Legislative Update on HealthCare

August 4, 2010

Legislative Update

HHS Clarifies New Open Enrollment Requirements
The Department of Health & Human Services (HHS) has provided clarification regarding the new special open enrollment period required by the Patient Protection and Affordable Care Act of 2010 (PPACA). Individuals are now eligible to re-enroll for coverage if they had coverage cancelled because they had reached the lifetime dollar maximum of their policies or are dependents under age 26 who had aged off of their parents’ policies.
A notice of the special enrollment opportunity must be provided, the enrollment must be held no later than the first day of the first plan/policy year beginning on or after Sept. 23, 2010, and it must be at least 30 days. Eligible individuals are to be treated as HIPAA special enrollees, meaning they have the right to enroll in any of the benefit plans available to similarly situated individuals. The effective date of coverage will be first day of the new plan/policy year. There is no retroactive coverage for the interim period.
We will be providing employers with sample language of a notice they can share with their employees, who will then self-identify if they fall into either of these two categories. The notice will inform them that the lifetime limit on the dollar value of all benefits no longer applies to them and they are once again eligible for benefits. We also will have a similar statement for dependents.
Please note that this special open enrollment also applies to anyone covered by individual policies and who have reached their lifetime maximum or have aged out.
Preventive Health Benefits under PPACA Outlined
Blue Cross and Blue Shield of Texas (BCBSTX) benefit coding experts, medical directors and customer service leaders have carefully reviewed the recently released Interim Final Rule for preventive health benefits under the Patient Protection and Affordable Care Act of 2010 (PPACA). These benefits will be paid without any cost-sharing (deductibles, copays or coinsurance) when using network providers (100 percent coverage not applicable when using out-of-network providers). Using a combination of procedure codes (which providers use to indicate the services they render) and diagnostic codes for individual patients, we have determined what updates are needed to our claims adjudication systems to comply with PPACA.
At a high level, the following categories of benefits will be preventive and will be paid at 100 percent:

Health education/counseling services

Immunizations

Preventive care

Routine bone density test

Routine breast exam

Routine colonoscopy

Routine colorectal cancer screening – lab

Routine digital rectal exam

Routine gynecological exam

Certain routine lab procedures

Routine mammogram

Routine Pap smear

Routine physical

Routine prostate test

Smoking cessation

Well baby care

Many of these procedures are currently covered benefits in most of our plans (although there are exceptions, particularly in the individual market). The difference will be that these will be paid at 100 percent, while currently they may be subject to deductibles, copays, and/or coinsurance. Therefore, we do not anticipate a significant impact on costs.
While the regulations provided guidance, there are still some issues that are not clear. We anticipate that we will continue to review and revise our claims system logic on some details. However, we have tried to be inclusive in our initial coding, especially because we want to encourage our members to receive the appropriate preventive care.
For those clients (particularly large, ASO accounts) who are requesting additional detail, please work with your BCBSTX account representative for a complete inventory of benefit codes.
Appeals Process Is Being Evaluated with New Interim Rule
Earlier this year, BCBSTX announced that in addition to our already robust appeals process, we will implement a new or enhanced third party appeals process across all our products, as required by PPACA. However, with the release of the new Interim Final Rule, there have been additional questions as to the extent the rules may change our process. We are currently working through an analysis of our processes and what may need to change as a result of the new Interim Final Rule.