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"20, The Health Insurance Portability and Accountability Act of 1996 (HIPAA), which amended ERISA, the Public Health Service Act, and the Internal Revenue Code, establishes minimum federal standards and requirements concerning guaranteed issue and renewability of health coverage, limits exclusions for preexisting medical conditions, provides for credit against maximum preexisting condition exclusion periods for prior health coverage, prohibits individual discrimination based on health factors, and limits disclosure of personal health information.21 HIPAA applies to both employee benefit plans and state-regulated insurers.22, The Consolidated Omnibus Budget Reconciliation Act of 1986 (COBRA) provides for continuation of group health coverage that would otherwise be terminated.23 Former employees and their dependents who lose coverage may temporarily continue their health coverage at group rates if they are willing to pay up to 102 percent of those rates, and they qualify under the terms of the statute. Id. In some sectors of the economy (e.g., construction, service industries, and retail), employment-based health insurance is less common than in other sectors of the economy (e.g., finance and manufacturing).31 Employer size matters as well; the larger the firm, the more likely it is that employees will be offered employment-based health insurance.32 Not all employees take advantage of employment-based health insurance, and some employees obtain coverage for themselves, but not for their beneficiaries.33 Although it is common parlance to speak of "employer contributions" to the cost of health care coverage, employees ultimately bear these costs, in the form of lower salaries and fringe benefits.34, A. See also Crippen 9/30 at 155. 178 Short & Grafe, supra note 177, at 247. The Supreme Court considered the boundaries of ERISA preemption in four recent cases: Aetna Health Inc. v. Davila, 124 S. Ct. 2488 (2004); Kentucky Ass 'n of Health Plans, Inc. v. Miller, 538 U.S. 329 (2003); Rush Prudential HMO, Inc. v. Moran, 536 U.S. 355 (2002); Pegram v. Herdrich, 530 U.S. 211 (2000). This is comparable to allowing a person to purchase auto insurance for a car wreck after its happened. The burden of providing this uncompensated care varies tremendously. From there, I went on to earn my CPC-A (now CPC), CCA, and HCS-D credentials. Some individuals can afford to purchase health insurance, but voluntarily elect to bear the risk of not doing so.173 For many others, health insurance is prohibitively expensive when weighed against the cost of food, shelter, and basic necessities.174, The uninsured cut across a large swath of the United States: some are young and healthy, some are not; many are below the poverty line and others are reasonably wealthy. 327, 332 (1990) ("A widely shared (but incorrect) position is that charitable equals charity."). The scope of services provided to Medicaid recipients includes: inpatient and outpatient hospital services, prenatal care, childhood vaccines, physician services, and nursing facilities services for persons aged 21 or older.135, In 2002, total Medicaid enrollment was 50.8 million, up from 44.2 million in 2000. w4.31 v 1 ?ck=nck. Your email address will not be published. Competition will not transfer resources to those who do not have them.199 Proposals to address these matters should be carefully evaluated to ensure that the consequences of any reform are pro-competitive. See also American Academy of Pediatrics, The State Children's Health Insurance Program, at http://www.aap.org/advocacy/schipsum.htm (last visited June 23, 2004). Medicare approves private insurers to manage the plans, and Medicare beneficiaries have the option to choose a health care provider from the list. 13 McCarran-Ferguson Act 1013(b). For further discussion of P4P programs, see supra Chapters 1 and 3. Darling 6/12 at 101 ("[A]ll [health] benefits are foregone wages or other benefits paid for by the worker"). 108 39 Boards of Trustees of the Federal Hospital Insurance & Federal Supplementary Medical Insurance Trust Funds Ann. Eligible plans must have an annual deductible of at least $1,000 for an individual and at least $2,000 for a family, but the sum of the annual deductible and the other annual out-of-pocket expenses (other than premiums) cannot exceed $5,000 for an individual or $10,000 for a family. 204 See Lansky 6/12 at 70-89 (reporting on findings from studies and surveys conducted by the Foundation for Accountability (FACCT)); Lansky Presentation, supra note 203, at 4-16; Comstock 6/12 at 110-11; Gingrich 6/12 at 51-52 ("Everybody ought to have an electronic health record. "); Kongstvedt, Compensation, supra note 168, at 137; Burgess 4/9 at 107-108 (noting some economists argue that a mix of FFS and capitation helps balance incentives to under and over-use health care services). Sec. One panelist also noted the "huge distortions created by the tax system." 123 Francis 9/30 at 135-36; Antos 9/30 at 115, 124; Lemieux 9/30 at 147-53. See infra Chapter 6. According to Medicare.gov, Part C covers the following: Original Medicare still covers hospice care, some new Medicare benefits, and some costs related to clinical research studies. These waivers are authorized by the Social Security Act 1115. Co., 514 U.S. 645 (1995). 100 See HHS, supra note 95, 8, at 63-68 (entitled "Other Insurance and Ways to Pay Health Care Costs"). ERISA generally preempts state laws that apply to self-insured plans, including plans that purchase such stop loss insurance coverage.45 In American Medical Security v. Bartlett, the Fourth Circuit held that ERISA preempted a state regulation that was designed to subject to the state's insurance laws self-insured plans carrying stop-loss insurance below state-specified minimum levels.46, Most cases have held "that ERISA preempts application of state insurance laws to self-insured plans that have arrangements with TPAs" to provide administration and claims processing services.47 The case law is mixed whether ERISA preempts state laws if a self-insured plan contracts with an insurer to provide access to a provider network. Sec., 111 F.3d at 362. They influence the areas in which competition can exist, and the rules under which it has to exist, and the risks and rewards, and the institutional framework within which all of those things take place. Institute for Health Care Research & Policy, A Consumer's Guide to Getting and Keeping Health Insurance in the District of Columbia (2002), available at http://www.healthinsuranceinfo.net/dc.pdf. Some photos, graphics, and other materials used on this website are copyrighted and used with permission or licensed for use on this website, but may not be copied and distributed without the copyright holders permission. "91 This section focuses on two key government-funded programs: Medicare and Medicaid. . The case does not clarify whether state laws governing TPAs or PPOs are preempted when contracting with ERISA plans. 57 M. Young 6/12 at 91-92; M. Young Presentation, supra note 51, at 2. Bd. 154, 2000) (stating that expenses are higher because insurance companies use agents to screen individuals for the highest risks, "people in the individual market are older, sicker and poorer than those in the group market [and that] they are also unsubsidized by either their employers or by the government [and] lapse rates are high as people acquire coverage when they have the money, and drop it when they run out of funds"). 2004) (stating that market forces in this context "meet certain fundamental conditions, including that the buyers are (reasonably well) informed, are using their own money (at least at the margin), and face a choice among competing alternative suppliers"). Their response has been to move to lower cost plans, even if it means more hassles to access specialists. Speaker Gingrich noted that consumer choice also implies individual responsibility and accountability. So, they don't buy it for various reasons."). Life Ins. Persp. 89 See, e.g., Karen Pollitz et al., supra note 15, at 12; Agency for Healthcare Research & Quality (AHRQ), Pub. Id. 45 See Am. And, so, you can't have precisely the same utilization controls."). 8 McCarran-Ferguson Act, 15 U.S.C. 1051 et seq. See also Pension & Welfare Benefits Admin., U.S. Dept of Labor, Health Benefits Under The Consolidated Omnibus Budget Reconciliation Act (2001), at http://www.labor.gov/ebsa/pdf/cobra99.pdf. Secure .gov websites use HTTPS We help drug and device manufacturers obtain coverage for their products under government and private insurance programs. When I started my education in medical coding, I had so many questions. 185 Levy 9/26 at 39 (noting that when the uninsured do seek treatment, "acuity is greater and treatment is more complicated."). No. 56 See, e.g., M. Young 6/12 at 91, 95; Kaiser Family Found., supra note 52, 4, at 62 (in 2003, 62 percent of covered workers had more than one health plan option, and this percent has been relatively stable since 1996). Many obtain coverage through a government program or purchase an individual insurance policy. ); participation and vesting requirements (29 U.S.C. 2 (Kaiser Comm'n on Medicaid & the Uninsured, Issue Paper Pub. It includes reduced-fee care; charity care, for which the uninsured do not pay anything; and bad debts incurred by the uninsured."). Bindman et al., Preventable Hospitalizations and Access to Health Care, 274 JAMA 305 (1995); P.D. According to one report, employee contributions in 1996 accounted for approximately 30 percent of total health insurance premiums. 102 Pub. 42 See generally Dechene, supra note 18, 2.12.7, at 2-52. Beneficiaries who are eligible for Medicare benefits are automatically eligible for Part A hospital insurance. Part B services (according to Medicare.gov) include:. Medicare Part C is otherwise known as Medicare Advantage (formerly Medicare+Choice). Some Medicare beneficiaries receive additional health insurance through employer provided retirement programs. See supra Chapter 1. Official websites use .gov 4 (Kaiser Comm'n on Medicaid & the Uninsured, Issue Paper Pub. There is no inherent reason we can't have a nationwide market based on something like eBay, where people can go online with very little intermediation cost and buy into a national risk pool . You should individually be able to buy group insurance."). 144 Id. Co. v. Royal Drug Co., 440 U.S. 205, 221, 224 (1979) ("[T]he primary concern of both representatives of the insurance industry and the Congress was that cooperative ratemaking efforts be exempt from the antitrust laws" as long as they were regulated by the state.). See generally, U.S. Dep't of Health & Human Services (HHS), Choosing a Medigap Policy: A Guide To Health Insurance For People With Medicare, at http://www.medicare.gov/Publications /Pubs/pdf/02110.pdf. See also Antos 9/30 at 121-22; Lemieux 9/30 at 144-47. We provide state of the art advice about reimbursement from government and private sources. One survey found that the number of PPOs increased sevenfold between 1987 and 1994.155 Another survey found that the number of employees enrolled in PPOs doubled between 1994 and 2002, and that in 2002, 50 percent of all employees enrolled in health insurance used PPO products.156 It is difficult to obtain precise and reliable data on the number of PPOs and their exact enrollment.157 Commentators attribute PPOs' rapid expansion to private insurers' attempts to control spiraling medical costs, providers' defensive reactions to the growth of HMOs, and consumer and employer preferences for greater choice in selecting primary care and specialized physicians than many HMOs offered.158, Some commentators believe PPOs have had considerable success in obtaining volume discounts from physician-participants.159 One study found that two national insurers offered physicians payments that on average were approximately 11 to 20 percent lower for PPO products than for their indemnity plans.160 Another commentator stated that PPOs began by paying physicians about 20 percent less than their average charge, but some "more aggressive" payors have asked providers to accept a fixed discounted-fee schedule for all services, often based on a Medicare fee schedule.161, Commentators state that most physicians are willing to accept the discounted fees that PPOs offer because they expect to obtain additional patients.162 Many PPOs include a "rapid payment" clause for certain claims, which makes their plans more appealing to providers.163 Two panelists noted that a consumer may end up paying higher prices if their physician ceases to participate in the PPO but the consumer continues to see that physician.164 Some panelists noted that physicians typically participate in multiple PPO and HMO plans, which can increase contracting costs.165, Commentators question whether PPOs provide sufficient incentives for the delivery of cost-effective care.166 A panelist observed that consumers enrolled in PPOs can easily refer themselves to specialists, which can lead to excess costs.167, Some commentators believe that PPOs can improve quality of care by implementing utilization review, creating clinical protocols, and using credentialing.168 Although PPOs can undertake these steps on their own, payors are encouraging such strategies with economic incentives tied to various quality measures.169 Others question whether PPOs can improve quality, contending that PPOs may not be able to encourage or compel changes in physician behavior.170 They also argue that PPOs may not have sufficient access to quality-related data to implement certain care quality systems because "PPO participants are free to use out-of-network providers and no specific physician is responsible for all of their care."171. (PHS) 97-1525, 1997); Helen R. Burstin et al., The Effect of Change of Health Insurance on Access to Care, 35 INQUIRY 389 (1998-99); John A. Ayanian et al., Unmet Health Needs of Uninsured Adults in the United States, 284 JAMA 2061 (2000)). As one panelist remarked, "Medicare's administrative requirements shape the business environment for everybody in the health care sector and changes to the Medicare program have spillover effects on the rest of the market. 76 Alain Enthoven, Market Forces And Efficient Health Care Systems, 23 Health Affairs 25,25 (Mar./Apr. The uninsured and their families bear some of the costs for their health care. 186 Robert M. Williams, The Costs of Visits to Emergency Departments, 334 New Eng. The specific attachment point is the amount above which the insurer must reimburse the employer for eligible claims made by an individual plan participant. 171 See Hurley et al., supra note 151, at 65; but see Dechene, supra note 18, 2.4.2.3, at 2-12 (contending that provider-initiated PPOs may have greater access to performance related data). 191See, e.g., M. Ryan 3/26 at 32 ("[W]ith a high incidence of uninsured patients, we can find that we have a high incidence of patients who become inpatients for whom there is little or no reimbursement. This estimated figure varies significantly, however, depending on the time period employed and the survey data that is used. Health care investors turn to Ropes & Gray to evaluate whether a potential health care investment or acquisition will be profitable or a health care product or service worthwhile to license. 116 Id. 187 IOM, supra note 30, at 5. 157 See Wu 4/23 at 128 (stating that it is hard to find accurate data on PPO enrollment because PPOs "lack many of the reporting and operating standards that [apply to] HMOs. 67M. See Hyman & Hall, supra note 28, at 25. See also U.S. Dept. All Medicare beneficiaries are able to enroll in Part D, prescription drug plan. For example, some courts have held that a state's any willing provider laws will apply to PPOs established by an insurance company, even if the insurer is developing the PPO for use by an ERISA plan.48 Others have held such laws are preempted by ERISA.49 The Supreme Court's recent decision in Kentucky Ass 'n of Health Plans, Inc. v. Miller does not settle this area of the law.50, One speaker provided an overview of the priorities of employees and employers in dealing with health insurance coverage.51 Employees want good coverage at a reasonable price that is administratively simple, covers alternative treatments, and continues into retirement.52 Employees also are concerned about costs.53 A 2002 study reported that 43 percent of employees feared that their employment-based coverage would be cut back within the next year, 21 percent feared they would not be able to afford the increases in out-of-pocket expenses, and 8 percent feared they would lose their employment-based benefits within one year.54 From an employee perspective, if premium increases are larger than salary increases, take-home pay declines.55, Surveys reveal that choice is important to many employees, but employers vary greatly in the number of insurance plan options they offer their employees.56 The larger the employer, the more likely there will be more than one coverage option, but the health plan options can change from year-to-year.57, According to several panelists, employers are questioning whether they should be providing health insurance coverage.58 One speaker cautioned that employers cannot maintain the health care financing structure the way it is and, without changes, many employers will be forced to take more drastic measures with respect to providing employment-based health care coverage.59 Another speaker suggested that employers were likely to continue providing health coverage, but the amount of money they contribute will not keep pace with the cost of health care.60 Some panelists asserted that small employers face greater challenges than large employers.61, Some commentators criticize employment-based insurance coverage because it reflects the coverage preferences of employers instead of employees.62 Others argue that the existence of employment-based health insurance impedes achieving universal coverage.63 Some panelists suggest that the regulatory environment favors large employers over small employers and those that purchase individual policies.64, Despite these employee and employer misgivings, as well as commentator criticisms, one benefits consultant stated that there is a continuing role for employment-based coverage.65 He noted that employers can devote greater resources to understanding the various insurance product offerings and can represent a larger purchasing group than individual employees. Health care organizations, manufacturers and investors seeking reimbursement for goods and services need to understand an intricate set of rules and regulations. Pursuant to Implementation of Medicare Advantage Program, 42 U.S.C. 52 M. Young 6/12 at 91-94. v. Whitcomb, 778 F.2d 239 (5th Cir. at 7. It ought to be compatible across all the systems. We understand even the most controversial issues confronting providers and others. 1012-1014 (1945). Contact the Webmaster to submit comments. This rule has an important anti-fraud rationale, but it creates difficulties when services are more efficiently delivered without this requirement. Hospice care (according to Medicare.gov)is usually provided in the home, but it may also be covered in a hospice inpatient facility. (Fall 2000), available at http://hcs.harvard.edu/~epihc/currentissue/fall2000/barry.html; John Billings et al., Recent Findings on Preventable Hospitalizations, 15 Health Affairs 239 (Fall 1996); A.B. 61 See, e.g., M. Young 6/12 at 95-96; Gingrich6/12 at 15-16. The Act was a response to the Supreme Court's decision in United States v. South-Eastern Underwriters Ass'n, 322 U.S. 533 (1944), in which the Supreme Court held that insurance is commerce, and when transacted across state lines, is interstate commerce and subject to federal law, including the antitrust laws. 136 John Holahan & Brian Bruen, Medicaid Spending: What Factors Contributed to the Growth Between 2000 and 2002? Co. v. Massachusetts, 471 U.S. 724 (1985); Am. Sources and Regulation of Employment-Based Coverage. 16 NAIC, supra note 12, at 1. 80 See G. Kelly 6/12 at 118; G. Kelly (stmt), supra note 40, at 3, 5-6. 180 American College of Physicians, No Health Insurance? for Health Statistics, Vital Health Stat. Auto. 28 David A. Hyman & Mark Hall, Two Cheers for Employment-Based Health Insurance, 2 Yale J. There are two types of attachment points - specific (or individual) and aggregate. 1999); Sharon Silow-Carroll et al., In Sickness and In Health? 172 Mills & Bhandari, supra note 2 at 1, 4. 68M. 162 See Folland et al., supra note 153, at 257 ("[T]he provider may enjoy a large increase in patient care business by joining the network. 163 Folland et al., supra note 153, at 257; Wagner, supra note 151, at 21. (noting that exclusion from income in a progressive tax system means that subsidy varies with income, with greater subsidies going to those with higher incomes). 75 Butler, supra note 29, at 23-24. See Myths about the Uninsured: Hearing on the Uninsured Before the Health Subcomm., House Comm. There is no legal obligation to purchase health insurance. v. Blue Cross & Blue Shield, 522 N.W.2d 902 (Mich. Ct. App. M+C was renamed Medicare Advantage (MA) pursuant to the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA).102 MA allows Medicare beneficiaries to join privately operated managed care plans.103 The plans are paid an administratively determined rate by Medicare and plans also may charge an additional premium and offer additional benefits.104 Medicare beneficiaries who joined MA plans often received greater benefits (e.g., prescription drug coverage) in exchange for accepting limits on their choice of providers.105 In 2002, MA plans were providing health care to 5 million Medicare beneficiaries, down from 6.35 million enrollees in December 1999.106 Congress added a new Part D to Medicare as part of the MMA. HIPAA also contains a number of provisions relating to fraud and abuse enforcement, which are not addressed in this Report. The Mental Health Parity Act generally requires group health plans and insurers to provide for parity in lifetime and annual dollar limits on mental health benefits with dollar limits on medical and surgical benefits. As of January 1, 2004, employees may contribute to health savings accounts that can earn tax free interest and be rolled over from year to year. See also Royal Drug, 440 U.S. at 221-24, 229-30 n.36 & 37; St. Paul Fire & Marine Ins. Gabel etal., Employers' Contradictory Views About Consumer-Driven Health Care: Results from a National Survey, 2004 Health Affairs (Web Exclusive) W4-210, 214, 217&218n.13 (noting the first evaluations of employers' views about consumer-driven health care's impact are ambiguous), at http://content.healthaffairs.org/cgi/content/full/hlthaff.w4.210v1/DC1; Mark A. 1985), Moore v. Provident Life & Accident Ins. 1, 6 fig.2, 7. The McCarran-Ferguson Act was adopted in 1945 to resolve a dispute over the authority of state and federal governments to regulate the business of insurance.8 The McCarran-Ferguson Act clarified that the states had the authority to tax, license, and regulate insurance companies regardless of the insurance company's state of incorporation, as well as the authority to allow insurance companies to engage in cooperative rate-making.9 Section 2(b) of the McCarran-Ferguson Act specifically reserved authority for Congress to enact laws superceding state insurance laws and regulations, as long as the federal law specifically relates to the business of insurance.10. 169 See Buxton 5/8 at 99 (stating that Blue Cross and other payors are working on the use of tiered fees for physicians to encourage higher quality outcomes and also stating that such incentives are "the wave of the future. 130 Id. 135 See Id. With end-stage renal disease (ESRD) requiring dialysis or kidney transplant, Part A services are reported by hospitals using diagnosis codes and procedure codes that together determine Medical Severity-Diagnosis Related Groups (MS-DRG) assignment, according to, Step-by-Step Medical Coding, 2018 Edition., Drugs while being treated in the hospital, Phone and television in the room unless included in the room charges. The Business of Medicine? 65 M. Young 6/12 at 99; Darling 6/12 at 107. Co. v. Pireno, 458 U.S. 119, 129(1982). 155 Norton & Zuckerman, supra note 153, at 78. 106 Pizer & Frakt, supra note 104, at 83 & n. 1. Attorney advertising. ); funding requirements (29 U.S.C. at 86. See also Eric R. Wagner, Types of Managed Care Organizations, in Essentials of Managed Health Care 21 (Peter R. Kongstvedt ed., 4th ed. 1395c. J.L. See also Kaiser Family Found., supra note 52, 4, at 64 (38 percent of covered workers have just one plan option; 74 percent of large employers offered employees a choice between at least two health plans versus 26 percent of small employers (less than 200 employees) that offered a choice). 158 Dechene, supra note 18, 2.1, at 2-3, 2.2, at 2-5 ("Many [PPOs] were formed as a defensive alternative to the growth of HMOs. "83 Another panelist identified a number of regulations that restrict competition -sometimes by design, and other times unintentionally.84, In 1999, approximately 16 million working-age adults and children almost seven percent of the population under the age of 65 obtained health insurance coverage through individually issued, non-group policies.85 One set of commentators suggest the small market share for individual health insurance is due, at least in part, to the tax-subsidies provided for employment-based coverage.86 Individual insurance policies generally are more expensive than group policies because there is no spreading of underwriting risk, and adverse selection and marketing and administrative expenses are greater than with group policies.87 Nonetheless, according to two panelists, regulation has altered this situation in some states, making small group coverage more expensive than individual insurance.88 Consumers can obtain guidance about purchasing individual policies from various sources, including insurers, government, industry associations, and independent groups.89.

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