Healthcare Association of New York State Jeffrey Gold & Cara Zucker Henley January 10, 2012.

Healthcare Association of New York State www.hanys.org

The Healthcare Legislative Landscape

Jeffrey Gold & Cara Zucker Henley

•January 10, 2012


FEDERAL LEGISLATIVE UPDATE


vs.Representative

Michele Bachmann(R - Minnesota)

Former Representative Newt Gingrich(R - Georgia)

GovernorJon Huntsman

(R - Utah)

Former Representative Ron Paul

(R - Texas)

GovernorRick Perry(R - Texas)

Former GovernorBuddy Roemer(R - Louisiana)

Former GovernorMitt Romney

(R - Massachusetts)

Former SenatorRick Santorum

(R - Pennsylvania)

Federal Landscape - Election 2012

PresidentBarack Obama

Iowa CaucusWinner

Dropped Out

Iowa CaucusRunner Up

http://en.wikipedia.org/wiki/File:Bachmann2011.jpg
















Federal Landscape – Challenge to PPACA

• In fall 2010, the Supreme Court agreed

to hear Florida et. al. v. United States

Department of Health and Human Services

• The Supreme Court will hear oral arguments beginning March 26

• A decision is expected in the late fall


Health Benefit Exchanges

• Virtual marketplace where individuals and small businesses can compare and purchase health insurance policies


A Brief Timeline

2013 2014 2015

HHS to certify each State’s

Exchanges or elect to oversee

Exchange operations

State based Exchanges must be operational

State based Exchanges must

be financially self sustaining


State Action to Implement Health Insurance Exchanges

National Conference of State Legislatures, http://www.ncsl.org/?TabId=21388

http://www.ncsl.org/?TabId=21388


Affordable Insurance Exchange “Partnership Options”

• Option 1: Plan managementStates take the lead on working with health plans who want to participate in the exchange to offer coverage.

• Option 2: Selected consumer assistanceStates will help consumers understand their options – states will conduct outreach and education and will provide in-person consumer support for Exchanges.

• Option 3: Both Option 1 and Option 2


The Shared Savings Program (SSP)

• Encourages collaborative care through the ACO model for Medicare fee-for-service (FFS) beneficiaries

• Providers paid FFS rate + incentive payments earned by providing high value health care

• Great enthusiasm in New York to transition into an era of collaborative care

• Proposed rule had a chilling effect on this excitement



• HANYS submitted comments to CMS detailing its concerns with the proposed requirements for the SSP• We recommended the rule be modified in

four key areas:–Beneficiary Assignment–Program Parameters–Risk Tracks–Shared Savings and Incentive Payments



• CMS received over 1300 comments from stakeholders on the proposed rule• In response to the large amount of

criticism it received, CMS made significant changes to the final SSP rule


STATE LEGISLATIVE UPDATE


State Landscape

State of the State January 4, 2012

Deliver Budgetby January 17, 2012

Approval Rating (12/20/11)

68%

First Day of Session January 4, 2012

Pass BudgetApril 1, 2012

End of Legislative SessionJune 21, 2012


State Landscape

Redistricting

Election 2012


2012-13 Budget

• Cuomo’s tax restructuring plan produces ~$1.9B per year, reducing future budget deficits

• Next year’s budget deficit is estimated to be ~$2.2B


Medicaid Redesign Team (MRT)

• Phase 1: MRT developed a package of reform proposals that achieved the Governor’s Medicaid budget target, introduced significant structural reforms that will bend the Medicaid cost curve, and achieved the savings without any cuts to eligibility.

• Phase 2: MRT created a coordinated plan to ensure that the Medicaid program can function within a multi-year spending limit and improve program quality. Work groups focusing on specific issues developed recommendations for the MRT.


MRT Work Groups and Timeline• Affordable Housing• Basic Benefit Review• Behavioral Health Reform• Health Disparities• Health Systems Redesign:

Brooklyn• Managed Long Term Care

Implementation and Waiver Redesign

• Medical Malpractice Reform • Payment Reform and Quality

Measurement• Program Streamlining and

State/Local Responsibilities• Workforce Flexibility and

Change of Scope of Practice

November 1: MRT approved recommendations of behavioral health, program streamlining and state/local responsibilities, managed long-term care and waiver redesign, and health disparities work groups. December 13: MRT approved recommendations of basic benefit review, workforce flexibility/change of scope of practice, affordable housing, and payment reform/quality measurement work groups.

There were no recommendations from the Health Systems Redesign: Brooklyn or the Medical Malpractice Reform work groups.


Health Insurance Exchanges

• Identified as a priority in Governor Cuomo’s State of State Address

“Almost 16% of New Yorkers . . . are uninsured . . . We have a unique

opportunity to address this challenge by developing a New York State Health

Insurance Exchange . . .”2012 State of the State Address


New York Exchange Grants

$1 Million

$27.4 Million

$10.7 Million

$39.1 Million

EarlyInnovator

Grant

PlanningGrant

Phase IGrant


New York Health Benefit ExchangeA.8514(Morelle)/S.5849(Seward)

• Public benefit corporation• Nine voting directors• Separate Exchanges for small group and

individual markets• Five regional advisory committees• No purchasing model chosen

Passed Assembly – June 23, 2011


G.O.P. Senators in Albany Block Federal Aid to Fulfill

Part of Health Law“[S]everal Republican lawmakers in New York, say they do not want to have anything to do with what they call “Obamacare,” [and] have thus far succeeded in blocking the state from seeking large amounts of federal assistance to put into place a mandatory health insurance exchange . . .”

New York Times, September 11, 2011


NY ACO Demonstration Program• Article 29-E of PHL authorizes the

Commissioner of Health to establish a demonstration program to test ACOs as a delivery system

• Seven certificates of authority will be issued and none can be issued after December 31, 2015


FEDERAL VS. STATE LAW

Federal State

NameShared Savings Program: Accountable Care Organizations

ACO Demonstration Program

AgreementEach ACO is required to enter an agreement with the Secretary for three years

None specified

Limitation on # of ACOs None Seven

PopulationServed

At least 5,000 Medicare FFS beneficiaries None specified


FEDERAL VS. STATE LAW

Federal State

Entities That May Be an ACO

Group practice arrangements, networks of individual physician practices, joint ventures between hospitals and physicians, hospitals employing physicians and other groups of providers as determined by the Secretary

Hospitals, home care agencies, entities that provide services to those with mental illness, developmental disabilities, or addiction, licensed medical professionals

Participating Payers

MedicarePreference will be given to ACOs in arrangements with third-party payers

Third-party payers

Reimbursement FFS + gainsharing or shared savings None specified


Gottfried’s ACO BillA.8869

• Converts the budget statute from a demonstration to a permanent program

• Eliminates the limit of seven ACO certificates that can be issued

• Extends the date by which new certificates can be issued from December 31, 2015 to December 31, 2016


Gottfried’s ACO BillA. 8869

• Requires an ACO to include an FQHC, although DOH may waive this requirement if there is no FQHC in the area

• Limits payers from imposing cost-sharing requirements on ACO enrollees that are higher than they otherwise would be

• Deems an ACO to be a health plan for certain purposes, including in relation to access to utilization review and external appeal

• Adds ACOs to the definition of "managed care provider" in the social services law

• Authorizes $10 million to be allocated without a competitive bid to promote the formation of ACOs and improve their operation


UnitedHealth Group $50,000,000

Aetna $20,000,000Cigna $10,000,000Wellpoint $10,000,000Excellus $775,000MVP Healthcare $535,000Guardian Life $500,000Independent Health $475,000CDPHP $300,000Health Now $212,500

Cuomo’s Settlements & New Database

Total$92,797,500


UnitedHealth Group $50,000,000

Aetna $20,000,000Cigna $10,000,000Wellpoint $10,000,000Excellus $775,000MVP Healthcare $535,000Guardian Life $500,000Independent Health $475,000CDPHP $300,000Health Now $212,500

Total$92,797,500

FAIR Health, Inc.

Cuomo’s Settlements & New Database


“FAIR Health is an independent, not-for-profit corporation whose mission is to bring transparency to healthcare costs and health insurance information through comprehensive data products and consumer resources. FAIR Health uses its national database of billions of billed medical and dental services to power a free website that enables consumers to estimate and plan their medical and dental expenditures. The website also offers clear, unbiased educational articles and videos about the healthcare insurance reimbursement system. In addition to its consumer offerings, FAIR Health licenses data products to businesses, governmental agencies, healthcare providers and researchers. With its professional staff of experts in healthcare, statistics, technology and communications, FAIR Health strives to offer accurate, consistent and timely information to all stakeholders in the healthcare system.”

FAIR Health, Inc.

http://www.fairhealthus.org/about-us/mission


New York Proposed LegislationA.7489-A(Gottfried)/S.5068(Hannon)

• Requires plans to provide enrollees with description of methodology for reimbursing OON services

• Policy must provide significant coverage of the 80th percentile of UCR as determined by FAIRHealth– S.5068 - Services performed by same or similar specialist in the

same county– A.7489-A - Services performed by same or similar specialist and

provided in the same zip code or geographic area

• Passed Assembly – June 1, 2011 Recalled from Senate and Amended – June 13, 2011

Healthcare Association of New York State www.hanys.orghttp://www.crainsnewyork.com/article/20111128/PULSE/111129963


HANYS’ Managed Care 2012 Legislative Agenda

• Ban administrative denials• Silence of a health plan in response to a claim

shall be deemed an approval, not a denial• Prohibit unilateral payor down coding• Extend timeframe for provider appeals to 120

days• Find legislative fix for non-par

provider/balance billing issue at hospitals


Jeffrey GoldVice President, Managed Care &

Special Counsel(518) 431-7730 or [email protected]

Cara Zucker HenleyPolicy Specialist, Managed Care

(518) 431-7827 or [email protected]

mailto:[email protected]

mailto:[email protected]

Healthcare Association of New York State Jeffrey Gold & Cara Zucker Henley January 10, 2012.

Documents

excitement slide

states exchanges

late fall slide

self sustaining slide

shared savings program

health plans

options states

proposed rule