University Health Services Student Services Building 100 W. Dean Keeton The Influence of Health Insurance on College Health: Do you want to be In-Network?

University Health Services

Student Services Building100 W. Dean Keeton

The Influence of Health Insurance on College

Health:

Do you want to be In-Network?

ACHA 2014 Annual MeetingWednesday, May 28, 2014



Presenter

LeAnn Gutierrez, PhD, MBA

The University of Texas at Austin

Associate Director, Business and Ancillary Services



Objectives Discuss the influence of the Affordable

Care Act on college health

Identify alternative funding models Recognize important factors to consider

when shifting to insurance billing



Increased knowledge of key provisions of Affordable Care Act that can impact college health

Increased awareness about funding model alternatives and considerations

Understanding of key factors to consider for participation in insurance billing for a more informed decision-making process

What You Should Take Away Today



Affordable Care Act Overview

Background

Goals

Timeline

Key Provisions



BackgroundThe Affordable Care Act Becomes Law in March 2010 The law implements comprehensive

health insurance reforms Reforms scheduled from 2010 through

2015 Department of Health and Human

Services (HHS) issued a proposed regulation to ensure students enrolled in these plans benefit from important consumer protections in the ACA in February 2011

HHS issued final rule on March 21, 2012

(http://www.healthcare.gov/law/timeline/index.html)



Affordable Care Act Goals

Holds insurance companies accountable

Lowers health care costs

Guarantees more choice

Enhances the quality of care for all

Americans

(http://www.whitehouse.gov/healthreform/healthcare-overview)



Affordable Care Act Timeline: 2010

New Consumer Protections

Improving Quality And Lowering Costs

Increasing Access To Affordable Care

(http://www.healthcare.gov/law/timeline/full.html)



Student Health Coverage Goals

Ensure that students have access to coverage and benefits from the ACA’s Patient’s Bill of Rights

Treat student health insurance plans as individual market plans to extend all of the protections provided to enrollees in with several adjustments given plan uniqueness

Self-funded plans exempt Grandfathered plans exempt until 2014

(http://www.healthcare.gov/news/factsheets/2012/03/student-health-plans03162012a.htm)



2010 Key Provisions:New Consumer Protections

Prohibits denying coverage of children based on pre-existing conditions

Prohibits insurance companies from rescinding coverage

Eliminates lifetime limits on insurance coverage

Regulates annual limits on insurance coverage

Effective for health plan years beginning on or after September 23, 2010.Rule doesn’t apply to “grandfathered” individual health insurance policies.




2010 Key Provisions:Improving Quality and Lowering Costs

Providing small business health insurance tax credits

Offers relief to Seniors who hit Medicare prescription drug “donut hole”

Provides Free Preventative Care Cracks down on Fraud



2010 Key Provisions:Increasing Access to Affordable Care

Provides state-based programs for access to insurance with pre-existing conditions

Extends coverage for young adults Extends coverage for early retirees Rebuilds primary care workforce Holding insurance companies accountable

for unreasonable rate hikes Allows states to cover more residents for

Medicaid Increases payments to rural health care

providers Strengthens community health centers



2011 Key Provisions

Offers RX discounts to Seniors (Medicare) Provides Free Preventative Care to Seniors HHS Quality Improvement Plan Community care transitions program for

Seniors Proposal to extend life of Medicare Trust

Fund Increase access to services at

home/community Lowers health care premiums Addresses overpayments



2012 Key Provisions

Value-Based Purchasing Program (Medicare) Encourages Integrated Health Systems Reduces paperwork/administrative costs Understands and fights health disparities Provides options for new, voluntary options

for long-term care insurance



2013 Key Provisions

Improves preventative health coverage (Medicaid)

Expands authority to bundle payments Increases Medicaid payments for primary

care providers Provides additional funding for CHIP



2014 Key Provisions

Prohibits discriminations (pre-existing/gender)

Eliminates annual limits on coverage Ensures coverage for participants on clinical

trials Tax Credits for individuals between 100-44%

FPL Establishes affordable insurance exchange Increases access to Medicaid Promotes individual responsibility Ensures free choice



Student Insurance Coverage Special Timelines

Annual Limits on essential health benefits

No less than $100,000 for policy years beginning on or after 7/1/12 but before 9/23/12

$500,000 for policy years beginning on or after 9/23/12 but before 1/1/14

No annual limits as of 1/1/14 Medical Loss Ratio-changes to

methodology for reporting and rebates only in 2013

Notice Requirement until 2014




Plan Design Differences as a result of ACA & New Vendor Administration of ACA in 2012

Benefit 11-12 Plan 12-13 ACA Change -New Plan

Dependent EligibilityUnmarried children not self -supporting

All children up to age 26

Routine STI Testing Under Health Center Charges ($500 maximum and $25 copay)

Now covered at 100%

Allergy Medicines and Prescriptions for STI treatment

$1,300 maximum prescription benefit

$1,300 limit removed

Inpatient Psychotherapy Covered up to 30 day maximumCovered as any other sickness (30 day limit removed)

Medical Emergency Benefits, $75 Copay

Covered up to $1,000 $1,000 limit removed

Flu Shot Benefit Covered at 80% up to $20 Now covered at 100% (no maximum)

Benefits for HPV and Cervical Cancer Screening (under X-rays and Labs)

Covered at 80% up to $75 Now covered at 100% (no maximum)

PrescriptionsCovered up to $1,300, with copays

Limit of $1,300 removed. Birth Control covered at 100%

Outpatient PsychotherapyLimited to 20 visits per year, daily limits of $65 per day individual/$20 for group visits

20 visit limit removed, paid as any other sickness, internal limits removed

Ambulance Services $300 maximum $300 limit removed

Alcohol/Drug AbusePreviously covered under mental health with limits

Covered without daily limits

Wellness Benefit/ Routine Preventive (including immunizations)

Paid at 100% in network and 60% out-of-network, to $500 maximum

Now paid at 100% (no maximum)



Key ACA Factors Influencing College Health

Provides Free Preventative Care Pre-existing conditions (For Children until 2014)

Extends coverage for young adults (All Plans, Except for one temporary exception until 2014)

Eliminates lifetime limits on insurance coverage (All Plans)

Regulates annual limits on insurance coverage (Not required for grandfathered plans until 2014)

Access to state/federal exchange plans



UT at Austin Insurance Claim Volume

Trends

Per month Per year

3,000 36,000

Per month Per year

4,200 50,400

2012 – 2013

Per month Per year

3,500 42,000

2011 – 20122010 – 2011

2013 - 2014 thru 4-13

Per month Per year

4,500 36,456



UT at Austin Insurance Utilization Trends

Students using insurance at UHS

Students not using insurance at UHS

63% 37%

Students using Insurance at UHS


66% 34%

2012 - 2013

Students using insurance at UHS


69% 31%

2010 - 2011 2011 - 2012



UT at Austin Insurance Payor Trends

2010 -2011 Payors

%

BCBS 44%Aetna 11%SHIP 22%United HealthCare 10%Other 13%

2011 - 2012 Payors

%


Insurance Payor Mix

2013 - 2014 thru 4-14 Payors

%

BCBS 52%SHIP 20%United HealthCare 12%Aetna 8%Other 8%

2012 -2013 Payors

%




Alternative Funding Models Faculty and Staff Services

Ancillary services or self-supporting arm (physical therapy)

Flu shot campaigns, Travel services

Explore Potential Campus Partnerships

Summer programs

Research support (example: lab)

Physical exam clinics for club sports

Visiting scholars, post-docs, ESL

In-Network Status with insurance payors



Considerations for Insurance Billing

HIPAA Compliance

Clinical Documentation

Coding: CPT, HCPCS, ICD-9/ICD-10

Contracting: credentialing, NPI, CAQH, referrals

Charges Structure: charges philosophy, discounts, co-pays, ancillary reimbursement

Financial

patient collections and revenue potential

Expenses related to third-party filing



Charges Philosophy UHS charges for services

Provider encounters, minor procedures, lab tests, x-rays, medications, supplies, immunizations, nutrition services, and physical therapy

Charges based on 150% Allowable Medicare Fee Schedule (in some exceptions cost is used)

Miscellaneous/Administrative Charges: missed appointments, after-hours, medical records release, service extension fees

Discounts

Insurance contractual adjustments

Self-pay amounts: students and faculty/staff



Appointment Scheduled

Check-In-Registration

into EHR-Insurance information-Reason for

visit

Patient Encounter

-What's Wrong-Plan of Action-EHR

Documentation

-EHR CodingClaim Filing/Billing

-Charges review and

post-Claim

Submission-

Clearinghouse for errors-Claim goes

to payer

Claim Payment or

Denial-Payment

posted and processed

-Denial appealed

Claim Appeals

Processing-

Documentation reviewed

and submitted

for reconsiderat

ion-Claim re-files and

processes

Patient responsibility-Collect from patient in C/I

or Bursar

Claim Lifecycle



Questions?



Thank You!



References

ACHA. Health Care Reform FAQ. Retrieved from http://www.acha.org/Topics/Health_Care_Reform/FAQs_for_IndividualCoverageClassification.cfm.

Healthcare.gov. (2011). Affordable care index. Retrieved from http://www.healthcare.gov/law/timeline /index.html.

Healthcare.gov. (2011). Glossary. Retrieved from http://www.healthcare.gov/glossary/d/donuthole.html.

Healthcare.gov. (2011). Preventative services. Retrieved from http://www.healthcare.gov/news/ factsheets/2010/07/preventive-services-list.html.



References

Healthcare.gov. (2012). Student Health Plans. Retrieved from http://www.healthcare.gov/news/ factsheets/2012/03/student-health-plans03162012a. html.

The White House. (2011). The affordable care act. Retrieved from http://www.whitehouse.gov/healthreform /healthcare-overview.

Documents

University Health Services Student Services Building 100 W. Dean Keeton The Influence of Health Insurance on College Health: Do you want to be In-Network?