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Health Care Changes for Small Businesses in 2016

It’s been about six years since the passage of the Affordable Care Act, but some provisions of the health care law that can improve health care options for small businesses are still being implemented – like employee choice. By learning about this addition and other aspects of the law, small business owners can empower themselves to make the best decisions regarding health coverage for themselves and their employees. In many ways, health care options for small businesses are remaining the same this year. For instance, the Small Business Health Options Program in Illinois will continue offering an array of cost-competitive insurance plans from which employers can choose. And as always, qualified small businesses that purchase health insurance through SHOP may receive federal tax credits to help offset the cost of coverage.

Employee Choice, a Positive New Change

There are several new features of the law being implemented this year, though. One of the biggest and most promising changes is the implementation of employee choice, which is now available in every state. Employee choice allows small business workers to choose from a number of plans from different insurance carriers. Under employee choice, workers choose which carrier they’d prefer to use, instead of business owners choosing for them. This option plays a key role in distinguishing SHOP from the outside health insurance market, and it’s popular among small business owners. In fact, Small Business Majority’s polling found two-thirds of small employers believe allowing employees to choose among multiple carriers is an important element of the health care marketplaces.

While employee choice is a great development for small businesses, options under Illinois’s employee choice program aren’t as robust as they could be. In some parts of Illinois, only one or two insurance providers are participating in SHOP. While employers can still choose different levels of coverage from participating providers, more providers will need to participate to boost options for small businesses.

Taking Advantage of the New Opportunities 

If your business has fewer than 51 full-time employees, you can enroll in SHOP at any time during the year to take advantage of employee choice. In order to begin the enrollment process now, entrepreneurs should visit www.getcoveredillinois.gov or the National Association of Health Underwriters to contact a health insurance broker who is trained and certified to enroll small businesses for SHOP Marketplace plans. Brokers are well-versed in the ins-and-outs of the ACA, and there’s often no extra cost to utilize their services.

While 2016 offers changes in Illinois’s small business health insurance landscape, small business owners shouldn’t be concerned. Changes like employee choice are a step in the right direction for entrepreneurs. The best bet is for employers to arm themselves with information; that way, they can choose health coverage that maximizes benefits for their business.

Geri Aglipay
Outreach Manager, Midwest Region and Greater Chicago
Small Business Majority 

99306 CPT® Code Description, Progress Notes, RVU, Distribution (Level 3 Initial Nursing Facility Care)

This 99306 CPT® lecture reviews the procedure code definition, progress note examples, RVU values, national distribution data and explains when this code should be used in the nursing facility setting (nursing home).  CPT stands for Current Procedural Terminology. This code is part of a family of medical billing codes described by the numbers 99304-99306.  CPT® 99306 represents the high (level 3) initial nursing facility care visit (whether you are the attending or a consultant) and is part of the Healthcare Common Procedure Coding System (HCPCS).  This procedure code lecture for initial nursing facility care, to be used for new or established patients, is part of a complete series of CPT® lectures written by myself, a board certified internal medicine physician with over ten years of clinical hospitalist experience in a large community hospitalist program. I have written my collection of evaluation and management (E/M) lectures over the years to help physicians and nonphysician practitioners (nurse practitioners, clinical nurse specialists, certified nurse midwives and physician assistants) understand the complex criteria needed to stay compliant with the Centers for Medicare & Medicaid Services (CMS) and other third party insurance companies.

You can find my entire collection of  medical billing and coding CPT® lectures together in one place on my Pinterest site (CPT® lectures here and other associated E/M lectures here).  You don't need to be a Pinterest member to get access to any of my CPT® procedure lectures. As you gain understanding of these E/M procedure codes, remember you have an obligation to make sure your documentation supports the level of service you are submitting for payment. The volume of your documentation should not be used to determine your level of service. The details of your documentation are what matter most. In addition, the E/M services guide says the care you provide must be "reasonable and necessary" and all entries should be dated and contain a CMS defined legible signature or signature attestation, if necessary.

99306 MEDICAL CODE DESCRIPTION


My interpretations discussed below are based on my review of the 1995 and 1997 E&M guidelines, the CMS E&M guide and the Marshfield Clinic audit point system for medical decision making. These resources can be found in my hospitalist resources section. The Marshfield Clinic point system is voluntary for Medicare carriers but has become the standard audit compliance tool in many parts of the country. You should check with your own Medicare carrier in your state to verify whether or not they use a different criteria standard than that for which I have presented here in my free educational discussion.  I recommend all readers obtain their own updated CPT® reference book as the definitive authority on CPT® coding.  I have provided access through Amazon to the 2016 CPT® standard edition pictured below and to the right. CPT® 99306 is a new or established patient procedure code and can be used by certain qualified healthcare practitioners to get paid for their initial admission or consulting role for initial nursing facility care.  The American Medical Association (AMA) describes the 99306 CPT® procedure code as follows:

 Initial nursing facility care, per day, for the evaluation and management of a patient, which requires these 3 key components:  A comprehensive history; A comprehensive examination; Medical decision making of high complexity.  Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs.  Usually, the presenting problem(s) are of  high severity.  Typically, 45 minutes are spent at the bedside and on the patient's facility floor or unit.

The initial nursing facility care codes should be used whether the patient is an established patient or a new patient to the provider.  An established patient is defined as an individual who has received professional services from a doctor or other qualified health professional of the exact same specialty and subspecialty who belonged to the same group practice within the past three years.

This medical billing code can be used for time based billing when certain requirements are met. However, documentation of time is not required to remain compliant with CMS regulations.  If billed without time as a consideration, CPT® 99306 documentation should comply with the rules established  by the 1995 or 1997 guidelines referenced above. The three important coding components for an inintial nursing facility care note are the:
  1. History
  2. Physical Exam
  3. Medical Decision Making Complexity
For all initial nursing facility care notes (99304-99306), the highest documented three out of three above components determine the correct level of service code. Compare this with the requirement for the  highest documented two out of three above components for subsequent nursing facility care encounters (99307-99310).  Again, three out of three components are needed to determine the correct level of care for CPT® 99306.  The following discussion details the minimum requirements necessary to remain compliant with CPT® 99306.    In addition, as with all E/M encounters, a face-to-face encounter is always required.  In the case of initial nursing facility care codes 99304-99306, Medicare does not allow incident to billing, where the the service is provided by someone other than the physician and the physician may collect 100% of allowable charges in these situations.  Services billed incident to are billed under the physician's provider number.  Per Medicare document MLM 4426:
“Incident to” E/M visits, provided in a facility setting, are not payable under the Physician Fee Schedule for Medicare Part B. Where a physician establishes an office in a facility, the “Incident to” E/M visits and requirements are confined to this discrete part of a SNF/NF designated as his/her office. The place of service (POS) on the claim should be “office” (POS 11).

Documentation requirements for a CPT®99306 initial nursing facility encounter are as follows:
  • Comprehensive history:  Requires 4 or more elements of  the history of present illness (HPI) OR documentation of the status of THREE chronic medical conditions. At least one item each from past history (illnesses, operations, injuries, treatments), social history and family history is also required. In addition, a complete review of systems is also required (10 or more organ systems). 
  • Comprehensive examination:  The CMS E&M services guide on pages 29 and 30 describe the acceptable body areas and organ systems for physical exam.  Either a general multi-system examination or complete examination of a single organ system (with other symptomatic or related body area(s) or organ system(s)--1997 guidelines) is acceptable.  For a general multi-system examination,  1997 guidelines require documentation of at least two bullets each in at least nine organs systems or body areas (described on pages 50-53 in E/M services guide) while 1995 guidelines require findings from about 8 or more of the 12 organ systems, not otherwise specified.   Requirements for a complete single organ exam are discussed in the  E/M services guide from pages 57-79. 
  • Medical decision making of high complexity (MDM):  This is split into three components. The 2 out of 3 highest levels in MDM are used to determine the overall level of MDM. The level is determined by a complex system of points and risk. What are the three components of MDM and what are the the minimum required number of points and risk level as defined by the Marshfield Clinic audit tool? 
    • Diagnosis (4 points) 
    • Data (4 points) 
    • Risk (high); The risk table can be found on page 35. 
The medical decision making point system is highly complex. I have referenced it in detail on my E/M pocket cards linked here and described below as well. These cards help me understand what type of care my documentation supports. I carry these cheat sheet cards with me at all times and reference them all day long.  As a hospitalist who performs E/M services almost exclusively, these cards have prevented me from under and over billing thousands of times over the last decade.  Note, while I don't have a card specifically for initial nursing facility care codes, the E/M documentation requirements for the low (99304), mid (99305) and high (99306) initial nursing facility care encounters are equivalent to the requirements for the low, mid and high level initial inpatient hospital care E/M visits for which I do have a card available.

CLINICAL EXAMPLE OF CPT® 99306


Here is a note for a high level initial nursing facility encounter (CPT® 99306) for new or established patients.  In this case, an internist is being asked to evaluate a patient as a consultant at the request of the nursing facility physician attending.    
C/C: My leg is red
HPI:  78yo female with  calf pain. Admitted for weakness to the SNF following a recent stroke.  She has left lower extremity 6/10, dull and constant pain that started two days ago and is associated with edema and erythema.  Internist was asked to evaluated as a consultant at the request of the rehab physician.  (4 elements from HPI)
PFSH:  Recent stroke, HTN, HLP. on Lipitor, aspirin, and lisinopril.  Quit smoking on the day of her hospital admission 6 days ago.  Mother with a history of stroke.    (All 3 elements documented)
ROS:  Except as dictated above, all other systems were reviewed and otherwise negative without further pertinent positives or negatives (10+ROS documented.  This notation is allowable under E/M rules)
Exam: 120/80 85 102.7 temp, well appearing (9 organ systems with at least 2 bullets each)
HENT:  Normal
Eyes:  Normal
CV:  Normal
Respiratory:  Normal
GI:  Normal
Psychiatric:  Normal
Lymphatic:  Normal
Neurological:  Mild residual weakness in left leg and arm following stroke.  Cranial nerves intact.
Skin:  Edema, warmth, redness left leg, lines consistent with cellulitis, marked with skin marker.
Labs
WBC 13K (1 point for documenting lab in complexity of data decision making section).  Venous Doppler report reviewed.  No clot.  (1 point for documenting review of a vascular study report in  complexity of data decision making). 
Impression
  1. Cellulitis (4 points for new problem, further workup planned under the number of diagnosis for medical decision making) 
    Plan
    Start antibiotics.  Reviewed case details with rehab physician  Vitals stable except for fever. Initiate oral antibiotics. Check a sed rate and xray of the leg to verify no fracture from falling after stroke.  Reviewed old records, no xray done during acute care stay in the hospital  (2 points for documenting discussion of case with another health care provider/reviewing old records).  Continue work up with followup lab in am.  Follow glucose to verify lack of diabetes as this can change antibiotic coverage decisions.  Follow Cr to adjust antibiotic dosing.    See orders for full details.
    This patient meets criteria for a level three initial nursing care facility care code because it contains all the required medically necessary and reasonable elements for a comprehensive history, a comprehensive physical exam and high complexity medical decision making.  Note, the only documentation difference between a level 3 (CPT ® 99306)  initial nursing facility care evaluation and the level 2 (CPT® 99305) initial nursing facility care evaluation is the requirement for high vs moderate complexity in MDM respectively.  History and physical exam element requirements are otherwise identical.

    Medical decision making in this initial encounter is high complexity because this patient achieved 4 points for a new problem with further workup planned under the diagnosis component and they received 4 points under the data portion as well (1 + 1 + 2).   In this clinical example, the risk table does not apply.  However, I use the risk table every day to qualify my patients for level three initial care codes.  I think physicians constantly underestimate their level of risk because they deal with the same medical problems day in and day out and their daily encounters do not appear risky to them.  But remember,  the risk is for the patient, not for the physician.  Documentation of high risk drug toxicity  is frequently underestimated when choosing the level of E/M service.   I highly recommend physicians read and understand the risk table to better understand why they are likely  undercoding every day.

    The point system detailed above  is part of the Marshfield Clinic audit tool I use every day with my bedside E/M pocket cards detailed below.  High impact risk table elements are part of these cards.  I use them  to make sure my billing and coding accurately reflects the level of service I provide. Why am I able to document the things I did above and have it comply with E/M rules?  Detailed next are important points to remember when documenting the history, physical exam and MDM.  This information is referenced in detail directly from the E/M services guide linked above.

    E/M DOCUMENTATION PEARLS 

     

    The information detailed below comes straight from the E/M services guide. Read and understand these important nuggets of information. What and how you document is far more important than the volume you document. Providing auditors with documentation you have provided the services listed below will elevate your level of service quite rapidly into higher levels of E/M service. You are already providing this service.  Let CMS give you credit for the work you are doing, but are probably forgetting to document appropriately.   Remember to document, document, document.
    • History
      • The chief complaint, ROS and PFSH may be listed as separate elements or included in the description of the HPI.
      • A ROS and PFSH obtained during an earlier encounter does not need to be re-recorded if there is evidence the physician reviewed and updated the previous information.    This update may be documented by describing new ROS  or PFSH information or noting there has been no change in the information and noting the date and location of the earlier ROS and or PMFSH.  The E/M services guide does not place a time limit on how far back the previous documentation can be reviewed.  
      • The ROS and PFSH can be recorded by ancillary staff or on a form completed by the patient and the physician must note they have reviewed and confirmed the information and supplement any other relevant information.
      • If the physician is unable to obtain a history from the patient or other source, the physician should describe the patient's condition which prevents obtaining a history.    
    • Physical Exam
      •  Specific abnormal and relevant negative findings of the affected or symptomatic body area(s) or organ systems(s) should be documented. Writing "abnormal" is not sufficient.
      • Abnormal findings on exam should be described
      • Writing "negative" or "normal" is sufficient to document normal findings related to unaffected areas or asymptomatic organ systems. 
    • Medical Decision Making (accurate  documentation of these issue can quickly increase level of MDM service being provided):
      • Number of Diagnoses and/or Management Options:
        •  Each diagnosis should have documentation that the problem is improved, controlled, resolving, resolved, uncontrolled, worsening or failing to change as expected.
        • For problems without a diagnosis, the assessment may be stated in the form of a differential diagnosis such as possible, probable, or rule out diagnosis.  
        • Document the initiation or change in treatment.  
      • Amount and/or Complexity of Data to be Reviewed:
        • Document a decision to obtain and review old medical records or obtain history from sources other than the patient, such as family or other caretakers. 
        • Document relevant findings from the review of old record or discussion with family or other caretakers.  Simply documenting "Old records reviewed" or "additional history obtained from family" without elaboration is not enough.
        • Document your discussion of contradictory or unexpected test results with the interpreting physician.
        • Document you personally reviewed an image or tracing or specimen.
        • Notations such as "wbc elevated" or "chest x-ray unremarkable" is acceptable.
      • Risk or Significant Complications, Morbidity, and/or Mortality
        • Remember to document comorbidities and other factors that increase the complexity of MDM by increasing the risk of complications, morbidity and mortality. 
        • Referral for urgent invasive procedures and surgeries should be documented or implied.
        • USE THE TABLE OF RISK!  That's what it's there for.  I have detailed the most common risk elements I use in my daily practice on my E/M card shown below.   
      • There are many other points to consider when documenting MDM.  There are too many to list here individually, but most are described in the MDM portion of my E/M bedside pocket cards detailed below.  In addition, I recommend thoroughly reviewing pages 13 through 18 of the E/M services guide for a thorough understanding of the finer points of E/M coding.


    MEDICARE RULES FOR INITIAL ENCOUNTER:  PHYSICIAN VS QUALIFIED NONPHYSICIAN PRACTITIONER EVALUATION


    The Centers for Medicare & Medicaid Services (CMS) has rules defining which qualified healthcare professionals are allowed to bill for the initial nursing facility (NF) care encounter.  Medical Learning Network Matters documents MM4246 and SE1308  and this summary document are great resources to help providers navigate these complex rules. Briefly, Medicare distinguishes between delegation of physician visits in skilled nursing facilities (SNF -- Place of Service Code 31, for patients in a Part A SNF stay), and nursing facilities (NF -- Place of Service Code 32, for patients who do not have Part A SNF benefits, patients who are in a nursing facility or in a non-covered SNF stay).  The setting is determined by whether the visit to a patient in a certified bed is to a resident whose care is paid for by Medicare Part A in a SNF or to a resident whose care is paid for by Medicaid in a NF.

         SNF FACILITY RULES (PLACE OF SERVICE CODE 31)


    The initial comprehensive visit in a SNF must be provided by a physician and must occur no later than 30 days after a resident's admission into the SNF.  The physician may not delegate the initial visit to another qualified health professional in a SNF stay.  However, after the initial comprehensive visit in a  SNF (99304-99306) the physician may delegate future subsequent care visits (99307-99310) to other qualified nonphysician practitioners (NPP), whether they are employed by the facility or not.  With these follow-up visits, physician co-signature is not required.  Note also, no visits at SNFs may be billed as split/shared services.  

         NURSING FACILITY RULES (PLACE OF SERVICE CODE 32)


    At the option of the state, any required physician task in a NF (including tasks which the regulations specify must be performed personally by the physician, such as the initial comprehensive evaluation) may also be satisfied when performed by qualified non-physician practitioners who are not an employee of the facility but who are working in collaboration with the physician and must be completed no later than 30 days after admission.      That means, in this place of service code 32, the initial nursing facility encounter (99304-99306) can be delegated to qualified non-physician practitioners such as nurse practitioners (NPs), physician assistants (PAs) and clinical nurse specialists (CNSs) who are not employees of the facility but work in collaboration with the physician.  They may also perform other required physician visits and medically necessary follow-up visits (99307-99310).  Visits by non-physician practitioners employed by the NF may not take the place of the physician required visits, but can perform medically necessary visits and write orders based on those visits.    Note also, no visits at NFs may be billed as split/shared services.  

         DUALLY-CERTIFIED FACILITIES (SNF/NFs)


    In situations where beds are dually certified under Medicare and Medicaid, the facility must determine how the resident stay is being paid.

    WHAT CODE TO USE WHEN CONSULTING IN A NURSING FACILITY


    Medicare eliminated consult codes in 2010.  So what code should a physician or qualified NPP use when evaluating a patient as a consultant for the initial visit in a SNF or NF?  Transmittal 2282 from the CMS manual helps explain.
    "The general policy of billing the most appropriate visit code, following the elimination of payments for consultation codes, shall also apply to billing initial visits provided in skilled nursing facilities (SNFs) and nursing facilities (NFs) by physicians and nonphysician practitioners (NPPs) who are not providing the federally mandated initial visit. If a physician or NPP is furnishing that practitioner’s first E/M service for a Medicare beneficiary in a SNF or NF during the patient’s facility stay, even if that service is provided prior to the federally mandated visit, the practitioner may bill the most appropriate E/M code that reflects the services the practitioner furnished, whether that code be an initial nursing facility care code (CPT codes 99304-99306) or a subsequent nursing facility care code (CPT codes 99307-99310) when documentation and medical necessity do not meet the requirements for billing an initial nursing facility care code."

    ARE PROLONGED SERVICE CODES ALLOWED?


    Prolonged service codes (CPT® 99356 and 99357) are allowed for medically necessary prolonged care services for code groups 99304-99306 (initial nursing facility care) and 99307-99310 (subsequent nursing facility care) and 99318 (annual nursing facility assessment).

    CAN I BILL FOR ACUTE CARE HOSPITAL DISCHARGE AND NURSING CARE FACILITY ADMISSION ON THE SAME DATE?


    Per the Medicare Claims Manual 30.6.9.2.D (page 60)

    D. Hospital Discharge Management (CPT Codes 99238 and 99239) and Nursing Facility Admission Code When Patient Is Discharged From Hospital and Admitted to Nursing Facility on Same Day
    A/B MACs (B) pay the hospital discharge code (codes 99238 or 99239) in addition to a nursing facility admission code when they are billed by the same physician with the same date of service.


    CAN I BILL OFFICE OR ER VISIT AND INITIAL NURSING FACILITY CARE ON THE SAME DATE?


    No.  Per the August 2015 CMS Manual Change Request 9231 (page 13):

    C. Office/Outpatient or Emergency Department E/M Visit on Day of Admission to Nursing FacilityMACs may not pay a physician for an emergency department visit or an office visit and a comprehensive nursing facility assessment on the same day. Bundle E/M visits on the same date provided in sites other than the nursing facility into the initial nursing facility care code when performed on the same date as the nursing facility admission by the same physician.

    CAN I BILL FOR INITIAL NURSING FACILITY CARE IF I EVALUATE THEM AT A HOSPITAL BEFORE TRANSFER?


    Medicare Contractor WPS provided this insight during their question and answer publication here:

    Question 3: Can the admission to a Skilled Nursing Facility (SNF) or Nursing Facility (NF) be performed from the hospital? Is there a requirement that the patient must be seen physically in the home within a certain time period? 
    Answer: We received confirmation from CMS on this question.  When the physician is performing the assessment for the admission to the SNF or NF at the hospital, the physician may bill this using place of service (POS) 31 - SNF or 32 - NF.  If the patient is discharged from the hospital and admitted to the SNF or NF on the same day, both services may be approved by Medicare when the physician provides both services. You can find more information in the IOM Publication 100-04, Chapter 12, Section 30.6.9.2 D. There are requirements as to the time-frame for the assessment and plan of care for the patient in a SNF. You can find more information in the IOM Publication 100-04, Chapter 12, Section 30.6.13.

    CAN I BILL A DISCHARGE AND ADMISSION ON THE SAME DATE TO AN INPATIENT REHABILITATION FACILITY (POINT OF SERVICE 61)

    Medicare Contractor WPS provides more insight from here:

    Question 12: The patient is discharged from the acute care hospital and admitted to an Inpatient Rehabilitation Facility (IRF) on the same day. Can we bill a discharge visit and an admission on the same day when performed by the same physician? 
    Answer: No. The CMS IOM Publication 100-04, Chapter 12, Section 30.6.9.1.E states that when a transfer from one facility to another occurs, the physician may bill a subsequent hospital visit code.

    DISTRIBUTION OF ESTABLISHED PATIENT CARE CODES 


    What is the distribution of CPT® code 99306 relative to other levels of service in this medical code group (99304-99306)?  Data from the most recent 2014 CMS Part B National Procedure Summary Files data (2014 zip file) shows how many CPT® 99306 encounters were billed and the dollar value of their services for Part B Medicare.    As you can see in the image below, E/M code 99306 had 1,346,325 allowed services in 2014 with allowed charges of $227,436,197.75 and payments of $175,681,052.90.  Based on a review of the summary file, a total of 2,723943 visits were allowed for 99304-99306 in 2014. The code CPT®99306 was used 49.4% of the time in this code group (99304-99306).

    photo 6960ad26-5fed-4b1d-9902-14ff684ccba4_zpsmlbirtzt.png
    Screen shot of 2014 Part B National Procedure Summary File for Nursing Facility codes.

    RVU VALUE 


    How much money does a CPT® 99306 pay?  That depends on what part of the country you live in and what insurance company you are billing.  E/M procedure codes, like all CPT® billing codes, are paid in relative value units (RVUs).  This complex  RVU discussion has been had elsewhere on The Happy Hospitalist. For raw RVU values, for 2016 a CPT® 99306 is worth 4.68 total RVUs.  The work RVU for 99306 is valued at 3.06.  A complete list of RVU values on common hospitalist E/M codes is provided at the linked URL.  What is the Medicare reimbursement for CPT® code 99306? In my state, a CPT® 99306 pays just over $158 in 2016.  The dollar conversion factor for one RVU in 2016 is $35.8043.


    My coding card taught me that I should be billing for the work I'm providing and it has taught me how to document appropriately. You can see many more of my E/M lectures by clicking through to the link provided here.  If you need bedside help determining what level of care you have provided, I recommend reviewing the pocket card described below.


    		LINK TO E/M POCKET CARD POST

    EM Pocket Reference Cards Using Marshfield Clinic Point Audit

    Click image for high definition view



    The Budget Crisis Impact on Centers for Independent Living

    Like many other human services providers, the Illinois Network of Centers for Independent Living
    (INCIL) is being hit hard by the Illinois budget crisis. Access Living is one of the 22 Centers for Independent Living (CILs) in Illinois. The CILs serve 95 of the 102 counties in Illinois. INCIL’s Executive Director, Ann Ford, shared the following, based on reports from 19 of the 22 CILs, which employ between 450-500 people:

    •39 CIL staff have been laid off state wide since July 1, 2015
    •93 CIL staff are working reduced hours because of furlough days, experiencing pay cuts ranging from 20% to 40%
    •21 vacant CIL positions remain unfilled throughout the state (delaying hires is one way to save money)
    •Two CILs are in the process of closing satellite offices
    •All CILs are restricting travel, including in some areas travel to consumers’ homes
    •At least four CILs are developing contingency plans to close in the event funding doesn’t come within the next six months
    •It is difficult to determine how many consumers have gone without services. A reasonable estimate would be 800 to 1,000 people statewide
    •The impact includes the enormous emotional toll this issue is taking on staff at all CILs, as they take on increased workloads while losing a portion of their income.

    The CILs are doing the very best they can to continue to provide services to empower people with disabilities to live as independently as possible in the community. Quite often they are a real lifeline for many people with disabilities. During this difficult state budget crisis, know that your local CILs have been doing everything they can to show why their programs matter to the local community. The CILs are still waiting for just over $4 million in FY 16 budget money for CILs from the state of Illinois, as well as other funds specific to certain disability programs they run.

    While Access Living has been holding on, we are very concerned about our fellow CILs at risk of closing. Please contact Ann Ford at annford@incil.org if you have questions about the network; you can also check www.incil.org to see what CILs serve your area. We also urge you to contact your Governor, state senators and representatives to urge them to work on a budget solution ASAP so that disability services are not further impacted.

    Ann Ford
    Executive Director
    Illinois Network of Centers for Independent Living 

    This was originally shared as an Advocacy Alert from Access Living.

    Key Lessons from Health & Medicine’s Budget Forum

    On January 15, 2016, Health & Medicine hosted a meeting of The Chicago Forum for Justice in forum proceedings notes as a reference guide for the forum’s content.

    Our notes are written as a summary and while they can’t fully capture the presentations, videos of each of the five mini panels are available on the event webpage, as are slides from speakers who used them in their presentations. We thank CAN TV for recording, editing, and sharing videos of the forum, extending the potential impact of our panelists’ presentations.

    We hope these notes will be useful for advocates and policymakers seeking to understand issues related to the budget, think about potential revenue solutions, and consider strategies, framing, and narratives likely to advance progress.  Health & Medicine will be convening a small group soon to review the forum proceedings and discuss next steps for our work on this critical area, which we’ll share on our website.

    While the budget problems and solutions are more complex than this, here are some main points that have emerged for me from conversations and from the presentations and discussion at the conference:

    • Illinois lacks sufficient revenue, which represents a structural budget problem, priming the State to have recurring budget shortages and hampering our ability to provide Illinoisans with the public services they need and want, thus harming the health of the public, and disproportionately harming vulnerable communities.
    • The structural budget problems have several potential revenue solutions, including a progressive income tax structure and efforts to ensure corporations pay their fair share, both of which are more equitable than our current system and would better grow revenue in proportion to the size of Illinois’ economy.
    • State elected officials are collectively responsible for passing a budget and using a selection of revenue solutions that will help preserve and improve the vital health, social, and education programs and services that support people’s health and Illinois’ economy.  Inaction on the structural revenue shortages that Illinois faces is an unacceptable abdication of the governing duties our public officials share.

    Of course, these salient points are based on a range of facts and history about Illinois’ taxes and budgets, beyond the scope of this post.  A significant amount of such relevant detail is covered in the forum proceedings notes, as well as the slides and videos on the event webpage (linked to above).

    Also, related to this subject, Health & Medicine’s Executive Director, Margie Schaps, had two letters focused on Illinois’ budget published in the last couple of weeks:



    Wesley Epplin
    Director of Health Equity
    Health & Medicine Policy Research Group

    Blacks Hit Especially Hard in Illinois Budget Impasse

    February is Black History Month – and Illinois’ eighth month without a State budget. As we highlight black people’s contributions to the American narrative, the message sent by Illinois’ budget impasse is hardly celebratory.

    All Illinoisans are suffering as the fragile web of supportive services slowly unravels. Communities across the state are feeling the ripple effects of layoffs, reduced services, slow State payments and the tension that comes with sustained uncertainty.

    In the midst of our shared suffering, we must acknowledge this sad truth. People of color, especially black people, are enduring the deepest battle scars from this budget stalemate. And if history is our teacher, these will become the scars of future generations. America’s tortured racial history is embedded in the laws and policies that govern all of us, resulting in widening social, health and economic gaps that operating without a state budget only exacerbates.

    Earlier this month, Heartland Alliance’s Social IMPACT Research Center issued a report that illustrates how pervasive these disparities are in Illinois. The study reports that despite significant dips over the past several decades, the number of Illinoisans living in poverty today, 14.4%, is almost the same as it was in the late 1960s (14.7%). While under 10% of whites in Illinois are living in poverty and Hispanic and Asian populations each have poverty rates of close to 20%, a whopping 30.6% of black people are living in poverty statewide, while making up less than 15% of Illinois’ population. And what is even more disheartening is that 43.2% of black children under the age of 17 are poor. In fact, poverty among black people outpaces that of whites, Latinos, and Asians in all age categories.

    The report lays out a number of health and economic disparities by race. But what is at least as important as the data is the case the authors lay out for the “legacy of inequality” that colors public policy in America. The report offers a historical soundbite of the legalized racist policies of the past that benefited whites and created barriers for people of color, policies and practices that ignore the generational impact of those benefits and barriers, and the practice of mid-twentieth century redlining that seems to have intertwined race, ZIP code and opportunity into perpetuity.

    This budget impasse threatens any progress made towards reducing inequalities in Illinois. For example, last year, for the first time in decades, Chicago saw fewer than 1,000 new HIV cases. That does not happen without a network of community organizations and institutions focused on communities hardest hit by the epidemic — black bisexual and gay men, transgender women of color, and black heterosexual women living in communities with high HIV rates. Blacks make up only 15% of the State’s population but account for 50% of new HIV cases. Yet, the governor’s proposed budget includes a devastating 66% cut to the African-American HIV/AIDS Response Act, a dedicated line of HIV funding that supports the black community, the community hardest-hit by HIV. This at a time when an estimated 6,525 Illinoisans do not know their HIV status and nearly 50% of people living with HIV in this State are not receiving any medical care or HIV medications.

    One thing is abundantly clear this Black History Month in “the land of Lincoln:” Elections have consequences. We must continue to put pressure on the Governor and our state Legislature to approve a humane budget with a revenue increase even as we prepare ourselves for the next budget battle. As the late poet Maya Angelou often said, “When you know better, you do better.” We can do a lot better, Illinois.

    This article was originally posted on RebootIllinois.com.

    Kim Hunt
    Executive Director, Pride Action Tank
    AIDS Foundation of Chicago

    Food Keeps Illinois Families Healthy: Help Illinois Reduce the SNAP Gap

    Forty-eight million Americans live in food insecure households, meaning they worry about where and how to find their next meal. Many of these individuals and families are covered by Medicaid but are not receiving critical nutritional support. They are eligible for SNAP which could help support their nutrition and improve their health, but they are not enrolled.

    What is SNAP?

    The Supplemental Nutrition Assistance Program (SNAP, formerly Food Stamps) helps low-income households purchase adequate, nutritious food. Benefits are distributed monthly on an Electronic Benefits Transfer card, known as “Link” in Illinois, which acts much like a debit card. Money from SNAP can be spent at authorized retailers, and some farmers markets, on any foods that recipients prepare and eat at home. SNAP recipients nationally spend over 85 percent of benefits on fruits and vegetables, grains, dairy, meat and meat alternatives. Beneficiaries also increase the amount of money they spend on groceries each month, instead of simply replacing their food budget with SNAP dollars. By supplementing, not replacing, grocery budgets and allowing for the purchase of more nutritious food, SNAP reduces food insecurity in low-income households. This is particularly true of households with children.

    Why Help Consumers Apply for SNAP Benefits?

    Connecting more Medicaid recipients with SNAP benefits can address food insecurity and inadequate nutrition, which this population experiences at high rates, and improve health outcomes. In addition to helping a family afford healthier food, children who receive nutrition supports are healthier and more likely to finish school while participating in the program. A report recently released by the White House Council of Economic Advisers details the long-term benefits of this program, including: for mother’s receiving support during pregnancy, reductions in incidences of low birth-weights; and for adults who received support when they were children, reductions in obesity rates and metabolic syndrome, increased likelihood of having completed high school, and significant improvements in overall health and economic self-sufficiency among women.

    New Opportunities in Illinois to Reduce the SNAP Gap

    The Affordable Care Act has made it easier for low-income individuals and families to access public benefits by helping states pay for electronic systems to apply for benefits. In Illinois, the new Application for Benefits Eligibility enables applicants to submit a single application for both SNAP and Medicaid. However, despite this improved online application, we have not fully reduced the “SNAP Gap”—the number of Medicaid clients who are income-eligible for SNAP but do not receive this benefit.  We need to work with medical providers, medical plans, social service organizations and other partners to make sure that everyone who is eligible for SNAP gets the help they need to pay for healthy food.

    The newest change to the Illinois SNAP program is that on January 1, 2016, Illinois raised the gross income limit for SNAP from 130% to 165% of the federal poverty level, making nearly 40,000 low-income working families newly eligible for SNAP. With more families in Illinois now eligible for SNAP and the ability to submit a single application for both SNAP and Medicaid benefits, it’s time to close the SNAP Gap and make sure families have the food they need to stay healthy. If you’re not familiar with SNAP’s application process join us on HelpHub for more information and resources for both providers and consumers.

    MacKenzie Speer
    Advocacy Program Associate
    Sargent Shriver National Center on Poverty Law


    Clarifying, Eliminating and Enforcing Special Enrollment Periods

    As the Health Insurance Marketplace grows and matures, we continue to listen and learn to find ways to make it work even better for consumers and those who serve consumers. We know that each year, as the Marketplace evolves, we must seek to continually adapt and refine the way we operate. In addition to continually improving the consumer experience, we also must make changes to keep the Marketplace vibrant, stable and strong.

    The fundamental principles to achieve this are simple: the Marketplace must be attractive for consumers, and the Marketplace must be attractive for insurance companies that offer plans on it.

    Consumers need to know that affordable options are available and that insurers are competing for their business. We know that consumers want affordable health care and value the insurance they’re finding at the Health Insurance Marketplaces. This Open Enrollment we’ve seen a significant influx of new consumers – many of them young – making it clear there is still a large untapped market for insurance companies to serve.

    The Marketplace must also be attractive to insurers, so that they make quality plans available at affordable prices and continue to drive innovation, and so consumers can find plans that meet their health and budget needs. Building an attractive Marketplace starts with establishing a predictable, stable set of rules that help to keep the risk pool balanced. As the Marketplace grows and evolves, we continue to analyze data to understand how our rules are impacting insurers and consumers and to make sure they are working to sustain a stable Marketplace. By having clear rules for how the Marketplace operates and making adjustments when needed, we are creating a more stable rate environment with more affordable plan choices for consumers.

    One of the areas we have been reviewing closely is the special enrollment periods we offer. Special enrollment periods are an important way to make sure that people who lose their health insurance during the year or who experience a major life change like getting married or having a child, have the opportunity to enroll in coverage through the Marketplaces. People who experience these qualifying events have the opportunity to enroll in coverage outside of the normal Open Enrollment period from November 1 to January 31, similar to how enrollment works in the employer market. In addition, in the first two years of the Marketplace, a number of special enrollment periods were created for consumers who were still learning how to enroll in coverage for the first time.

    As the Marketplace matures and consumers learn more about how and when to enroll, we continue to review the rules around special enrollment periods in order to keep them fair for consumers and for issuers. We are taking initial steps in adjusting how special enrollment periods work – and will continue to make further adjustments in the future based on what we learn from continued monitoring and analysis of special enrollment period usage and compliance.

    The action we are taking today announces the elimination of several unnecessary special enrollment periods, clarifies the definitions of other special enrollment periods, and provides stronger enforcement so that special enrollment periods serve the purpose for which they are intended and do not provide unintended loopholes.

    Eliminating Unnecessary Special Enrollment Periods

    Last month, we announced that the Tax Season special enrollment period will no longer be offered. Today we are announcing the elimination of six other special enrollment periods that are no longer needed. Just as the Marketplace evolves, so too does consumer behavior. The rules we use to operate the Marketplace need to keep up with these changes. As such, special enrollment periods are no longer available for:

    • Consumers who enrolled with too much in advance payments of the premium tax credit because of a redundant or duplicate policy
    • Consumers who were affected by an error in the treatment of Social Security Income for tax dependents
    • Lawfully present non-citizens that were affected by a system error in determination of their advance payments of the premium tax credit
    • Lawfully present non-citizens with incomes below 100% FPL who experienced certain processing delays
    • Consumers who were eligible for or enrolled in COBRA and not sufficiently informed about their coverage options
    • Consumers who were previously enrolled in the Pre-Existing Condition Health Insurance Program
    We’ll continue to monitor how special enrollment periods are used and may make changes in the future as Marketplace systems and operations continue to improve.

    Clarifying Eligibility

    Our review of current special enrollment periods also showed that some of the eligibility guidelines need to be further clarified so consumers can understand the intent and so they will not be abused. Today we are updating guidance to more clearly define the special enrollment period that is available to consumers who permanently moved, and as a result, gained access to new health plans. Specifically, we clarify that this special enrollment period cannot be used for a short-term or temporary move where the consumer doesn’t plan to stay in their new location, including situations in which a consumer is admitted to a hospital for treatment in a different area. This clarification is intended to assist consumers, brokers, issuers and others in understanding who is eligible for this special enrollment period.

    If we identify other areas where the rules for special enrollment periods are unclear, we will issue additional clarifying guidance as needed.

    Enforcing the Rules

    Finally, we will take steps to make sure that consumers understand and comply with the rules. We will conduct an assessment of plan selections that are made through certain special enrollment periods to evaluate whether consumers properly accessed coverage. Our program integrity team will pull samples of consumer records nationally and may request additional information from some consumers or take other steps to validate that consumers properly qualified for these special enrollment periods. The findings from the assessment will help us to inform future policy and operational improvements to enhance program integrity. Additional details will be provided in the coming weeks.

    We will also emphasize more strongly to applicants that the law requires that consumers provide accurate information to the Marketplace, and they may be subject to penalties under federal law if they intentionally provide false or untrue information.

    There is still time for consumers who need coverage to enroll during the Open Enrollment period that ends on January 31st. While there will continue to be special enrollment periods for people who lose coverage mid-year or experience other life changes, this channel for enrollment will not be available for the vast majority of consumers. For example, special enrollment periods are not allowed for people who choose to remain uninsured and then decide they need health insurance when they get sick.  Consumers who do not currently have other health insurance coverage should enroll through the Marketplace now during these last two weeks of Open Enrollment, to make sure they have coverage if they get sick and to avoid the tax penalty.

    This was originally posted on the CMS Blog.

    Kevin Counihan
    CEO
    Health Insurance Marketplace 

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