Prevention Wellness

This reform also includes creating task forces on Clinical Preventative Services and Community Preventative Services to develop, update, and disseminate evidence-based recommendations on the use of clinical and community prevention services.

Grants will assist in improving the health of our nation’s workforce and will reduce employer health care costs. Participating employers must offer the programs to all employees and cannot mandate participation nor use participation as a condition to receive any financial incentive.

Prevention and wellness measures of the bill include:

1. Expansion of Community Health Centers;
2. Prohibition of cost-sharing for preventive services;
3. Creation of community-based programs to deliver prevention and wellness services;
4. A focus on community-based programs and new data collection efforts to better identify and address racial, ethnic, regional, and other health disparities;
5. Funds to strengthen state, local, tribal and territorial public health departments and programs
   

Lorria Trujillo

Information cited from:

House Committees on Ways, Means, Energy and Commerce, and Education and Labor (December 4, 2009). Affordable Health Care for America Act: Detailed Summary. Retrieved from http://energycommerce.house.gov/Press_111/health_care/hr3962_DETAILEDSUMMARY.pdf.

Kaiser Family Foundation (October 15, 2009). Health Care Reform Proposals. Retrieved from http://www.kff.org/healthreform/upload/healthreform_tri_full.pdf.

Medicare Provisions

The Affordable Healthcare for America Act (2009) is planning on making provisions to Medicare, mainly for cost saving purposes. One way they are attempting to do this is by altering the benefits received by the low income population. This population includes individuals making less than $17,000 and couples making less than $34,000 annually. This act suggests, “increasing the threshold used to determine eligibility for the Medicare Savings Program.” (2009). By making it more difficult to get Medicare, less people will be given the benefits of Medicare and therefore decrease spending. This Act would also implement cost sharing between Medicare and Medicaid for Medicare beneficiaries over the age of 65.

The Medicare provisions are also focusing on reforming the prescription drug benefits. The plan is hoping to eliminate a prescription drug coverage gap by, “progressively increasing the initial coverage limit and decreasing the annual out of pocket threshold coverage limit.” (2009). This would also involve a negotiation of drug prices between the Secretary of HHS and manufactures. Hopefully this would make it possible to provide a 50% discount on brand-name drugs for Medicare beneficiaries.

Here is a pie graph for a simplistic breakdown of Medicare’s planned spending and saving in the Affordable Healthcare for America Act (2009).




Kaiser Family Foundation (November 21, 2009). Summary of Key Medicare Provisions in H.R. 3962, Affordable Health Care for America Act. Retrieved from http://www.kff.org/healthreform/upload/7948_HR3962_Summary-2.pdf

Alia Torfa

Overall Approach to Expanding Access to Coverage and Individual Mandate

America’s Affordable Health Choice Act of 2009 is one portion of the current health care reform proposals. It is especially concerned with key amendments affecting the health care reform proposal bill. The following paragraphs summarize and explain the significant issues related to the proposal.

The main objective of the proposal is to provided health insurance to all individuals. Insurance coverage would be required. Individuals who do not have coverage would be obligated to pay a 2.5 % penalty. The penalty would be applied to a persons income before taxes are taken out (gross income). But the penalty cannot be more than the average premium under a basic insurance exchange plan for an individual or family coverage. Exceptions to the penalty do exist for religious purposes, people with dependents (ex. children), and those who are financially unable to afford the penalty.

Individuals and small businesses are given the opportunity to compare different coverage options this idea is also known as a health insurance exchange. The exchange would offer small businesses and individuals the opportunity to purchase coverage. Those who are 400% or less than the federal poverty level are offered premiums or cost sharing credits. A Premium is the amount of money an insurance company charges an individual for coverage. Cost sharing is the percentage not covered by the insurance plan that must be paid by the individual receiving the insurance coverage. Businesses/employers are required to provide health insurance. If they opt out of this option they are required to contribute to an insurance exchange trust fund.

Information cited from:
Kaiser Family Foundation (October 14, 2009). Health Care Reform Proposals. Retrieved from http://www.kff.org/healthreform/upload/healthreform_tri_full.pdf.

Cost sharing. (Fall, 2006). Retrieved October 14, 2009, from
http://web.mit.edu/osp/www/referencemanual/chapter/ch4_cost_sharing.pdf


Heather Simpson

Employer Requirements

Offer coverage to employees and contribute 72.5% of premium cost for single coverage and 65% for family coverage in the lowest cost plan or pay 8% into the Health Insurance Exchange Trust Fund. There would be an exemption for employers that would have job losses as a result of the requirement. The breakdown is as follows:
*Annual payroll <$500,000 is exempt.
*$500,000-$585,000 pays 2% of payroll
*$585,000-$670,000 pays 4%
*$670,000-$750,00 pays 6%

Employers automatically enroll employees in lowest cost premium plan unless the employee opts out or chooses different coverage under the employer plan.

Remington Stickney

Information cited from:
Kaiser Family Foundation (October 15, 2009). Health Care Reform Proposals. Retrieved from http://www.kff.org/healthreform/upload/healthreform_tri_full.pdf.

Premium Subsidies to Individuals

The premium subsidies to individuals will provide affordable premium credits to individuals who are eligible and families with incomes of up to 400% federal poverty level (FPL) to purchase insurance through the Health Insurance Exchange program.
The premium credits will be based on the average cost of the three lowest cost basic health care plans within that area. The cost will then be placed on a sliding scale so that the main contributions are limited to pay a set percentage of their income for the specified income tier, the tiers are as follows:
-133-150% FPL: 1.5 - 3% of income
-150-200% FPL: 3 - 5% of income
-200-250% FPL: 5 - 7% of income
-250-300% FPL: 7 - 9% of income
-300-350% FPL: 9 - 10% of income
-350-400% FPL: 10 - 11% of income

The plan will provide affordable cost-sharing credits for individuals that are eligible and families with incomes of up to 400% FPL. The cost-sharing credits reduce the cost-sharing amounts and the annual cost-sharing limits and have the effect of increasing the actual value of the basic benefit plan a certain percentage of the full value of the plan for the specified income tier, the tiers are as follows:
-133-150% FPL: 97%
-150-200% FPL: 93%
-200-250% FPL: 85%
-250-300% FPL: 78%
-300-350% FPL: 72%
-350-400% FPL: 70%

The premium and cost-sharing credits will have limited availability to US citizens and lawfully residing immigrants who meet the income limits and are not enrolled in qualified or employer-based or individual coverage, Medicare, Medicaid, TRICARE, or VA coverage. Individuals who have access to employer-based coverage are eligible for the premium and cost-sharing credits if the cost of the employee premium exceeds 11% of the individual’s income.

Information cited from:
Kaiser Family Foundation (October 15, 2009). Health Care Reform Proposals. Retrieved from http://www.kff.org/healthreform/upload/healthreform_tri_full.pdf.

Tina Wederski

Expansion of Public Programs

1. Expand Medicaid to all individuals (children, pregnant women, parents, and adults without dependent children) with incomes up to 133% FPL. Newly eligible, non- traditional (childless adults)

2. Medicaid beneficiaries may enroll in coverage through the Exchange if they were enrolled in qualified health coverage during the six months before becoming Medicaid eligible.

3. Provide Medicaid coverage for all newborns who lack acceptable coverage and provide optional Medicaid coverage to low-income HIV-infected individuals and for family planning services to certain low-income women. In
addition, increase Medicaid payment rates for primary care providers to 100% of Medicare rates. [E&C Committee amendment: Require states to submit a state plan amendment specifying the payment rates to be paid under the state’s Medicaid program.]

4. The coverage expansions (except the optional expansions) and the enhanced provider payments will
be fully financed with federal funds. [E&C
Committee amendment: Replace full federal financing for Medicaid coverage expansions with 100% federal financing through 2014 and 90% federal financing beginning in year 2015.]

5. Require Children’s Health Insurance Program (CHIP) enrollees to obtain coverage through the Health Insurance Exchange (in the first year the Exchange is available) provided the Health Choices Commissioner determines that the Exchange has the capacity to cover these children and that procedures are in place to
ensure the timely transition of CHIP enrollees into the Exchange without an interruption of coverage. [E&C Committee amendment: Require that CHIP enrollees not be enrolled in an Exchange plan until the Secretary certifies that coverage is at least comparable to coverage under an average CHIP plan in effect in 2011. The Secretary must also determine that there are procedures to transfer CHIP enrollees into the exchange without interrupting coverage or with a written plan of treatment.]

Kennadi Lower

Premium Subsidies to Employers

Premium subsidies to small employers who have fewer than 25 employees and average wages of less than $40,000 will be provided with a health coverage tax credit. While Employers with fewer than 10 employees and average annual wages of $20,000 or less are able and pay full credit of 50% of the premium costs are also able to receive the tax credit. However, the tax credit is not permitted for firms that are increasing in size and wages and for employees that are earning more than $80,000 per year.
Employers that are providing health insurance coverage to retirees between the ages of 55 to 64 will be provided with a temporary reinsurance program. The premium program will reimburse the employers for 80% of retiree claims that are between $15,000 and $90,000. These payments from the reinsurance program will be used to lower the costs for those that enroll into the employer plan. A total of $10 billion is set aside for over ten years for the reinsurance program.

Information cited from:
Kaiser Family Foundation (October 15, 2009). Health Care Reform Proposals. Retrieved from http://www.kff.org/healthreform/upload/healthreform_tri_full.pdf.

Tina Wederski

Tax Changes Related to Health Insurance

Individuals who do not have acceptable health coverage will be faced with a tax of 2.5% of their total income.

Information cited from:
Kaiser Family Foundation (October 15, 2009). Health Care Reform Proposals. Retrieved from http://www.kff.org/healthreform/upload/healthreform_tri_full.pdf.

Tina Wederski

Creation of Insurance Pooling Mechanisms

"America's Affordable Health Choice Act of 2009" will create a National Health Insurance Exchange. This means that individuals and employers can purchase qualified insurance, including private health plans and a public health insurance option.

The public health insurance option will offer basic, enhanced, and premium plans.
These plans are:
*Basic plan includes essential benefits package, reduced cost sharing compared to the basic plan, and covers 85% of benefit costs of the plan
*Enhanced plan includes essential benefits package, reduced cost sharing compared to the basic plan, and covers 85% of benefit costs of the plan
*Premium plan includes essential benefits package with reduced cost sharing compared to the enhanced plan, and covers 95% of the benefit costs of the plan
*Premium plus plan is a premium plan that provides additional benefits, such as oral health and vision care

Plans that are participating in the Exchange are required to be issued and guaranteed renewability. Also, information will be provided to consumers by a telephone hotline, website, and during open enrollment periods. This allows consumers to choose among the plans for themselves.

Kristen Reid

Information cited from:
Kaiser Family Foundation (October 15, 2009). Health Care Reform Proposals. Retrieved from http://www.kff.org/healthreform/upload/healthreform_tri_full.pdf.

Benefit Design

Benefit designs for House Tri-Committee America Affordable health choice act of 2009 (H.R. 3200) create an essential benefits package that provides a comprehensive set of services:
• covers 70% of the actuarial value of the covered benefits,
• limits annual cost-sharing to $5,000/individual and $10,000/family,
• and does not impose annual or lifetime limits on coverage.

The Health Benefits Advisory Council, chaired by the Surgeon General, will make recommendations on specific services to be covered by the essential benefits package as well as cost-sharing levels. [E&L Committee amendment:
• Require early and periodic screening,
• diagnostic,
• and treatment (EPSDT) services for children under age 21 be included in the essential benefits package.]

[E&C Committee amendment: Prohibit abortion coverage from being required as part of the essential benefits package; require segregation of public subsidy funds from private premium payments for plans that choose to cover abortion services beyond Hyde—which allow coverage for abortion services to save the life of the woman and in cases of rape or incest; and require there be no effect on state or federal laws on abortions.]

All qualified health benefits plans, including those offered through the Exchange and those offered outside of the Exchange (except certain grandfathered individual and employer sponsored plans) must provide at least the essential benefits package.

Kaiser, H. (Oct2005). Focus on health reform: Health care reform proposal. Retrieved on Nov. 25, 2009 from http://www.kff.org/healthreform/upload/healthreform_tri_full.pdf


Vangie Yazzie

Changes to Private Insurance

A Health Choice Administration will be established, this administration will help establish qualifying health benefits standards, establish the Exchange, administer the affordability credits, and enforce the requirements for qualified health benefit plan. There will be new standard adopted for financial and administrative transactions, this will make business transactions simpler and more efficient. There will no longer be individual market insurance available, those who area already covered will be grandfathered into the new program. Market regulations will be intact to regulate spending cost of all insurance companies. These market standard will also helps all people with appeals, and for grievances.

Jennifer Kidd

State Role

*Require states to enroll newly eligible Medicaid beneficiaries into the state Medicaid programs and to implement the specified changes with respect to provider payment rates, benefit enhancements, quality improvement, and program integrity.

*Require states to maintain Medicaid and CHIP eligibility standards, methodologies, or procedures that were in place as of June 16, 2009 as a condition of receiving federal Medicaid or CHIP matching payments.

*Require states to enter into a Memorandum of Understanding with the Health Insurance Exchange to coordinate enrollment of individuals in Exchange-participating health plans and under the state’s Medicaid program.

*May require states to determine eligibility for affordability credits through the Health Insurance Exchange.

Kaiser, H. (Oct2005). Focus on health reform: Health care reform proposal. Retrieved on Nov. 25, 2009 from http://www.kff.org/healthreform/upload/healthreform_tri_full.pdf

Vangie Yazzie

Improving Quality/Health System Performance

• Establishing a Center for Comparative Effectiveness Research within the Agency for Healthcare Research and Quality to conduct research, support, and synthesize research on outcomes, effectiveness, and appropriateness of health care services and procedures.
• Increasing Medicaid payments for primary care providers and providing Medicare bonus payments to primary care practitioners to strengthen primary care and care coordination.
• Conduct pilot programs through Medicare and Medicaid to test payment incentive models for accountable care organizations and bundling of post-acute care payments and to assess feasibility of reimbursing qualified patient-centered medical homes.
• Improve coordination of care for dual eligibilities.
• Establish the Center for Quality Improvement to implement best practices in the delivery of health care services.
• Require disclosure of financial relationships between health entiities.
• Reduce racial and ethnic disparities.

Information cited from:
Kaiser Family Foundation (October 15, 2009). Health Care Reform Proposals. Retrieved from http://www.kff.org/healthreform/upload/healthreform_tri_full.pdf.

Bina Solanky

Prevention/Wellness

• Develop a national strategy to improve the nation’s health through evidence-based clinical and community based prevention and wellness activities.
• Improve prevention by covering only proven prevention services in Medicare and Medicaid.

Information cited from:
Kaiser Family Foundation (October 15, 2009). Health Care Reform Proposals. Retrieved from http://www.kff.org/healthreform/upload/healthreform_tri_full.pdf.

Bina Solanky

Cost Containment

Simplify health insurance administration with timely claims and denial of management processes and use of standard electronic transactions.

Limit annual increases in Exchange plans by no more than 150% of the annual percentage increase in medical inflation.

Medicare modifications:
*Reduce payments for preventable hospital readmissions.
*Modify market updates to account for productivity for inpatient facilities.
*Medicare Advantage plans would be 100% free-for-service payments, with bonuses for quality.

Medicaid modifications:
*Increase drug rebate percentage and extend prescription drug rebate to managed plans.
*Require drug manufacturers to provide drug rebates for dual eligibles enrolled in Part D plans.
*Negotiate lower drug prices for part D plans and Advantage Part D plans.
*Reduces DSH payments by $6 billion in 2019.
*Refuse payments to certain nosocomial infections.

Hospitals must report nosocomial infections to centers for Disease Control and Prevention.

Allow FDA to approve generic versions of biologic drugs and grant biologic manufacturers 12 years of exclusive use before generics can be developed.

Allow provider screenings, enhanced oversight periods, and enrollment moratoria in areas that are at risk for fraud in all public programs.

Medicaid and Medicare program providers and suppliers will be required to establish compliance programs.

Remington Stickney

Information cited from:
Kaiser Family Foundation (October 15, 2009). Health Care Reform Proposals. Retrieved from http://www.kff.org/healthreform/upload/healthreform_tri_full.pdf.

Long-term Care

The will be a program available to all working adults to be enrolled in. The program will offer living assistance within a community, cash benefits to live off of, and support to maintain a residence in a community. This program will be available by payroll deductions, similar to a savings account. The program is optional, but all employees will automatically be enrolled, but they can personally choose to opt out. All those who complete the program will receive the benefits when needed.

Jennifer Kidd

Other Investments

Other investments that are going to be addressed in "America's Affordable Health Choices Act of 2009" are making improvements to the Medicare program, reform Graduate Medical Education, support the training of health professionals, provide grants to state health departments, and study the feasibility of adjusting the poverty level.

There are several actions that need to be done to improve the Medicare program. First, the sustainable growth rate for physicians need to be reformed by creating incentive payments for primary care. Second, the Medicare Part D coverage gap needs to be eliminated. This will require drug manufacturers to discount brand-name prescriptions. Thirdly, the asset test for Medicare Savings Program and Part D Low-Income Subsidies will need to be increased. And lastly, the cost-sharing for preventative services will be eliminated.

Kristen Reid

Information cited from:
Kaiser Family Foundation (October 15, 2009). Health Care Reform Proposals. Retrieved from http://www.kff.org/healthreform/upload/healthreform_tri_full.pdf.

Financing

The cost is estimated at $1.042 trillion over 10 years. Half the cost is financed through saving from Medicare and Medicaid. The remaining costs are supplemented through a surcharge imposed on families that make more than $350,000 a year and individuals that make more than $280,000 a year. This is a 1% surcharge for families between $350,000-$500,000, 1.5% for families making $500,000-$1,000,000, and 5.4% for families making >$1,000,000 a year. The surcharges are can be adjusted if savings are more than expected.

Remington Stickney

Information cited from:
Kaiser Family Foundation (October 15, 2009). Health Care Reform Proposals. Retrieved from http://www.kff.org/healthreform/upload/healthreform_tri_full.pdf.