The Latest You Should Know About Managing Health Care Reform

From the HR blog at TLNT.
From the HR blog at TLNT.

Little by little we’re learning more about the complex piece of legislation called the PPACA (the Patient Protection and Affordable Care Act).

Over the past few months the Obama administration has provided sample notices regarding the new dependent eligibility rules, on the annual and lifetime limit changes and primary care physician designation, and OB/GYN self referral change – which we rewrote – and provided clarity on Grandfathered plans and other key pieces of the legislation.

As you and your HR staff prepare for open enrollment and develop your material, it’s important you stay up to date on health care reform news and incorporate relevant material into your key messages.

Here are the latest events you should know about:

Preventive services defined

The Department of Health and Human Services (HHS) and the Department of Labor (DOL) announced the recommended preventive services new plans and issuers must cover at no cost to the employee when administered by an in-network provider.

These new regulations do not apply to employers who plan to keep their grandfathered status – health plans that existed when health care reform was passed and plan to stay the same, or very similar year over year.

In particular, an employer-sponsored plan must by the first day of the first plan year beginning on or after September 23, 2010, cover:

  • Evidence-based preventive services: An independent panel of scientific experts, called the U.S. Preventive Services Task Force, ranks preventive services based on evidence of their benefits. Preventive services with a “grade” of A or B, like breast and colon cancer screenings, screening for vitamin deficiencies during pregnancy, screenings for diabetes, high cholesterol and high blood pressure, and tobacco cessation counseling will be covered under these rules. See the complete list of Grade A and B preventive services.
  • Routine vaccines: Health plans will cover a set of standard vaccines recommended by the Advisory Committee on Immunization Practices ranging from routine childhood immunizations to periodic tetanus shots for adults. See a list of recommended immunizations for children age 0-6 [PDF], 7-18 [PDF], catch-up immunizations [PDF], and adults [PDF].
  • Prevention for children: Health plans will cover preventive care for children recommended under the Bright Futures guidelines. These guidelines provide pediatricians and other health care professionals with recommendations on the services they should provide to children from birth to age 21 to keep them healthy and improve their chances of becoming healthy adults. The types of services that will be covered include regular pediatrician visits, vision and hearing screening, developmental assessments, immunizations, and screening and counseling to address obesity and help children maintain a healthy weight. Click here for a complete list of recommended services.
  • Prevention for women: Health plans will cover preventive care provided to women under both the Task Force recommendations and new guidelines being developed by doctors, nurses, and scientists, which are expected to be issued by August 1, 2011.

Claims regulations defined

The administration released interim final rules that give consumers more power to appeal coverage decisions made by their health plans or insurance, which the administration hopes will help support and protect consumers and end some of the worst insurance company abuses.

Patients in every state will have the right to:

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  • Appeal decisions including claims, denials and recessions made by their health plan.
  • Appeal decisions made by a health plan through the plan’s internal process.
  • Appeal decisions made by a health plan to an outside, independent decision-maker, no matter what state a patient lives in or what type of health coverage they have

Health care providers will have to:

  • Notify a claimant of a benefit determination as soon as possible.
  • Provide the claimant, free of charge, any new or additional evidence used by the plan or issuer to make a claims determination.
  • Avoid conflicts of interest by ensuring the independence and impartiality of the people involved in making the decision.
  • Provide notice to the claimant in a culturally and linguistically manner.
  • Provide a description of available internal appeals and external review processes.

If a claimant’s internal appeal is denied, the claimant has the right to appeal to an independent reviewer under standards set by the National Association of Insurance Commissioners (NAIC). See the NAIC standards.

Third round of “donut hole” rebate checks mailed

HHS mailed the third round of one-time, tax-free $250 rebate checks to eligible Medicare beneficiaries whose drug costs are so high they have reached the Medicare Part D prescription drug coverage gap known as the “donut hole.”

In 2011, Medicare beneficiaries who reach the donut hole will receive a 50 percent discount on their brand name medications.

In addition:

  • Medicare beneficiaries will receive free preventive care services like mammograms and certain colon cancer tests and a free annual physical starting in 2011;
  • By 2018, seniors can expect to save on average almost $200 per year in premiums compared to what they would have paid without the new law, and most beneficiaries will also see a significant reduction in their Medicare coinsurance as a result of the Affordable Care Act; and *The life of the Medicare Trust Fund is extended by 12 years.

Jennifer Benz is Chief Strategist and Founder of Benz Communications, a San Francisco-based consultancy that focuses on custom, comprehensive benefits and HR communications services. Jen is an active member of the Council for Communication Management, the International Association of Business Communicators, the Northern California Human Resources Association and Women in Consulting. Contact her at


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