Consumer Protections and Information Standards

Saturday, December 12, 2009

Previously, I noted that to be a “qualified health benefits plan”, a plan must meet provisions for affordable coverage, essential benefits, and consumer protection. Similar to ERISA and other “worker rights” laws, the Act outlines appeals and informational dissemination processes.

The Act grants the ability to the Health Choices Commissioner (Commissioner) and the Secretary of Labor (Secretary) to jointly establish, standardize, coordinate, and “harmonize” various consumer, provider, and carrier marketing protections and informational practices. This standards apply to plans offered through Health Insurance Exchanges and may apply to non-Exchange and other plans “only to the extent specified by the Commissioner”.

The Act outlines mechanisms to protect consumers, providers, carriers, and others:
o Timely grievance/appeals process for internal/external claims reviews/payments
o Accurate/timely informational/plan transparency/disclosures, including enrollee/participant rights
o Plain language use (Similar to requirements in ERISA for SPD’s, SMM’s, & SAR’s)
o Cost-sharing transparency (deductibles, co-pays, coinsurance) (Many plans currently provide this via enrollment materials and/or web portals.)
o Reimbursement transparency between the carrier and provider (How will provider confidentiality be maintained?)
o Pharmacy benefit managers (PBM) transparency, statistical reports on numbers of Rx’s, average payments , mail-order vs retail, discounts, rebates, generic vs name-brand, enrollment turnover, and other information.
o Confidential annual public PBM transparency reports by Commissioner.
o Annual PBM reports by Commissioner to: State/Federal law enforcement (fraud), Comptroller General, Medicare Payment Advisory Commission, Secretary of Health and Human Services, and Director Congressional Budget Office
o Penalties for PBM’s who fail to comply or falsify information.
o Standardization of coordination/subrogation of benefits/claims process
o Administrative simplification of processes
o State prohibitions on discrimination against health care providers
o Protection of physician Rx information/Congressional biased marketing/sales practices report
o Dissemination of advance care planning information
o Information related to other “end-of-life” planning tools
o Does not promote suicide, assisted suicide, euthanasia, or mercy killing. regardless of legality
o Does not require advanced directive or a physician’s order for life sustaining treatment or other end-of-life planning document
o Does not require consent to restrictions on the amount, duration, or scope of
medical benefits otherwise covered under a plan
o Advanced directive defined: includes living will, comfort care order, or
durable power of attorney for health care
o No restrictions on palliative/hospice care or service for pain or discomfort
o No preemption of state law regarding advance planning, palliative
care, or end-of-life decision-making.

How will plans be able to achieve “administrative simplification” with all of this additional compliance and reporting requirements? Will new reporting requirements add to the cost of Rx and PBM’s?