Health Insurance Reform State Updates

The Legislative New Mexico health insurance Health and Human Services Interim Committee has endorsed rate reviews and health insurance exchange bills.

Governor Dave Heineman has announced that Bruce Ramge has been appointed Director of the Department of Nebraska Health Insurance, effective immediately.

Governor Steve Beshear has announced changes designed to save more than $142 million in the Kentucky health insurance Medicaid program over the next two years.

Illinois Health Insurance Reform Implementation Council is requesting public comments on a proposed health insurance exchange.

Florida Health Insurance, Now in special session, a significant Republican majority is emphasizing a message of fewer taxes, more discretion in spending, and greater accountability in state government.

While Governor-elect Jerry Brown has not yet announced his priorities for California health insurance, his website does state that he supports requiring health care cost transparency.

Health Insurance Reform Washington Update

Summary of what has been happening in Washington as of Aug. 6, 2010.

Senators Introduce New Legislation to Increase Transparency and Competition in Insurance Industry
Senators Mark Pryor (D-AR), Jay Rockefeller (D-WV) and Barbara Boxer (D-CA) introduced “The Insurance Competition and Transparency Act” (S. 3685) in the Senate Committee on Commerce, Science and Transportation on Aug 2. The legislation would authorize the Federal Trade Commission (FTC) to use its authority under the Federal Trade Commission Act to “investigate and disclose information about practices employed by insurance companies that may reduce competition in the marketplace.”

The bill goes a step further and explicitly states that since many insurance companies have non-profit status, it would eliminate the exemption under the Act for non-profit insurers. S. 3685 is based on an amendment that was filed by Senators Pryor, Rockefeller and Boxer during the Senate’s health reform debate in December 2009.

Senate Passes Child Nutrition Bill
Led by the Senate Agriculture Committee Chairwoman Blanche Lincoln (D-AR) and Ranking Member Saxby Chambliss (R-GA), the Senate passed the “Healthy, Hunger-Free Kids Act of 2010” (S. 3307) by unanimous consent on Aug. 5. The legislation authorizes a $4.5 billion increase over 10 years for school lunches and other nutrition programs. It also gives the Agriculture Department authority to set nutrition standards for foods sold in vending machines and in a la carte lines in schools.

Of the $4.5 billion, the legislation provides $1.2 billion to increase the number of children receiving food, in an effort to meet President Barack Obama’s pledge to end childhood hunger by 2015. The remaining $3.2 billion would be used to improve the quality of school meals. The cost of the legislation is entirely offset. Review the Congressional Budget Office’s budgetary impact report.

Chairman Tom Harkin (D-IA) of the Senate Health, Education, Labor and Pensions Committee commended Agriculture Committee Chairwoman Lincoln for her work on the bill, noting that it passed both the Agriculture Committee and the full Senate without a single dissenting vote.

The House of Representatives still needs to pass its version of the bill, “The Improving Nutrition for America’s Children Act” (H.R. 5504), in order for President Obama to sign the bill before Sept. 30, when many of the programs are set to expire. The House Education and Labor Committee approved the measure on July 15.

The American Academy of Pediatrics also commended the Senate for its action on the legislation and pushed the House to follow the Senate’s lead. “The AAP urges the House to follow the Senate’s swift action on this bill and pass strong child nutrition legislation when Congress reconvenes in September. All children deserve a healthy future, which starts with access to healthy, nutritious meals every day.” See the American Academy of Pediatrics’ entire statement.

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Patient Protection, Preventive Care, and Pre-existing Conditions

Patient Protection, Preventive Care, and Pre-existing Conditions

In this week's Health Insurance Reform Update, we're sharing new information about three provisions: "patient protection" regulations, new preventive care regulations, and high risk pools ("pre-existing condition insurance plans"). While there's a lot of information to digest, we're working hard to make sure you and your clients get the most from the law.

Patient Protection Provisions
The Department of Health and Human Services (HHS), the Department of Labor, and the Department of the Treasury filed a 4-part interim final rule (IFR) on June 23, 2010 that provides further detail on requirements related to pre-existing condition exclusions for kids, lifetime and annual limits, rescission, and other "patient protections". Below is an overview of key points:

Pre-existing conditions
The recently enacted health care reform legislation prohibits health plans from using pre-existing conditions to deny health care coverage to an individual beginning in January 2014. Under the IFR, the Department of Health and Human Services requires health plans to implement this provision for children under the age of 19, beginning with plan years on or after September 23, 2010.

Annual limits
The new legislation also prohibits contracts from having lifetime limits and limits a health insurer's ability to have annual limits on "essential health benefits" (which have yet to be completely defined). Regardless of whether the plan is grandfathered, our plans will no longer include lifetime dollar limits for plan years beginning on or after September 23, 2010. We will also be removing certain annual limits. While we continue to wait on additional guidance from HHS that will further define "essential health benefits", we are making a good faith effort to comply with the regulation prohibiting annual limits on these benefits.

Rescission
Rescission is now limited to fraud or intentional misrepresentation of material fact. Based on the recent IFR, a health insurer may only terminate a member's coverage in the event of a mistake in eligibility (without fraud or misrepresentation) prospectively, not retroactively. We were the first health insurer to implement the rescission provision, implementing federal legislation regarding individual market rescissions effective May 1. This was well ahead of the effective date contained in the legislation, building on our leadership in the early implementation of reform legislation.

"Patient Protections"
The legislation also contains a number of other provisions that the Administration is calling "patient protections." This group of provisions includes:

• Primary care physicians - For plans that require a primary care physician, allowing all members to choose any available in-network provider as their primary care doctor, including a participating pediatrician for children
• OB-GYN providers - Allows individuals to seek care from an in-network OB-GYN provider without requiring pre-authorization or referral from a primary care physician
• Emergency room services - Emergency room services protection including no pre-authorization for emergency services and limited cost-sharing for out of network services

Resource: EasyToInsureME http://www.easytoinsureme.com/health-insurance-quotes.html

This Week in Health Insurance Reform

Did you know health care fraud constitutes nearly 3% of all health care spending, according to the National Health Care Anti-fraud Association? This translates to $69 billion lost to fraud annually, or over $100 million per day. Blue Cross and Blue Shield companies' anti-fraud investigations resulted in overall savings and recoveries of more than $510 million in 2009, according to data released May 26, 2010, by the Blue Cross and Blue Shield Association. This represents a significant increase compared with 2008 and contributed to a three-year average return of $7 for every $1 spent on anti-fraud efforts.


This Week in Health Care Reform: June 4, 2010

As lawmakers complete a week long recess in their home states, Obama administration officials move forward on implementing certain provisions of the health insurance reform legislation. Recent national polling shows a majority of Americans strongly favor repeal of the law.


Health Care Reform

Young Adults Might Not Be Covered Ahead of Schedule: WellPoint's affiliated health plans and other insurers began extending medical coverage for qualifying graduating students on June 1, well in advance of the September 23 deadline. However, many employers plan to wait to provide the extended coverage until they are legally required to do so, with an effective date of January 2011 for most employers.

Senate Fails to Extend Bill for Doctors: Before leaving for the Memorial Day recess, House Democratic leaders scaled back health care language from the jobs bill before passing the bill. In the package, doctors who treat Medicare patients would see a 2.2% payment increase for the remainder of this year and a 1% payment increase in 2011. Extensions of COBRA subsidies and additional Medicaid funding for states were removed from the bill. Lawmakers in the Senate will vote on the bill when they return from recess next week.

Florida Judge Denies Government's Motion: Health and Human Services Secretary Kathleen Sebelius asked a federal judge in Florida for a one-month extension to respond to the joint lawsuit filed by 20 states' attorneys general who challenged the constitutionality of the new health care reform law. U.S. District Judge Roger Vinson denied the administration's request for an extension and instructed HHS officials to respond by the June 16 deadline.

Public Opinion

Americans Want Repeal of Health Care Reform: A recently released Rasmussen report suggests that Americans are strongly in favor of repealing President Barack Obama's health care reform law. Sixty percent of those polled favor repeal, while 62% believe the new legislation will increase the budget deficit.

Majority of Americans Unhappy with Reform: According to a new Quinnipiac University poll, 51% of Americans are unhappy with the new health care reform legislation and 70% are "dissatisfied" or "very dissatisfied" with the way things are going for the nation.

Looking Ahead

Lawmakers return to Washington on Monday ahead of a contentious primary runoff in Arkansas between Democrats Sen. Blanche Lincoln and Lt. Gov. Bill Halter, with health care reform at the center of the debate. The winner of Tuesday's Democratic nomination will face Republican Rep. John Boozman in the November elections.

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Health Care Reform Update from Easy To Insure ME

May 12, 2010

Read this week about what is happening on the federal legislative front of Health Care Reform.

House Hearing on Health Care Pricing Transparency Proposals
The House Energy and Commerce Subcommittee on Health held a hearing on May 6, 2010 regarding legislative proposals aimed at improving transparency for health insurance consumers. Three separate transparency bills were listed on the hearing agenda, although the discussion among subcommittee members and witnesses focused broadly on the merits of transparency and the possibility of unintended consequences.

Representative Steve Kagen (D-WI) testified in support of the H.R. 4700 bill he has introduced, which would require health care providers and insurers to publicly disclose, on a continuous basis, all prices for health care-related items, products, services and procedures. Kagen said that this bill would “establish a very competitive medical marketplace” and allow families to “make their health care decisions based upon quality, and the price and the service of available caregivers.”

Michael Cowie, an antitrust attorney with Howrey LLP and a former official with the Federal Trade Commission (FTC), expressed concern that the Kagen bill would conflict with existing antitrust provisions that are intended to prevent collusion that could contribute to higher costs. Cowie also cited economic studies showing that mandatory publication of pricing terms often leads to higher pricing.

Steven Summer, a Colorado Hospital Association representative, suggested a four-prong approach to improving transparency: expanding existing transparency efforts through collaborations between states and state hospital associations; requiring insurers to make estimated out-of-pocket costs available on a pre-care basis; conducting more research on the pricing information that consumers want and need; and making pricing information consumer-friendly.

The other transparency bills discussed at the hearing were:

* H.R. 2249, introduced by Representative Michael Burgess (R-TX), would require states, as a condition of participating in Medicaid, to establish laws for the disclosure of information on hospital charges, to make such information available to the public, and to provide individuals with information about estimated out-of-pocket costs for health care services.
* H.R. 4803, introduced by Representative Joe Barton (R-TX), would require health insurance plans to make available to enrollees and potential enrollees specified information, including covered items and services, a list of limitations and restrictions, the number of participating providers according to specialty type, information on cost-sharing, a description of the claims appeal process, and other information.


Although both Democrats and Republicans voiced support for stronger measures to improve transparency, it is not clear at this time whether the subcommittee will be marking up any of the legislative proposals discussed at the hearing.

House Republicans Urge Democrats to Hold Hearings on Health Care Reform Law
Republican Members of the House Energy and Commerce Health Subcommittee repeatedly urged Energy and Commerce Committee Chairman Henry Waxman (D-CA) to hold a series of hearings on the new health insurance reform law during the recent Subcommittee hearing on health care pricing transparency (see above information). Chairman Waxman gave no indication that he intends to hold hearings on the reform legislation.

Republicans have specifically requested to hear the testimony of Centers for Medicare and Medicaid Services Chief Actuary Rick Foster regarding a report his office prepared on the impacts of the health insurance reform legislation. The report estimates that the law will increase health care costs by approximately 1 percent over the next ten years, and will cause approximately 14 million Americans to lose their current employer-sponsored coverage.

In an April 28 letter to Chairman Waxman, Ranking Member Joe Barton (R-TX) wrote, “We believe that inviting Mr. Foster’s testimony is invaluable to our efforts to rein in health care costs and government spending. We therefore ask that you invite him to testify as soon as possible.”

Senator Feinstein Continues Seeking Support for Federal Review of Insurance Rates
Senator Dianne Feinstein (D-CA) continues to seek support for legislation she has introduced, which would give the federal government the authority to review and block health insurance rate increases.

The Health Insurance Rate Authority Act of 2010 (S. 3078) would authorize the HHS Secretary to conduct health insurance rate reviews in states where the state insurance commissioner does not have the authority or capability to do so. The legislation would also give the HHS Secretary the authority to block “unreasonable” rate increases. The bill currently has six cosponsors.

On April 28, Senate Health, Education, Labor, and Pensions Committee Chairman Tom Harkin (D-IA) held a hearing on the legislation in which he stated that “it’s my intention to move toward a markup or at least do something to get the bill moving” this year. Also, Senator Feinstein has indicated that she may seek to move the legislation by offering it as an amendment to an unrelated bill.

Representative Jan Schakowsky (D-IL) has introduced companion legislation (H.R. 4757) in the House, which currently has 27 cosponsors.

Possible McCarran-Ferguson Amendment
Senator Patrick Leahy (D-VT), chairman of the Senate Judiciary Committee, filed an amendment on May 6 that proposes to repeal portions of the McCarran-Ferguson Act as they apply to health insurance plans. Chairman Leahy filed this amendment with respect to the financial regulatory reform bill currently being debated on the Senate floor. Senate leaders are hoping to complete action on this bill by May 14.

The Leahy amendment is based on legislation, Health Insurance Industry Fair Competition Act (H.R. 4626), that the House approved in February. The health insurance industry has repeatedly stated that the McCarran-Ferguson Act is extremely limited in scope and has nothing to do with competition in the health insurance industry, which is the issue the House bill purports to address. However, opponents of repeal say this move could have unintended consequences and could disrupt initiatives to enhance efficiency, reduce costs and improve the quality and safety of patient care. Currently, the federal government intensely examines, and takes action on every merger involving health insurance plans. Also, all insurers are subject to state antitrust laws, as well as state rate regulation and other state laws enforced by State Attorneys General and insurance regulators.

Karen Ignagni, president of America’s Health Insurance Plans (AHIP), said that such legislation “attempts to remedy a problem that does not exist” and that repeal efforts are “based on a misperception of the scope and impact” of the exemption.

As of this writing, Chairman Leahy has not yet offered the amendment for consideration. Among the approximately 130 amendments that have been filed for the financial regulatory reform bill, only a small portion will likely be considered by the Senate. As noted above, Senator Dianne Feinstein (D-CA) has not yet filed an amendment for a federal rate review process.

New HELP Committee Staff
Jenelle Krishnamoorthy has been named health policy director for the Senate Health, Education, Labor and Pensions (HELP) Committee. Krishnamoorthy served as the lead health staff member for HELP Chairman Tom Harkin (D-IA). She succeeds David Bowen, who worked for the HELP Committee for 10 years.

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Current Health Insurance Reform Issues

No sooner had President Obama signed the last piece of the health insurance reform package on March 30 than he hit the road, traveling to a number of states to sell the public on the new health care law of the land. On their Easter/Passover recess break, many members of Congress were engaged in their own hearts and minds campaign on health reform back in their home districts. A new Gallup poll, however, seems to show that Democratic supporters of the bill have the tougher selling job. The poll shows that 47 percent of Americans believe it is a good thing that the bill passed while 50 percent believe it to be a bad thing. And, the results show that both opponents and proponents agree that the new law does not do nearly enough to address rising health care costs. Health plans, such as Aetna, have maintained that the success of health care reform will hinge on addressing health care costs, and we have pledged to continue working toward reforms that would achieve affordability.

Federal

Since Congress was in recess last week, there is no Federal report this week.

States

ARIZONA: After a lengthy debate in special session, the legislature voted along party lines to permit a lawsuit challenging the newly enacted federal health care reform law. It is unclear whether Governor Jan Brewer will join other states in the lawsuit filed in Florida, since the attorney general has advised that he will not participate in any litigation on this issue. Brewer had asked lawmakers for authority to go around the attorney general and sue on the state's behalf.

COLORADO: A bill prohibiting the use of gender as an underwriting factor in setting rates for individual policies passed both chambers and will become effective with plans issued or renewed after January 1, 2011. The bill is part of Governor Ritter’s health reform package.

GEORGIA: A bill that originally would have imposed a tax on health plans – the language regarding a health plan tax was removed recently -- was passed out of the Senate last week. However, whether the Governor will sign the bill in its current form is not clear.

IDAHO: The legislature adjourned a week early last week, but not before passing a number of items to close out the session. Governor Otter has signed a number of the bills, including the “Idaho Health Freedom Act”, reserving citizens' right to choose or decline health care services without being penalized by the federal government and authorizing the state attorney general to seek legal recourse to uphold this policy. Also signed were bills regulating the relationship between third-party administrators and insurers, and establishing an immunization board to maintain a single distribution center for providers and determine an assessment on carriers to fund the program. Another bill amends the duties of the Commission of Health Information Technology Planning to include monitoring the state’s health data exchange and recommending improvements to IT capabilities. Bills awaiting the governor’s signature include a proposed prohibition on a carrier’s ability to require a participating dentist from charging a member at a non-par rate for services that are not covered under the provider contract, and a proposed requirement that both the prescribing physician and patient be notified by the pharmacist of generic substitutions for epilepsy or seizure drugs. Defeated were mandates for oral chemotherapy parity and prosthetic limbs, an any-willing-provider requirement, and a bill permitting small employers to enroll in the state employees’ plan.

ILLINOIS health insurance : The House has unanimously passed the Illinois Health Information Exchange and Technology Act to establish a state authority to operate the Illinois Health Information Exchange. Expected to pass in the Senate, the bill supports the adoption of electronic health records among health care providers in Illinois, and building the infrastructure necessary to make HIE possible. Aetna was one of three insurers supporting the new act as part of a coalition of provider, consumer groups and unions. The HIE is designed to promote and facilitate the sharing of health information among health care providers within Illinois and in other states, and foster the widespread adoption of electronic health records. The bill also sets forth the Authority's powers, with public and private representation, to facilitate the secure exchange of electronic health records to deliver better health care. No later than January 1, 2015, each state agency that implements, acquires, or upgrades health information technology systems shall use systems and products that meet minimum standards adopted by the Authority for accessing the HIE.

IOWA: The Iowa legislature ended its annual legislative session last week and passed bills that include a clinical trial mandate for cancer patients, a prohibition of dental fee schedules for non-covered services, and an increase in the amount the guaranty association will pay for hospital, med-surg and major med coverage. Also, an Insurance Department omnibus bill that passed includes several insurance reform amendments, including making rate increase applications public record and requiring an annual report from the Commissioner to include information from health plans on medical loss ratios, rate increase data, health care expenditures in Iowa and their effect on premiums, ranking and quantification of the factors that result in higher and lower costs, the plan’s current capital, surplus and reserves, any apparent medical trends affecting insurance costs, and any other data the commissioner might deem pertinent. Carriers now must also notify policyholders of any application for a rate increase exceeding the average annual health spending growth rate stated in the most recent national health expenditure projection published by CMS. Additional amendments included a mental health & substance abuse mandate for veterans, an expansion of IowaCare, the establishment of a health information clearinghouse/exchange, and prohibition of plans using genetic information to discriminate among patients. Bills of interest that died would have created mandate-light health benefit plans, a public access cost and quality transparency portal, mandated coverage for autism, and income tax deductions for section 125 health plans.

MAINE: The legislature passed legislation that would prohibit health plans from imposing annual, lifetime or other caps on the amount they will pay for covered medical services. If signed by Governor John Baldacci as expected, the bill would take effect January 1, 2011. The legislation defines "health plan" as a plan offered or administered by a carrier that provides for the financing or delivery of health care services to persons enrolled in the plan (other than a plan that provides only accidental injury, specified disease, hospital indemnity, Medicare supplement, disability income, long-term care or other limited benefit coverage). A similar provision in the federal health care reform legislation recently enacted by Congress abolishes lifetime or annual dollar limits on essential health benefits. The federal reform law allows health plans to establish restricted annual limits on essential health benefits prior to January 2014 and to place limits on benefits that are considered non-essential health benefits.

MASSACHUSETTS: The Massachusetts Division of Insurance (DOI) has rejected 235 of 274 rate increases filed for small businesses, using 90-day emergency regulations that require HMOs to file any proposed increases to small group rates or changes to small group rating factors at least 30 days in advance of their effective dates. The emergency regulations also require HMOs to provide a significant amount of additional information when filing any proposed small group rate increases or rate changes. The DOI sent letters to carriers outlining the reasons for its actions, including: the disapproved rate filings failed to illustrate how the carriers pay similarly situated providers differing rates of reimbursement based solely on quality of care, mix of patients, intensity of services, and geographic location at which care is provided; the disapproved rate filings failed to demonstrate that carriers have renegotiated provider reimbursement rates; and the disapproved rate filings were significantly above the medical consumer price index without an adequate explanation for the wide difference.

MICHIGAN: Pulling attention away from the legislature's individual market reform bills, Governor Jennifer Granholm implemented an executive order that would put into motion a cabinet level workgroup titled "Health Insurance Reform Coordinating Council" on federal health care reform issues to be implemented in Michigan. Her goal is to identify steps that must be taken to ensure that Michigan citizens reap the full benefits outlined in the federal reform bill, including benefits for dependents to age 26, tax credits for small business, Medicaid expansion beginning in 2014, insurance reforms (e.g., eliminating pre-existing condition exclusions and rescissions),a health insurance exchange, preventative services without co-pays, and changes in the Medicare donut hole. Office of Financial and Insurance Regulation Director Ken Ross will be part of the overall implementation. His immediate assignment is to create a health insurance ombudsman office, begin the framework for the health insurance exchange, as well as have ongoing communication with Health and Human Services and NAIC on the overall rules.

SOUTH DAKOTA: As the legislature adjourned last week, Governor Mike Rounds vetoed a subrogation bill that would have prevented insurers from any subrogation rights until the injured party was first "made whole." The Senate tried but failed to overturn the veto. Legislation that was signed by the Governor included a bill prohibiting contracts between an insurer and a dentist that require the use of a fee schedule for non-covered services, a bill changing the premium rate-setting procedure for the high-risk pool,and a Joint Resolution opposing the federal health care reform proposals passed in the U.S. Senate and House. Several significant bills that died included a provision to allow South Dakota to opt out of federal health reform and a bill repealing premium and annuity taxes for insurers.

TEXAS: Last week, the Senate Committee on State Affairs held a joint hearing with the Senate Committee on Health & Human Services to discuss the impact of federal health care reform on the state. The committee heard from Health & Human Services Commissioner Tom Suehs, Texas Department of Insurance Commissioner Mike Geeslin and Special Projects Director Dianne Longley, and the Employees Retirement System. Suehs estimated the cost to the State would total $27 billion over 10 years. When asked why his estimate was so much higher than that of the CBO, Suehs stated that “I know that I’ve got a higher population of uninsured than most states have total population.” Commissioner Geeslin focused his opening comments on the massive scope of the bill and how much change it will bring to consumers. In response to a question, Geeslin said that a new rate review authority could respond to a rate increase they deemed unjustified not with an enforcement action but only to inform the public that the rate increase was deemed unjustified. He also pointed out that the state can opt out in 2017 if it can demonstrate that it could provide similar coverage. He clarified that the exchange function could be outsourced but not to a Medicaid agency or a private insurer. Both agency heads confirmed that their need to add staff to implement the law will be substantial. The Committee members were in agreement that many future hearings would be required to keep up with the pace of reform implementation. Aetna will continue to monitor these hearings.

WASHINGTON: Partisan debate over federal health care reform is moving from the nation's Capitol to the states. Several states, including Washington, are challenging its individual mandate in federal court. Governor Chris Gregoire, a supporter of the health-care overhaul, is threatening to file a lawsuit against Attorney General Rob McKenna in an effort to block his participation in the suit organized and funded through the Florida Attorney General’s office. At the same time, the Democrat-controlled legislature may try to block McKenna’s participation by cutting funding to the Attorney General’s Office, or requiring that McKenna receive approval from the Governor prior to continued participation. Fourteen states are now participating in the lawsuit.

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Health Reform What am I paying for?

Health Care Reform - Timeline

The federal health care reform legislation, known as the Patient Protection and Affordable Care Act, signed by the President on March 23, 2010, and the Health Care and Education Reconciliation Act approved by Congress, signed by the President today, will expand the availability of health care coverage to millions of Americans. While some of the measures will be implemented this year, many do not take effect until 2014 and some extend out to 2020.

Below is a high-level overview of the timeline. It is important to note that many of these reforms and their effective dates are subject to the rules and regulations process both at the state and federal levels – which could alter the intended timing of implementation.

2010

New Programs:
* Temporary retiree reinsurance program is established
* National risk pool is created, small business tax credit is established
* $250 rebate for Medicare members who reach the ”doughnut hole”

Insurance Reforms:
* Prohibits lifetime benefit limits – based on dollar amounts
* Allows restricted annual limits on the dollar value of certain benefits
* Coverage rescissions/cancellations are prohibited (except for fraud or intentional misrepresentation)
* Cost-sharing obligations for preventive services are prohibited
* Dependent coverage up to age 26 is mandated
* Internal and external appeal processes must be established
* Pre-existing condition exclusions for dependent children (under 19 years of age) are prohibited
* New health plan disclosure and transparency requirements are created

2011

Insurance Reforms:
* Uniform coverage documents and standard definitions are developed
* Minimum medical loss ratios are mandated

Medicare Reforms:
* Medicare Advantage cost sharing limits effective
* Medicare beneficiaries who reach the doughnut hole will receive a 50% discount on brand name drugs
* A 10% Medicare bonus will be provided to primary care physicians and general surgeons practicing in underserved areas, such as inner cities and rural communities.
* Medicare Advantage plans would begin to have their payments frozen.

Other:
* Employers are required to report the value of health care benefits on employees' W2 tax statements.
* Annual industry fee for pharmaceutical manufacturers of brand name drugs.
* Voluntary long term care insurance program would be made available to provide cash benefit for assisting disabled individuals to stay in their homes or cover nursing home costs. Benefits would start five years after people begin paying a fee for coverage.
* Funding for community health centers would be increased to provide care for many low income and uninsured people.

2012

* Hospitals, physicians, and payers would be encouraged to band together in "accountable care organizations."
* Hospitals with high rates of preventable readmissions would face reduced Medicare payments.

2013

* Individuals making $200,000 a year or couples making $250,000 would have a higher Medicare payroll tax of 2.35% on earned income —up from the current 1.45%. A new tax of 3.8% on unearned income, such as dividends and interest, is also added.
* Medical expense contributions to flexible spending accounts (FSAs) limited to $2,500 a year—indexed for inflation. In addition, the thresholds for claiming itemized tax deduction for medical expenses rise from 7.5% to 10% of income.
* Medical device manufacturers would have a 2.9% sales tax on medical devices; devices such as eyeglasses, contact lenses, and hearing aids would be exempt.
* Eliminates deduction for expenses allocable to Medicare Part D subsidy for employers who maintain prescription drug plans for their Medicare Part D eligible retirees.

2014

Coverage Mandates & Subsidies:
* Individual and employer coverage responsibilities are effective.
* Individual affordability tax credits are created and small business tax credits are expanded.

Health Insurance Exchange & Insurance Reforms:
* State individual and small group health insurance exchanges operational.
* Guaranteed issue, guaranteed renewability, modified community rating and minimum benefit standards (“essential benefits” plan) effective.
* Lifetime and annual dollar limits are prohibited for essential benefits.
* Pre-existing condition exclusions are prohibited.

Taxes & Fees:
* Addition of new taxes on health insurers

Medicaid and Medicare Reform:
* Medicaid expanded to cover low income individuals under age 65 up to 133% of the federal poverty level—about $28,300 for a family of four.
* Minimum medical loss ratio of 85% required for Medicare Advantage plans

2018

Taxes & Fees:
* Tax (“Cadillac tax”) imposed on employer sponsored health insurance plans that offer policies with generous levels of coverage.

2020

Medicare Reform:
* Doughnut hole coverage gap in Medicare prescription benefit is fully phased out. Seniors continue to pay the standard 25% of their drug costs until they reach the threshold for Medicare catastrophic coverage.

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