He alth Car e Ac c ountability Or dinanc e (HCAO) Sug g e ste d Re visio ns to Minimum Sta nda rds SF De pa rtme nt o f Pub lic He a lth No ve mb e r 6, 2012
Bac kgr ound - HCAO ffe c t: Sinc e 2001. In E s: CCSF Co ntra c to rs & Cove r e d E mploye r L e sse e s. e me nt: Pro vide he a lth insura nc e tha t Re quir me e ts the Minimum Sta nda rds o r pa y a fe e to DPH. ds Re vie w/ Re vision : At Minimum Standar le a st e ve ry 2 ye a rs. fe e : Pa y to DPH fo r wo rke rs no t E mploye r o ffe re d a c c e pta b le insura nc e . 2
HCAO Minimum Standar ds Wor k Gr oup Co nve ne d b y DPH to re vie w & re c o mme nd re visio ns to the Minimum Sta nda rds. 17 o rg a niza tio ns we re re pre se nte d. T he Wo rk Gro up me t fo ur time s, Se pte mb e r 12 thro ug h Oc to b e r 24. He a lth Co mmissio n ha s the a utho rity to re vise Minimum Sta nda rds. 3 November 2, 2012
Minimum Standar ds E sta b lishe d in 2001, re vise d in 2004, 2008, a nd 2010. Goals inc lude : Co mpre he nsive ra ng e o f se rvic e s Affo rda b le fo r the e mplo ye e – minimize c o st-sha ring Affo rda b le fo r the e mplo ye r Ac c e ssib le fo r the e mplo ye r – pla ns must e xist tha t me e t the Sta nda rds 4 November 2, 2012
Sta nda rds witho ut Cha ng e s Re c o mme nde d Minimum Standar ds ds 2011 Standar ds/ 2013 Standar Re quir e me nt Standard 1: Type of Plan Required Any type of plan that meets the Minimum Standards as described below. Standard 2: Employee Premium The employer must pay 100% of the employee’s health coverage Contribution premium. Standard 3: Annual Out-of-Pocket In-Network: No higher than a $4,000 maximum, including all types (OOP) Maximum of employee cost-sharing (deductible, copayments, coinsurance, etc.). Out-of-Network: Not specified. Standard 7: Coinsurance Percentages 20% in-network 50% out-of-network Standard 8: Copay for Preventive Care In-Network services are not subject to a deductible, copay, or Visits & Services coinsurance (per health reform rules). Preventive care services from an out-of-network provider are subject to the plan’s out-of-network requirements. Standard 9: Copayments for Physician $30 maximum. Office Visits for Primary Care, Out-of-Network: Not specified. Perinatal/Maternity 5 November 2, 2012
Sta nda rds witho ut Cha ng e s Re c o mme nde d Minimum Standar ds ds 2011 Standar ds/ 2013 Standar Re quir e me nt Standard 10: Services: These services must be covered. Hospital inpatient, physician & • hospital service When coinsurance is applied to services: • Rehabilitative therapies, 20% in-network outpatient and inpatient 50% out-of-network • Outpatient services and procedures When copayments are applied for these services: Not specified. • Surgery & anesthesia • Organ transplants Cancer clinical trials • • Outpatient diagnostic services (x- ray, labs, etc.) • Perinatal and maternity care, including delivery services and postpartum care • Physical, Occupational, and Speech Therapy • Skilled nursing services • Home health services Durable medical equipment • • Hospice care Standard 11: Mental Health Services These services must be covered. Inpatient & Outpatient ♦ Alcohol & Substance Abuse Services When coinsurance is applied to services: Inpatient & Outpatient 20% in-network ♦ 50% out-of-network When copayments are applied for these services: Not specified Standard 12: Emergency Room Limited to treatment of medical emergencies. The in-network Services & Ambulance deductible and coinsurance also apply to emergency services received from an out-of-network provider.
Sta nda rds with Cha ng e s Re c o mme nde d Minimum Standar ds ds 2013 Re c omme ndations 2011 Standar Re quir e me nt k: No hig he r tha n a $4,000 Sta nda r d 4: Pr e sc r iption In- Ne twor k: No hig he r tha n a In- Ne twor ma ximum, inc luding a ll type s o f e mplo ye e Dr ug De duc tible $300 ma ximum. c o st-sha ring (de duc tib le , c o pa yme nts, c o insura nc e , e tc .). k: No t spe c ifie d. Out- of- Ne twor k: No t spe c ifie d. Out- of- Ne twor k: No hig he r tha n a $4,000 k: No hig he r tha n a Sta nda r d 5: R e g ula r In- Ne twor In- Ne twor ma ximum, inc luding a ll type s o f e mplo ye e $2,000 ma ximum. If a n (Me dic al Se r vic e s) c o st-sha ring (de duc tib le , c o pa yme nts, e mplo ye r o ffe rs a pla n with a De duc tible c o insura nc e , e tc .). de duc tib le hig he r tha n $2,000, the e mplo ye r must fund a k: No t spe c ifie d. He a lth Re imb urse me nt Ac c o unt Out- of- Ne twor (HRA) o r He a lth Sa ving s Ac c o unt (HSA) fo r the a mo unt e xc e e ding the $2,000 ma ximum de duc tib le (e .g ., e mplo ye r- funde d HRA o r HSA o f $500 fo r a pla n with a $2,500 de duc tib le ). k: No t spe c ifie d. Out- of- Ne twor Sta nda r d 6: Pr e sc r iption No t spe c ifie d. Co ve ra g e o f no n-fo rmula ry Must pro vide pre sc riptio n drug Dr ug Cove r a g e drug s no t re q uire d. c o ve ra g e , inc luding c o ve ra g e o f na me -b ra nd drug s. 7 November 2, 2012
Impac t of He alth Re for m Ne w pro visio ns wo uld b e in pla c e fo r 2013 o nly. Wo rk Gro up wo uld re c o nve ne in 2013 to re c o mme nd ne w sta nda rds fo r 2014 in lig ht o f full ACA imple me nta tio n. 8 November 2, 2012
Conc lusion HCAO is a n impo rta nt pie c e o f SF ’ s inno va tive e ffo rts to re duc e the numb e r o f uninsure d in SF . With the c ha ng e s disc usse d to da y, HCAO will c o ntinue to a c hie ve its g o a ls. A re so lutio n is a tta c he d fo r a ppro va l: Appro ve s the 2013 Minimum Sta nda rds o n 1/ 1/ 13 Suppo rts re c o nside ra tio n o f Sta nda rds fo r 2014 9 November 2, 2012
Comme nts, Que stions & Disc ussion 10 November 2, 2012
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