BROKERS & EMPLOYERS: CONSIDER A MEDICARE CARVE-OUT OPTION FOR BENEFIT COST REDUCTION.
Posted: 12/5/2011 9:14:06 AM | By: Nanette Poserina
File Under: HISI News

Express Scripts — your smart choice for Medicare.re Solutions 2

As a plan sponsor trying to determine the best Medicare program to offer your retirees, you may find it difficult to decipher all the complexities. Medicare comprises many moving pieces. There are a lot details to understand and manage. On the plus side, you have a varietyof options available, and we have the expertise to help you implement the optimum solution.

Express Scripts is an industry-leading pharmacy benefit manager (PBM) with extensive knowledge of Medicare programs and requirements. Our experience, clinical insight and operational strength are delivered through a dedicated team of experts. At Express Scripts, we are always in alignment with you. That means your best interests are our best interests.

And because we are on the same side, we develop your Medicare offering as if our own dollars and beneficiaries were at stake.

We understand your goals are to provide a quality benefit, simplify plan management and get the best value for your plan dollar. Our best practices focus on evidence-based clinical solutions and member satisfaction, while maximizing cost effectiveness. Since no two situations are identical, we first evaluate your specific circumstances and then define the optimal strategy. The result is an effective and appropriate plan tailored to your unique needs.

Bonus points.

Put your best option in play. Avoid leaving money on the table. Express Scripts has demonstrated expertise in reducing both operational costs and drug spend while maximizing Centers for Medicare & Medicaid Services (CMS) reimbursement. More than 400 plan sponsors who have opted for retiree programs through Express Scripts have received over $1.5 billion in federal subsidies or savings on retiree prescription drugs. We will work with you to determine which type of Medicare program yields the optimum benefit for your plan and your retirees. Our proprietary analytics and savings modeling allow us to compare options and develop a solution that saves your plan the most money and best meets the needs of your retiree population. In addition, a well-run Medicare program can help reduce your total healthcare spend. Through cost-effective, clinically appropriate programs and targeted, behavioral science-based messaging, beneficiary claims can be managed to the lowest possible cost.

Your Medicare prescription benefit options include:

Prescription-Drug Plan (PDP)

Power Plan

Premier Plan

Retiree Drug Subsidy (RDS)

Medicare Part B plan paired with either of the PDPs or an RDS plan

The Express Scripts Medicare Part B program is both a complement to your other Medicare programs as well as a stand-alone option. It is a “complete solution” because we handle virtually everything for you.

HHS DOES NOT EXEMPT INSURANCE AGENT COMMISSIONS IN FINAL MLR RULES
Posted: 12/5/2011 8:38:24 AM | By: Nanette Poserina
File Under: HISI News

HHS DOES NOT EXEMPT INSURANCE AGENT COMMISSIONS IN FINAL MLR RULES

By Bob Graham

Posted: December 4, 2011

Update: Added comments from Independent Insurance Agents & Brokers of America, 12/5/11, 8:27 a.m. ET.

The U.S. Health and Human Services Department issued final rules for its medical loss ratio, declining the request of insurance agent trade groups and state insurance regulators to exempt agent and broker compensation.

Janet Trautwein

The thwarting of ongoing efforts to free agent and broker commissions from the MLRs came as the HHS’ Centers for Medicare & Medicaid issued its final rule for the MLRs. The MLRs are a key piece of implementing the Patient Protection and Affordable Care Act, passed in March 2010, which “will ensure health insurance companies spend at least 80% of consumers’ health insurance premiums on medical care, not income, overhead and marketing,” according to an HHS statement.

Since the new rule took effect Jan. 1, some agents and brokers have seen up to a 50% reduction in their commissions as carriers sought not to run afoul of the rule, according to a Government Accounting Office analysis. Carriers must invest at least 80% of individual and small-group premiums, and 85% of large-group premiums on medical care, leaving the remainder for administrative costs, including agent and broker compensation.

Insurance companies that fail to meet the new standard are required to provide a rebate to consumers.

The National Association of Insurance Commissioners (NAIC) was specifically charged by Congress to craft MLR guidelines for the federal reform law, said Janet Trautwein, CEO of the National Association of Health Underwriters, in a statement.

“Just last week, the NAIC passed a resolution urging HHS and Congress to take action to preserve the role of professional health insurance agents and brokers as consumer advocates and advisors,” Trautwein said. “This unprecedented action by the NAIC shows the commitment of our nation’s state insurance commissioners to protecting consumer and employer access to professional health insurance agents and brokers, and we will continue to work with HHS to find an acceptable solution to this ongoing problem.”

Trautwein called on Congress to support the NAIC’s recommendation and address the “critical issue” by passing H.R. 1206, e bipartisan legislation introduced by Representatives Mike Rogers (R-Mich.) and John Barrow (D-Ga.) that would exclude agent and broker compensation from the MLR calculation and provide state insurance regulators with greater flexibility with medical loss ratio implementation.”

The federal reform law is the subject of more than 20 federal challenges, including one that the U.S. Supreme Court will rule on next year. If the law were invalidated by the court, it remains unclear what might happen to agent and broker compensation.

Charles Symington, senior vice president of government affairs for the Independent Insurance Agents & Brokers of America (Big I), said the group is “extremely disappointed” in the final rule, saying HHS “completely ignored” the NAIC’s recently passed resolution.

“This relief is essential in order for consumers to have continued access to the professional services of agents and brokers,” Symington said. “It was our association’s understanding that the administration looked to the state insurance regulators for their expertise on this issue. For this final regulation to have been issued with no changes to the treatment of agent compensation so quickly on the heels of the NAIC’s resolution is surprising and will not only harm our thousands of small business owners but most importantly the consumers they serve.”

The MLR rule applies to health plans covering about 74.8 million Americans. Estimates from last year indicate that, starting in 2012, up to 9 million Americans could receive rebates worth from $600 million to $1.4 billion, according to HHS officials.

HHS says any MLR rebates will not be taxed. Rather than having insurers send checks that could be taxed, workers in group health plans can receive rebates in a way that is not taxable, HHS said.

Consumers will receive a notice, showing not just the amount of any rebate, but also what the insurer’s MLR means regardless of whether there is a rebate, and how the insurer’s MLR has improved under the new law. In addition, data on the special types of plans, mini-meds and ex-patriate plans, will be publicly posted in the spring, HHS said.

Keep strong policies on how MLR is calculated: The final rule makes only a minor change to a quality improvement definition to promote insurer improvements in defining or coding of medical conditions for a limited window of time.

The new rules “phase down the special circumstances adjustment” for mini-med plans. In 2011, so-called mini-med plans received a special circumstances adjustment to their MLR in the form of a multiplier of 2.0 for 2011. The final rule phases it down from 1.75 in 2012 to 1.5 in 2013 and 1.25 in 2014. Mini-med plans will be banned by the prohibition on annual limits in the federal reform law, starting in 2014.

The final rule, after reviewing data, keeps the ex-patriate plan multiplier adjustment at 2.0 because of their “unique structure,” officials said. The multiplier also “levels the playing field between non-profit and for-profit insurers in states with premium taxes.”

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SUPREME COURT WILL HEAR HEALTHCARE REFORM CHALLENGE THIS SPRING
Posted: 11/15/2011 4:58:38 AM | By: Nanette Poserina
File Under: HISI News

November 14, 2011

In This Issue

	Supreme Court Will Hear PPACA Challenge This Spring
	NAIC to Vote on Agent and Broker Resolution on November 22
	Time’s Almost Up, Supercommittee
	Georgia Granted Partial MLR Relief
	The HIT Will Be Significant, According to the NFIB
	This Week in Washington
	Have You Registered for Capitol Conference 2012?

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Supreme Court Will Hear PPACA Challenge This Spring

This morning, the U.S Supreme Court granteda writ of certiorari in the challenge that 26 states and the National Federation of Independent Businesses (NFIB) have raised against the Obama administration regarding the constitutionality of the Patient Protection and Affordable Care Act (PPACA). Today’s announcement sets the stage for oral arguments by March and the potential for a decision in late June—right in the midst of the 2012 presidential campaign.

Today's action by the Supreme Court isn’t particularly surprising; on the day the law was signed, there were experts predicting that PPACA would wind up on the Supreme Court docket. However, the information released by the court regarding their consideration is significant because it gives a number of key clues as to how the case will progress in the months going forward.

First of all, even though the justices discussed five appeal challenges to PPACA (and are slated to consider a sixth challenge by the Commonwealth of Virginia next week), they decided to only grant certiorari to the 26-state/NFIB challenge. This case was previously heard by the United States Court of Appeals for the 11th Circuit, in Atlanta, which has thus far been the only appeals court to declare the individual mandate provisions of PPACA unconstitutional. However, the 11th Circuit declined to strike down the rest of PPACA as the plaintiffs requested, even though the law does not contain a “severability clause.” The 11th Circuit also upheld the law’s expansion of the Medicaid program, rejecting the state’s contention that that it also exceeded congressional authority.

When setting the scope of its hearing on the case today, the Supreme Court allowed for five and a half hours of oral arguments. That may not seem like a lot for a challenge to a 1,000+ page law, but for the Supreme Court, this is a unprecedented amount of time. The court has agreed to hear arguments about not only the mandate, but also the law’s Medicaid expansion, and whether or not certain provisions of the law, like the individual mandate, may be “severed” from the rest of it. It’s the contention of the NFIB and the states that if one provision is struck down, the entire law must be as well because the measure does not contain a “severability clause,” and even the Obama administration has said publicly that it is “absolutely intertwined” with at least the insurance market reform provisions of the measure that make all policies guarantee issue and bar the consideration of preexisting conditions from 2014 on forward.

The justices will also hear at least an hour of arguments as to whether a federal tax law, the Anti-Injunction Act, should apply in this case. The Anti-Injunction Act prevents court action on a tax until it actually takes effect. The individual mandate penalties do not take effect until 2014, so if the court finds that the law applies, it would prevent review of the mandate until at least 2014. However, in defending the constitutionality of the individual mandate up until this point, the Obama administration has repeatedly argued that the penalties are just that—penalties—and not a tax, so the commerce clause of the Constitution should not apply. It would be hard for them to change their argument now and support a delay on a mandate ruling until 2014.

Finally, the court’s action today seems to indicate that all nine justices will be involved in deciding this case. Various groups have been arguing that both Justices Elena Kagan and Clarence Thomas should recuse themselves from the case. A variety of conservative activists have been arguing for months that Kagan should recuse herself, since she previously served as President Obama’s Solicitor General. However, Kagan and the Justice Department have long maintained that Kagan was never involved in the development and defense of this case. PPACA supporters have encouraged Justice Thomas to recuse himself since his wife has lobbied for entities that have opposed the law, and some groups feel this alleged conflict of interest was not disclosed. However, the court documents released today showed that neither justice exempted themselves from the consideration of whether or not certiorari should be granted in this case. Kagan did recuse herself from discussions in six other matters, but not the health care cases. It seems clear, at this point, that both justices plan to participate.

Both sides expressed support for the Supreme Court’s actions today. The administration commented almost immediately, saying, “we know the Affordable Care Act is constitutional and are confident the Supreme Court will agree.” Karen Harned, executive director of NFIB’s Small-Business Legal Center, said in a statement “After months of uncertainty and frustration, small-business owners are finally within the reach of some clarity on how this law will ultimately impact their lives and their livelihoods.”

HISI.NEWS RELEASE

PAHU HEALTH REFORM: RESOURCES
Posted: 10/27/2011 10:17:53 PM | By: Nanette Poserina
File Under: HISI News

PAHU’S PATH TO CONSTRUCTIVE HEALTH REFORM: RESOURCES

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We believe all Americans deserve a health care system that delivers both world-class medical care and financial security. Americans deserve a system that is responsible, accessible and affordable. This system should boost the health of our people and our country's economy. Americans also deserve a system that is realistic. An American Solution—NAHU's Vision for Affordable and Responsible Health Care Reform is a comprehensive approach to meeting this challenge, and a yardstick for evaluating other proposals.

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As implementation of the Patient Protection and Affordable Care Act (PPACA) progresses, NAHU is dedicated to ensuring continued access to the crucial services of state-licensed health insurance agents, brokers and consultants who work on a daily basis to help individuals and employers of all sizes purchase health insurance, use their coverage effectively and make sure they get the most out of the benefits they have purchased. Consumers' need for help from a licensed professional will only increase as the new health reform law is fully implemented and the compliance demands on employers and individuals increase.