Rollout of ACA provisions taking many twists and turns

Based on a partnership with Urology Times, articles from the American Association of Clinical Urologists (AACU) provide updates on legislative processes and issues affecting urologists. We welcome your comments and suggestions. Contact the AACU government affairs office at 847-517-1050 or info@aacuweb.org for more information

Since becoming the law of the land in March 2010, the Patient Protection and Affordable Care Act (ACA) has altered insurance industry practices, expanded certain Medicare benefits, and initiated new payment and service delivery models. Much of the upheaval and organizational transformation over these last 3 years has been borne by the private sector as governments planned new institutions to handle millions of newly insured citizens.

Here’s how some of the ACA’s key provisions are shaping up and what to look for in the months ahead.

Exchanges must launch before Oct. 1; contract scrutiny urged

Health insurance exchanges are a key component in this new bureaucracy, as they will be the mechanism through which more than 20 million individuals and employees of small businesses purchase health insurance. While the federal government never expected states to forgo the operation of its own exchange, 26 states rejected the local option, while another seven chose to partner with the U.S. Department of Health and Human Services. These 33 jurisdictions represent 64% of the population.

Leaders of the federal and state exchanges are frantically seeking to certify qualified health plans, creating and testing the user experience and educating consumers on how to buy coverage through the online marketplace before the start of open enrollment Oct. 1, 2013. Urologists and practice administrators are reporting with increasing frequency that they are being notified of material changes to their contracts pursuant to “all products” clause provisions. Only 12 states and the District of Columbia restrict all products clauses, which require physicians to accept any enrollee from any of the plan’s various products.

Even in those states with limited protections from this practice, insurers suggest the law does not apply in this case since the plans are not “new products” but rather a “reconstitution” of an existing product. And in Illinois, where all products clauses are the norm, insurers insist they are under no obligation to notify physicians, instead directing them to their corporate website. Blue Cross Blue Shield of Illinois executives aren’t worried about any physicians opting out, either, because contracts stipulate that if they no longer accept one product, they can no longer accept patients from any BCBS plan.

Medicaid expansion attracts GOP-led states; private-public partnerships

As of early summer, 26 governors announced support of Medicaid expansion according to the framework established by the ACA, and an additional four state executives will seek approval for an alternative model to cover childless adults who earn up to 133% of the federal poverty level.

The ACA provides for full federal funding of newly eligible enrollees for 3 years, beginning Jan. 1, 2014. While special legislative sessions are being pondered in those states yet to make a decision, even a 1-year delay could mean lost federal funds totaling hundreds of millions of dollars to cover low-income residents.

A growing number of governors who rejected health insurance exchanges and initially opposed the ACA’s Medicaid expansion are proposing to use funding allocated to states to cover individuals earning up to 133% of the federal poverty level (about $15,000 for an individual) to buy private insurance in the online marketplaces. Since the population earning between 100% and 138% of federal poverty level are eligible for both Medicaid expansion funds and federal subsidies to purchase insurance, lawmakers hope to direct newly eligible citizens in that direction, rather than take them on the state’s rolls.

Arkansas Governor Mike Beebe (D), having received legislative approval for his state’s public/private plan, will soon learn what changes federal Medicaid officials require before granting a waiver to implement his novel approach. Iowa Governor Terry Branstad (R) and legislative leaders approved a similar plan that will be subject to authorization by CMS.

While more and more Medicaid patients are enrolled in managed care, whether expansion takes place via public programs or market-based premium support is an important distinction for providers given disparate reimbursement schemes. Federal support for either option becomes available Jan. 1, 2014.

New law protects provider licensure from political motives

Urologists in Washington state achieved a major accomplishment May 20, 2013, when Gov. Jay Inslee (D) signed SB 5215, concerning health care professionals contracting with public and private payers. Among other provisions, the new law prohibits tying physician licensure to participation in Medicaid or any other public or private payer arrangement.

Sponsored by 2011 AACU Distinguished Leadership Award honoree Sen. Randi Becker (R), SB 5215 was inspired by the AACU’s Medical Practice Freedom campaign. Sen. Becker learned about states’ attempts to require physicians to contract with Medicaid programs at the 2011 AACU State Advocacy Conference. After a trial run in the 2012 legislative session, she made the issue a top priority in 2013. Sen. Becker, who assumed responsibility for the Health Care Committee this year, successfully shepherded SB 5215 through the legislative process and credits urologists for overcoming the threat of a partial veto as the bill reached Gov. Inslee’s desk.

This significant achievement demonstrates the effectiveness of your professional organizations, the value of your continued membership, and the ability of urologists to impact public policy.UT

Subscribe to Urology Times to get monthly news from the leading news source for urologists.