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Home > Healthcare Reform
The Financial Professional's Guide to Healthcare Reform
The Financial Professional's Guide to Healthcare Reform
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The Financial Consultants' Guide to Healthcare Reform is a comprehensive reference guide interpreting and applying healthcare reform law for consultants, appraisers, accountants, and attorneys. It provides an historical backdrop on how the healthcare system got to it's present state, including the Massachusetts Reform and Medicare Advantage, along with an explanation of the principal types of health insurance in the United States and how "insurance" actually works. A review and explanation of each of the reform provisions follows, including an analysis of what the implications are for providers, consumers and business, and what responses each of these communities might have to the reform.

Using the authors' insights and firsthand experiences in U.S. healthcare finance, The Financial Consultants' Guide to Healthcare Reform explains the healthcare law for individuals and businesses alike, what to expect from it and what actions they need to take to comply.

  • Interprets and applies the healthcare reform law;
  • Provides examples of what the impact of the law might look like; and
  • Extensive use of sidebars to provide in-depth analysis or background on particular topics of import, where the reader may need more detail to understand the context of reform's changes.

The Financial Consultants' Guide to Healthcare Reform provides a complete handbook to healthcare reform for financial consultants, both for understanding this important legislation as well as for planning responses to it.

  • Written for consultants, appraisers, accountants, and attorneys
  • Written by major figures in the world of healthcare valuation and consulting

Table of Contents

  • Foreword xvii
  • Preface xix
  • Acknowledgments xxiii

    CHAPTER 1: Introduction

    • A Brief Recap of the History of Reform
    • Early Reform Efforts
    • Tax Deductibility of Health Insurance
    • The Great Society: Medicare and Medicaid
    • The 1970s: Medicare HMOs and ERISA
    • Regulation: The Anti-Kickback Statute
    • Prospective Payment Systems
    • The 1990s
    • Rise of Managed Care
    • The Stark Law: Anti-Referral Statute
    • Balanced Budget Act of 1997
    • Balanced Budget Revision Act and Benefits Improvement and Protection Act
    • Failure of Managed Care
    • Provider Integration and Consolidation
    • Summary of the Healthcare Market in 2000
    • The New Century
    • One Size Fits All? Geographic Disparities in the U.S. Healthcare System
    • Profit and Nonprofit Hospitals and Health Insurers
    • History of Blue Plans
    • Medicare: The Other White Meat
    • Other Market-Based Studies
    • Geo-Clinical Differences
    • Summary

    CHAPTER 2: Massachusetts

    • The Time Line of Massachusetts Reform
    • Early Reform Legislation in Massachusetts
    • Acts of 1996
    • Targeting the Small Group Market
    • Targeting the Trade Associations Offering Health Insurance to their Members
    • The Intervening Years
    • Components of the 2006 Massachusetts Legislation
    • Merging the Small Group and Individual Markets
    • Commonwealth Care Subsidies
    • Key Features of Massachusetts Reform
    • Recounting the Results of Reform in Massachusetts
    • Universal Coverage
    • Response of the Healthcare Provider Community
    • Differing Views of Massachusetts Reform
    • Special Commission on the Health Care Payment System
    • The Alternative Quality Contract
    • State Government Reports Tracking the Results of Reform
    • The Small Group and Individual Market versus Self-Insured Market
    • Massachusetts Quarterly Reports
    • Massachusetts Attorney General’s Report
    • Similar Experience in Other Markets
    • Specific Comparisons
    • Take from the Poor and Give to the Rich?
    • Impact on Market Share of Financially Weaker Providers
    • Most Favored Nation Clauses
    • Tiered Pricing
    • Recent Legislative Changes through August 2010
    • Open Hearings in December 2009
    • August 2010 Changes in Massachusetts
    • Open Enrollment
    • Review of Premium Increases
    • Tiered Network Requirement
    • What Can We Learn from the Massachusetts Experience?

    CHAPTER 3: Insurance Reforms

    • What is Insurance?
    • Components of Health Insurance and Healthcare Entitlement
    • Sources of Coverage
    • Medicare
    • Medicaid
    • Self-Insured Employers
    • Small Group (Small Business) Insureds
    • Individual Insureds
    • Large Group—Business Not Self-Insuring
    • Uninsured 50
    • Health Insurers
    • How Do Health Insurers Provide Health Insurance?
    • Understanding Acturial Risk
    • How Does Self-Insurance Work?
    • Regional and Industry Factors in Health Insurance
    • The Reform of Health Insurance
    • Minimum Essential Coverage
    • Preventive Medicine Services
    • The Precious Metals of Health Insurance Policies
    • Defining Actuarial Value
    • Deductibles
    • Glossary of Health Insurance and Medical Terms
    • Consumer Protection Provisions
    • Guaranteed Availability and Renewability of Insurance in the Small Group and Individual Market
    • Elimination of Lifetime Limits on Coverage
    • Elimination of Annual Limits on Coverage
    • Prohibition Against Rescission of Coverage
    • Appeals of Benefit Denials
    • Self-Insured Plans
    • Insured Plans
    • Government Review of Premium Increases
    • Waiting Periods for Coverage
    • Protections for Children
    • Prohibition Against Exclusion for Preexisting Conditions
    • Administrative Simplification
    • Grandfathered Health Insurance Plans
    • Medical Loss Ratios
    • Cost Containment
    • Insurer Provisions
    • Provider Provisions
    • Cost-Effective Medicine
    • Rating and Other Reforms in the Small Group and Individual Market
    • Different Forms of Rating Health Insurance Policies
    • Merger of Small Group and Individual Markets
    • Illustration
    • Mini-Med Plans
    • Insurance Exchanges
    • Establishment of the Exchanges
    • Requirements of Exchanges
    • Qualified Health Plans
    • Open Enrollment Periods
    • Functional Requirements
    • Benefit Requirements
    • The Massachusetts Experience
    • Chapter Summary
    • Implications and Responses for Small Business
    • Implications and Responses for Larger Businesses
    • Implications for the Provider Community
    • Some Thoughts for Lenders and Small-Business Investors
    • Appendix 3.1: Selected Legislative Text for Insurance Exchanges
    • Appendix 3.2: CMS Proposed Regulations—Glossary of Health Insurance and Medical Terms
    • Appendix 3.3: Using the Massachusetts Health Connector

    CHAPTER 4: Medicare Advantage Plans

    • How Many Medicare Beneficiaries are in Medicare Advantage Plans?
    • Health Maintenance Organization (HMO) Plans
    • Preferred Provider Organization (PPO) Plans
    • Private Fee-for-Service (PFFS) Plans
    • Special Needs Plans (SNP)
    • Geographic Distribution of Medicare Advantage Enrollees
    • History of Medicare Advantage and Its Predecessors
    • Age, Gender, Severity of Illness, and Risk Score Adjustments to the Capitation Rates
    • Medicare Advantage and the Medicare Modernization Act
    • Enrollee Benefits
    • Choosing a Medicare Advantage Plan
    • Changes from the Reform
    • Minimum Medical Loss Ratio
    • Payment Rates
    • Effect on Beneficiary ‘‘Rebates’’ or Enhanced Benefits
    • Quality-Based Incentive Payments
    • Rebates
    • Low Enrollment Plans
    • New Plans
    • Implications for the Provider Community
    • Implications for Insurers
    • Implications for Medicare Advantage Beneficiaries
    • Appendix 4.1: PPACA Sections Affecting Medicare Advantage
    • HCERA } 1102. Medicare Advantage Payments
    • HCERA } 1103. Savings from Limits on MA Plan Administrative Costs
    • PPACA } 3203. Benefit Protections and Simplifications
    • PPACA } 3204. Simplification of Annual Beneficiary Election Period
    • PPACA } 3206. Extension of Reasonable Cost Contracts
    • PPACA } 3208. Making Senior Housing Facility Demonstration Permanent
    • PPACA } 3209. Authority to Deny Plan Bids

    CHAPTER 5: Medicaid Expansion

    • Introduction and Overview
    • Medicaid Enrollment and Spending
    • Eligibility Changes
    • Basic Categories of Medicaid-Eligible Individuals
    • New Rules
    • Maintenance of Effort (MOE) Requirement
    • Modified Adjusted Gross Income or MAGI
    • Presumptive Eligibility
    • Key Expansion Groups
    • Coverage of Men
    • Coverage of Women without Children
    • Community First Choice Option
    • Legislative Provisions
    • Other Incentives for Home and Community-Based Services
    • Spousal Impoverishment and Home and Community-Based Services
    • Other Requirements
    • Benefits
    • New Standards for Benchmark-Equivalent Coverage
    • Preventive Care for Adults
    • Medical or Health Homes
    • Birthing Centers
    • Prescription Drug Coverages
    • Miscellaneous Provisions
    • Financing the Changes
    • Expansion States
    • Special Adjustment to FMAP for States Recovering from a Major Disaster
    • Implications and Responses for Low-Income Uninsured and Taxpayers
    • Appendix 5.1: Table of Medicaid Provisions in the PPACA
    • Appendix 5.2: Subtitle D—Medicare Part D Improvements for Prescription Drug Plans and MA-PD Plans 1

    CHAPTER 6: Mandates, Subsidies, Penalties . . . and Taxes

    • The Individual Mandate
    • Amount of the Penalty
    • Examples
    • Example: Single Individual with No Dependents, 2014 to 2016, with Household Income up to $50,000
    • Example: Single Individual with No Dependents, 2014 to 2016, with Household Income up to $500,000
    • Example: Family of Four, 2014 to 2016, with Household Income up to $125,000
    • Failure to Pay Penalty Imposed on Individuals
    • Impact of the Mandate
    • Congressional Budget Office Analysis
    • Government Accountability Office
    • Geographic Disparities in the Cost of Insurance
    • Subsidy Eligibility
    • Tax Credits and Subsidies
    • Tax Credits
    • IRS Credit Examples for Middle-Class Families
    • Subsidies
    • How the Credits and Subsidies Impact Premium Cost
    • Employer Requirements
    • Definition of Large Employer
    • Large Employers Not Offering Coverage
    • Large Employers Offering Coverage
    • Large Employers with More Than 200 FTEs
    • Notice 2011–36
    • The Role of the Tax Code and the Internal Revenue Service
    • Nondiscrimination Rules in the Provision of Health Insurance
    • Suspension of Compliance and Penalties
    • Possible Solution to the Nondiscrimination Provision for Insured Businesses
    • Inexplicable Changes to Flexible Spending Accounts: Notices 2000–59 and 2011–5
    • Payment or Reimbursement of Medicines or Drugs Prescribed after January 1, 2011
    • Exceptions
    • Debit Cards
    • Inventory Information Approval System (IIAS)
    • Maximum Deferral
    • Itemized Deductions for Medical Expenses Reporting of Health Benefits on Form W-2 Aggregate Cost of Applicable Employer-Sponsored Coverage Reportable Coverage
    • Example for Family Coverage
    • Examples Where Flexible Spending Account (FSA) Exists
    • Methods of Calculating the Cost of Coverage
    • COBRA Applicable Premium Method
    • Modified COBRA Applicable Premium Method
    • Terminated Employees
    • Health Insurance Information Provided by Employers to All Employees
    • Annual Return to IRS on Coverage
    • Tax Treatment of Healthcare Benefits Provided with Respect to Children under Age 27: Notice 2010–38
    • Tax Credit for Employee Health Insurance Expenses of Small Employers: Notices 2010–44 and 2010–82
    • Definition of Eligible Employer
    • Steps to Determine Whether an Employer Is Eligible for a Credit
    • Determine the Employees Who Are Taken into Account for Purposes of the Credit
    • Determine the Number of Hours of Service Performed by Those Employees
    • Calculate the Number of the Employer’s FTEs
    • Determine the Average Annual Wages Paid Per FTE
    • Determine the Qualifying Premiums Paid by the Employer That Are Taken into Account for Purposes of the Credit
    • Years Prior to 2014
    • Premiums Taken into Account
    • Phaseout
    • Example for Taxable Small Employer
    • Example for a Tax-Exempt Small Employer
    • Tax-Exempt Employers Not Described in } 501(c) and Exempt Under } 501(a)
    • Consumer Operated and Oriented Plan (CO-OP Program)
    • Funding of Patient-Centered Outcomes Research: Notice 2011-35
    • Excise Tax on High-Cost Employer-Sponsored Health Coverage
    • Applicable Employer-Sponsored Coverage
    • Computation of Annual Limit in 2018
    • Health-Cost Adjustment Percentage
    • Self-Insured Plans
    • Exceptions
    • Computation of Annual Limit after 2018
    • Entity Responsible for Paying the Tax
    • Added Medicare Tax on the Upper-Middle Class and High-Income Individuals
    • Wages
    • Investment Income
    • Threshold Amount
    • Net Investment Income
    • Application to Estates and Trusts
    • Active Interests in Partnerships and S Corporations
    • Modified Adjusted Gross Income
    • Increased Medicare Part B Premium
    • Increased Medicare Part D Premium
    • Internal Revenue Code Changes for Tax-Exempt Hospitals
    • Required Financial Assistance Policy
    • Limitation of Charges to Patients Eligible for Financial Assistance
    • Prohibition against Extraordinary Collection Actions
    • Section 4959 Excise Tax
    • Form 990 Requirements
    • Implications and Responses for Small Business
    • Tax Changes
    • Implications and Responses for Larger Business
    • Implications and Responses for Individual Taxpayers and Consumers
    • Mandate and Subsidies
    • Taxes
    • Some Thoughts for Lenders and Small-Business Investors
    • Appendix 6.1: Table of Internal Revenue Service Notices
    • Appendix 6.2: Table of Regulations (Treasury Decisions)
    CHAPTER 7: Delivery System Reforms

    • Overview of Delivery System Reforms
    • Hospital Value-Based Purchasing
    • Hospital VBP Rulemaking
    • Purpose
    • Use of Measures
    • Scoring Methodology
    • Quality Measures
    • Performance Periods
    • Performance Standards
    • Funding
    • Value-Based Incentive Payment
    • Demonstration Programs
    • Hospital Readmissions Reduction Program
    • Defining Readmissions
    • Calculation of the Adjustment Factor
    • Risk Adjustment, Timing, and Reporting
    • Payment Adjustments for Conditions Acquired in Hospitals
    • Payment Bundling
    • The Argument for Bundling
    • Voluntary National Pilot Program
    • HHS Obligations
    • Revisions of Market Basket Updates and Incorporation of Productivity Improvements into Market Basket Updates
    • Independent Payment Advisory Board
    • IPAB Cost Containment Proposals
    • Membership
    • Annual Reporting
    • Medicare Geographic Payment Disparities
    • Medicare and Medicaid Disproportionate Share Hospital Payment Program
    • Medicare DSH
    • Medicaid DSH

    CHAPTER 8: Accountable Care Organizations

    • Historical Parallels
    • Precursor to ACOs: Physician Group Practice (PGP) Demonstration
    • Program Results According to CMS
    • Center for Medicare and Medicaid Innovation
    • Independence at Home Medical Practices
    • The Proposed Regulations of March 31, 2011, and the Final Regulations of October 20, 2011
    • Eligibility and Governance
    • Eligibility
    • ACO Professional
    • Hospital
    • Provider Identification
    • Legal Structure and Governance
    • Leadership and Management Structure
    • Agreement Requirement
    • Starting Dates for ACO Agreement
    • Processes to Promote Evidence-Based Medicine and Patient Engagement
    • Primary Care Providers and the Assignment of Beneficiaries to the ACO
    • Post-Agreement Declines in Beneficiaries Below 5,000
    • Annual Reporting
    • Data Sharing
    • Sharing of Claims Data with the ACO
    • Initial Data Sharing
    • Subsequent Data Sharing
    • Data Use Agreement (DUA)
    • Beneficiary Opportunity to Opt Out of Data Sharing
    • Future Regulatory Changes
    • Future Changes to the ACO
    • Examples of Significant ACO Changes as Specified by CMS
    • Material Change
    • Quality and Other Reporting Requirements
    • Design of Quality Measure Table
    • CMS Program, NQF Measure Number, Measure Steward
    • National Quality Forum (NQF) 260
    • Physician Quality Reporting System Measures
    • EHR Incentive Program Measures
    • Hospital Inpatient Quality Reporting Program
    • Consumer Assessment of Healthcare Providers and Systems (CAHPS)
    • Calculating the Performance Score for Each Measure within a Domain
    • Aggregating the Individual Domain Scores
    • Public Reporting of Quality Performance Standard Scores
    • Shared Savings Determination
    • Track 1
    • Track 2
    • Setting the ACO Budget or Expenditure Benchmark
    • Included Expenditures
    • Adjustments
    • Catastrophic Claims Adjustment
    • CMS Outline of Steps to Determine Budget
    • Other Adjustment Issues
    • Minimum Savings Rate (MSR)
    • Limits on Shared Savings or Sharing Cap: Performance Payment Limit
    • One-Sided Model
    • First Dollar Shared Savings
    • Withhold of Shared Savings
    • Loss Factors Specific to the Two-Sided Model
    • Minimum Loss Rate (MLR)
    • Shared Loss Rate
    • Comment from the Regulations
    • Maximum Shared Loss Cap
    • Example from the Proposed Regulations
    • Repayment of Loss Mechanism
    • Comparing the Features of the Two Tracks or Models
    • Claims Run-Out
    • ACO Distribution of Shared Savings
    • Public Reporting of Shared Savings
    • Termination of the ACO Agreement
    • By CMS
    • By the ACO
    • Overlap with Other Shared Savings Initiatives
    • Pioneer ACOs
    • Advanced Payment ACO Model
    • Eligibility
    • Advanced Payment Structure
    • Recoupment of Advance Payments
    • Antitrust Issues
    • The Internal Revenue Service and ACOs
    • Implications for Beneficiaries
    • Implications for Providers
    • Performance Factors to Watch in the Future
    • Some Thoughts for Lenders and Small-Business Investors

    CHAPTER 9: Healthcare Workforce

    • Innovations in the Healthcare Workforce
    • National Health Care Workforce Commission
    • State Workforce Development Grants
    • National Center for Health Workforce Analysis
    • Increasing the Supply of the Healthcare Workforce
    • Federally Supported Loan Funds and Retention Programs
    • Commissioned and Reserve Corps
    • Healthcare Workforce Education and Training
    • Enhanced Primary Care Training
    • Training Grant and Demonstration Programs
    • United States Public Health Sciences Track
    • Support of the Existing Healthcare Workforce
    • Primary Care Reimbursement and Other Workforce Improvements
    • Medicare Bonus Payments to Primary Care Physicians and
    • General Surgeons
    • FQHC Improvements
    • Distribution of Unused Residency Positions
    • Counting Resident Time and Non-Provider Settings
    • Counting Resident Didactic and Scholarly Activities
    • Preserving Resident Caps from Closed Hospitals
    • Other Provisions
    • Improving Access to Healthcare Services
    • Funding of FQHCs and CHCs
    • Designating MUPs and HPSAs
    • Other Access Improvement Provisions of PPACA

    CHAPTER 10: Transparency and Program Integrity

    • Physician Ownership and Other Transparency
    • Limitation on Physician Ownership of Hospitals
    • Transparency of Physician Ownership
    • Physician-Owned Imaging Services
    • Prescription Drug Transparency
    • PBM Transparency
    • Nursing Home and SNF Transparency
    • Compliance Program Accountability
    • Nursing Home Compare
    • Cost Reporting Reforms
    • CMP Reduction
    • Independent Monitor Demonstration
    • Facility Closure
    • Culture Change
    • Nationwide Background-Check Program
    • Patient-Centered Outcomes Research
    • Medicare, Medicaid, and CHIP Integrity Provisions
    • Provider Screening and Other Enrollment Requirements under Medicare, Medicaid, and CHIP
    • Enhanced Medicare and Medicaid Program Integrity Provisions
    • National Practitioner Data Bank
    • Maximum Medicare Claims Submission Period
    • Enrollment Requirement and Documentation on Referrals for Ordering Physicians
    • Face-to-Face Encounter Requirement for Home Health and DME
    • Enhanced Civil Monetary Penalties
    • Stark Self-Referral Disclosure Protocol
    • Expansion of the DMEPOS Competitive Bid Process
    • Expansion of the Recovery Audit Contractor (RAC) Program
    • Additional Medicaid Program Integrity Provisions
    • Additional Program Integrity Provisions
    • Elder Justice Act 3
    • Healthcare Fraud Enforcement

    CHAPTER 11: Section 340B Expansion

    • Overview of the 340B Program and Reforms
    • Expansion of Covered Entities
    • Program Integrity Provisions
    • Manufacturer Compliance
    • Covered Entity Compliance
    • Administrative Dispute Resolution
    • Regulations Implementing 340B Legislation
    • Proposed Rule on Civil Monetary Penalty
    • Proposed Rule on Administrative Dispute Resolution Process
    • Proposed Rule on Orphan Drugs

    CHAPTER 12: Medical Tort Litigation Demonstration Program

    • ACA Demonstration Program Provisions
    • HEALTH Act

    CHAPTER 13: Other Provisions

    • Physician Quality Reporting System
    • Physician Feedback Program
    • Impact of the ACA
    • Misvalued Codes Under the Physician Fee Schedule
    • Proposal for Validation of RVUs
    • Proposal for Consolidating Reviews of Potentially Misvalued Codes
    • Modification of Equipment Utilization Factor for Advanced Imaging Services
    • Adjustment in Technical Component Discount on Single-Session Imaging to Consecutive Body Parts
    • About the Authors
    • Index

  • Publication Date: May 2012
    Number of Pages: 432
    ISBN 10: 1118093224
    ISBN 13: 978-1118093221
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