States Taking the Lead in Strengthening Consumer Protection

Recently, five more States strengthened their laws protecting consumers in disputes with their health insurance plans. The District of Columbia, Massachusetts, New Hampshire, Ohio and Wisconsin have bolstered their laws surrounding the part of the appeals process known as “external review.”  These five States join 33 others that provide these State-based external review protections that ensure consumers have a voice. The remaining States’ consumers are protected by a Federal process.

The strengthened appeals rights are one of several common-sense consumer protections and insurance market reforms established by the Affordable Care Act. Having a meaningful appeals process ensures that you actually receive the benefits that your insurer has promised.

So, what exactly is an external review? 

It means having an independent third party review your insurer’s decision, no matter where you live, thanks to the Affordable Care Act. Often, you can resolve disputes with your health plan by asking your insurer to reconsider its decision, in a process known as an “internal appeal.” But if, for example, your insurer still denies payment after the internal appeals process, you now can ask for an external review by an independent review organization to decide the matter.  Insurance companies must accept the outcome of this external review.  This means that your insurance company no longer gets the final say, and that patients and doctors get a greater measure of control over health care decisions.

These protections are important because when an insurer refuses to pay for a covered health care service, consumers could be faced with a large unplanned bill, and may not be able to afford the care their doctors say they need.

The Affordable Care Act sets these new important appeals standards for consumer protections and encourages States to take the lead in ensuring their own residents benefit from them.  Where States have not yet passed laws implementing these consumer protections, HHS has set up a process to ensure that consumers in these States also benefit from the same protections and standards.  If a State changes its external review process in the future, the State may request a new determination at any time. 

Having DC, Massachusetts, New Hampshire, Ohio and Wisconsin step up to the plate to ensure consumers’ external review rights is a perfect example of how the Affordable Care Act empowers States to protect consumers.

This post was originally published on The HealthCare Blog on November 22, 2011
By Eliza Bangit, Acting Director of the Consumer Support Group

Communications Tips – Supreme Court and the Affordable Care Act

This week, the Supreme Court may grant a writ to hear a case questioning the constitutionality of the Affordable Care Act. There will be a number of questions raised by this action. Consider the following points in talking with colleagues and the press.

Main Points:

1. The Affordable Care Act is supported by the text of the constitution and years of judicial precedent.
a. If one reads the constitution, including the amendments, there is no question that this law is supported by the words in the constitution.
b. At the Appellate level, two very conservative judges have supported the constitutionality of the law (Silverman appointed by Reagan and Sutton appointed by G.W. Bush).
c. The DC Circuit upheld the constitutionality of the health law on 11-8-11.

2. People challenging the law are playing politics—using the courts to attempt to accomplish what they didn’t succeed at through the legislative process.
a. Some people don’t want to rein in insurance companies.
b. They have other priorities; ordinary American families are not one of them.

3. This law provides protections for American families:
a. A child getting sick is no longer a reason for a lifetime of denial of care;
b. Preventive services will give our children and our parents better chances for healthier and longer lives;
c. Insurance companies can no longer take unfair advantage of ordinary Americans with practices like charging women more than men for health insurance.


Those trying to manipulate our judicial process and the constitution for political expediency should reflect on America’s history. George Washington couldn’t clothe his troops because the Articles of Confederation didn’t allow the government to raise funds for his army. The constitution was written so, as our first President said, ‘we can have national solutions to national problems.’

Top Five Facts That Illinois Social Workers Should Know about the Affordable Care Act

Illinois Health Matters will be an exhibitor at the National Association of Social Workers (NASW) Illinois Statewide Conference today, Thursday November 10. We are excited to meet the hundreds of social workers who will be in attendance and to talk about what else? Health reform! As a short primer, we thought we'd list, the top five facts that all Illinois social workers should know about the Affordable Care Act - i.e., the national health care reform law.

1. Demand for Your Services Will Grow 
In 2014, as a result of the Affordable Care Act, over 1.1 million people in Illinois will become eligible for insurance through Medicaid or the new subsidized insurance product on the exchange; thus, social workers will have more insured paying patients.

2. REALLY, Demand for Your Services Will Grow 
Essential Health Benefits are still being defined now but include behavioral health and habilitative and rehabilitative care - services provided by and important to social workers.

3. Your Role Will Be More Important Than Ever
The Affordable Care Act emphasizes coordinated care arrangements through new initiatives such as Accountable Care Organizations and Health Homes both of which rely primarily on the care coordination provided by professionals such as social workers.

4. You Will Be Instrumental in Improved Health Outcomes
In 2014, hospitals will no longer be reimbursed for certain re-admissions so presumably they will invest in discharge planning and social workers to provide transition care to the home and community and avoid re-admissions.

5. More Jobs for Social Workers
Community Health Centers are receiving large increases of funding to provide primary care and coordinated care to the newly insured population and will need to hire social workers to provide care coordination and linkage and referral to low income populations who have not had experience getting into care.

If you have health reform questions, you can find us on twitter at @ilhealthmatters. We will be live tweeting from the NASW conference using the hashtag #NASWIL. Hope to see you there! Or you can always email us at info@illinoishealthmatters.org. We will answer your questions directly and possibly feature them on our website.

Lastly, we are having a one-day raffle for a $50 Amazon.com Gift Card for people who sign up for our e-newsletter today, November 10, 2011. So, be informed and enter to win! Entrants will be notified by email.

Care Transitions & Health Reform: What's the Big Deal?

You may have heard the buzz about care transitions as an aging professional, or health care professional, or even if you are simply keeping up on current events. Transitions in care are a form of care coordination during a transitional event. Care transitions are broadly defined. Here are a few examples: transitioning within a hospital from the emergency room to an in-patient floor; transitioning from a nursing home back home; transitioning from private payer health insurance to Medicare. Right now the focus is on the transition from the hospital—and there’s good reason for this. Here’s a few key numbers to explain why:

19.6% According to a study published in the New England Journal of Medicine in April 2009, 19.6% of Medicare beneficiaries discharged from a hospital stay were readmitted to a hospital within 30 days. That means almost 1 out of every 5 Medicare beneficiaries to leave the hospital returns in 30 days or less! If you open the window of time after discharge to 90 days, this number jumps to 34%–this is more than 1 out of 3 Medicare beneficiaries. In Illinois, the study showed our 30-day readmissions to be slightly higher than the national average at 21.7%.

$17.4 Billion According to the same article referenced above, the cost of the readmissions for Medicare beneficiaries totaled $17.4 Billion for one year! This is almost 17% of the $102.6 billion that Medicare reimbursed hospitals for the year of the study. With health care costs in the United States continuing to increase, care transitions are understandably an identified area for health care systems improvement.

$500 Million In accordance with section 3026 of the Affordable Care Act, CMS made $500 Million available for the new Community Care Transitions Program (CCTP). CCTP is a unique funding opportunity for community-based organizations (CBOs) to lower readmissions to the hospital. CBOs are able to apply for reimbursement of care transition service provision through a Medicare fee-for-service mechanism. CCTP requires CBO partnership along the continuum of care including: hospitals, skilled nursing facilities, home health agencies and more.

2014 The Illinois Hospital Association is partnered with Blue Cross Blue Shield of Illinois to address high hospital readmission rates through the “PREP” Program. PREP stands for Preventing Readmissions through Effective Partnerships, and 201 hospitals in Illinois have pledged to lower hospital readmissions in the state by 2014. One of the five initiatives of the PREP Program is improving transitions of care.

3025 Section 3025 of the Affordable Care Act introduces penalties to hospitals for preventable readmissions. Starting in 2013, Section 3025 allows CMS to withhold up to 1% of Medicare payment reimbursement to hospitals. By 2015, up to 3% of Medicare reimbursement to hospitals may be withheld due to preventable readmissions. This means that hospitals that do not improve their readmission rates will receive an overall reduced Medicare reimbursement from CMS. For medium to large hospitals, a 1% reduction in reimbursement is estimated to cost from $500,000 to $1,000,000 in lost revenue. If hospitals don’t figure out how to lower readmissions, it is going to cost them a lot of money.

12 Let’s take a look at what’s happening in Illinois with care transitions from the hospital. The Illinois Transitional Care Consortium (ITCC) was formed to more effectively address needs of older adults transitioning from the hospital to the community by linking hospital based services with the aging network through intensive care coordination. ITCC consists of 12 partners: community-based organizations, hospitals, a university research facility, and a policy and advocacy research organization. ITCC developed the Bridge Model: a unique social work led model of transitional care that builds upon the Care Coordination Unit (CCU) system and Aging Network in Illinois. ITCC is currently developing a proposal for funding through the Community Care Transitions Program (CCTP), described above.

For more information on care transitions, please feel free to contact me, Kristen Pavle, Associate Director of the Center for Long-Term Care Reform at Health & Medicine Policy Research Group.

This post was originally posted on the Chicago Bridge's blog site. For more information on older adults, visit the Chicago Bridge website.

CLASS Act, Voluntary Long-Term Care Insurance Program of Affordable Care Act, is Called-Off

On October 14, 2011, the Obama Administration announced that the voluntary long-term care insurance program of the Affordable Care Act, the “CLASS Act,” is not viable for implementation. The announcement came from Kathleen Sebelius, Secretary of the United States Department of Health and Human Services, in the form of a letter to the Speaker of the House of Representatives. In this letter, Ms. Sebelius describes the thorough research done on the financial and structural solvency of the CLASS Act if implemented. The bottom line: the CLASS voluntary long-term care insurance program will not work because the cost will be too high for individuals who need care.

What is Long-Term Care?

Let’s take a look at what long-term care is before getting into why we need long-term care insurance. Long-term care (LTC) covers a broad range of services and supports for individuals requiring medical and/or social care over an extended period of time. 

• This includes activities of daily living (ADLs) like feeding and bathing; and instrumental activities of daily living (IADLs) like grocery shopping and doing laundry. 
• Long-term supports and services (LTSS) can be delivered in two main areas: institutions (like nursing facilities) or the home and community based setting (Assisted Living, Supportive Living, private apartment or home).

To learn more about how Illinois LTC measures compared to other states, read my blog post about a recently published study on LTC across the country.

What does this announcement mean to people with long-term care needs?

The CLASS Act offered a way for the United States to start addressing the long-term care needs of millions of Americans.  Persons with disabilities and older persons are the largest populations with LTC needs.  For more information on what the CLASS proposed to do, read Illinois’ Health Matters Blog Post by Lisa Ekman on the CLASS Act.

According to the National Clearinghouse for Long-Term Care Information, over 20 million people had LTC needs in 2008, with more than half of these people being over age 65. According to Politico Pro, only 7 million of these individuals have the private insurance to cover their LTC needs.

With the advance of medical technology and the aging of our population, people are living longer and with chronic conditions that require LTC. Here are some statistics:

• The number of adults 65 years and older will more than double from 40 million today to over 85 million by 2050. See Census Bureau data here and here.   
• An estimated 130 million Americans live with at least one chronic disease, and at least 65 million older adults experience multiple chronic conditions[1]. 
• 25% of older adult Medicare beneficiaries have more than four chronic conditions and are responsible for at least 80% of Medicare spending[1].

Now that the CLASS Act has been called off, the American public should be asking: “What is our country going to do for people who need long-term care?” Right now, we simply do not have a LTC system that can handle the number of people who need LTC. Medicare only pays a small portion of long-term services and supports; Medicaid requires people to spend down their savings in order to access LTC. And both Medicare and Medicaid are constantly under attack at a federal level for budget cuts. Meanwhile, the millions who require LTC will continue to have LTC needs, many of which will go unmet.

What Can You Do?

If:

• You are a person with a disability or an older adult who requires long-term care, OR 
• You know someone who requires LTC, OR  
• You support the program for those who have LTC needs

Then:

Share your story, and call your Senators and other elected officials! Simply call their offices and tell them that you support, and would like the Senator to also support, Medicare and Medicaid because these programs help you address America’s (perhaps your) LTC needs. More specifically, you can tell them that you do not want any cuts to benefits or changes to eligibility for these programs.

For your reference:

• Senator Dick Durbin’s Illinois office phone number is: (217) 492-5089 
• Senator Mark Kirk’s Illinois’ office phone number is: (217) 492-4062

Your voice and your stories are important and are a way to tell our elected Congressmen WHY we need LTC programs, and WHY we need to protect Medicare and Medicaid.  
 
Questions? Comments? Please let me know, I look forward to hearing from you and continuing the conversation.

For additional resources on how the Affordable Care Act addressing LTC, please download the Health Care Reform Impact in Illinois, Long-Term Care Reform Provisions Brief.

Kristen Pavle
Associate Director
Center for Long-Term Care Reform
Health & Medicine Policy Research Group
312.372.4292 x 27

[1] Boult, C., Karm, L., & Groves, C. (2008) Improving chronic care: The “Guided Care” model. The Permanente Journal. 12 (1), 50-54.

Latest Developments in the implementation of an Illinois Health Benefits Exchange: Senate Bill 1313

Back in the spring, the Illinois General Assembly passed a bill enacting the intent to create a health benefits exchange, a state-wide marketplace called for by the federal Affordable Care Act that will act as a tool to aid consumers to shop for insurance. The exchange has the potential to create a competitive and regulated environment that will keep health insurance costs at reasonable levels, and thus more available to individuals and small businesses, while also making the process of shopping for insurance more straightforward and manageable. In order for the health benefits exchange to operate this way, it is important that the exchange is created with the needs and protection of consumers and small businesses in mind. Earlier this fall, the study committee on the exchange released a report on their findings.  This past week, during the Illinois General Assembly Fall veto session, steps were taken to establish the exchange. State Representative Mautino introduced his amendment (House Amendment 2) to SB 1313, a bill which dictates the makeup of the health benefits exchange governing board.

Decisions that have been made in SB1313, House Amendment 2:

The composition of the health exchange governing board has been outlined in the amendment to SB 1313 in a way that supports a board that is likely to take interest in consumers and small businesses. The board, as outlined in the amendment, will be made of 9 members:

·         2 from the Attorney General’s office

·         1 small business owner

·         1 employee of a small business

·         1 consumer representative

·         1 community-based health care provider who primarily serves individuals under 200% of poverty

·         1 health actuary or economist

·         1 member of organized labor

·         1 individual who qualifies for Medicaid

None of the seats on the board will go to legislators, brokers, or insurers. There are also pieces in the amendment that support the creation of a racially and geographically diverse board, as well as clauses that protect against board members who have conflicts of interest in the governing of an exchange board.

Decisions not made in SB 1313:

The amendment puts the board in charge of deciding how the exchange will be financed.  There are many options outlined in the amendment, some that support the interest of the consumer, such as a fee levied on insurance companies, and some that are less supportive, such as a fee to users of the exchange.

What will happen next:

Now that the bill has been filed, it needs to be approved. On November 8^th, the House Insurance Committee will be holding a hearing to discuss SB 1313.   The Committee has 11 Democrats and 9 GOP members.  In order for the bill to pass the House, it will need to get support from 71 votes, opposed to the normal 60, due to rules of the veto session. If you want to see a health benefits exchange that supports the interests of individuals and small businesses, call your state representative and tell them to vote Yes on SB1313.