Making Reform Work for You — An Update

In this issue, we look at how the Patient Protection and Affordable Care Act (PPACA) may affect your practice in 2011 and beyond, by type of coverage.

Commercial Plans
The law mandates that qualified health plans must provide coverage for selected preventive services obtained in network without members incurring out-of-pocket costs in the form of copays, coinsurance or deductibles. These selected preventive services are rated A or B by the US Preventive Services Task Force, and there are separate guidelines for infants, children and adults. This provision of the law applies to patients whose policy was issued or renewed on or after September 23, 2010.

Medicare
As of January 1, 2011, the health reform law also eliminates preventive service cost-sharing for Medicare enrollees.

In addition, PPACA:

• Authorizes coverage for a comprehensive health risk assessment and a personalized prevention plan. (The health risk assessment regulations are not expected to take effect until July 2011.)
• Increases provider payments for certain preventive services to 100 percent of actual charges or the prevailing plan fee schedule rates.
• Provides a 10 percent bonus payment to primary care physicians from 2011 through 2015.
• Provides incentives to enrollees to complete behavior modification programs.These incentives will become effective when guidelines are developed.

Medicaid
As of January 1, 2011, the health reform law also eliminates preventive service cost-sharing for Medicaid enrollees. Medicaid Managed Care enrollees have no cost-sharing obligations for preventive service.

In addition, PPACA:

• Permits Medicaid enrollees with at least two chronic conditions — one chronic condition and a risk of developing another — or at least one serious and persistent mental health condition to designate a practitioner as their medical home. States opting to participate in this program will receive a 90 percent Federal Medical Assistance Percentage (FMAP) for two years.
  
  Note: All Medicaid Managed Care members must select a PCP to provide their primary and preventive care and to arrange for specialty care. Medicaid members with chronic conditions may designate the treating specialist as their PCP, provided the specialist is qualified to do so. If the medical home
  referral requires an NCQA-certified medical home provider, we would need to help members identify available providers.
• Provides comprehensive Medicaid coverage for tobacco-cessation services for pregnant women. New York State Medicaid members are already covered for smoking cessation via the New York State Quit-Smoking Program.
• Establishes a Community-Based Collaborative Care Network program to support consortiums of health care providers that coordinate and integrate health care services for low-income uninsured and underinsured populations. (Funds will be appropriated for five years, beginning in 2011, and practitioners must submit grant requests directly.)
• Provides incentives to enrollees to complete behavior modification programs. These incentives will become effective when guidelines are developed.