The financial professional's guide to healthcare reform

A comprehensive reference guide interpreting and applying healthcare reform law for consultants, appraisers, accountants, and attorneysThe Financial Consultants'Guide to Healthcare Reform provides an historical backdrop on how the healthcare system got to its present state including the Massachusetts Reform and Medicare Advantage along with an explanation of the principal types of health insurance in the United States and how "insurance" actually works. A review and explanation of each of the reform provisions follows, including an analysis of what the implications are for providers, consumers and business and what responses each of these communities might have to the Reform. Using the authors' insights and firsthand experiences in U.S. healthcare finance, this bookexplains the new healthcare law for individuals and businesses alike, what toexpect from it and what actions they need to take to comply.Interprets and applies the health care reform lawProvides examples of what the impact of the law might look likeExtensive use of sidebars to provide in-depth analysis or background on particular topics of import, where the reader may need more detail to understand the context of Reform's changes.Written for consultants, appraisers, accountants, and attorneysWritten by major figures in the world of healthcare valuation and consultingThe Financial Consultants' Guide to Healthcare Reform provides a complete handbook to healthcare reform for financial consultants, both for understanding this important legislation as well as for planning responses to it. INDICE: ForewordPrefaceAcknowledgmentsChapter 1 IntroductionA Brief Recap of the History of ReformEarly Reform EffortsTax Deductibility of Health InsuranceThe “Great Society:” Medicare and MedicaidThe 1970s: Medicare HMOs and ERISARegulation: The Anti-kickback StatuteProspective Payment SystemsThe 1990sRiseof Managed CareThe Stark Law: Anti-referral StatueBalanced Budget Act of 1997Balanced Budget Revision Act and Benefits Improvement and Protection ActFailure of Managed CareProvider Integration and ConsolidationSummary of the Healthcare Market in 2000The New CenturyOne Size Fits All? Geographic Disparities in the U.S. Healthcare SystemProfit and Nonprofit Hospitals and Health InsurersHistory of Blue PlansMedicare: The Other White MeatOther Market-based StudiesGeo-Clinical DifferencesSummaryChapter 2 MassachusettsThe Model for Federal Healthcare Reform and a Case Study on What to ExpectThe Timeline of Massachusetts ReformEarly Reform Legislation in MassachusettsActs of 1996Targeting the Small Group MarketTargeting the Trade Associations offering Health Insurance to theirMembersThe Intervening YearsComponents of the 2006 Massachusetts LegislationMerging the Small Group and Individual MarketCommonwealth Care SubsidiesKey Features of Massachusetts ReformRecounting the Results of Reform in MassachusettsUniversal CoverageResponse of the Healthcare Provider CommunityDiffering Viewsof Massachusetts ReformSpecial Commission on the Health Care Payment SystemThe Alternative Quality ContractState Government Reports Tracking the Results ofReformThe Small Group and Individual Market versus Self-Insured MarketMassachusetts Quarterly ReportsMassachusetts Attorney General's ReportSimilar Experience in Other MarketsSpecific ComparisonsTake from the Poor and Give to the Rich?Impact on Market Share of Financially Weaker ProvidersMost Favored Nation ClausesTiered PricingRecent Legislative Changes through August, 2010Open Hearings in December of 2009August 2010 Changes in MassachusettsOpen EnrollmentReviewof Premium IncreasesTiered Network RequirementWhat Can We Learn from the Massachusetts Experience?Chapter 3 Insurance ReformsWhat is “Insurance?”Componentsof Health Insurance and Healthcare EntitlementSources of CoverageMedicareMedicaidSelf-Insured EmployersSmall Group (Small Business) InsuredsIndividual InsuredsLarge Group - Business not Self-InsuringUninsuredHealth InsurersHow Do Health Insurers Provide Health Insurance?Understanding Actuarial RiskHow Does Self-Insurance Work?Regional and Industry Factors in Health InsuranceThe Reform of Health InsuranceMinimum Essential CoveragePreventive Medicine ServicesThe Precious Metals of Health Insurance PoliciesDefining Actuarial ValueDeductiblesGlossary of Health Insurance and Medical TermsConsumer Protection ProvisionsGuaranteed Availability and Renewability of Insurance in the Small Group and Individual MarketElimination of Lifetime Limits on CoverageElimination of Annual Limits on CoverageProhibition Against Rescission of CoverageAppeals of Benefit DenialsSelf-insured PlansInsured PlansGovernment Review of Premium IncreasesWaiting Periods for CoverageProtections for ChildrenProhibition Against Exclusion for Preexisting ConditionsAdministrative Simplification“Grandfathered” Health Insurance PlansInterim Regulation Provisions Resulting in Loss of Grandfathered StatusMedical Loss RatiosCost ContainmentInsurer ProvisionsProvider ProvisionsCost Effective MedicineRating and other Reforms in the Small Group and Individual MarketDifferent Forms of Rating Health Insurance PoliciesMerger of Small Group and Individual MarketsIllustrationMini-Med PlansInsurance ExchangesEstablishment of the ExchangesRequirements of ExchangesQualified Health PlansOpen Enrollment PeriodsFunctional RequirementsBenefit RequirementsThe Massachusetts ExperienceChapter SummaryImplications and Responses for Small BusinessImplications and Responses for Larger BusinessesImplications for the Provider CommunitySome Thoughts for Lenders and Small Business InvestorsAppendix 3.1: Selected Legislative Text for Insurance ExchangesAppendix 3.2: CMS Proposed Regulations -- Glossary of Health Insurance and Medical TermsAppendix 3.3: Using the Massachusetts Health ConnectorChapter 4 Medicare Advantage PlansHow Many Medicare Beneficiaries are in Medicare Advantage Plans?Health Maintenance Organization (HMO) PlansPreferred Provider Organization (PPO) PlansPrivate Fee-for-Service (PFFS) PlansSpecial Needs Plans (SNP)Geographic Distribution of Medicare Advantage EnrolleesHistory of Medicare Advantage and its PredecessorsAge, Gender, Severity of Illness and Risk Score Adjustments to the Capitation RatesMedicare Advantage and the Medicare Modernization ActEnrollee BenefitsChoosing a Medicare Advantage PlanChanges from the ReformMinimum Medical Loss RatioPayment RatesEffect on Beneficiary “Rebates” or Enhanced BenefitsQuality-Based Incentive PaymentsRebatesLow Enrollment PlansNew PlansImplications for the Provider CommunityImplications for InsurersImplications for Medicare Advantage BeneficiariesAppendix 4.1: PPACA Sections Affecting Medicare AdvantageHCERA o 1102. Medicare Advantage PaymentsHCERA o 1103. Savings from limits on MA plan administrative costs.PPACA o 3203. Benefit protections and simplifications.PPACA o 3204. Simplification of annual beneficiary election periodPPACA o 3206. Extension of reasonable cost contractsPPACA o 3208. Making senior housing facility demonstration permanentPPACA o 3209. Authority to deny plan bids.Chapter 5 MedicaidExpansionIntroduction and OverviewBasic Medicaid Benefits before ReformMedicaid Enrollment and SpendingEligibility ChangesBasic Categories of Medicaid-Eligible IndividualsNew RulesMaintenance of Effort (MOE) RequirementModified Adjusted Gross Income or MAGIPresumptive EligibilityKey Expansion GroupsCoverage ofMenCoverage of Women without ChildrenCommunity First Choice OptionKey Elements of the Community First Choice OptionLegislative ProvisionsOther Incentives for Home and Community-based ServicesSpousal Impoverishment and Home and Community-based ServicesOther RequirementsBenefitsNew Standards for “Benchmark-Equivalent” CoveragePreventive Care for AdultsMedical or Health HomesBirthing CentersPrescription Drug CoveragesMiscellaneous ProvisionsFinancing of the ChangesExpansion StatesSpecial Adjustment to FMAP for States Recovering From a Major DisasterImplications and Responses for Low Income Uninsured and TaxpayersAppendix 5.1: Table of Medicaid Provisions in the PPACAAppendix 5.2: Subtitle D—Medicare Part D Improvements for Prescription Drug Plans and MA-PD PlansChapter 6 Mandates, Subsidies, Penalties … and TaxesThe Individual MandateAmount of the PenaltyExamplesExample: Single Individual with No Dependents, 2014-2016, with Household Income up to $50,000:Example: Single Individual with No Dependents, 2014-2016, with Household Income up to $500,000Example: Family of Four, 2014-2016, with Household Income up to $125,000Failure to Pay Penalty imposed on IndividualsImpact of the MandateCongressional Budget Office AnalysisGovernment Accountability OfficeGeographic Disparities in the Cost of InsuranceSubsidy EligibilityTax Credits and SubsidiesTax CreditsIRS Credit Examples for Middle Class FamiliesExample 1: Family of Four with Income of $50,000, Purchases Benchmark PlanExample 2: Family of Four with Income of $50,000, Purchases Less Expensive PlanExample 3: Family of Four with Income of $50,000, Parents Are Between the Ages of 55 and 64SubsidiesHow the Credits and Subsidies Impact Premium CostEmployer RequirementsDefinition of Large EmployerLarge Employers not Offering CoverageLarge Employers Offering CoverageLarge Employers with more than 200 FTEsNotice 2011-36The Role of the Tax Code and the Internal Revenue ServiceNondiscrimination Rules in the Provision of Health InsuranceSuspension of Compliance and PenaltiesPossible Solution to the Nondiscrimination Provision for Insured BusinessesExampleSimple Cafeteria Plans for Small BusinessesGrandfathered Health PlansInexplicable Changes to Flexible Spending Accounts Notices 2000-59 and 2011-5Payment or reimbursement of medicines or drugs prescribed after January 1, 2011ExceptionsDebit CardsInventory Information Approval System (IIAS)Maximum DeferralItemized Deductions for Medical ExpensesReporting of Health Benefits on Form W-2Aggregate Cost of Applicable Employer-Sponsored CoverageReportable CoverageExample for Family CoverageExamples where Flexible Spending Account (FSA) ExistsMethods of Calculating the Cost of CoverageCOBRA Applicable Premium MethodModified COBRA Applicable Premium MethodTerminated EmployeesExample 1Example 2Health Insurance Information Provided by Employers to All EmployeesAnnual Return to IRS on CoverageTax Treatment of Health Care Benefits Provided With Respect to Children Under Age 27 Notice 2010-38Tax Credit for Employee Health Insurance Expenses of Small Employers: Notices 2010-44 and 2010-82Definition of Eligible EmployerSteps to determine whether an employer is eligible fora creditDetermine the employees who are taken into account for purposes of the creditExcluded EmployeesDefinition of Family MemberSeasonal workersAggregation RulesDetermine the number of hours of service performed by those employeesWeeks-Worked EquivalencyDays-Worked EquivalencyCalculate the number of the employer's FTEsDetermine the average annual wages paid per FTEDetermine the qualifying premiums paid by the employer that are taken into account for purposes ofthe creditYears prior to 2014Premiums Taken into AccountPhaseoutExample for taxable small employerExample for a tax-exempt small employer.Tax-Exempt Employers Not Described in o501(c) and Exempt Under o501(a)Consumer Operated and Oriented Plan (CO-OP program)Funding of Patient-Centered Outcomes Research Notice2011-35Excise Tax on High Cost Employer-Sponsored Health CoverageApplicable Employer Sponsored CoverageComputation of Annual Limit in 2018Health cost adjustment percentageS

• ISBN: 978-1-118-09322-1
• Editorial: John Wiley & Sons
• Encuadernacion: Cartoné
• Páginas: 432
• Fecha Publicación: 13/06/2012
• Nº Volúmenes: 1
• Idioma: Inglés