The January 2014 issue of Compliance Today discusses the Affordable Care Act (ACA) and its essential health benefits (EHB) requirements, including ten statutory categories that private and Medicaid plans must cover. It highlights the importance of understanding plan options and the implications of non-compliance, such as penalties for remaining uninsured. Additionally, the article emphasizes the role of managed care plans in guiding consumers through their coverage choices and the need for transparency in insurance policies.

1. Compliance
TODAY
January 2014
a publication of the health care compliance association
www.hcca-info.org
Permissible vs. Proper:
The fine line between rules and values
an interview with Michael Josephson
President and Founder, Josephson Institute of Ethics
and 2014 Compliance Institute Keynote Speaker
See page 16
28
Physician practice management
arrangements: State fee-splitting
prohibitions and the corporate
practice of medicine
Janice A. Anderson and
Cullin B. Hughes
35
Some
thoughts
on
tone at
the top
Bret S. Bissey
42
Compliance and
quality of care, Part 2:
The physicians’ perspective
Michelle Moses Chaitt, Mark L.
Mattioli, Richard E. Moses,
and D. Scott Jones
47
New developments
in data analytics:
From data
mining to
data prospecting
Karen Nelson
This article, published in Compliance Today, appears here with permission from the Health Care Compliance Association. Call HCCA at 888-580-8373 with reprint requests.

2. by Natalie Franklin
Essential health benefits
under the ACA
»» Ten statutory essential health benefit (EHB) categories were established under the ACA.
»» Private, employer-based, and Medicaid health plans must provide minimum EHBs.
»» Four coverage groups (Bronze, Silver, Gold, and Platinum) are available.
»» Open enrollment in the state health insurance marketplaces started October 1, 2014.
»» Fee or “tax” for failure to obtain coverage starts in 2014.
Compliance Manager for Symbius Medical, a nationwide durable medical
equipment company in Phoenix, AZ.
T
he Patient Protection and Affordable
Care Act1 (enacted on March 23, 2010)
was amended by the Health Care and
Education Reconciliation Act of 20102 (enacted
on March 30, 2010). Nevertheless, three years
after its promulgation, the Affordable Care
Act (ACA) remains widely misunderstood. Few truly understand its
basic foundations, and details on its
implementation are still emerging,
still being crafted. Thankfully, there is
some help out there to help navigate
the new world of healthcare.
Franklin
Beginning in 2014, non-grand­
fathered individual and small group
health plans, as well as Medicaid benchmark
and benchmark-equivalent plan must provide
the essential health benefits (EHBs) designated
under the ACA. EHBs are designed to be
equal to the scope of benefits provided under
a typical employer-sponsored health plan and
are the minimum services a health plan must
cover. The final rules published in the Federal
Register on February 25, 20133 and July 15, 20134
outline the EHB that private health plans
and Medicaid Alternative Benefit Plans,
respectively, must provide, consistent with
Section 1302 of the ACA. EHBs will include
items and services in ten statutory benefit
categories, including:
·· Ambulatory patient services
·· Emergency services
·· Hospitalization
·· Maternity and newborn care
·· Mental health and substance use
disorder services, including behavioral
health treatment
·· Prescription drugs
·· Rehabilitative/habilitative services
and devices
·· Laboratory services
·· Preventive and wellness services
and chronic disease management
·· Pediatric services, including oral
and vision care
Uniformity and transparency of coverage
provisions are expected to fuel competition
between health plans, and many insurers will
likely offer more than the minimum. So, how
will one know which plan to choose?
Individuals are able to shop for insurance
coverage on state health insurance exchanges,
called “marketplaces.” These marketplaces are
intended to allow an apples-to-apples comparison of insurance plan offerings. In addition to
888-580-8373
www.hcca-info.org
Compliance Today
January 2014
Natalie Franklin (nfranklin@symbiusmedical.com) is the Corporate
61

3. Compliance Today
January 2014
catastrophic plans, insurance packages will be
categorized under four groups: Bronze, Silver,
Gold, and Platinum. These plans are defined
by law to denote increasing levels of coverage
from 60%–90% of actuarial value, also called
“metal levels.” Further, the ACA requires
a standardized Summary of Benefits and
Coverage (SBC). All of these rules are intended
to allow consumers to simplify benefit package comparison and make an informed choice
concerning their coverage. Open enrollment
began on October 1, 2013, with coverage beginning on January 1, 2014. Still, for many people,
trying to navigate coverage and get the best
bang for the buck is a daunting process.
Nevertheless, it behooves one to choose
coverage before 2014, because most individuals
who remain uninsured after that date (either
through an employer-based or individual plan,
Medicare, Medicaid, or through the health
insurance exchange) will wind up paying a fee
or “tax,” as well as remaining responsible for
the full cost of their health care. This fee begins
at 1% of annual income or $95 per person,
whichever is higher, and increases to 2.5% or
$695 per person in 2016. Households between
100%–400% of the federal poverty level comprised
of persons who are in the U.S. legally, enrolled
in a qualified health plan, and not eligible for
Medicare, Medicaid, or an employer-sponsored
health plan may be eligible for premium tax
credits. The Internal Revenue Service recently
launched a website, Affordable Care Act Tax
Provisions,5 to provide guidance to individuals,
employers, tax preparers, and others about the
financial impacts of the ACA.
Contact us
email
helpteam @ hcca-info.org
phone 888-580-8373
fax 952-988-0146
mail
HCCA
6500 Barrie Road, Suite 250
Minneapolis, MN 55435
62 www.hcca-info.org
888-580-8373
Managed care plans should carefully craft
their policies in compliance with the mandates
of the ACA. Smart plans will also strive to
be a patient advocate, mindful that patients
have more choices, and will enjoy more
transparency than ever before. It is critical to
provide sound information to allow consumers to make an informed choice, and be able
to explain different coverage options and
provide appropriate referrals. Insurers must
be prepared to explain what services are covered under each category in plain language.
For instance, what specific treatment or care
will be available as a habilitative service, considering there is really no consensus among
insurers to define this category other than the
Medicaid definition? What behavioral health
services will each plan offer, considering the
ACA requires coverage consistent with the
Mental Health Parity and Addiction Equity
Act?6 And ultimately, why should a consumer
purchase their health insurance from your
company? How do your plans stand out
among all the rest?
The U.S. Centers for Medicare and Medicaid
Services launched a website7 to help answer
questions about health insurance market places,
the ACA, and coverage choices. Don’t wait until
the last minute to know your options.
1.
Pub. L. 111-148
2.
Pub. L. 111-152
3. Federal Register, No. 37, February 15, 2013. Available at
78
http://1.usa.gov/1dLKQZ1
4. Federal Register, No. 135, July 15, 2013. Available at
78
http://1.usa.gov/1bbeHWi
5.
IRS Affordable Care Act Tax Provisions. Available at
http://1.usa.gov/1bdzXY7
6. U.S.C. 18031(j). Available at http://1.usa.gov/IAL0n8
42
7.
The Centers for Medicare and Medicaid Services: Healthcare.gov
website. Available at: www.healthcare.gov
To learn how to place an
advertisment in Compliance Today,
contact Margaret Dragon:
email
phone
Compliance
TODAY
January 2014
A PUBLICATION OF THE HEALTH CARE COMPLIANCE ASSOCIATION
WWW.HCCA-INFO.ORG
Permissible vs. Proper:
The fine line between rules and values
an interview with Michael Josephson
President and Founder, Josephson Institute of Ethics
and 2014 Compliance Institute Keynote Speaker
See page 16
margaret.dragon @ hcca-info.org
781-593-4924
28
Physician practice management
arrangements: State fee-splitting
prohibitions and the corporate
practice of medicine
Janice A. Anderson and
Cullin B. Hughes
35
Some
thoughts
on
tone at
the top
Bret S. Bissey
42
Compliance and
quality of care, Part 2:
The physicians’ perspective
Michelle Moses Chaitt, Mark L.
Mattioli, Richard E. Moses,
and D. Scott Jones
47
New developments
in data analytics:
From data
mining to
data prospecting
Karen Nelson