Mental Health Parity and Addiction Equity Act of 2008 Congressional Testimony

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					                            Government Affairs Committee Update


Next Government Affairs Committee Call: Monday, June 15, 2009 at 2:30pm eastern



NBCH Comments on Wellstone & Domenici Mental Health Parity & Addiction Equity Act of
2008 (MHPAEA) (effective January 1, 2010): The U.S. Department of Health and Human
Services and Department of Labor requested comments on MHPAEA, specifically it's impact on
employers in terms of cost, paperwork reduction/administration, as well as regulatory flexibility.
After conferring with the Government Affairs Committee (GAC), as well as purchaser, provider
and consumer organizations, we developed comments to formally submit today, May 28, 2009.
We believe it is important to take advantage of this opportunity to register our comments and
concerns with the new parity law in behalf of our coalitions and their employers. To access
NBCH’s comments, go to: http://www.nbch.org/resources/policypapers.cfm

In terms of background, MHPAEA creates new rules for any financial requirement (e.g., cost-
sharing) or treatment limitations (e.g., visit limits) on mental health and substance use disorder
benefits so that they are no more restrictive than predominant requirements or limitations applied
to substantially all medical and surgical benefits covered by a plan. MHPAEA also reauthorized
several provisions relating to parity in annual and lifetime dollar limits for group health plan
coverage enacted as part of the Mental Health Parity Act of 1996.


DOL Releases Form for Expedited Review of Denial of COBRA Premium Subsidy: On May
21, 2009, the U.S. Department of Labor (DOL) updated its COBRA ARRA webpage with
information on application for review of denial of the COBRA premium reduction (recently
provided under the American Recovery and Reinvestment Act (ARRA)) and the application form
to be used by individuals requesting expedited review. ARRA included a temporary subsidy of
continued COBRA coverage for individuals (within certain income limits) who have been
involuntarily terminated from employment on or after September 1, 2008, through December 31,
2009.

Under ARRA, employees may appeal an employer’s denial of a request for the COBRA premium
reduction. DOL will review appeals related to private-sector employer plans and HHS will review
appeals for federal, state, and local governmental employees as well as appeals related to group
health insurance provided pursuant to state continuation coverage laws. Individuals requesting a
review must submit an application form. DOL is required to make a determination within 15 days
business days of receipt of a properly completed request for review.

The form includes 10 questions to determine subsidy eligibility and lists the documentation that
could assist the DOL in making a determination, including the applicant’s COBRA election notice,
a “Request for Treatment as an Assistance Eligible Individual” or other form used to request the
premium reduction, insurance card, payroll stubs, any documentation detailing the date and
circumstances of the termination of the employee’s employment, or any documentation the
applicant was provided regarding the denial of the premium reduction. (Source: American
Benefits Council, Benefits Byte, May 22, 2009)
                           National Health Care Reform Update


Health Care Reform- The Public Plan Option
Political Landscape: Currently, the question of whether to provide a public plan option
has become the most contentious question in the health reform debate today. It invokes
fundamentally partisan positions on a number of relevant issues, including cost control,
the proper role of government in the system, and whether a level playing field can be
created between public and private plans.

The idea of a government-run plan to compete with private insurers and drive down costs
is proving to be politically challenging but still is viewed by many as essential to the
passage of broad, meaningful health overhaul legislation. Most Republicans vehemently
oppose any form of a government-directed insurance plan, while many Democrats,
especially those in the far left wing of the party, are demanding its inclusion. So, the
major work of the White House is to focus on neutral territory between Democrats and
Republicans on the role, if any, a new "public plan option" should play in covering the
uninsured. However, at this point in the search for a balanced approach, Congress and the
White House still are trying to determine the definition of what exactly a public plan is or
should be. There is discussion of having private sector elements in a public plan to
attract at least some Republican support, but avoiding defections by those who ardently
believe that direct government funding of health care is the only long-term solution to
controlling costs and providing universal coverage.

But in keeping its options open, the Obama administration clearly is encountering
confusion about the concept, which is likely to keep the public plan issue firmly on the
front burner of the debate for some time.

In terms of status, currently, the congressional standing committees with health care
jurisdiction (in the Senate –Health, Education, Labor and Pensions (HELP) and Finance;
and in the House- Ways & Means, Energy & Commerce, Labor & Education) are holding
hearings, ―roundtable sessions‖ and private stakeholder meetings on various components,
such as delivery and financing, of health care reform with each committee supposedly
overseeing the development of its own complementary part of the overall bill.
Committee markups are slated for June with bill passage promised, at least in the House,
by August recess.



In particular, the Senate Finance Committee has completed two of three ―roundtables‖
that are serving as a form of hearing on health overhaul approaches under consideration
by the panel. The committee plans private meetings in which members will be asked to
react to legislative proposals it is considering. Areas of discussion in the roundtables
include delivery, coverage options and financing.

   In that regard, this week Senate Finance Committee leaders released a detailed health
coverage options paper requiring individuals to carry health insurance that in many cases
would be purchased with government subsidies and employer contributions and obtained
through a ―Health Insurance Exchange‖ site on the Internet directing consumers to each
coverage option in their zip code. The first paper dealt with proposals to improve patient
care and reduce costs, and the third paper will deal with financing.

The following are the major components of the coverage options paper:

      The policy options document was quiet on the controversial question of
       establishing a government-run public health insurance program as one of the
       coverage options. It lists options ranging from a new health insurance program
       modeled after Medicare that would require all of the doctors, hospitals, and other
       providers in that program to participate, to no ―public program‖ at all.
      Would provide Medicare to 55 to 64-year-old uninsured Americans who would
       like to buy into the program.
      Increase eligibility in Medicaid to uninsured parents, children and pregnant
       women in households with incomes up to 150 percent of the federal poverty level.
      Expand Medicaid to all individuals with incomes at or below 115 percent of the
       federal poverty level.
      More insurance regulation are other options in the document, which would
       sharply limit how much insurance rates could vary and guarantee access to
       insurance coverage, blocking insurers from denying coverage based on health
       status.
      Provision of a small group insurance exchange is another option presented.
       Individuals and groups of 2 to 10 could buy through the insurance exchange
       immediately after its creation. The rest of the small group market —11 to 50
       employers or as defined by the states — would be able to buy insurance through
       the exchange once rating rules are fully phased in by the state in question. Four
       benefit options would be created: lowest, low, medium, and high. All insurers
       would have to offer coverage in each category. All plans would be required to
       offer preventive benefits, primary care, emergency services, hospitalization,
       physician services, prescription drugs, and other benefits. Plans could not include
       annual or lifetime limits on coverage and would have to provide first-dollar
       coverage of preventive care.
       Tax credits would be provided for individuals under 400 percent of the poverty
        level to help offset premium costs. Eligible low-income individuals would be able
        to use the credits to buy coverage through the exchange. Subsidies would shrink
        in size as income level rises up to the 400 percent level. Small businesses with 10
        or fewer full-time workers could get a tax credit equal to 50 percent of coverage
        costs. Credits would be available to larger businesses but be phased out for firms
        with more than 25 workers.
       Individual mandate: On the question of an individual mandate to carry health
        insurance, everyone would be required to buy coverage through the individual
        market, any grandfathered plan or in the group market. Exemptions would be
        allowed for religious objections or those in the country illegally.To ensure
        compliance, the consequence for not being insured would be an excise tax equal
        to a percentage of the premium for the lowest-cost option available through the
        exchange for the area where the individual lives. The tax would be phased-in and
        would equal 25 percent of the premium for the first year, 50 percent the second
        year and 75 percent thereafter. Individuals could apply for exemptions from the
        penalty if the lowest-cost option exceeds 10 percent of income, or an individual is
        below 100 percent of the federal poverty level, or ―hardship.‖ The requirement
        would begin Jan. 1, 2013 or sooner if possible, the paper says.
       Employer mandate: As for an employer requirement, the paper sets out as an
        option a ―pay or play‖ model in which all employers with more than $500,000 in
        payroll a year would either offer their full-time workers health insurance
        coverage, or pay an assessment. Those employers with total annual payroll of less
        than $250,000 would be exempt from offering coverage.
       Large employer mandate: The coverage offered by those larger employers would
        have to have an actuarial value equal to the lowest coverage option, as well as
        first-dollar coverage for preventive care, and the employer would be required to
        contribute at least 50 percent of the premium for the employer-sponsored
        insurance. (Source: CQ HealthBeat, May 11, 2009)

    For more information on the Senate Finance Health Care Coverage Options Paper, go
    to: http://finance.senate.gov/press/Bpress/2009press/prb051109.pdf




                              Other Health Care Policy Updates:


1) NBCH Comparative Effectiveness Research (CER) Issue Brief: April 2009
Heralded for the past several years as cornerstone for reducing health care costs and increasing
the quality of care, many lawmakers and health care experts say more research should be done
to study which medicines, devices, and procedures work best at treating different diseases. As a
nation, if we can better align treatment with medical best practices, it is probably that we could
improve the quality of care patients get and bring down costs of health care across the board
To that end, a small, safe step toward health care reform and a modest proposal to accelerate
comparative effectiveness research was signed into law on February 17, 2009 by President
Obama as part of the $787 billion spending bill intended to stimulate the economy. But the vocal
opposition to the provision took Democrats somewhat by surprise and probably foretells difficult
fights ahead when President Obama seeks to make broader changes to the health care system,
including an expected expansion of the comparison studies. Compared to the overall size of the
stimulus, the $1.1 billion dedicated to comparative effectiveness research, while far more than the
$50 million the government spent in fiscal 2009 on such research, is small relative the cost of the
work that needs to be done.

Given this new interest and focus on CER by Congress and the President, we thought it would be
a good time to develop a policy paper that outlines the current CER political landscape, as well as
the pro and con arguments, including those of major stakeholders. The NBCH Government
Affairs Committee hopes that the coalition members and their employers find this paper to be a
useful resource to better understand the issues involved with CER. To access the paper,
please go to: http://www.nbch.org/resources/policypapers.cfm

2) Do you have a federal health care reform communications strategy? As the health care
reform debate progresses, in preparation for congressional action, some of our coalition
colleagues are looking for suggestions on how to work with their employer members. In specific,
what are some tactical approaches about which you have heard or that you currently are using
to interact with employer members relative to health care reform? We are specifically interested
in strategies involving policy/marketing/communications with employer coalition members.
Please forward ideas or suggestions to Kelli Pedas at kmoler@nbch.org. We will aggregate
feedback and provide to the entire membership via the biweekly newsletter.

3) Comments on Wellstone & Domenici Mental Health Parity & Addiction Equity Act of
2008 (MHPAEA) (effective January 1, 2010): The U.S. Department of Health and Human
Services (DHHS) currently is requesting comments on MHPAEA, which, in part, reauthorizes and
builds upon the 1996 mental health parity bill, specifically its impact on employers in terms of
cost, paperwork reduction/administration, as well as regulatory flexibility. NBCH is planning to
provide comments to DHHS, which are due May 28, 2009, and we are working with other
organizations to help inform our development of comments to DHHS. It is important that we take
advantage of this opportunity to register our comments in behalf of our coalitions and their
employers, but we need your help to accurately report the concerns and issues with this new
legislation.

Please take some time this week to solicit information from your coalition members regarding
issues and concerns with the 1996 law, as well as the new mental health and substance
                                                                                        nd
abuse parity law. We plan to have our comments prepared by next Friday, May 22 , which we
will distribute to our coalition members then in hopes that it will serve as a template for coalition
and employer comments to DHHS. We were informed this week that the more purchaser-oriented
responses the better.

The following background and excerpt may be helpful resources:

The Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) creates new rules
for any financial requirement (e.g., cost-sharing) or treatment limitations (e.g., visit
limits) on mental health and substance use disorder benefits so that they are no more
restrictive than predominant requirements or limitations applied to substantially all
medical and surgical benefits covered by a plan. MHPAEA also reauthorized several
provisions relating to parity in annual and lifetime dollar limits for group health plan
coverage enacted as part of the Mental Health Parity Act of 1996.
Excerpt: "The Departments are requesting comments . . . with respect to the following specific
areas: (i) What policies, procedures, or practices of group health plans and health insurance
issuers may be impacted by MHPAEA? What direct or indirect costs would result? What direct or
indirect benefits would result? Which stakeholders will be impacted by such benefits and costs?

(ii) Are there unique costs and benefits for small entities subject to MHPAEA (that is, employers
with greater than 50 employees that maintain plans with fewer than 100 participants)? What
special consideration, if any, is needed for these employers or plans? What costs and benefits
have issuers and small employers experienced in implementing parity under State insurance laws
or otherwise? . . . The Departments [also] are seeking comments to aid in the development of
regulations regarding MHPAEA." (U.S. Department of Health and Human Services)
Also, here is a link to the DHHS comments request in the Federal Register. Please carefully
review page 3 for which DHHS is seeking comments.
http://edocket.access.gpo.gov/2009/pdf/E9-9629.pdf

4) How to Get Involved with the PCMH National Movement:

The Executive Director of the Patient Centered Primary Care Collaborative (PCPCC),
Edwina Rogers, will be holding briefings over the phone for any organization or
individual who wishes to learn more about the Patient Centered Medical Home (PCMH)
and the Collaborative. The next briefing will be held on Tuesday, June 2nd, at 11:00 AM
EST. If you wish to participate, please dial into the call-in number: 712.432.3900 and
enter passcode 471334#. To download the PCPCC presentation materials, please click
here (http://www.pcpcc.net/content/general-presentation-materials) and download the
document entitled "PCPCC PowerPoint Slides".

5) David Blumenthal Takes Over as National Health IT Chief

As of Monday, April 20th, David Blumenthal assumed his role as the new national
coordinator for health IT, replacing Robert Kolodner as head of the Office of the National
Coordinator (ONC) for Health IT. Blumenthal will leave his physician practice with
Partners HealthCare in Boston and his role as a professor at Harvard Medical School to
join ONC. Blumenthal will be responsible for $2 billion in discretionary funding
allocated for ONC under the federal stimulus package. ONC's stimulus funding also will
be used to establish a national research center to provide technical support to health care
providers' adopting health IT. (Source: Patient Centered Primary Care Collaborative)

              Challenges Hospitals to Reduce Health
6) DHHS Sebelius
Care Associated Infections
Following reports released by the Department of Health and Human Services (DHHS)
indicating that patient safety measures have worsened, HHS Secretary Kathleen Sebelius
last week challenged hospitals to reduce the number of health care associated infections
(HAIs) in their facilities. According to DHSS, HAIs drive up the cost of health care in
the United States by up to $20 billion each year and are among the top ten leading causes
of death.
Sebelius called on hospitals to reduce the number of Central Line Associated Blood
Stream Infections in intensive care units by 75 percent over the next three years. DHHS
also plans to make $50 million in grants available for states to fight HAIs using funds
from the economic stimulus law. (Source: CQ HealthBeat)

7) Sebelius Releases Annual Quality & Disparities Reports, Says Improving Quality
is Key to Health Care Reform

On May 6, according to the 2008 National Healthcare Quality Report published annually
by the Agency for Healthcare Research and Quality (AHRQ), patient safety in the U.S. is
not improving. The 2008 report shows nearly a 1 percent decline in patient safety since
2007. In addition, the report showed that improvements in health care quality are
unevenly spread across the difference settings of patient care. Although care delivered in
hospitals has increased approximately 3 percent per year, for example, the report said that
care in ambulatory settings only improved at a rate slightly more than 1 percent.

In addition, the 2008 National Healthcare Disparities Report also published by AHRQ
showed that at least 60 percent of measures of quality of care are not improving for
Blacks, Asians, American Indians/Alaska Natives, Hispanics and poor people.

 ―Today‘s reports show why we can‘t wait to enact comprehensive health reform,‖
Sebelius said in the related DHHS release. ―The status quo is unsustainable and we
cannot allow millions of Americans to continue to go without the care they need and
deserve.‖ For more information about the 2008 Health Care Quality and Disparities
Reports, go to: http://www.ahrq.gov/qual/qrdr08.htm




Baucus Hails Longer Payback Period for Health
Overhaul
By John Reichard, CQ HealthBeat Editor

  Although the budget blueprint passed late Thursday night by the Senate does not
specify how an overhaul will be paid for, Senate Finance Committee Chairman
Max Baucus on Friday hailed the vote as a major step toward comprehensive reform.

   ―The budget includes a health care ‗reserve fund‘ that will ensure a health reform bill
can meet the budgetary rules when it is considered by the Senate this year,‖ Baucus said
in a press release. ―Health care reform is an investment in America‘s system that will
reduce costs over time. This budget recognizes that investment by allowing health reform
to be paid for in the long run and that flexibility is essential to making health reform
work.‖

  The Senate budget resolution requires that the costs of an overhaul be paid for over the
period of 11 years, not the usual 6 years and 11 years, Baucus said. That means that
overhaul provisions that don‘t generate savings for several years could be used to help
pay the costs of an overhaul, giving Baucus greater flexibility in obtaining favorable
scoring from the Congressional Budget Office of the costs of a legislative proposal.

   Finding the ―pay-fors‖ for the $100 billion plus per year required for universal
coverage would still be an enormous challenge, but arguably a mix of Medicare cuts,
taxation of high cost health benefits, and shrinkage of the value of deductions for more
affluent Americans would make it possible if still improbable. Much will depend on the
determination and skill of the White House and congressional leaders in persuading
taxpayers, employers, medical product companies, hospitals, insurers, and doctors that
the benefits they could receive from universal coverage in the form of greater security,
lower costs, and added business would compensate for the lower reimbursements and
higher tax bills that would result.

Two Senate Panels Confirm Plan to Move Separate
Health Bills
By Drew Armstrong, CQ Staff

  The Senate Finance Committee and Health, Education, Labor and Pensions Committee
have solidified their plans to move separate health care overhaul bills that will eventually
be combined on the floor, likely after markups that are targeted for early summer.

  Aides to both committees confirmed the plans Wednesday.

  ―This has sort of always been the plan,‖ said an aide to Finance Committee Chairman
Max Baucus, D-Mont. ―We‘re talking to each other to ensure that the two committee
products can be merged on the floor,‖ said the aide.

   The two committees are working closely together to coordinate the separate pieces of
legislation, according to aides, especially with respect to jurisdictional issues.

   ―Chairman Kennedy believes strongly that having one legislative approach is the best
way to guarantee quality and affordable healthcare for the American people,‖ said
Anthony Coley, spokesman for HELP panel Chairman Edward M. Kennedy, D-Mass.
―He and Chairman Baucus are working very closely together. They have established a
joint process that will culminate in complementary legislation on the floor by early
summer.‖

  Baucus and Kennedy each have working groups where committee staff meet regularly
with industry and lobby organizations. Aides to the two committees also meet with each
other every other Friday to discuss their health care overhaul efforts.

   The Finance Committee is expected to mark up a bill in June, with the goal of floor
action soon after. The HELP Committee has set a markup for around that time, but an
aide would not reveal the exact date.
Kennedy, Baucus Announce Early June Health
Overhaul Markups
By John Reichard, CQ HealthBeat Editor

   The chairmen of the two key committees that will lead Senate efforts to craft health
overhaul legislation announced Monday that they plan early June markups of very similar
legislation that ―can be quickly merged into a single bill for consideration on the Senate
floor.‖

  ―We have a moral duty to ensure that every American can get quality health care,‖
Sens. Edward M. Kennedy, D-Mass, and Max Baucus, D-Mont., said in a letter to
President Obama announcing the late spring markup schedule. ―We must act to contain
the growth of health care costs to ensure our economic stability; to help American
businesses deal with the health care challenge; and to make sure that we are getting our
money‘s worth.‖ Kennedy chairs the Senate Health, Education, Labor and Pension
Committee and Baucus the Senate Finance Committee.

   The timetable suggests that the committees won‘t hold hearings on the measures prior
to a markup. A Baucus aide said the actual legislation, which is still being drafted, would
be unveiled when it goes to markup. (See related story, CQ HealthBeat, April 20, 2009)

   In other overhaul-related developments, the Pharmaceutical Research and
Manufacturers of America (PhRMA) and the left-leaning advocacy group Families USA
said they will team up to push for expansion of the Medicaid program, subsidies to fund
the purchase of health insurance by individuals and a cap on out-of-pocket costs to
protect families hit by big health bills.

   ―One of our goals in the proposal is to establish a nationwide Medicaid eligibility at
133 percent of the federal poverty limit,‖ a PhRMA source said. ―Several million
uninsured Americans can get coverage through this.‖ A second goal is ―to provide
subsidies for moderate-income individuals and families in a reformed market,‖ the source
said. The two lobbying organizations won‘t specify subsidy levels, but the source noted
that ―of the 47 million uninsured Americans, about 30 million uninsured Americans have
incomes 200 percent of the federal poverty level or below. So overall, about 65 percent of
uninsured Americans could be eligible for a subsidy if it were set at 200 percent.‖

   The organizations plan an afternoon press briefing Tuesday to announce the details of
what they said would be a multimillion-dollar campaign to promote the changes. Other
elements of the proposal call for revamping the insurance market to prevent companies
from denying coverage based on health status and allowing the use of Medicaid funds to
buy private coverage if doing so saves Medicaid money. Insurers have said they would
agree to stop denying coverage based on health status if individuals were required to buy
coverage, a mandate that would assure a mix of good and bad risks to allow them to
absorb the cost of claims for people with costly medical conditions.
  Meanwhile Finance Committee staff prepared Monday for the first of three
―roundtables‖ that will serve as a form of hearing on health overhaul approaches under
consideration by the panel. The committee plans private meetings in which members will
be asked to react to legislative proposals it is considering.

   Baucus and Sen. Charles E. Grassley of Iowa, the top Republican on the Finance
Committee, prepared questions they plan to ask participants at the first roundtable
session, scheduled for Tuesday. For example, they plan to ask Glenn Steele, the head of
the Danville, Pa.-based Geisinger Health Clinic, whether the system‘s model of
―integrated care‖ in which doctors and hospitals collaborate to control casts can be
widely applied elsewhere in the United States. Another likely question is ―what tools
does Geisinger provide to its staff to empower them to provide high-quality and efficient
care?‖

  They plan to ask Glenn Hackbarth, chairman of the Medicare Payment Advisory
Commission, what role a stronger primary care role, ―bundled‖ payments covering both
hospital and doctor care and payment systems rewarding quality and efficiency could
play in controlling costs. They plan to query Mark McClellan of the Brookings Institution
about the feasibility of setting up ―Accountable Care Organizations to combine
unaffiliated providers into health care teams to boost efficiency and quality.‖

   Questions also are planned for American Hospital Association President Rich
Umbdenstock about industry concerns about payment systems that reward quality and
efficiency; Aetna Executive Ron Williams on the feasibility of competitive bidding in the
Medicare Advantage program; Debra Ness of the National Partnership for Women and
Families on the impact on patients of revised payment systems; Alan Korn of the Blue
Cross - Blue Shield Association on incentives to improve coordination of care by
providers; and Peter Lee of the California Business Group on Health about the employer
perspective on revised payment systems.




Kennedy, Baucus Announce Early June Health
Overhaul Markups
By John Reichard, CQ HealthBeat Editor

April 20, 2009 -- The chairmen of the two key committees that will lead Senate efforts to
craft health overhaul legislation announced Monday that they plan early June markups of
very similar legislation that "can be quickly merged into a single bill for consideration on
the Senate floor."

"We have a moral duty to ensure that every American can get quality health care," Sens.
Edward M. Kennedy, D-Mass, and Max Baucus, D-Mont., said in a letter to President
Obama announcing the late spring markup schedule. "We must act to contain the growth
of health care costs to ensure our economic stability; to help American businesses deal
with the health care challenge; and to make sure that we are getting our money's worth."
Kennedy chairs the Senate Health, Education, Labor and Pension Committee and Baucus
the Senate Finance Committee.

The timetable suggests that the committees won't hold hearings on the measures prior to a
markup. A Baucus aide said the actual legislation, which is still being drafted, would be
unveiled when it goes to markup.

In other overhaul-related developments, the Pharmaceutical Research and Manufacturers
of America (PhRMA) and the left-leaning advocacy group Families USA said they will
team up to push for expansion of the Medicaid program, subsidies to fund the purchase of
health insurance by individuals, and a cap on out-of-pocket costs to protect families hit
by big health bills.

"One of our goals in the proposal is to establish a nationwide Medicaid eligibility at 133
percent of the federal poverty limit," a PhRMA source said. "Several million uninsured
Americans can get coverage through this." A second goal is "to provide subsidies for
moderate-income individuals and families in a reformed market," the source said. The
two lobbying organizations won't specify subsidy levels, but the source noted that "of the
47 million uninsured Americans, about 30 million uninsured Americans have incomes
200 percent of the federal poverty level or below. So overall, about 65 percent of
uninsured Americans could be eligible for a subsidy if it were set at 200 percent."

The organizations plan an afternoon press briefing Tuesday to announce the details of
what they said would be a multimillion-dollar campaign to promote the changes. Other
elements of the proposal call for revamping the insurance market to prevent companies
from denying coverage based on health status and allowing the use of Medicaid funds to
buy private coverage if doing so saves Medicaid money. Insurers have said they would
agree to stop denying coverage based on health status if individuals were required to buy
coverage, a mandate that would assure a mix of good and bad risks to allow them to
absorb the cost of claims for people with costly medical conditions.

Meanwhile Finance Committee staff prepared Monday for the first of three "roundtables"
that will serve as a form of hearing on health overhaul approaches under consideration by
the panel. The committee plans private meetings in which members will be asked to react
to legislative proposals it is considering.

Baucus and Sen. Charles E. Grassley of Iowa, the top Republican on the Finance
Committee, prepared questions they plan to ask participants at the first roundtable
session, scheduled for Tuesday. For example, they plan to ask Glenn Steele, the head of
the Danville, Pa.–based Geisinger Health Clinic, whether the system's model of
"integrated care" in which doctors and hospitals collaborate to control casts can be widely
applied elsewhere in the United States. Another likely question is "what tools does
Geisinger provide to its staff to empower them to provide high-quality and efficient
care?"
They plan to ask Glenn Hackbarth, chairman of the Medicare Payment Advisory
Commission, what role a stronger primary care role, "bundled" payments covering both
hospital and doctor care and payment systems rewarding quality and efficiency could
play in controlling costs. They plan to query Mark McClellan of the Brookings Institution
about the feasibility of setting up "Accountable Care Organizations to combine
unaffiliated providers into health care teams to boost efficiency and quality."

Questions also are planned for American Hospital Association President Rich
Umbdenstock about industry concerns about payment systems that reward quality and
efficiency; Aetna Executive Ron Williams on the feasibility of competitive bidding in the
Medicare Advantage program; Debra Ness of the National Partnership for Women and
Families on the impact on patients of revised payment systems; Alan Korn of the Blue
Cross–Blue Shield Association on incentives to improve coordination of care by
providers; and Peter Lee of the California Business Group on Health about the employer
perspective on revised payment systems.

Baucus Lays Out Health Care Overhaul Details
By Drew Armstrong, CQ Staff

April 24, 2009 -- House Sen. Max Baucus, D-Mont., said Friday that while he has not
written off the idea of a government-run insurance plan for his health care overhaul
proposal, it probably won't be his first line of attack, preferring to focus instead on the
system for self-insured companies.

At a breakfast with reporters hosted by the journal Health Affairs, Baucus laid out details
of his health care overhaul plans, many of which he will share in greater depth in a
closed-door session April 29 with Finance Committee members.

While a government-run insurance plan was still on the table, Baucus said "it might be a
bit on the side of the table." Instead, he said, he would focus on preserving the insurance
system for self-insured companies while expanding private insurance and public
programs such as Medicaid, the insurance program for the poor. "We'll end up with more
private insurance and more public insurance," he said.

He later backed off that statement slightly, saying he might return to the government-run
idea later on. Baucus has previously backed the idea of a government-run plan to
compete with private insurers and drive down costs, but the political difficulty of the idea
has put pressure on him to drop it. Many Republicans vehemently oppose any idea of a
government-run insurance plan, while many of the left are demanding its inclusion.

His vision would make substantial changes to the insurance market, but with the goal of
letting those who have insurance that they like keep it.

For many uninsured looking to buy coverage, Baucus would like to "set up a system
similar to Massachusetts," where people can buy insurance through a "connector" that
offers standard minimum benefit plans with subsidies for those who cannot afford it.

It would be a national marketplace, Baucus said, or at least with a common national
standard. "I think the whole system should be more national, and the benefits have to be
more national. You can't have benefits be one level in one state, and another level in
other states."

But he would try to make sure that it did not deeply impact companies that buy insurance
already. Health care experts have theorized that any large change to the insurance market,
especially with a government-run plan option, would result in some companies and
people shifting from company-provided insurance to the independent or government
market.

"The system I envision is where self-insured companies, ERISA companies, can keep
their own plans and manage health insurance in the way that they have. We're not going
to change the ways self-insured companies handle health care for employees," Baucus
said.

Many large companies are self-insured. Instead of buying coverage directly from a health
insurer, they take on the risk themselves and pay an insurer to administer the plan. To the
employee, there is little difference, but the company can lower costs by taking on the risk
itself. Companies that self-insure are governed by the Employee Retirement Income
Security Act (PL 93-406), better known as ERISA.

Many smaller businesses, however, are not self-insured. For those companies and for
people buying insurance on their own Baucus said, "we'll set up a system similar to
Massachusetts, where an individual looking for health insurance can go to the exchange
and get health insurance from a health care company authoring insurance on the
exchange, somewhat similar to the [Federal Employee Health Benefit Plan]," the system
under which federal employees buy insurance, Baucus said.

"We have to reform the health care insurance market," he continued, by eliminating
insurance companies' ability to deny coverage based on pre-existing conditions, along
with other changes like guaranteeing people's ability to buy coverage.

Baucus' November "white paper" will serve as the foundation for the bill, he told
reporters. Baucus is writing his own bill out of the Finance Committee, while Health,
Education, Labor and Pensions Committee Chairman Edward M. Kennedy, D-Mass., is
drafting a related but separate bill that will be combined with Baucus' on the floor.

In his white paper, Baucus included the idea of a government-run insurance option that
would compete, with some limits, with private insurers. He also proposed temporarily
opening up Medicare enrollment for people between the ages of 55 and 65, and
expanding Medicaid to cover 7.1 million more people.
The private session with Finance Committee members will focus on how care is
delivered and paid for, with future sessions on other topics.

"We're working on that," Baucus said. "My problem is getting numbers from [the
Congressional Budget Office]. That's slowing us down a little bit."

It will likely be the first time members have a chance to see details of what Baucus and
the committee's ranking Republican, Charles E. Grassley of Iowa, have planned.

Baucus wants to revamp health care payment systems like Medicare so they foster more
efficient payment trends. Some areas of the country with efficient health systems spend
far less to get the same quality of care as other, far more costly regions.'

Experts like former Congressional Budget Office director Peter R. Orszag, now the
director of the White House Office of Management and Budget, have predicted that
getting high-cost areas more in line with the country's more efficient regions could save
hundreds of billions of dollars.

"Our job is to transfer that more broadly to the rest of the country, mostly through
Medicare," Baucus said of the low-cost, efficient areas. "We're really trying to get
internal savings in the system."

CQ TODAY PRINT EDITION
April 27, 2009 – 10:12 p.m.
Negotiators Reach Deal on Budget
By Paul M. Krawzak and David Clarke, CQ Staff

   House and Senate budget negotiators reached agreement Monday night on a budget
resolution, setting the stage for Democrats to move the legislation through Congress by
Wednesday to mark the first 100 days of Barack Obama‘s presidency.

  Most details had been decided earlier in the day, but negotiators were working into the
evening to assuage the concerns of the Blue Dog Coalition, a group of fiscally
conservative House Democrats who want the Senate to commit to advancing a bill this
year that would put into law the pay-as-you-go rule, which requires tax cuts and new
mandatory spending to be offset with tax increases or budget cuts elsewhere in the
budget.

   Senate Budget Chairman Kent Conrad‘s office announced a deal on the overall budget
resolution Monday night, although the specifics were unclear at press time.

  As a condition of supporting the House budget in March, Blue Dog leaders won a
provision in the House version of the budget (H Con Res 85) that would pave the way for
a House vote on statutory pay-as-you-go legislation.
  But a tentative agreement between House and Senate negotiators did not include a
corresponding requirement for the Senate to vote on similar legislation, raising questions
about what, if any, impact it ultimately would have.

  As a result, Blue Dog leaders were pressing Monday for some kind of commitment
that the Senate would also vote on pay-as-you-go legislation.

  ―Congress doesn‘t have the will to do the right thing on fiscal responsibility,‖ said Rep.
Allen Boyd, D-Fla., a Blue Dog leader and a member of the budget conference
committee. ―We‘ve proven that time and time again.‖

  Anticipating an agreement and aware of the 100-day milestone on Wednesday, the
House Rules Committee approved a procedural rule allowing the budget agreement to be
voted on by the House on Tuesday.

Other Differences Bridged

  Democratic lawmakers announced agreements earlier in the day on other issues.

   The most controversial provision in the agreement is a fast-track procedure called
reconciliation. It would allow Democrats to pass an overhaul of the nation‘s health care
system and student aid legislation with a simple majority in the Senate, rather than with
the 60 votes needed to end debate and thus bypass opposition from Republicans and
possibly some moderate Democrats.

  Reconciliation instructions were included in the House budget resolution but not the
Senate version (S Con Res 13).

  The procedure came under heavy fire during a conference committee meeting Monday.

  The Senate Budget Committee‘s ranking Republican, Judd Gregg of New Hampshire,
blasted Obama for supporting reconciliation, saying he could understand the president‘s
shaking the hand of Venezuelan President Hugo Chavez but ―I can‘t understand
embracing his politics, basically shutting down the minority.‖

  Conrad, D-N.D., predicted that it ultimately would not be used, at least not for health
care.

  ―It is there as an insurance policy,‖ Conrad said, adding that the instructions would not
be effective until Oct. 15.

  ― ‗Gun‘ would be more accurate than ‗insurance policy,‘ ‖ Gregg responded.

  Conrad ruled out using reconciliation to pass a cap-and-trade system for reducing
carbon emissions, which would cap the emissions and set up a market-based trading
system. Republicans argue that Democrats could use reconciliation for energy legislation,
even though the budget resolution only specifies its use for health care and student aid.

Debating the Impact

   The budget resolution is a nonbinding blueprint that provides a framework for tax and
spending bills that can be moved later in the year. Most importantly, it sets spending
levels for the appropriations committees.

  House leaders were hoping to have a vote on the fiscal 2010 budget resolution
Tuesday, with the Senate to follow on Wednesday.

  Conrad lauded the agreement for addressing Obama‘s top priorities — reducing the
nation‘s dependence on foreign oil, improving education, overhauling the health care
system and reducing the deficit — while including $764 billion in tax cuts.

  Republicans countered that the plan is fiscally unsustainable; Gregg said it would leave
the next generation with ―a debt which under no circumstances they can afford.‖

   Though exact details of the agreement had not been released Monday, Conrad said it
would reduce by $10 billion Obama‘s request for $1.096 trillion in non-emergency
discretionary spending in fiscal 2010.

  The plan would reduce the deficit to $523 billion, or 3 percent of gross domestic
product, in 2014, Conrad said.

   Tax reductions in the agreement include $512 billion to extend existing ―middle-class‖
tax cuts, $214 billion for a three-year alternative minimum tax fix to prevent the levy
from reaching further into the middle class, $72 billion for Obama‘s estate tax proposal
and $97 billion in loophole closures.

  Under the agreement, the estate tax rate would be 45 percent. The exemption would be
$3.5 million for individuals and $7 million for couples, indexed for inflation.

   As Republicans kept the spotlight on what they called the irresponsible spending that
the resolution would authorize, House Speaker Nancy Pelosi, D-Calif., sent a letter to
committee chairmen asking them to find ways to cut spending on programs under their
jurisdiction and report back to her by June 2.

   ―A vigorous oversight process, with the goal of reducing inefficiency and
consolidating operations, is one way for Congress to demonstrate our commitment to
fiscal discipline,‖ said Pelosi, who did not give a total figure she wants cut.

   Last week, Obama asked his Cabinet to come up with plans to cut $100 million in
spending. He said it was a down payment on bigger cuts, while Republicans decried it as
a pittance.
CQ HEALTHBEAT NEWS
May 11, 2009 – 5:27 p.m.
Finance Panel Package a Mix of Mandates, Subsidies,
Public Plan Options
By CQ Staff

  Senate Finance Committee leaders released detailed health coverage options late
Monday requiring individuals to carry health insurance that in many cases would be
purchased with government subsidies and employer contributions and obtained through a
―Health Insurance Exchange‖ site on the Internet directing consumers to each coverage
option in their zip code.

  The policy options document punts on the controversial question of establishing a
government-run public health insurance program as one of the coverage options, perhaps
the most divisive issue so far in the health overhaul debate. It lists options ranging from a
new health insurance program modeled after Medicare that would require all of the
doctors, hospitals, and other providers in that program to participate, to no ―public
program‖ at all.

   It also would open Medicare to 55 to 64-year-old uninsured Americans who would like
to buy into the program and increase eligibility in Medicaid to uninsured parents, children
and pregnant women in households with incomes up to 150 percent of the federal poverty
level. One of the alternatives would open Medicaid to all individuals with incomes at or
below 115 percent of the federal poverty level.

  Other options in the document would sharply limit how much insurance rates could
vary and guarantee access to insurance coverage, blocking insurers from denying
coverage based on health status.

   Committee Chairman Max Baucus, D-Mont., and the panel‘s top Republican,
Charles E. Grassley of Iowa, said in a joint statement that they would present the
coverage options at a meeting Thursday to obtain ―thoughts and ideas‖ from other
committee members. The options released Monday are the second of three papers panel
members will debate before holding a markup in June of comprehensive overhaul
legislation. The first paper dealt with proposals to improve patient care and reduce costs,
and the third paper will deal with financing.

   Financing is also the subject of a committee ―roundtable‖ Tuesday that will hear
testimony from public witnesses. A financing options document will be released before a
committee meeting on that topic set for May 20.

   Under the policy options paper released Monday, insurance companies would have to
issue coverage to all individuals and would no longer be allowed to bar individuals with
pre-existing conditions from coverage.
   Premiums in the individual market and for groups of 2 to 10 could vary based on age,
family composition, and tobacco use and by geography, but otherwise would not vary
within a rating area. Rates could vary based on age by a ratio of no more than five to one.
The rate limits would take effect in 2013. The rating rules for individuals and groups of 2
to 10 would apply to other small groups as defined by states, including groups of 11 to 50
people. They also could include the self-employed and/or groups of up to 100 people
depending on current state law. Rating rules for the small group market other than
individuals and groups of 2 to 10 would be phased in over a period of 3 to 10 years.

   Individuals and groups of 2 to 10 could buy through the insurance exchange
immediately after its creation. The rest of the small group market —11 to 50 employers
or as defined by the states — would be able to buy insurance through the exchange once
rating rules are fully phased in by the state in question.

  People could keep their current coverage and plans will continue to offer the coverage
they have today, ―but these grandfathered plans will only be available to those people
who are enrolled today,‖ according to the committee summary of the coverage options.

   Four benefit options would be created: lowest, low, medium, and high. All insurers
would have to offer coverage in each category. All plans would be required to offer
preventive benefits, primary care, emergency services, hospitalization, physician
services, prescription drugs, and other benefits. Plans could not include annual or lifetime
limits on coverage and would have to provide first-dollar coverage of preventive care.

   Tax credits would be provided for individuals under 400 percent of the poverty level to
help offset premium costs. Eligible low-income individuals would be able to use the
credits to buy coverage through the exchange. Subsidies would shrink in size as income
level rises up to the 400 percent level. Small businesses with 10 or fewer full-time
workers could get a tax credit equal to 50 percent of coverage costs. Credits would be
available to larger businesses but be phased out for firms with more than 25 workers.

  In the Medicare-like option for a new public plan, the federal government would set
payment rates and there would be no solvency requirements. Another alternative would
be a public plan run through regional third-party administrators, that would establish
provider networks and negotiate rates. A third alternative would be a state-run public
health insurance plan. Another option would be no public plan alternative but ―expanding
coverage through a reformed and better regulated market.‖

  The committee option on Medicaid suggested that all state Medicaid programs might
be required to raise income eligibility for pregnant women, children and parents—for
example, up to 150 percent of the federal poverty level, or $33,000 a year for a family of
four. There would then be three ways to ensure access to the program.

   The first option would be for increased coverage through the current Medicaid
structure, under which Medicaid would be expanded to cover everyone with an income at
or below 115 percent of the federal poverty level and the federal government would
provide short-term full funding for newly eligible beneficiaries. The new standard rates
would be phased in over time.

   A second option would be to allow those eligible for Medicaid to access the program
through the Health Insurance Exchange, as well as expand Medicaid to cover people at or
below 115 percent of the federal poverty level and also provide short-term full federal
funding for newly eligible beneficiaries until the new standard rates kicked in.

   A third approach would expand mandatory coverage for children, pregnant women and
parents like the first two options, through Medicaid, but in a different way for childless
adults. They would instead be eligible for federal tax credits to buy coverage, either a
private plan through the exchange or public coverage through Medicaid. The tax credit
would be used like a ―voucher‖ that the recipient would use to buy into the state‘s
Medicaid program and states would be required to accept it.

   As for the Children‘s Health Insurance Program (CHIP), the paper says that once the
exchange is up and running, there will be more coverage available for children of low and
middle-income workers and the need for the program as it is currently structured will
diminish. Under the option in the paper, there would be no federal changes to CHIP until
after Sept. 20, 2013, and after that date the CHIP would be offered through the exchange
and provide additional benefits for children not eligible for Medicaid.

   The paper also lays out the option of making mandatory coverage for prescription
drugs apply to the categorically and medically needy, and changing Medicaid law to
eliminate smoking cessation drugs and barbiturates from Medicaid‘s excluded drug list.

   Currently the federal government share of Medicaid costs is determined by the federal
medical assistance percentage (FMAP), which varies by state and is determined by
statute. One option would provide an automatic increase in that percentage during periods
of economic downturn after Jan. 1, 2012.

  On Medicare, an option is explored that would allow people between the ages of 55
and 64 who don‘t have employer-sponsored insurance or Medicaid coverage to
voluntarily enroll in Medicare, beginning Jan. 1, 2011. The option would end once the
exchange was up and running, though those already enrolled could stay in Medicare.

   On the question of an individual mandate to carry health insurance, the option would
be to say that all individuals have a ―personal responsibility requirement‖ to obtain health
insurance coverage. Everyone would be required to buy coverage through the individual
market, any grandfathered plan or in the group market. Exemptions would be allowed for
religious objections or those in the country illegally.

  To ensure compliance, the consequence for not being insured would be an excise tax
equal to a percentage of the premium for the lowest-cost option available through the
exchange for the area where the individual lives. The tax would be phased-in and would
equal 25 percent of the premium for the first year, 50 percent the second year and 75
percent thereafter. Individuals could apply for exemptions from the penalty if the lowest-
cost option exceeds 10 percent of income, or an individual is below 100 percent of the
federal poverty level, or ―hardship.‖ The requirement would begin Jan. 1, 2013 or sooner
if possible, the paper says.

   As for an employer requirement, the paper sets out as an option a ―pay or play‖ model
in which all employers with more than $500,000 in payroll a year would either offer their
full-time workers health insurance coverage, or pay an assessment. Those employers with
total annual payroll of less than $250,000 would be exempt from offering coverage.

  The coverage offered by those larger employers would have to have an actuarial value
equal to the lowest coverage option, as well as first-dollar coverage for preventive care,
and the employer would be required to contribute at least 50 percent of the premium for
the employer-sponsored insurance.

  Employers that do not demonstrate they have offered the required level of coverage to
their employees would have to pay an assessment, under this option. It would be an
excise tax calculated as an amount per employee per month based on the employer‘s
gross receipts for the tax year.

  The second option is to not require employers to offer health insurance.

   Baucus and Grassley‘s proposals would put new emphasis on preventive care and
wellness programs in Medicare, designed to lower costs by keeping people from getting
sick, or by managing chronic conditions like diabetes and obesity before they develop
into expensive acute problems. Their proposals would create a ―personalized prevention
plan‖ for Medicare enrollees that would include health screening. The proposal would
create an individual care program for each beneficiary to keep them healthy, developed in
consultation with a ―qualified health professional,‖ likely a doctor or nurse.

  While the proposals would eliminate many of Medicare‘s co-payments and other cost-
sharing requirements for preventive care, it would do so only for health services with a
high rating by a government-appointed task force. Health services that have been
determined not to improve or maintain health could be removed from the list of services
Medicare pays for, unless a doctor decided that they were necessary.

   Preventive programs paid for by Medicaid would get a similar treatment. Preventive
procedures considered most effective would not have co-pays, and states could apply for
funds that would give Medicaid beneficiaries a refund if they met certain health goals,
like weight loss, quitting smoking or other wellness programs. Companies with wellness
programs would get a similar benefit, receiving a tax credit for putting in place effective
wellness programs to keep employees healthy, up to $200 per employee in some cases.

  Baucus and Grassley‘s proposal would also expand optional programs for people to get
care at home that they would otherwise receive in a Medicaid-funded institution, like a
nursing home. States could expand waivers to let more people into the program, and
federal matching funding for home-based care would increase by 1 percent.

   An immigration fight could develop over one proposal — to let childless, legal
immigrants enroll in Medicaid before the five-year waiting period that currently applies.
During debate over an expansion of the State Children‘s Health Insurance Program (),
some lawmakers opposed to immigration reform took issue with a similar proposal for
legal immigrant children and their parents.

   Other proposals include standardizing how health programs collect data on race and
ethnicity, and updating the computer databases used by Social Security Administrations,
which are becoming obsolete.

  • Policy Options | Press Release (pdfs)




Week of May 27th


Study Finds No Connection Between Quality and Cost
in Hospitals
By Jane Norman, CQ HealthBeat Associate Editor

  In a study that could have implications for the health overhaul in Congress, researchers
have found that there‘s not necessarily a link between more expensive hospital services
and the quality of care for chronically ill patients. In some instances, the care actually
declined when spending went up.

  The study on the Web site of Health Affairs, a public policy magazine, was conducted
by researchers from Dartmouth College and Harvard University and analyzed care for
Medicare beneficiaries in their last two years of life. Included were 2,172 U.S. hospitals
across the country. The National Institute on Aging provided funding.

  Laura Yasaitis of Dartmouth said in a statement that the researchers found no evidence
that hospitals with higher spending on patients at the end of life provided better care,
whether the hospitals were scattered across the country or in one region, or were
academic medical centers. ―In fact, in some cases hospitals that spent more provided
worse care,‖ said Yasaitis, a student at Dartmouth Medical School and a researcher at the
Dartmouth Institute for Health Policy and Clinical Practice.

   The other researchers were Elliott Fisher and Jonathan Skinner of Dartmouth and
Amitabh Chandra at Harvard‘s Kennedy School of Government. Chandra said some
hospitals in the same region provided exemplary care for lower costs, pointing to the
need for better reporting of both costs and quality and a greater understanding of what
leads to an improvement in performance.
   Lawmakers working on health care are focused on finding ways to reduce rising costs
in the U.S. health care system and at the same time provide a higher quality of care and
expanded access. President Obama has said his priorities are to control costs, guarantee
doctor choice and assure high-quality, affordable health care.

  The study looked at end-of-life spending for patients with three common conditions —
heart attacks, pneumonia and congestive heart failure. It took the analysis down to a
hospital-by-hospital level, rather than studies in the past done at the regional level,
though individual hospitals were not named.

  Average end-of-life spending was $16,059 for the lowest-spending fifth of hospitals
and the average was $34,742 in the highest-spending fifth of hospitals.

  Quality was measured by using data from a program that measures the percentage of
patients receiving a specific, often low-cost, evidenced-based therapy. That would
include, for example, whether aspirin was given at arrival and discharge to those who had
suffered heart attacks, and whether patients with pneumonia received a blood culture
before being administered their first antibiotic.

   For all of the quality indicators studied, the association with spending was either zero
or negative, the study said. The researchers also said their study might be limited because
the quality measures they used might penalize hospitals that treat sicker patients, and also
because they looked at process-of-care measures rather than outcomes.

  • Report (pdf)



Council Comments on Senate Finance Committee Coverage Options Paper

On May 22, the Council submitted formal comments to the Senate Finance
Committee in response to their recent paper, Expanding Health Care Coverage:
Proposals to Provide Affordable Coverage to All Americans, released May 11. As
we reported in the May 18 Benefits Byte, the document was based partially on
the May 5 roundtable hearing.



Most notably, it includes a section on "shared responsibility" regarding mandates
for employers and employees. The options include an individual mandate, along
with various open enrollment periods and guaranteed issue by insurance
companies. This section also discusses employer responsibility, including the
possibility of a "pay or play" employer requirement, under which large employers
would be obligated to provide coverage or pay an assessment to a general
health fund. The coverage document also examines additional measures to
address coverage, including provisions for insurance market reform, creation of a
public health insurance option, reform of Medicaid and Medicare, prevention and
wellness measures and long-term care.



The Council's comment letter asserts that "for our members, the best reform
options are those that preserve and strengthen the voluntary role employers play
as the largest source of health coverage for most Americans. By keeping
employers engaged as sponsors of health coverage, we also keep the innovation
and expertise employers bring to the table in the collective effort to achieve
broad-based, practical health system reform."



The Council's letter addresses several of the committee's proposed options
directly:

      Individual mandate: The Council supports a requirement for all individuals to obtain
       and maintain health coverage in a reformed health care system, including incentives for
       obtaining and maintaining coverage.
      Employer “Pay or Play” requirement: A “pay or play” approach would be an
       inappropriate coverage solution because the myriad requirements that would inevitably
       be imposed on those who might prefer to sponsor health coverage would ultimately, if
       unintentionally, result in a net reduction in employer-sponsored coverage by leading
       some companies to simply “pay” rather than “play”. A federal minimum benefit standard
       is needed only for the purpose of determining whether individuals have enrolled in
       qualified health coverage and have met their individual coverage obligation. The Council
       also recommends that there be a safe harbor for qualified high-deductible health care
       coverage.
      Employee opt-out from employer plans: The Council suggests an alternative
       approach, building on the premium support program in the Children’s Health Insurance
       Program (CHIP) where premium subsidies available to lower income individuals may be
       used for the employee share of the premium for employer-sponsored coverage. If an
       opt-out provision is included as part of health reform legislation, it should not apply where
       employers are providing meaningful health insurance coverage, nor should employers be
       required to pay their “normal” premium contribution to the insurance exchange for
       coverage that an individual is not obtaining through their employer plan.
      Temporary Medicare buy-in: Rather than provide a stop-gap opportunity to enroll in
       Medicare, the priority should be to achieve market reforms as quickly as possible so that
       Americans of all ages will be able to obtain the health coverage they need through
       competitive private plan options.
      Public health insurance plan option: The Council recommends focusing on the
       conditions needed to achieve a reformed and well-regulated private market, which will be
       challenging enough without attempting to introduce public plan options that risks
       destabilizing the insurance market at the time when it will be undergoing significant
       change and meeting demanding new standards.
      Employer wellness credits: The Council supports incentives to encourage the
       development of innovative and effective employer wellness programs and recommends
       that any tax credits for these purposes be available to employers of all sizes since many
       of the most innovative efforts in this area are being pursued by large employers.
       Expedited and streamlined procedures be considered for obtaining a certification as a
        qualified wellness program, both to minimize any administrative burdens of obtaining the
        certification and to increase certainty about the availability of the tax credit when planning
        a qualified program.
       Medicaid enrollment and retention improvements: It will be essential for states
        to increase their efforts to reach and enroll eligible individuals for these safety-net health
        insurance programs.




The committee is expected to consider these options as it develops concrete
legislative proposals in the coming weeks. The Council will also submit
comments soon on the Committee's Financing Comprehensive Health Care
Reform: Proposed Health System Savings and Revenue Options. For more
information, contact Kathryn Wilber, senior counsel, health policy, or Paul
Dennett, senior vice president, health care reform, at (202) 289-6700.

NBCH Comments on Wellstone & Domenici Mental Health Parity & Addiction Equity Act of 2008
(MHPAEA) (effective January 1, 2010):
The U.S. Department of Health and Human Services and Department of Labor requested
comments on MHPAEA, specifically it's impact on employers in terms of cost, paperwork
reduction/administration, as well as regulatory flexibility. After conferring with the Government
Affairs Committee (GAC), as well as purchaser, provider and consumer organizations, we
developed comments to formally submit today, May 28, 2009. We believe it is important to take
advantage of this opportunity to register our comments and concerns with the new parity law in
behalf of our coalitions and their employers. To access NBCH’s comments, go to:
http://www.nbch.org/resources/policypapers.cfm

In terms of background, MHPAEA creates new rules for any financial requirement (e.g.,
cost-sharing) or treatment limitations (e.g., visit limits) on mental health and substance
use disorder benefits so that they are no more restrictive than predominant
requirements or limitations applied to substantially all medical and surgical benefits
covered by a plan. MHPAEA also reauthorized several provisions relating to parity in
annual and lifetime dollar limits for group health plan coverage enacted as part of the
Mental Health Parity Act of 1996.



DOL Releases Form for Expedited Review of Denial of COBRA Premium
Subsidy

On May 21, 2009, the U.S. Department of Labor (DOL) updated its COBRA
ARRA webpage with information on application for review of denial of the
COBRA premium reduction (recently provided under the American Recovery and
Reinvestment Act (ARRA)) and the application form to be used by individuals
requesting expedited review. ARRA included a temporary subsidy of continued
COBRA coverage for individuals (within certain income limits) who have been
involuntarily terminated from employment on or after September 1, 2008, through
December 31, 2009.
Under ARRA, employees may appeal an employer’s denial of a request for the
COBRA premium reduction. DOL will review appeals related to private-sector
employer plans and HHS will review appeals for federal, state, and local
governmental employees as well as appeals related to group health insurance
provided pursuant to state continuation coverage laws. Individuals requesting a
review must submit an application form. DOL is required to make a
determination within 15 days business days of receipt of a properly completed
request for review.

The form includes 10 questions to determine subsidy eligibility and lists the
documentation that could assist the DOL in making a determination, including the
applicant’s COBRA election notice, a “Request for Treatment as an Assistance
Eligible Individual” or other form used to request the premium reduction,
insurance card, payroll stubs, any documentation detailing the date and
circumstances of the termination of the employee’s employment, or any
documentation the applicant was provided regarding the denial of the premium
reduction. (Source: American Benefits Council, Benefits Byte, May 22, 2009)

				
DOCUMENT INFO
Description: Mental Health Parity and Addiction Equity Act of 2008 Congressional Testimony document sample