2011 California Legislative Actions

Recent 2011 California legislative actions include:

ABX1 21 – designed to fund a large chunk of the Healthy Families budget by extending by a year a tax on Medi-Cal managed care organizations;

AB 922 – designed to expand and move the Office of the Patient Advocate. It took on an amendment that also moves its parent agency, the Department of Managed Health Care. Those agencies currently reside under the Department of Business, Transportation and Housing.

SB 946 -  require private insurers to cover treatment for autism.

These bills now moves to Gov. Jerry Brown’s desk for review.



Employers Can Help Battle Chidlhood Obesity

As childhood obesity in the United States has tripled over the past 30 years.  Obesity is a growing epidemic affecting children, their families and the nation. The United States currently has the highest percentage of overweight youth in its history. More than one-third of children in the United States are considered overweight or obese, leading to increased health risks, higher health care costs and decreased parental productivity at work., now is the time for employers to take the lead in the battle against the growing problem of overweight and obese children, according to the National Business Group on Health.

“Child obesity is impacting employers today and will into the future as these children become the workforce of tomorrow,” says Helen Darling, president and CEO of NBGH, whose members include 329 large U.S. employers. “Parents have an enormous impact on the childhood obesity epidemic. The good news is that employers can play a critical role in fighting the childhood obesity epidemic by helping families develop healthy lifestyles at work and in the home”.

A recent survey of 83 of the nation’s largest companies conducted by the National Business Group on Health identifies the following programs employers currenlty have in place to help fight childhood obesity:

- One third of employers (33%) offer online weight management tools to children.

- More than one in four employers (28%) offer telephonic or online coaching for weight management to children

Beyond promoting healthy lifestyles in the home, employers will soon face a growing demand for obesity treatment in children.

“With the new guidelines for screening under The Patient Protection and Affordable Care Act, many more children nationally will be identified as overweight or obese,” says LuAnn Heinen, vice president and director of NBGH’s Institute on Innovation in Workforce Well-being. “Employers can provide tools and resources to support and empower employees and work with health plans and community resources to develop and promote new approaches to childhood obesity prevention and treatment.”

Employer toolkit expanded

NBGH also announced that it has updated its employer toolkit, “Childhood Obesity:  It’s Everyone’s Business,” to include examples of family-focused wellness programs that four forward-thinking companies are doing to fight childhood obesity. The toolkit also includes a new section on how employers can design their benefit programs to ensure that they are in accordance with new screening guidelines required by PPACA and support obesitytreatment options for children.

The employer toolkit was developed and updated with support from the U.S. Department of Health and Human Services, Health Resources Services Administration’s Maternal and Child Health Bureau. It’s available free of charge and can be found at www.businessgrouphealth.org.

Gary Whiddon is a wellness consultant affiliated with WELCOA university and can assist you in forming a wellness program for your employees.  Please contact him at (888) 474-6627 for information on setting up a prgram for your employees.


Proposed Rules for Summary of Coverage Available

In follow up to our post from August 18, 2011, the departments of Labor and Health and Human Services (with the
Treasury) laid out the new proposed rules for the “uniform summary of coverage” that is required under PPACA.   Health insurers and group health plans have to provide consumers with clear, consistent and comparable information about their health plan benefits and coverage starting in 2012.

All health plans and issuers would provide a summary of benefits and coverage, along with a glossary of terms to employees before enrollment.  Health plans and issuers will also provide notice at least 60 days before any significant modification is made in the plan or coverage during the plan or policy year.  The summary of benefits coverage would be some simple standard boxes for comparison shopping. If the exchanges are in place by 2014, this would allow an employee to compare employer sponsored coverage against other market-available options.

As these are merely proposed, there is nothing final and employers do not have to immediately act, nor can then act until the proposed
uniform definitions are drafted. But employers and plan sponsors should keep this information handy as a reference point for developing a long-term compliance strategy.

For more details about the proposed regulations, please go to the dol website at www.dol.gov.


HHS Announces Proposed Rule for Uniform Benefit Summaries

On August 17, the Department of Health and Human Services (HHS) released a Notice of Proposed Rulemaking for Uniform Benefit Summaries under the Patient Protection and Affordable Care Act (PPACA).

The intent of Uniform Benefit Summaries is to provide individuals with standardized information so they can review medical plans, compare insurers and make decisions about medical plan choices.  The proposed rule provides additional guidance on the information that must be provided to all individuals enrolling in a medical plan on or after March 23, 2012.

This provision applies to individual and employer-sponsored medical plans, regardless of grandfathered status or funding. It does not apply to retiree-only plans or to standalone dental and vision plans.

What Information Must be Included

Insurers and self-insured employers must provide a Summary of Benefits and Coverage (also referred to as an ‘SBC’ in the proposed rule) to individuals who apply for and enroll in medical plans. The Summary of benefits and Coverage is a required document that must be provided in the standard format.

There are four standard components:

  • A four-page Benefit Summary (double sided)
  • Medical Scenarios called “Coverage Examples” that  are patterned after the Food and Drug Administration food labels. They estimate customer costs based on the specific plan’s benefits for three medical scenarios – Maternity, Breast Cancer Treatment and Managing Diabetes
  • A standard glossary of medical and insurance terms
  • A phone number and website where individuals can get additional information including documents such as Certificates, Summary Plan Descriptions (SPDs) and policies

HHS asked the National Association of Insurance Commissioners (NAIC) to propose a format for the four components in the Summary of Benefits and Coverage. Here is a link to the documents proposed by NAIC: http://www.naic.org/committees_b_consumer_information.htm

The information on the NAIC website is not a guideline or example. It is the exact wording, format and layout that must be used. Insurers and employers will just insert plan details into the predetermined rows and columns.

The Benefit Summary must be a freestanding document and may not be incorporated into any other document. Supplemental
communication materials may be provided with it. Currently produced documents will not satisfy the requirements of the regulation.

The Coverage Examples must include three pre-defined medical scenarios: Maternity, Breast Cancer Treatment and Managing Diabetes. These scenarios are intended to show typical services and cost sharing under the plan. The numbers would be based on client-specific plans and costs. The estimates are based on national average costs and in-network benefit levels.

Who is Responsible for Providing the Information

For fully insured plans and HMOs, the insurer is responsible for producing and distributing the summaries. For self-insured
plans, the responsibility lies with the employer.

What is the Required Timing

Summaries must be provided when an employer or individual requests information about a plan, applies for coverage or enrolls in
a plan. They must also receive a summary if there are plan changes or if the individual has a HIPAA special enrollment event that prompts a new enrollment opportunity.

People enrolled in a health plan must be notified of any significant changes to the terms of coverage reflected in the Summary of
Benefits and Coverage at least 60 days prior to the effective date of the change. This timing applies only to changes that become effective during the plan or policy year but not to changes at renewal (the start of the new plan or policy year).

How Benefit Summaries will be Delivered

Summaries are required both before and after enrollment and may be delivered in paper and/or electronic format. There are
specific requirements for group vs. individual plans.

Penalty for Non-Compliance

The penalty for ‘willful’ non-compliance is up to $1,000 per enrollee for each failure to comply.

Next Steps

Comments on this proposed rule – including the specific request for expatriate plans – are due 60 days from the published date.

New HHS Guidelines for Women’s Preventative Services

 On Aug. 1, 2011, the Department of Health and Human Services (HHS) released new health  plan coverage   guidelines that will require health insurance plans to cover women’s preventive services such as well-  woman visits, domestic violence screening, and U.S. Food and Drug Administration (FDA)-approved contraception, without charging a copayment, coinsurance or a deductible.

Authorized under provisions of the Patient Protection and Affordable Care Act, these guidelines, developed by a committee of the Institute of Medicine of the National Academies, expand the previous list of preventive services that must be covered without charging a copayment, coinsurance or a deductible to include:

  • Well-woman visits
  • Screening for gestational diabetes for all pregnant women
  • Human papillomavirus DNA testing for all women 30 years and older
  • Annual sexually transmitted infection counseling for all sexually active women
  • Annual counseling and screening for HIV for all sexually active women
  • FDA-approved contraception methods, sterilization procedures and contraceptive counseling
  • Breastfeeding support, supplies, and counseling, including costs for renting breastfeeding equipment
  • Domestic violence screening and counseling

New health plans and non-grandfathered plans and issuers are required to provide coverage consistent with these guidelines in the first plan year (in the individual market, policy year) that begins on or after August 1, 2012.  It is possible that your current health plan covers these services now, but may have a copay or co-insurance percentage.