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Update on SB 1194 (The Insurance Navigator Act)

Starting October 2013, an estimated 1.6 million Illinois residents will be eligible for new and affordable forms of public and private health insurance coverage under the Affordable Care Act. But the overwhelming majority of the newly eligible have no idea how to access these options. Many Illinoisans will need more information and guidance through the enrollment process.

The Affordable Care Act requires each state’s Health Insurance Marketplace to establish a Navigator Program that will guide these individuals through their new coverage and enrollment options. These Navigators will serve an important role in ensuring that individuals benefit from the ACA.

On January 30th, the potential efficacy of the Navigator program was threatened by the introduction of Illinois Senate Bill 1194, which would create overly restrictive criteria for organizations applying for and performing navigator functions.

Here are the issues with SB1194 (as it was introduced):

  • SB1194 placed unnecessary restrictions on Illinois Navigators and In-Person Assistors, making it more difficult for low-income and hard-to-reach populations to connect to the application assistance that they need.  
  • Illinois is currently preparing a Navigator training and oversight system that makes SB 1194 unnecessary. 
  • Federal law already mandates some of what is outlined in SB1194, such as prohibiting Navigators from recommending specific insurance products. Once again, SB1194 is unnecessary.  
  • Language in SB1194 prohibited Navigators from facilitating enrollment in a Federally Qualified Health Plan, (QHP), one of the five Navigator duties already specified by the ACA.
Consumer advocates and community based-providers recognized these issues, and successfully lobbied state Senators to make changes in the bill.

Here’s what changed:
  • SB1194 now includes the Navigator duties as spelled out in the ACA.
  • SB1194 now includes a certification, instead of a licensure, requirement.
  • SB1194 excludes all prior language that restricted Navigator duties, (such as the ability to facilitate enrollment in a QHP).
  • SB1194 is now in alignment with Federal regulations regarding the training and responsibilities of Navigators.
  • SB1194 now allows for the training of Certified Application Counselors, (another type of Navigator not directly compensated by the Exchange), to be defined at a later date. This means that CAC training will align with federal guidelines.
What’s happening now?

These amendments were filed on April 22nd, passed in the Senate on the 24th, and were referred to the House Rules Committee earlier today. You can follow SB 1194’s status here.Thanks to all of the advocates for raising your voices against restricting the navigators in this new health care system.

Nadeen Israel
Policy Associate, Heartland Alliance for Human Needs & Human Rights

Please contact Nadeen at nisrael@heartlandalliance.org for more information on SB1194.




The “Rate Shock” Myth

As Affordable Care Act opponents continue grasping at straws to find fault with the law, an assertion perpetuated by the insurance industry that the ACA’s coverage expansions will significantly increase premiums has gained prominence. Lately, many insurance industry-funded studies and the resulting news coverage of them have focused on the potential for “rate shock” for the young and healthy, fear mongering young adults and others into thinking their rates will skyrocket come 2014. None of these reports address all of the protections written into the bill to prevent steep rate changes and many fail to accurately represent the true scope of benefits and costs. Community Catalyst has prepared this fact sheet to help cut through some of the confusing arguments swirling around.

Very few people will be affected by significant rate changes. To give a sense of how small this number is, more than half of employed 19-44 year-olds were covered through their employers. Of those who are not offered insurance through an employer, 92 percent of young adults expected to enroll in individual plans with subsidies through the Exchanges would not be subject to premium increases. This is not to say that nobody will experience rate changes, but it is important to understand the relative impact of increases and the small number of people affected.

Rate changes will primarily impact young men between the ages of 19-27, who have incomes higher than 400 percent of the federal poverty level (more than $45 thousand per year) and are not covered through their employers. And even these individuals will only experience moderate changes – on average an increase of 10-13 percent compared to current non-group rates, according to the Congressional Budget Office.

Most importantly, the ACA means everyone will gain increased value per health care dollar through better benefit packages and limits on how much patients can pay out-of-pocket. New plans will be required to meet certain standards of benefits, including covering maternity, mental health, prescription drug coverage, and charging no co-pay or deductible for preventive services including cancer screenings and contraception. These new standard benefits ensure that consumers will get greater value and better protections than many plans currently provide. Young adults will also have the option of enrolling in a catastrophic coverage plan that covers the same benefits but offers lower premiums with a higher deductible.

The law also makes the system fairer across gender and age groups. Currently, insurers commonly charge women more than men, simply because they have the potential to incur more costs through maternity care. This unfair practice costs women in the private market approximately $1 billion per year, but is outlawed under the ACA starting in 2014. Similarly, insurers are allowed to charge older adults significantly higher rates. The ACA places limits on this practice so older adults can only be charged a maximum of three times as much as younger adults. This change reflects a more accurate approximation of the health cost differences between young and old, correcting years of overcharging adults for their health care services. Finally, the ACA ends discrimination against those who have preexisting conditions. This is not irrelevant for young adults, since 16 percent of 16-24 year olds have preexisting conditions and either are unable to gain coverage or are pay higher rates because of their medical history.

When it all shakes out, the benefits of the ACA for young adults far outweigh any costs. The impact of premium changes will be limited, will help make the health insurance system fairer, and will ensure consumers get more bang for their buck.

Sarah Gordon, Private Insurance Team Intern
Community Catalyst

(Blog originally appeared here on the Health Policy Hub)

Medicaid Pay Increase For Hospitalists Confirmed For 2013-2014.

Are hospitalists going to get a Medicaid pay raise for 2013 and 2014?  The answer is yes, hospitalists qualify for Medicaid parity (with Medicare) as required by the Affordable Care Act (ACA).  For many states, Medicaid pays physicians and other providers a fraction of Medicare rates.  Legislation signed as part of the ACA mandates Medicaid rates to equal 100% of Part B Medicare rates in calendar year (CY) 2013 and 2014.  That means  if you haven't already seen increased rates, and you are a qualified physician providing qualfied primary care services, you will get increased Medicaid payments retroactively applied to January 1st, 2013.

When folks think of primary care, most likely think of the outpatient clinics for pediatrics, family medicine and internal medicine physicians.  But that's not how ObamaCare defines a primary care specialty.  That's right people, hospitalists, pediatric cardiologists and a whole lot of other practicing physicians now qualify as providers of primary care under ACA rules.

I was first alerted to this stunning CY 2013 and 2014 increase in Medicaid payments for hospitalists after reading an article from The Hospitalist titled Afordable Care Act (ACA) Provision Carries Pay Raise For Some Hospitalists.  Joshua Bowell, the Society of Hospital Medicine's senior manager of government relations, discusses the rules and how they apply to hospitalists.  It's a great article and I encourage all hospitalists to click the link above, read it and forward it to their billing company to make sure all necessary paperwork has been  filed to qualify for increased Medicaid payments and retroactive Medicaid payment increases that are required to start on  January 1st, 2013.

What are the specifics of this law?  You can read the  Fall 2011 rule abstract that implements section 1202 of the Affordable Care Act (ACA)  here.   I have taken the liberty of publishing it below for your review:
Title: Payments for Primary Care Services Under the Medicaid Program (CMS-2370-P)  
Abstract: This proposed rule would implement section 1202 of the Affordable Care Act that requires payment by State Medicaid agencies of at least the Medicare rates in effect in calendar years (CYs) 2013 and 2014 for primary care services delivered by a physician with a specialty designation of family medicine, general internal medicine, or pediatric medicine. This rule would implement the statutory payment provisions uniformly across all States. Specifically, this proposed rule would define, for purposes of enhanced Federal match, eligible primary care providers and identify eligible primary care services, as well as specify how the enhanced payment should be calculated. This proposed rule would also provide general guidelines for implementing the enhanced payment for managed care services.
So how does a hospitalist and a  pediatric cardiologist qualify for primary care under the proposed rule above?  Great question.  To understand the answer, one must understand how the rule defines the qualified physician providing the qualified primary care service.   I did a little digging to find out how.  Do you know how hard it is to find all this stuff?  The November 6, 2012 Federal Registrar published the final ruling (with a minor correction published December 14th, 2012) titled RIN 0938-AQ63 as it applies to the regulation mandating Medicaid parity with Medicare Part B payments for qualified primary care physicians.  Here is the lead summary paragraph of the final ruling:


How does this final ruling define a physician delivering a primary care service?   According to the Federal Registrar, the November 6th, 2012 final ruling amends several sections of the Social Security Act, specifically, 1902(a)(13), 1902(jj), 1932(f), and 1905(dd).  Effective March 20th, 2010,  section 1902(jj) of the Social Security Act now defines a primary care service as follows:



There you have it folks.  ObamaCare has defined, through amendment of the Social Security Act, exactly what primary care services are.  It is the delivery of evaluation and management services to title XVIII beneficiaries.  Title XVIII is Medicare.   It appears to me that any physician that submits payment for a qualified  E&M charge is submitting a service for a primary care service. What are the E&M codes eligible to receive higher Medicaid payments?  Evaluation and Management codes 99201-99499 of the Healthcare Common Procedure Coding System (HCPCS) and vaccine administration codes 90460, 90461, 90471, 90472, 90473 and 90474 have been lawfully determined to qualify for Medicaid parity payments in CY 2013 and 2014.

As a hospitalist, that means most E&M charges qualify for higher Medicaid payments.  All initial hospital codes, subsequent care codes, critical care codes, observation codes, and same day admit/discharge codes are included by law.  Yes folks, my critical care is considered primary care.  And my emergency room codes?  If I see a patient in the emergency room and decide not to admit them, my emergency department E&M code is considered a primary care service.  Sorry ER doctor, even though you submit the same code, you do not get parity under this law.  But why?  For many ER doctors, they are the Medicaid patient's primary care provider through dozens of ER visits a year.  If any doctor is the primary care doctor for a Medicaid patient, it's the ER physician because no primary care doctor will see them!  Why can't they get paid the higher rate?

Does any physician who submits an E/M code get parity payments for their primary care service?  Can a urologist get paid Medicaid parity for their office visits? Can a general surgeon get Medicaid parity for their cholecystectomy?  The answer is no.  Why can a pediatric cardiologist get Medicaid parity but a general surgeon can not?  The answer lies in how ObamaCare defines an eligible physician.  Return back to the summary statement above and you'll see the physician must have a specialty designation of family medicine, pediatric medicine or general internal medicine.  A urologist and general surgeon does not meet that requirement. But how does a pediatric cardiologist make the cut?

The answer lies in this law's interpretation. After the proposed rule was published in May, 2012, one hundred and seventy-seven comments were received.  Some of those comments reviewed below helped clarify the who is an eligible physician question.  Read this section thoroughly to fully understand who qualifies and who doesn't.  Click on the picture to take you directly  to the Federal Registrar paragraph contained within.


And that folks is how a pediatric cardiologist gets a Medicaid pay increase for their E&M services in CY 2013 and 2014.  The interpretation of this law adds 44 additional specialty designations to the qualifying list for Medicaid parity.  What is the gist of the argument?  A pediatric cardiologist is trained in the specialty designation of pediatric medicine and thus qualifies for Medicaid fee increases to match Medicare payment rates for 2013 and 2014.   The law says if a physician is recognized by the American Board of Physician Specialities (ABPS), the American Board of Medical Specialties (ABMS) or the American Osteopathic Association (AOA) as a specialist or subspecialist within the primary care categories, they receive Medicaid parity for their E/M charges.

What if the physician is not certified by any of these boards?  The law allows for Medicaid pay raises if  60% of the codes billed in the calendar year of enrollment were for qualified primary care services that has been defined above.  I suspect the 60% applies to the absolute number of codes submitted and not 60% of the total RVU value for the calendar year.  If the answer is absolute codes, then almost any qualifying physician could qualify by virtue of submitting at least two E&M codes for every non E&M procedure code done in the procedure suite.  That would give them a 66% rate of E&M charges which is  above the required 60% threshold.  I'm confident most medical subspecialists could clear the 60% threshold with no problem as long as they average at least two E&M charges for every non E&M procedure code they provide on any given day.

What about services provide by nonphysician practitioners?  Do nurse practitioners, pharmacists, midwives, certified registered nurse anesthetists  or other qualified nonphysician practitioners  receive the mandatory increases in Medicaid payments?  The answer is only if they are billing under the supervision of an eligible physician.  That means the answer is no for independent nonphysician practitioners but yes if they are working with physicians in the qualified specialties listed above.  Seems silly, doesn't it?  A pediatric cardiologist can spend 80% of their time in the cath lab doing procedures, but if they submit at least 60% of their codes as E&M charges they can get Medicaid parity on their office visits, hospital consults and hospital follow-up codes.  But the independently practicing certified nurse midwife administering the flu shot to protect mom and baby cannot.

Oh, and sorry OB/Gyn doctors.  You may be the only physician for your patients and provide 100% primary care to 80% of your patient population, but you don't qualify for federal subsidized Medicaid fee increases because you didn't train in pediatric medicine, family medicine or general internal medicine.   Maybe you should have been a pediatric cardiologist instead.  ObamaCare says they are  providing massive amounts of primary care these days, and by primary care, I mean telling the patient to contact their primary care provider to fill out the Family Medical Leave Act paperwork so they can have mom and dad at the bedside while they take Junior to the cath lab.

What about states that don't plan on expanding Medicaid eligibility?  That has no bearing on the requirement for eligible physicians providing eligible E&M services to get paid 100% of their Part B Medicare rate on their Medicaid charges for CY 2013 and 2014.  Whether states decide to expand Medicaid or not, qualified doctors  providing qualified E&M charges get a raise on their Medicaid payment rates.

What happens after 2014?  As noted in the Federal Registrar, states are required to report Medicaid participation rates to Congress in anticipation of decisions to continue or discontinue the current federal subsidy for qualifying Medicaid charges.  I'm sure that's  going to be another political fight.  I've asked a few of my colleagues about what they intend to do with  Medicaid.  All of them say they have no intention of expanding their clinic slots to include a greater proportion of Medicaid patients.  My facebook post confirms that.  They can easily fill up their clinic with follow-up visits on their current panel of patients with chronic disease. I suspect after these two years are up we're going to see no increase in Medicaid participation.  Physicians don't run their business on a two year horizon.  Imagine expanding a clinic to include a large influx of Medicaid patients only to try and balance the budget based on unstable Medicare politics and a Medicaid policy that falls off the cliff after CY 2014.

What physician in their right mind would budget that?  I'm willing to bet almost none.  The quirks of this law are simply mind boggling.  Pediatric cardiologists and hospitalists will get Medicaid parity for their ICU work but an independently practicing certified nurse midwife trying to take care of mom and baby as the only provider from conception to birth will not.  I don't need to say anything more.  Oh yeah, one last thing.  How much is this little experiment going to cost?  The expected cost to the federal government for this Medicaid parity pay increase is 5.6 billion dollars in calendar year 2013 and 5.745 billion dollars in 2014 (using 2012 constant dollars).  What's another 11 billion dollars we don't have matter, right?  

The “Culture of Coverage:” How Illinois is making the Health Insurance Marketplace Work

On March 29th, Illinois submitted an outreach and enrollment plan to the federal government, a requirement for all states participating in a state-federal partnership health insurance exchange. In the proposal, the marketplace team explains that they plan to treat outreach and enrollment like a political campaign, working not to elect a candidate but instead to introduce a new “health culture” to Illinoisans who have traditionally been excluded from coverage. The campaign will launch full-force in July in order to address skepticism and the general lack of awareness around the Affordable Care Act before enrollment begins on October 1st of this year.

Campaign values:
Illinois faces a variety of challenges, including limited English proficiency and low literacy rates, which make the task of reaching and enrolling certain populations of residents difficult. 78% of uninsured adults and 83% of the Medicaid population are unaware of insurance options under the ACA. To insure that Illinois is successful in promoting awareness of the Affordable Care Act, the marketplace team’s work will be guided by the following principles:

  1. Promotion of a State-wide Culture of Coverage; 
  2. Empowerment of Community-Based Organizations and Stakeholders; 
  3. Metric-Focused Encouragement of Enrollment; 
  4. Promote Health Care as a Value; and 
  5. Build a Strong and Trusted Reputation Among All Residents. 
Campaign strategy:
Based on the assumption that many Illinoisans aren’t aware of their options, the marketplace team will hire a professional marketing firm by the end of May. This firm will work to create a cohesive brand that speaks to target populations while establishing the Illinois marketplace as a trusted entity and something that residents will want to participate in. This media campaign will consist of television, print, outdoor, direct mail, online, and social media advertising.

The field program:
While the exchange branding is no doubt important, the marketplace team recognizes that empowering community partners to assist in the outreach and enrollment process may be the most effective way to achieve a “culture of coverage,” as these community partners are already known and trusted entities. This collaboration, titled the “field program,” will focus on the “4 E’s:” Engage, Empower, Educate, Enroll.

Staffing structure:  
Illinois will be divided into 8 “Outreach Regions,” which will be constructed geographically and by information around where the uninsured in Illinois reside. Each region will be headed by an Outreach Coordinator, who will report to the Director of Outreach & Consumer Education.

In order to assist with enrollment, three categories of assisters will be established. Similar training must be undergone in order to qualify for each category. The assister categories are as follows: 
  1. Navigators: part of a federally-run assistance program 
  2. In-Person Counselors: a state program that will coordinate with Regional Outreach Coordinators. Selected entities are expected to spend one year as assisters. 
  3. Certified Application Counselors: Additional national funding for individuals who aren’t funded through grant money.
It’s coming…
The marketplace team is already working hard to make sure the health insurance marketplace works in Illinois. In the meantime, click here to check out the full Illinois Health Insurance Marketplace Outreach & Education Plan!

Kathryn Bailey
Health & Disability Advocates

Will Illinois Have Enough Family Physicians Beyond 2014?

Do we have enough physicians to care for newly insured patients seeking care starting Jan. 1? Some will be covered by Medicaid; some gain coverage through the insurance marketplace; and others turning 65 join the ranks of Medicare. The Illinois Academy of Family Physicians believes that we are ready for 2014 – but are not prepared for future demand for primary care.

Illinois currently has the capacity to care for more than 5.3 million Medicaid patients, with more than 5,000 primary-care providers participating in team-based medical homes. When patients have a regular primary-care physician, they get the care they need to avoid costly emergency room visits and hospitalizations. Connecting new Medicaid patients with a family physician ensures they get the right care at the right time in the community setting, at a much lower cost. Otherwise uncontrolled chronic illnesses can develop into costly – and preventable – hospitalizations, which drives up medical costs for everyone.

Illinois has 11 medical school campuses. This year, only 9 percent of 1,089 doctors graduating from those medical colleges chose family medicine, according to IAFP data. And only one-third of that 9 percent — 35 people — will do their residency training in Illinois; the rest will leave for other states. Family physicians are the only physicians trained to care for all ages, both male and female.

Illinois should worry about the future of our state's primary-care physician workforce. Simply stated, too many physicians trained here choose to work in other states, and Illinois is not training enough primary-care physicians.

A NATIONAL PROBLEM, TOO

According to the American Association of Medical Colleges workforce data book, Illinois ranks 20th in the nation with 95 primary care physicians per 100,000 residents. As a nation, we are facing a staggering shortage of primary care physicians. So being in the middle of the pack should not be interpreted as a positive sign.

A 2010 study led by family physician Russell Robertson (now dean of Chicago Medical School) examined new physicians' plans for practice and the reasons for their choices. Almost one-half of graduating Illinois residents and fellows leave the state to practice elsewhere. While the primary reason for do so is for family, the medical liability climate is a major consideration for those who leave Illinois to practice.

How can we turn the tide? Medical schools need admission policies favoring students willing to practice in Illinois. We also must address medical school debt that keeps many from entering primary care. Those physicians should get loan repayment or loan forgiveness incentives to practice in areas in need of primary-care physicians. As well, the income gap between primary-care and specialty physicians must be narrowed. Medicare and Medicaid must take the lead and pay primary-care physicians in accordance with the quality care and coordination services they provide, and private insurers must support primary care.

Making primary-care practice a priority ensures that every Illinoisan entering the health care system has a medical home to care for them. A future without enough family physicians will leave patients without a medical home and on the doorsteps of emergency rooms instead.

Dr. Carrie E. Nelson is president of the Illinois Academy of Family Physicians, based in Lisle.
This article was first published in Crain's Chicago Business

Place of Service (POS) CMS List Coding Instructions Revised (CR7631).

Every physician or other provider encounter requires a place of service (POS) code for proper claims processing.  But how should a physician determine their point of service? The Centers for Medicare and Medicaid Services (CMS) put an end to that question once and for all with Change Request 7631.  Apparently, there have been too many errors over too many years with physicians and other providers reporting the wrong site of service location.  

As far as I can tell, this Change Request 7631 was originally submitted March 29th, 2012 under Transmittal 2435 in the CMS Manual System.  Transmittal 2435 was replaced by Transmittal 2561 on September 28th, 2012,  which was replaced by Transmittal 2563 on October 11, 2012, which was replaced by transmittal 2613 on December December 14th, 2012, which was finally replaced by Transmittal 2679 on March 29th, 2013 in the CMS Manual System.  But we're not done yet folks.  CMS says in transmittal 2679 they will discuss place of service for laboratory and pathology services through another change request at a later date.  Yes folks, single payer government Medicare efficiency is alive and well.

Transmittal 2679 establishes a national policy for the correct place of service code assignment.  CMS has a table of all POS codes that are used by all Medicare contractors, Medicaid and private insurance companies as well.  Each POS code is defined as a facility or nonfacility place of service for payment purposes under the Medicare Physician Fee Schedule (MPFS).   In the now rescinded December 11, 2009 Transmittal 1873, physicians were instructed to submit their two digit place of service based on their physical location during when providing the service (the service location).

This has now changed.  With only two exceptions, the place of service code shall now be the same location the beneficiary received their face-to-face service.  In cases where a face-to-face encounter is removed (such as providing the professional component in the interpretation of a diagnostic test) at a distant site, the POS code for the professional component shall be determined by the setting in which the technical component was provided.  The two exceptions to this face-to-face provision rule defined in Transmittal 2679 are defined as follows:
"For a service rendered to a patient who is an inpatient of a hospital (POS code 21) or an outpatient of a hospital (POS code 22), the facility rate is paid, regardless of where the face-to-face encounter with the beneficiary occurred"
But don't even think about moving to India or contracting with a bunch of radiologists from India. Medicare will not pay for your service. It says so right in Section 60 of this manual:
Payment may not be made for a medical service (or a portion of it) that was subcontracted to another provider or supplier located outside the United States. For example, if a radiologist who practices in India analyzes imaging tests that were performed on a beneficiary in the United States, Medicare would not pay the radiologist or the U.S. facility that performed the imaging test for any of the services that were performed by the radiologist in India.
Place of service codes carry a number between 01 and 99.   You can find the definitions of each POS code in Chapter 26 of the Medicare Claims Processing Manual (Section 10.5 starting on page 20).  They can be divided in to two main categories of payment:  facility payment rate and nonfacility payment rate.   The settings where point of service codes are paid at the facility rate are
  • Inpatient hospital (POS code 21)
  • Emergency room hospital (POS code 23)
  • Medicare participating ASC (POS code 24)
  • Skilled Nursing Facility for a Part A resident (POS code 34)
  • Ambulance on land (POS code 41)
  • Ambulance on air or water (POS code 42)
  • Inpatient psychiatric facility (POS code 51)
  • Community mental health center (POS code 53)
  • Psychiatric residential treatment center (POS code 56)
  • Comprehensive inpatient rehabilitation center (POS code 61)
Physician's services are paid at the nonfacility rate at the following point of service locations
  • Pharmacy (POS code 1)
  • School (POS code 3)
  • Homeless shelter (POS code 4)
  • Prison/Correctional Facility (POS code 9)
  • Home or private residence of patient (POS code 12)
  • Assisted living facility (POS code 13)
  • Group Home (POS code 14)
  • Mobile Unit (POS code 15)
  • Temporary lodging (POS code 16)
  • Walk-in retail health clinic (POS code 17)
  • Urgent care facility (POS code 20)
  • Birthing center (POS code 25)
  • Nursing facility and SNFs to part B residents (POS code 32)
  • Custodial care facility (POS code 33)
  • Independent clinic (POS code 49)
  • Federally qualified health center (POS code 50)
  • Intermediate health care facility/mentally retarded (POS code 54)
  • Residential substance abuse treatment facility (POS code 55)
  • Non-residential abuse treatment facility (POS code 57)
  • Mass immunization center (POS code 60)
  • Comprehensive outpatient rehabilitation facility (POS code 62)
  • End-stage renal disease treatment facility (POS code 65)
  • State or local health clinic (POS code 71)
  • Rural health clinic (POS code 72)
  • Independent laboratory (POS code 81)
  • Other place of service (POS code 99)
All of the above information has been nicely packaged into an easy to read MLN Matters publication for your quick and easy review, should you wish to proceed.  Because most of you don't care, I've taken the liberty of contacting CMS myself for better clarity on POS code 99.  They have agreed POS code 99 needs better clarity and have asked The Happy Hospitalist to use his influence to further the data mining expedition known as The Medicare National Bank.   In addition to these widely publicized point of service codes, CMS has contracted with The Happy Hospital to help further clarify "other place of service" codes as part of an effort to make the roll out of ICD-10 even more thorough.  Here is a list of recently approved point of service codes that will be included on the absolute most final transmittal ever, or at least until the next one is made.  
  • Cardiac arrest anywhere (POS code blue)
  • Cardiac arrest at a movie theater (POS code Blues Brothers)
  • GI endoscopy suite (POS code brown)
  • At an accountant's office (POS tax code)
  • At a medical coder's office (POS over coding)
  • At an FBI office (POS secret code)
  • At a CIA office (POS crack the code)
  • At Google Maps headquarters (POS zip code)
  • At the Friday night dance with the elderlies club (POS no code)
  • At a software convention (POS source code)
  • At a Department of Defense (POS morse code)
  • At a lawyers convention (POS code of conduct)
  • At a convention of conspiracy theorists (POS Da Vinci code)
  • In a supermarket (POS bar code)
  • In a childs playground (POS code word)
  • At war (POS code of honor)
  • At a boarding school (POS dress code)
  • At a construction site (POS building code)
Any questions?

Some of this post is for entertainment purposes only and likely contains humor only understood by those in a healthcare profession. Read at your own risk. 

Great News for the People of Illinois...Now What?

Yesterday, Governor Quinn announced that Illinois was awarded a $115 Million grant for its Health Insurance Marketplace (the online portal to enroll over a million adults and children into quality health plans). A large portion of this federal funding will pay for outreach activities and consumer assistance during the push to enroll the uninsured beginning on October 1 of this year.

This is great news for the people of Illinois.

With October 1 less than six months away, we need these federal funds to help get the word out about the availability of new insurance coverage options. According to Enroll America's research findings, the  majority  of  uninsured Americans  don’t  know the  health  reform  law  will  help  them:

  • 78% of  the  uninsured  don’t  know  about  the new  health  insurance  exchanges  
  • 83% of  people  who  could  be  eligible  for  the new  Medicaid  expansion  don’t  know about  it.  
Tremendous amount of work needs to get done to tell people about the new options and enroll them into a plan. 

Here's a timeline of what needs to happen to be ready by October 1, 2013. Since Illinois is running its exchange/marketplace in partnership with the federal government, we need to be mindful of activities by both the feds and the state:

Already Happened:
  • Illinois Marketplace Team Selects Training Vendor (UIC/Public Health)
  • Marketplace Team Releases Outreach & Education Plan & Conducts Outreach to Encourage Navigator & In Person Assister (IPA) Applications. (Read this fact sheet to learn about the different Consumer Assistance Entities needed).
  • Marketplace Team Receives Establishment Grant Funding
  • Illinois Marketplace Team Releases RFP for Media and Marketing Outreach Strategy.
  • CMS Releases Proposed Standards for Navigators and In Person Assisters (see here for a good summary)
  • Federal Government Releases Navigator RFP (Just released today, April 9, 2013; due June 7,
    2013; Expected Award Date - August 15, 2013). 
  • Advocates create the Illinois Consumer Assistance Matchmaking Spreadsheet to find partners in either the federal Navigator grant or the (yet to be released) Illinois Assister RFP.
Spring 2013:
  • Marketplace Team Issues RFP/Grant Application for IPA entities
  • Marketplace Team Approves IPA Training Materials
  • Marketplace Team selects firm for Media and Marketing Outreach Strategy (UPDATE: On 7/12/13 Fleishman Hillard is selected)
Summer 2013:
  • Federal Government Selects Navigator Entities (Due date for application: June 7, 2013)
  • Marketplace Team Selects IPA entities (see list here) 
  • Federal Government Takes Applications for Certified Application Counselors (sign up here)
  • Navigators, IPAs, Certified Application Counselors (CACs) Receive Training and Certification.
  • Media placement begins
October 2013 and beyond:
  • Navigators, IPAs & CACs Assist Consumers during Open Enrollment
  • Navigators, IPAs & CACs Provide Post-Enrollment Assistance & Assistance during Special Enrollment Periods
  • Program Oversight Conducted By Marketplace Team and Federal Gov’t.
The timeline is tight and we need all types of entities (community based organizations, hospitals, health departments etc.) to help with enrollment.

If you have any questions about  what this means for you or your organization, please don't hesitate to contact us at info@illinoishealthmatters.org.

Stephani Becker
IHM Project Director

Setting the record straight on health law’s delayed small business features

The Department of Health and Human Services’ proposal to delay critical requirements for small business health insurance exchanges in some states is a disappointment to Small Business Majority and millions of small businesses. It’s a letdown to small business owners and their employees looking forward to robust, competitive exchanges in 2014. We hope this proposal is recognized as counterproductive and is abandoned. 

That said, there’s a tremendous amount of misinformation circulating about what the rule would actually mean. We want to set the record straight.

What the Rule Would Do
The proposed rule would delay two features of small business exchanges in some states until 2015. It would not delay opening of the exchanges themselves. Exchanges will still open Jan. 1, 2014.

The rule would mean that in some states, two features of the exchange won’t be implemented: 1) employee choice and 2) premium aggregation. These are wonky healthcare terms, but the impact their delay would have is fairly straightforward. Stalling employee choice means small employers will have to wait until 2015 to be able to offer workers an array of health plans to choose from. Delaying premium aggregation means an administrative function that would simplify the payment process for employers also won’t be available for a year. The two features are linked—premium aggregation is not needed without employee choice.

The Facts
Exchanges still open; small businesses still have more than one plan option
What the rule would not do—despite a multitude of reports saying otherwise—is strip small businesses of any coverage choice whatsoever, essentially forcing all small business employers and their workers into one health plan.

Indeed, word on the street is that all small businesses that enroll in exchanges will have access to only one plan. Some reports have even gone as far as saying this plan will be government-run. Neither one of these is true.

Multiple private plans still available
Whether the rule is finalized or not, come 2014, two things will be true: there will be a full array of private health plans offered through the small business exchanges, and employers will be able to choose a plan from them. Their employees can then decide whether to enroll in it. This is essentially how the small group market works right now. What the rule means is that employees themselves will not have a menu of plans to choose from until 2015—which is a new benefit the law provides for small businesses.

Only applies to certain states
It’s also important to note the rule requires only states that have federally facilitated exchanges to delay these features a year. Federally facilitated exchanges are those created by the federal government in states that haven’t chosen to create them on their own. The 17 states implementing their own exchanges can still extend employee choice and premium aggregation to their customers starting in 2014. Nearly 40% of small businesses in this country do business in the 17 states implementing their own exchanges. That means there will be employee choice among health plans for those businesses next year—if their states choose to give it to them.

No impact on self-employed
What’s more, delaying this rule does not impact America’s 22 million self-employed individuals, nearly 30% of whom are uninsured. As planned, these entrepreneurs will still be able to purchase insurance through the individual exchanges in 2014—a huge boon to owners who have struggled to purchase affordable insurance for decades.

The Bottom Line
While certainly disappointing, delaying employee choice and premium aggregation is not the end of the world. Starting next year, small employers will still be able to pool their buying power in the exchanges, giving them the kind of clout large businesses currently enjoy. They’ll still get administrative help and, in many places, will have more choices of plans than they currently do. All the original features of exchanges will go into effect in 2015.

Small Business Majority has been talking to real small businesses across the country since the law was passed three years ago. We know they like the features of the exchange that could be delayed, along with other key provisions including: 1) being able to pool their buying power; 2) the Medical Loss Ratio provision requiring insurers to spend 80% of premium dollars on care; and 3) the preexisting condition ban. Our national opinion polling further underscores this.

We hope the proposed rule isn’t finalized, because small businesses nationwide are looking forward to employee choice and premium aggregation. Nevertheless, these features will still be in the exchanges in 2015—albeit a year late.

John Arensmeyer 
Founder & CEO, Small Business Majority

John Arensmeyer

(This post was originally posted here on the Small Business Majority blog)

One Step Closer to Knowing - DOI Issues QHP Guidance

Under the Affordable Care Act, one of the new options for individuals and small businesses to buy health insurance for themselves and their employees in 2014 will be the Illinois health insurance exchange or "marketplace."  On March 29, 2013, the Illinois Department of Insurance (DOI) issued guidance to Illinois insurers about the requirements for a plan to be certified as a Qualified Health Plan (QHP), which means that they meet all of the coverage and cost-sharing requirements of the Affordable Care Act and can be sold in the Illinois Marketplace. This brings us one step closer to knowing what the plans/process will look like beginning in 2014.

This guidance tells us that:

  • DOI, with the assistance of the Illinois Department of Public Health (DPH), will initially review the plans and then by July 31, 2013 recommend the plan for certification to the federal government agency (called "CCIIO") to formally certify the plan.
  • CCIIO will then be responsible for all contracting with the insurance plans and issuing the cost-sharing subsidies to people who enroll in the marketplace and purchase insurance. 
  • DOI will conduct QHP oversight in 2014.
  • Insurance plans must provide information about cost-sharing. For example, in 2014, deductibles in the small group market may not exceed $2,000 for self-only coverage and $4,000 for family coverage.
  • All insurance plans must offer at least one plan at the Silver and Gold level of coverage and at least one child-only plan.
  • Catastrophic plans can be offered but only to individuals under the age of 30 or is exempt from the Shared Responsibility Payment by reason of lack of affordable coverage or hardship.
  • Rates must be the same for products sold inside and outside the Exchange
  • The plans' networks must have "sufficient geographic distribution of providers" and must include providers that specialize in mental health and substance abuse services. In addition, as part of network adequacy, the guidelines specifies that plans must have Essential Community Providers (ECPs) that serve predominantly low-income, medically underserved individuals. (ECPs include FQHCs, Ryan White Providers and hospitals, among other entities. More information is available in HHS guidance here.) QHP issuers that do not include at least 20 percent ECP participation in network in the plan service area must submit an additional narrative justification in their QHP application. HHS has a non-exhaustive list of Essential Community Providers here.
  • There are also requirements for health insurance plans to design their premium rates only on the basis on geographic location, tobacco use and age. Within these categories, the guidance sets parameters which limit the rates that can be charged based on ratios. For example, within the age category, insurers may not charge a (non-smoker) person who is 64 years old a rate that is more than 3 times as high as they charge a (non-smoker) person who is 21 years old. 
Lastly, insurers must file rates for review with the DOI and must submit a justification for a rate increase. Beyond these guidelines, however, the state does not have the authority to directly approve or disapprove of the rates insurance companies will charge. Many consumer advocates have recommended that the state grant the Department of Insurance more authority to review & deny insurance rate increases, as they do in other states. State legislation (SB 2344) is currently pending to do so. 

We'll report back in a few months to let you know additional progress on the QHP selection in Illinois in order to get ready for October 1, 2013 enrollment.
 
Stephani Becker & Stephanie Altman
Health & Disability Advocates 
Illinois Health Matters 

Hospital Patient Chart Dropped = More Work For Nurses.

If I drop a patient's hospital chart, I would never expect someone else to put it back together.  I dropped it.  I put it back together.  I expect the same if I drop a cup of coffee all over the computers at the nurses station.  I spilled the coffee, I clean it up.   That's just my perspective.  That's why I'm surprised to see some nurses come to the rescue of the poor helpless doctor who dropped the patient's chart.  "I can clean that up for you", they say.  "Just leave it and I will put it back together", say other clerks and nurses.  It's almost as if there is a class in nursing school called How To Put Your Doctor's Dropped Patient Chart Back Together With A Smile While Keeping Your Angry Thoughts To Yourself.  On second thought,  maybe these nurses just figure the doctor will just make things worse.

Is this attitude unique to the nurses?  I've never seen another doctor offer to put together a chart that another doctor or another nurse dropped.  Oh, let me put that back together for you are words I have never heard another physician speak in my ten years of hurried hospitalist life.   To think there are some doctors out there who would not take responsibility for fixing their own patient charts makes me sad to call myself a doctor.  It's not something I understand, but then again, I also clean up all my own sharpies after a procedure and would not expect a nurse to do it for me.

Hospital patient charts can come in all shapes and sizes.  They can open side-to-side or top-to-bottom.  They can be secured with clips or they can be fastened together with ringed binders.  They can be large, small, big or small.   Most of my charts have ringed binders.  Occasionally, I may  open the rings to take out an EKG or an x ray report to review with another physician.   This is a dangerous time for potentially catastrophic chart annihilation.  If the chart is not safely resting in a place far away from the surface edge,   I guarantee it will find its way on to the floor in a million pieces.  Never  leave an open chart unattended.  That's  just asking for trouble.  

I've dropped, bumped, nudged and mishandled hundreds of hospital charts over the years.  Only a small percentage actually make it onto the floor in a scattered and disorganized array of lab results, progress notes, orders and nursing documentation that will never be read again.  I can tell you with confidence, my heart stops at the instant that chart hits the floor.  I think to myself, "Am I about to spend the next ten minutes putting together hundreds of pages of charting that nobody reads anyway?"  At the exact moment that chart hits the floor, I am frozen with anticipation from this gravity confirming event. 

The worst chart mishaps are those where the chart just falls.  I have no explanation why it falls.  Nobody is standing near it.  Nobody is touching it.  It just happens.  Bam!  Down goes the chart.  That's the moment when everyone looks around to see who is to blame and who is expected to put it back together.  In the old school world of hospital hierarchy, there was no question about who owned the task of hospital patient chart organizer.  It was, of course, the job of the nurse.  Today, that expectation lingers with some nurses.   For others, not so much, as this original Happy Hospitalist nursing ecard below helps to explain. Perhaps, someday, when the entire paper hospital chart is replaced by a fully electronic medical record, chart dropping hazards will disappear.  Unfortunately, the job of the nurse will not end there.  It will instead be replaced by helpless doctors  asking nurses to get lab results and xray reports pulled up in the computer.  For reasons that make no sense to me,  some doctors can complete medical school, residency and intensive fellowships requiring years of specialized training,  but they can't type their user ID and password into a computer to find information vital to their patient's care plan.

"Hey doctors.  You dropped the chart.  You put the damn thing back together.  Love, the nurses."

Hey doctors. You dropped the chart. You put the damn thing back together. Love, the nurses ecard humor photo.


This post is for entertainment purposes only and likely contains humor only understood by those in a healthcare profession.  Read at your own risk.


Obamacare Enters Its Big Year for Fighting Poverty

Obamacare, the Affordable Care Act (ACA), had its third birthday over this past weekend. So this is its first work week in its most important year. This is the year for the ACA’s heavy lifting, bringing affordable health coverage to 36 million uninsured Americans and ending discrimination against adults with pre-existing conditions, all effective as of January 2014. This is the year that the ACA becomes the biggest single measure in the fight against poverty in the last 50 years.
 
The ACA, of course, is usually discussed in terms of its impact on the health care system. And it is already doing a significant job on that front. In its birthday editorial, the New York Times aptly summarized the important contributions to reform of the health care system that the ACA has already produced:


That is a substantial list of accomplishments; moreover, the health care system is due for its most important improvements in the coming year. The upcoming big changes, however, will have an impact that should be understood in more than just health care terms. The progress that will be made in the fight against poverty will be truly remarkable.  

Half of the gain in covering the uninsured will be directed at people in the deepest poverty in our country. Since Medicaid began in 1965, it has had a gap. It never offered coverage to people aged 19-64 who are not officially disabled and not caring for a child in their home. 

These are young adults leaving high school or college (whose parents do not have employer-supported coverage); empty nest parents whose children are over 18; tens of thousands of veterans not covered by VA health programs (over 12,000 would gain Medicaid coverage just in my home state of Illinois); chronically unemployed people with serious mental and physical impairments who are not officially disabled; many of the homeless; and others. The ACA will fill that gap in Medicaid , providing coverage to all with income under 138% of the Federal Poverty Line ($15,415 per year for an individual and $26,344 for a family of three) in the states that choose to take the federal money that the ACA offers them to pay for it.

For many people in poverty, health coverage not only means health, reduction in pain, and expansion of life expectancy, it also means employability and productivity and upward mobility. It can improve learning capacity. It reduces family stress. It can be a major factor in reducing family and community violence. It is a vast improvement in quality of life and quality of opportunity.

The ACA also ends the high cost for Medicaid beneficiaries of making more money. Currently, when a Medicaid beneficiary succeeds in the workplace and escapes poverty, there is a penalty: the loss of health coverage when earnings exceed allowed Medicaid levels. Starting in January, though, the Healthcare Marketplaces in every state will offer affordable private insurance coverage to replace Medicaid when earnings call for termination of Medicaid eligibility. This private coverage removes a barrier to upward mobility. It also acts as a net to keep workers in the middle class if they lose employer-supported insurance, when a health emergency might otherwise mean a free-fall into poverty. And it is there to provide coverage for budding entrepreneurs who want to try for the American Dream and start their own businesses, but who currently are blocked because they cannot risk losing either Medicaid or employer-supported coverage.     

Obamacare already fights poverty by helping seniors on Medicare make ends meet and by helping young adults make their way in the workforce by staying on their parents’ insurance. And in the coming year, at least in the states that implement it thoroughly, Obamacare will make its biggest inroads against poverty.  

John Bouman
President, Sargent Shriver National Center on Poverty Law

(This guest blog was originally posted here in the Shriver Brief) 

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