Health Care Legislation Update, 3/2/2006
Pooled Purchasing: HB 1629 2
Creation of Health Plans for Uninsurables: HB 1629 3
Health Flex Pilot Program Expansion: HB 1629 4
Local Initiatives: HB 1843, SB 708 5
KidCare 6
Appropriate Use of Emergency Room Services: HB 1629 7
Protection of Safety-Net Providers: HB 1843, Appropriations Bill 8
Utilization of Electronic Health Care Information: HB 1629 9
Consumer Protection and Information, Promotion of Healthy Lifestyles: HB 1629 10
Evidence-based Medicine: HB 1629 12
Pooled Purchasing: HB 1629
Category / Health Care CoverageSummary of Legislation / · Creates the “Small Employers Access Program”. Provides for pooled purchasing of health insurance options for employers with 25 or less employees.
· Also permits municipalities, schools, hospitals, or nursing home employers in a rural community to participate.
· Authorizes OIR to competitively bid for geographic regions similar to those used by Healthy Kids Corporation.
· Provides for standard benefit packages and alternative benefit packages.
· Limits participation to employers who have not offered health insurance benefits for at least six months.
· Provides for an appropriation of $250,000 from the Insurance Regulatory Trust Fund for implementation of the Small Employers Access Program.
· Provides for: “Mutually supported benefit plan means an optional alternative coverage plan developed within a defined geographic region, which may include, but is not limited to, a minimum level of primary care coverage in which the percentage of the premium is distributed among the employer, the employee, and community generated revenue either alone or in conjunction with federal matching funds.”
Status / November 2004
· RFI developed to solicit ideas and gauge participation by small group carriers. Eight RFI responses received – Aetna, BCBS of Florida, Neighborhood Health Plan, Florida Health Care Plans, Humana, Pacific Life and Annuity, Total Health Choice and United Healthcare.
· J. Bracher and Associates contracted by OIR to assist in the design, evaluation and assessment of the program.
· Follow-up meetings/conference calls held with FL Chamber of Commerce, Capital Health Plan, and BCBS of Florida. Additional calls scheduled.
May 2005
· Final Project Report, Implementation of the Small Employers Access Program by J. Bracher & Associates completed February 2, 2005:
- RFI was issued to carriers with responses of little interest due to past experience with pooled purchasing in Florida.
· Recommendations:
- OIR should issue RFP to all small employer insurers requesting proposals to provide coverage to potential participants in the Program;
- This RFP should include a Question and Answer attachment responding, at a minimum, to the questions outlined in this report; and
- OIR should convene a group of insurers and insurer trade associations to develop consensus on, and support for, legislative recommendations related to the program.
March 2006
· (From OIR) A “Statement of Qualifications/Request for Quote—Small Employers Access Program” was issued on November 15, 2005, to obtain proposals from licensed health insurers to provide insurance coverage through the Small Employers Access Program as provide. Deadline for responses was January 15, 2006. No responses were received. A final report summarizing all activity, including the RFQ, is being prepared.
Creation of Health Plans for Uninsurable: HB 1629
Category / Health Care CoverageSummary of Legislation / · Creates the Florida Health Insurance Plan for people with no other option for coverage.
· Establishes the FHIP board and procedures.
· Requires that the plan administrator be selected through competitive bidding; combines membership of the comprehensive health association.
· Requires an actuarial study by December 1, 2004, regarding funding and impact on small employers. Includes $250,000 for the required actuarial study.
· Premiums will be capped at 300% of standard risk rate, subject to a sliding surcharge based on insured’s income.
· Requires an appropriation before action can be taken to implement the FHIP.
· Following completion of the actuarial study and implementation of the Florida Health Insurance Plan, existing risk pool members enrolled in the Florida Comprehensive Health Care Association will be subsumed under FHIP.
Status / November 2004
· DFS/OIR procured an actuarial study being completed by Mercer Oliver Wyman. OIR requested data from the active market to assist Mercer in its study. Data was received and modeling work began in mid-October. A report was issued November 11, 2004. Available online at: http://www.fldfs.com/companies/pdf/FHIP_Report.pdf.
· OIR appointed staff resources to assist the Florida Health Insurance Plan Board. The FHIP board met August 26, September 2, and November 10, 2004.
· New standard and basic plans, to cover current risk-pool enrollees, have been designed, approved by the board (8/26) and will be effective January 1, 2005. Notice of benefit changes and new premium rates were to be sent October 1, 2004.
May 2005
· Both House and Senate had bills went to the floor but neither chamber could accept the other’s bill. As a result, the FCHA continues to operate but is closed to new members.
March 2006
· An annual update to the actuarial report was submitted to the Governor on December 1, 2005.
Health Flex Pilot Program Expansion: HB 1629
Category / Health Care CoverageSummary of Legislation / · Eliminates geographic restrictions to make Health Flex an option statewide.
· Allows Health Flex plans to develop catastrophic coverage plans.
· Requires Health Flex Plans to comply with standard grievance procedures similar to HMOs.
· Requires regulatory oversight of plan advertisement and marketing procedure.
· Requires completion of an evaluation of the Health Flex Plan benefit packages and a report by the AHCA on or before January 1, 2005.
Status / November 2004
· Current participation is:
- JAXCare: 87
- American Care: 82
- Preferred Medical: 17
- Jackson Memorial Health Plan: 1,300
· Revisions to program application package completed including standards for plan marketing and advertising. Awaiting approval and transmittal to AHCA.
· May 2005.
· Same four plans, Palm Beach HCD expected to apply.
· Interviews and focus groups recommend increasing eligibility for participants from 200% of FPL to 250 or 300% of FPL.
· No change in 2005 Legislature.
· JaxCare received appropriation of $101,929 to provide services to uninsured individuals.
March 2006
· 2006 Annual Report on AHCA web: www.fdhc.state.fl.us.
· Current participation
· JaxCare: 319
· American Care: 39
· Preferred Medical Plan: 22
· The Public Health Trust of Dade County: 828
· New plan approved under the name of Vita Health, premiums on a sliding scale, sponsored and subsidized by the Health Care District of Palm Beach County, April 1, 2006.
· Plans recommend: Increasing the income eligibility standard; funds for subsidizing premiums; and establishing eligible small business based on mean or median income of all employees.
Local Initiatives: HB 1843, SB 708
Category / Health Care CoverageSummary of Legislation / · HB 1843: Supports local initiatives by providing for a review of the upper-payment-limit (UPL) funding option and how this option may be used to promote health care initiatives determined by the council to be state health care priorities.
· SB 708: Provides for a pilot program in Monroe County to establish a self-insurance plan to be administered through a non-profit corporation.
Status / November 2004
· Some local programs are utilizing Health Flex as a vehicle to provide limited benefit health insurance products to low-income uninsured adults:
- Jackson Health Plan has become a Health Flex provider enrolling 1,300 persons by November, 2004 with incomes below 200% FPL. This approach combines a local coverage initiative with Health Flex, enabling provision of a limited benefit package to otherwise uninsured persons and subsidizing the premium amount on a sliding scale with no premium required for persons with incomes below 100% FPL.
- JaxCare is an approved Health Flex plan provider and has enrolled 87 persons.
· The ability to subsidize the Health Flex Plan premium appears to make these limited benefit packages more attractive, since both local Health Flex plans have experienced faster enrollment than non-subsidized products. (See Health Flex section.)
· Alachua County enacted a ¼ cent sales tax to support health services for uninsured residents (passed by 62% of voters). The tax will generate $7 million a year. The program (CHOICES) will offer primary care, pharmacy assistance, limited hospital services and basic adult dental services along with a disease management program for persons with diabetes, hypertension, asthma, and congestive heart failure.
KidCare
Category / Health Care CoverageSummary of Legislation / · Conference Report on HB 1835: Permits use of additional local and family funds to serve additional children.
· Conference Report on HB 1837, SB 2000:
- Establishes open enrollment periods for Florida KidCare program.
- First enrollment period is January 1, 2005 to January 30, 2005.
- People on waiting list as of March 12, 2004 are eligible to enroll upon becoming law.
· Conference Amendment to HB 1843, SB 2000:
- Requires that children be enrolled on a first come, first served basis (rather than maintenance of a waiting list and enrollment from this list).
- Excludes enrollment of children whose parents have access to employer-sponsored insurance (unless the cost of the child’s insurance is more than 5% of the family income or the child has a pre-existing condition that precludes access to ESI).
- Requires proof of family income supported by copies of any federal income tax return for the prior year, any wages and earnings statements (W-2 forms), and any other appropriate document.
Status / November 2004
· The legislature funded the waiting list and increased funding for 2004-2005.
· January 2005 – open enrollment will begin and September and January open enrollment thereafter, if the Florida KidCare administrators unanimously recommend this and the Social Services Estimating Conference determines there is sufficient funding to continue through FFY 2007.
· Transfers between program components will be allowed outside of open enrollment periods (MediKids, Kid Care, etc.).
· Income verification now required using most recent pay stub or wage statement and tax return and W-2 and documentation of unearned income.
· If parents have access to ESI and ESI is “affordable” (costs 5% or less of annual income) child ineligible. If ESI is unavailable due to a pre-existing condition, child is eligible for KidCare. Voluntary cancellation of ESI within 6 months prior to application disqualifies child.
· If the program goes over budget, children will be disenrolled – last in, first out.
· Non-payment of premium results in ineligibility for 60 days (and this requirement was waived through November 1 following several hurricanes).
May 2005
· 2005 Legislature, HB 569, reversed the changes made to limited enrolment periods enacted in 2004. Enrollment had dropped from 336,689 to 226,016 in the past year. An open, year around, enrollment, process is now in effect.
Appropriate Use of Emergency Room Services: HB 1629
Category / Health Care Cost DriversSummary of Legislation / · Establishes an Emergency Room Diversion Program: Permits hospitals to develop emergency room diversion programs, including:
- An "Emergency Hotline", which allows patients to help determine if emergency department services are appropriate or if other health care settings may be more appropriate for care;
- A "Fast Track" program allowing non-emergency patients to be treated at an alternative site; and
- Provisions for follow-up care and case management.
· Other health care settings include:
- Health care programs funded with local tax revenue;
- Federally funded community health centers;
- County health departments; or
- Other non-hospital providers of health care services.
Status / · There is discussion regarding a possible pilot project in Palm Beach County that would develop community-wide call schedules for certain physician specialties.
May 2005
· Appropriations bill funds $250,000 for pilot emergency room diversion project in Naples.
· CS for CS for SB 838. Where feasible, safe, and cost effective, the agency shall encourage hospitals, emergency medical services providers, and other public and private health care providers to work together in their local communities to enter into agreements and arrangements to ensure access to alternatives to emergency services and care for those Medicaid recipients who need non emergent care. The agency shall coordinate with hospitals, emergency medical services providers, private health plans, capitated managed care networks as established in s. 409.91211, and other public and private health care providers to implement the provisions of ss. 395.1041 (7), 409.91255(3) (g), 627.6405, and 641.31097 to develop and implement emergency department diversion programs for Medic aid recipients.
Protection of Safety-Net Providers: HB 1843, Appropriations Bill
Category / Health Care CoverageSummary of Legislation / · HB 1843: Provides for reallocation of DSH funds not otherwise allocated to hospitals to non-state government owned hospitals (e.g. county hospitals) that have greater than 3,300 Medicaid days.
· Appropriations Bill (Page 48): Provides for funds in Specific Appropriation 202, $870,028 from the Grants and Donations Trust Fund and $1,246,829 from the Medical Care Trust Fund to be used for special Medicaid payments to hospitals providing low-income individuals access to primary care clinics.
- Hospitals that participated in the Primary Care DSH program in State Fiscal Year 2003-04 and are currently receiving special Medicaid payments for primary care are not eligible to receive funds under this section.
- AHCA is required to establish criteria for hospitals to receive funds under this section and a methodology for distributing the funds no later than November 1, 2005.
- At a minimum, a hospital qualifying to receive funds must provide financial support to a freestanding clinic in the hospital’s local community that provides primary care to individuals free of charge and/or on a sliding fee schedule.
Status / · The AHCA has been awarded a grant from HRSA to assess the capacity of Florida’s ambulatory “safety-net”. The grant will also include development of a state-wide strategic plan for the safety-net and funding will be sought from HRSA to develop and assist safety-net providers with implementations of plans designed to strengthen their capacity.
May 2005
· Safety-net providers recognized in Medicaid Reform legislation. Hospital safety-net is to be protected by waiver for UPL special payments with growth rate, disproportionate share funds; new managed care entities to include FQHCs, Rural Health Clinics, County Health Departments, etc.
March 2006
· The Florida Medicaid Reform Waiver secured an amount of $1billion per year for the hospital and ambulatory safety-net providers. On July 1, 2006, or upon implementation of the waiver, Florida will administer a Low-Income Pool program. The former special payments to hospitals under the Upper Payment Limit provisions will cease. CMS Terms and Conditions and Legislative Direction have been provided. AHCA must submit plan for the program to CMS.
Utilization of Electronic Health Care Information: HB 1629