for weak or unstable patients); range of motion and passive exercises that are not related to restoration of a specific loss of function, but are for maintaining a range of motion in paralyzed extremities; general exercise programs

Long term inpatient rehabilitation is not covered

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Virginia

Benchmark Plan: Anthem Health Plans of VA (Anthem BCBS) PPO KeyCare 30 with KC30 Rx Plan 10 30 50 OR 20 http://www.cms.gov/CCIIO/Resources/Data-Reso

urces/Downloads/virginia-ehb-benchmark-plan.pdf

Exchange Origin: Federally-facilitated Decision on Medicaid Expansion: Not Moving

Forward at this Time

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Virginia Rehab Coverage

Inclusions

Private-duty nursing ($500 per year)

Home health care services (100 visits per year)

Skilled nursing facility as part of hospice (100 days per admission)

Outpatient rehabilitation services (30 visits per year)

Habilitation services (30 visits per year)

Benefit limits are shared between rehabilitation and habilitation services

Exclusions

Long-term/custodial nursing home care not covered

Private nursing excludes inpatient services; must be certified; cannot be family member

Home health care does not include homemaker services, food, maintenance therapy

PT/OT excluded if no chance of improvement/reversal

Physiatrists as Rehabilitation Champions

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Lobbied successfully for inclusion of “rehabilitation and habilitation services and devices” in the health reform bill

Formed an Essential Health Benefits Task Force to draft a position on this issue

Conducted a webinar on Health Insurance Exchanges and provided members with tools to advocate for coverage of “rehabilitation and habilitation services and devices”

Participates in the Habilitation (“HaB”) Coalition to ensure that “habilitative services and devices” are treated appropriately in the context of the essential health benefits (EHB) package under the Affordable Care Act (ACA)

AAPM&R Efforts around Rehabilitation Coverage

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How can Physiatrists Protect and Enhance Coverage?

Monitor benefit coverage and network adequacy in your area

Contact state insurance offices to confirm coverage as EHB and establish point of contact

Request language in regulation to ensure clarity of coverage for Rehabilitation across settings

Get involved with your state PM&R societies to develop strategies

Feedback to AAPMR on roll-out

Useful Links

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Federal Exchange: www.healthcare.gov

CCIIO Survey of EHB Plans: http://www.cms.gov/CCIIO/Resources/Data-Resources/ehb.html

Registration for Technical Assistance Portal https://www.regtap.info/