Health Care Reform and You

Health Care Reform and You  MSA’s New H ACA Health Plans ? Health care reform means new and “reformed” health plans. We’ve enclosed a summary compa...
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Health Care Reform and You  MSA’s New H ACA Health Plans

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Health care reform means new and “reformed” health plans. We’ve enclosed a summary comparison of our new plans that comply with the Affordable Care Act (ACA) for individuals and small businesses (with up to 50 full-time employees). Most plans start January 1, 2014. Open enrollment for these plans began on October 1, 2013, and ends on March 31, 2014. We’ve highlighted some of the plans’ key elements below. Essential Health Benefits: Under the law, all plans must now include coverage (in some cases, without a member copayment) for 10 essential health benefits (EHBs). • Prescription drugs. • Ambulance service. • Emergency care. • Hospitalization. • Laboratory services. • Maternity and newborn care. • Mental health and substance use service. • Pediatric oral and vision services. • Rehabilitation and habilitative services. • Services for preventive care, wellness, and chronic disease management. Benefits in front of the deductible: To better support our members’ total health, we placed some benefits in front of the deductible. This means that our members can receive these services for a copayment even before they’ve met their plan deductible. Some of the benefits your patients can receive before they meet their deductible include:

• HMSA’s Online Care visits ($0 copayment). • Annual physical exams (well visits) — individual plans. • Generic prescriptions. • Adult vision benefits — individual plans. • Pediatric vision benefits. Additionally, Young Adults and Catastrophic plan members can use three physician visits per year at a copayment of $50 per visit before their deductible. Value-Added Benefits: Maintaining our focus on well-being and preventive care for our members, we’ve included value-added benefits in some of our individual plans. Copayments for these benefits don’t count toward a member’s deductible or maximum out-of-pocket cost. Benefits include: • Fitness membership ($75 annual copayment) for Bronze, Young Adults, and Catastrophic plans. • Complementary and Alternative Medicine (CAM) ($20 copayment, 12-visit maximum). Platinum members can use a CAM visit to see an acupuncturist, chiropractor, and/or medically referred massage therapist. All CAM specialists must be members of American Specialty Health. 1

 MSA’s New H ACA Health Plans (continued)

Non-Accumulating Benefits: These benefits don’t accumulate toward members’ maximum out-of-pocket costs: • Adult vision (if applicable). • Annual physical exam (well visit) for adults 22 years and older (if applicable). • Fitness membership (if applicable). • CAM visits (if applicable). Financial Assistance: Qualified individuals and small businesses may be eligible for federal subsidies and tax credits to help pay for their health insurance. • Individual Plan Members: -M  embers whose income is below 138 percent of the federal poverty level may be eligible for QUEST (Medicaid) coverage.

SUBSIDY ELIGIBILITY FOR INDIVIDUALS

- Members whose income is between 250 percent and 400 percent of the federal poverty level may qualify for a premium tax credit only.

Eligible for tax credit to lower premiums Eligible for cost-sharing subsidy to lower out-ofpocket costs

- Members whose income between 138 percent and 250 percent of the federal poverty level may qualify for a cost-sharing subsidy and a premium tax credit. The federal poverty level is determined by state and varies by the number of people in a household. In 2013, the Hawaii federal poverty level for a one-person household is an annual income of $13,230; for a four-person household, it’s $27,090. Tax credits and cost-sharing subsidies are available only through the state’s health insurance marketplace, the Hawai‘i Health Connector. If your patients have any questions about their eligibility for QUEST or financial assistance, have them contact HMSA. • Small Businesses: Employers may receive a tax credit of up to 50 percent of the total cost of premiums for two consecutive years beginning in 2014. The average annual employee wage must be less than $50,000, and the employer can’t have more than 25 “full-time equivalents” (that is, the total number of non-overtime hours worked by all employees of the company can’t exceed 1,000 per week). Tax credits are only available through the state’s health insurance marketplace, the Hawai‘i Health Connector. Small businesses are advised to consult their tax advisers. Note: Young Adults and Catastrophic plan members aren’t eligible for subsidies. 2

Eligible for QUEST Federal Poverty Level (FPL)

138%

250%

400%

Subsidy based on household size and income as percentage of FPL.

 reventive Health: P Tobacco Counseling ACA’s essential health benefits include preventive health services, like tobacco cessation. Patients who smoke or use other forms of tobacco have options to quit and resources to help them. Provider Counseling Research has shown that a doctor’s encouragement to stop smoking or using tobacco can be one of the strongest motivations for patients to quit. We encourage your efforts to talk with your patients about the health benefits of a tobacco-free lifestyle.

50% In your conversations:

of the cost of coverage • Review your patients’ tobacco histories.

• Identify any barriers they may have to quitting or getting help.

• Provide your patients with options to change their behaviors. Be sure to use the billing codes listed below for your counseling sessions.

Provider Counseling Billing Codes SERVICE

Tobacco use and tobacco caused disease

CPT OR HCPCS CODE

DESCRIPTION

99201 – 99215*

Office or outpatient visit for a patient who uses or smokes tobacco. The visit must cover: (1) the history of the tobacco use, (2) physical exam, and (3) a recommendation for further counseling and/or coordination of care. Differences in codes are time-based.

99401 – 99404

Preventive health care counseling that covers ways to reduce risk factors. Differences in codes are time-based.

99406

Smoking and tobacco cessation counseling (intermediate), longer than three minutes but up to 10 minutes.

99407

Smoking and tobacco cessation counseling (intermediate), longer than 10 minutes.

G0436†

Smoking and tobacco cessation counseling for asymptomatic patient (intermediate), longer than three minutes but up to 10 minutes.

G0437†

Smoking and tobacco cessation counseling for asymptomatic patient (intermediate), longer than 10 minutes.

* ICD-9 Codes V15.82 and 305.1 are required.



Modifier 33 is required.

Tobacco Cessation Resources • Nicotine Replacement Therapy: Prescription smoking-cessation drugs include Chantix®, Zyban and its generic, Nicotrol® Inhaler, and Nicotrol® NS (nasal spray). Over-the-counter (OTC) smoking and tobacco cessation aids include generic/brand nicotine patches, gum, and lozenges. Health plans with ACA benefits don’t have a copayment for Chantix or generic Zyban. Coverage varies by health plan; check your patient’s drug coverage on HHIN or by calling CVS/ pharmacy at 1 (855) 240-0543 toll-free (commercial plans), 1 (855) 479-3659 (Medicare Part D), or 1 (855) 220-5732 (QUEST). Note: All covered nicotine replacement therapies have a quantity limit of 180 days per calendar year.

• Support Network: Developed by Healthways, HMSA’s well-being solutions partner, QuitNet (www.quitnet.com) is the nation’s largest online support community for smokers who are trying to quit. The program features coaching sessions (available online or over the phone) with a Hawaii-based health coach, national online peer support, and a variety of online support tools. QuitNet is available to HMSA members at no charge. • Nicotine Patches and Gum: The Hawaii Tobacco Quitline offers coaching and OTC nicotine patches and gum to patients free of charge. Visit www.clearthesmoke.org or call 1 (800) 784-8669. 3

Hanalei

KAUAI Kapaa Mililani Waipahu Lihue Waialua

Waimea

 Potentially Growing A Membership Base

Koloa

Wahiawa Koolauloa

O

Koo

Waianae Kapolei - Makakilo Ewa - Kalaeloa

One of the most talked-about components of health care reform is the health insurance coverage mandate. Beginning January 1, 2014, almost everyone must have health insurance or pay a fine. Because of this and the expanded coverage of Medicaid (QUEST in Hawaii), we expect to see an influx of formerly uninsured people coming into the market.

Hickam - Pearl City

Ala Moana - Nuu Downtown - Kalihi Airport - Moanalua

In the state of Hawaii, an estimated 99,000 people don’t have health insurance. • About 11 percent of the state’s uninsured are children 18 years and younger. • On Oahu, Kauai, Maui, Molokai, and Lanai, about a third of all uninsured adults (ages 19 to 64) will be eligible for QUEST, about a third will be eligible for a federal subsidy through the state’s health insurance marketplace (Hawai‘i Health Connector), and about a third will remain uninsured. • On Hawaii Island, up to 86 percent of uninsured adults will be eligible for either a federal subsidy or for QUEST. We mapped out the general locations of the state’s uninsured adults who are projected to enter the market. This map will give you a general idea of the growth you may see in your practice’s area. Based on current trends, HMSA captures about 50 percent of the individual plan market and 54 percent of the QUEST market across the state — these numbers will vary by island and city/town. HMSA estimates a gain of about 37,000 new members (about 22,000 will be eligible for QUEST and 15,000 will be eligible for individual plans). New HMSA members will get a new member packet that emphasizes the importance of selecting a primary care provider (PCP) and information to help them choose one. We’re also encouraging PCPs to accept new patients if they have the capacity. We’ll let you know when actual enrollment information becomes available. Please take a moment to check your new patient status with HMSA. Go to hmsa.com, click on Find a Doctor, and search for your name. Click on View Details to see if we list your “accepting new patients” status correctly for each plan. To make changes to your status, call 948-5190 on Oahu or 1 (800) 603-4672, ext. 5190, toll-free on the Neighbor Islands, or email Provider Services at [email protected]. 4

LANAI

Uninsured Adults Projected to Enter the Market

OAHU

Kauai Lihue Waimea Hanalei Koloa Kapaa

600 700 800 800 1,500

olaupoko

Oahu Koolaupoko

5,600

Waianae Hickam - Pearl City Waipahu Downtown - Kalihi Ala Moana - Nuuanu Airport - Moanalua Ewa - Kalaeloa Mililani Waikiki - Palolo Hawaii Kai - Kaimuki McCully - Makiki Kapolei - Makakilo Wahiawa Koolauloa

4,600 4,500 3,800 3,400 2,900 2,700 2,300 2,200 2,100 2,100 1,800 1,700 1,400 1,100

Makapuu, Waimanalo, Kailua, Kaneohe, Kahaluu, Kualoa

McCully - Makiki Hawaii Kai - Kaimuki Waikiki - Palolo uanu

MOLOKAI

Wailuku

MAUI Makawao

Kaaawa, Hauula, Laie, Kahuku

Waialua

Lahaina

Molokai

600

Lanai

100

Maui Makawao Wailuku Lahaina Hana

3,800 3,400 1,300 300

Hawaii Island Hilo Puna Kau North Kona South Kona South Kohala Hamakua North Kohala

2,900 2,700 2,100 1,900 1,300 1,000 700 400

600

Hana

North Kohala Hamakua

HAWAII ISLAND South Kohala Hilo

0 - 999 1,000 - 1,999

North Kona Puna

2,000 - 2,999 3,000 - 3,999

4,000 - 4,999

Kau South Kona

5,000 - 5,999

5

T  he ACA 90-Day Grace Period ACA Law: Under the Affordable Care Act (ACA), members receiving a premium tax credit for an individual health plan will have a grace period of three months to pay their premiums. (This grace period only applies to members who have paid their first month’s premium. Members who don’t pay their bill for the first month of coverage will have their plans canceled.) The insurer must pay claims for these members for services provided during the first month of the grace period. The law allows insurers to mark services rendered during the second and third months of the grace period as pending and deny those services if members don’t pay their premiums. HMSA’s Policy: We want to minimize the impact of ACA-related changes on you. So we’ll pay all claims for services rendered during all three months of the grace period. Members who have not paid their premiums after 90 days will lose their coverage. Once a member’s coverage has been canceled, we’ll deny all subsequent claims for that member. We’ll continue to monitor this situation and let you know of any changes we make to this policy in the future.

90 DAYS HMSA

InsuraHealth nce X

 laims, Diagnosis Codes, C and Risk Adjustment HMS

A

InsuraHealth nce Y

For patients who got their health plans through the state’s health insurance marketplace the Hawai‘i Health Connector payments will be adjusted for their health statuses and/or disease burdens. This “risk adjustment” will be based only on the diagnosis codes you note in your claims information. In contrast, for patients who got their plans directly from HMSA, we may consider additional information to further clarify their conditions. What does this mean? The degree of detail with which you code your claims becomes even more important. We encourage you to use as many diagnosis codes as you need to most accurately reflect your patients’ health statuses and the impact of their treatment. 6

You

 remiums Changing P for Small Businesses The Affordable Care Act (ACA) will bring new health plans and premiums next year for businesses with up to 50 full-time employees. Plans will have added benefits such as prescription drug and children’s dental coverage. The ACA now requires HMSA and all other health insurers to rate individuals working at small businesses separately by age. For example, a company with 30 employees and dependents could have 30 different rates. The new benefits and age rating will cause rates to change for many businesses when they renew next year. HMSA can help small businesses prepare for this change. Contact your group’s HMSA representative or call 948-5555, option 3, on Oahu or 1 (800) 620-4672 toll-free on the Neighbor Islands.

You

EMPLOYER A

EMPLOYER B

 hy Should Your W Patients Choose HMSA? Options. HMSA offers your patients the largest provider network in Hawaii with more than 95 percent of the state’s doctors, specialists, hospitals, and other providers. Experience. A local nonprofit association, HMSA has been reliably serving the people of Hawaii for 75 years, the longest of any health plan in the state.

HMSA Have your patients call HMSA’s health care reform helpline at 948-6387 on Oahu or 1 (800) 465-4672 toll-free on the Neighbor Islands, Monday through Friday, 8 a.m. to 5 p.m. Or visit hmsa.com/reform.

Value. HMSA offers your patients top value for their health care dollar. We keep administrative costs low and spend more than 91 percent of premiums on health care.

Acronym Glossary

Service. HMSA provides in-person service at our neighborhood centers and local offices.

HCR Health care reform (refers specifically to ACA).

If your patients have questions about health care reform or if they want to choose HMSA, we’re here to help. We know our plans best, and our health plan experts can balance your patients’ health care needs with affordability to find the plan that’s right for them.

ACA The Affordable Care Act, passed into law March 2010, with many changes starting January 1, 2014.

EHB Essential health benefits, 10 benefits that every health plan must cover by law. CAM Complementary and Alternative Medicine. Information in this newsletter is based on HMSA’s review of the Affordable Care Act (ACA), also known as health care reform. It’s intended for informative purposes only and shouldn’t be used as tax, legal, or compliance advice. 7

Hawai‘i Health Connector The Affordable Care Act requires that states set up a neutral exchange (or marketplace) where individuals and employees of small businesses (up to 50 full-time employees) can compare, enroll, and buy health plans. Hawaii’s state health insurance marketplace is the Hawai‘i Health Connector. Here’s what you need to know: • The health plans offered on the Hawai‘i Health Connector have the same benefits as those offered outside the exchange.

Hawai‘i Health Connector

HMSA

• Employees of small businesses and individuals don’t have to use the Hawai‘i Health Connector to buy health insurance. They can go directly to a health plan like HMSA to get coverage.

HMSA Health Insurance X

HMSA Centers With a renewed focus on making health care information more accessible for consumers, HMSA will begin opening three neighborhood centers this year. At HMSA Centers, members and nonmembers can learn about health plan options, health care reform, and ways to maintain their overall health and well-being. MEDICAID EXPANSION No Rescissions HMSA plan experts will help consumers find and enroll in health NO denial because of pre-existing conditions plans that best meet their needs. Members will be able to pay their NoThe Lifetime/Annual Limits bills or talk to experts about claims and benefits. centers will PREVENTIVE CARE SERVICES also be a place for HMSA to hold community eventsEssential where peopleHealth Benefits SUBSIDIES can get health screenings and learn more about maintaining October 1, 2013 aindividual mandate Dependent Coverage Hawaii Health Connector healthy lifestyle.

Affordable Care Act

Tax Credits

Up to Age 26 Rating by age and tobacco use

Welcoming both members and nonmembers, HMSA Centers @ Honolulu opened on October 1, and centers are scheduled to open in Pearl City late October and Hilo (later this year).

8

Health Insurance Y

?

October 1, 2013 Essenti Hawaii Health Conn

Dependent Coverage Up

Affordable Care Ac

PREVENTIVE CARE SERV

October 1, 2013 guaran

Rating by age and tobacco u

individual mandate ME SUBSIDIES Tax Credits N

No Lifetime/Annual L

HMSA Center @ Honolulu Opened October 1, 2013

HMSA Center @ Pearl City Opens late October 2013

HMSA Center @ Hilo Opens late 2013

818 Keeaumoku St. 983-7281 Monday–Saturday, 8 a.m.–6 p.m.

Pearl City Gateway Center 1132 Kuala St., Suite 400 983-7282 Monday–Saturday, 9 a.m.–7 p.m.

Waiakea Center 325 E. Makaala St., Suite 303A 933-9093 Monday–Saturday, 9 a.m.–7 p.m.

(00) 1100-0289 10.13 AM

• Subsidies and tax credits are only available for health plans purchased on the Hawai‘i Health Connector.