Govexec.com is reporting that the National Community Pharmacists Association is seeking to revive H.R. 4489, a bill to more strictly regulate prescription benefit managers and prescription drug pricing in the FEHB Program.  The Association sent a letter to OPM endorsing the bill.  According to Govexec.com, “OPM spokesman Edmund Byrnes said the agency is in the process of putting together a formal response to NCPA’s recommendations.” The FEHBlog thinks that OPM’s February 2010 carrier letter on PBM arrangements effectively trumped the bill.

The Senate passed a bill today extending unemployment benefits but not extending the COBRA/TCC subsidy program beyond May 31, according to the Washington Post. That subsidy program does appear to be phasing out.

The AMA News features an interesting article on the coming struggle on Capitol Hill to fix the formula for reimbursing doctors under Medicare Part B.  Without a legislative fix, the formula will drop the reimbursement level by 23% on December 1, 2010. In mid-June, CMS implemented a similar drop for a few days when Congress dawdled with extending the fix past May 31. In the end, Congress increased the reimbursement formula by 2.2% through November 30, 2010. But Congress is finding it necessary to appropriate an additional $95 million to CMS to pay for reprocessing these claims.

On the Affordable Care Act front, reginfo.gov informs us that the Labor Department rule implementing the Act’s disputed claim process provision (PHSA Section 2719) has been pending final Office of Management and Budget review since July 16. The interim final rule implementing the Act’s preventive care mandate was published in yesterday’s Federal Register. The comment deadline is September 17, 2010.

Finally, the FEHBlog got a kick out of this Wall Street Journal article about doctor’s notes.  It reminds me of the Seinfeld episode in which Elaine is concerned about what her doctor is writing about her on his chart and she arranges for Kramer to try to steal the chart. Of course, one of the HIPAA Privacy Rule’s individual rights is the ability to review and even propose amendments to a doctor’s notes on you, but the Privacy Rule was not on the books in the 1990s.

What goes around comes around.  The New York Times reports this morning on a new trend among health insurers selling to individuals and small business — plans with narrow provider networks. Of course, in the 1990s health insurers pushed the managed care model featuring narrow networks and a primary care physician gatekeeper. The new model allows the patient to make his or her own health care choices among a smaller network of providers that the insurer presumably considers cost effective. The article indicates that larger employer have begun expressing interest in the approach. In the end it may be that only larger employer will have this option because the narrow network approach may run afoul of the Affordable Health Care Act’s requirement for qualified health plans operating in the health insurance exchanges beginning in 2014.

NCQA last week announced changes to next year’s HEDIS quality standards that can be used to measure the performance of  health plans.  OPM currently uses a subset of those standards with FEHB plans. OPM explained in its April 2010 call letter for 2011 benefit and rate proposals that

OPM plans to work with experts in the field to develop a refined set of performance measures that provide additional insights into plan quality. We will continue to endeavor to align our quality measurement requirements with existing NCQA processes wherever possible to reduce the burden on plans. Other large employers and purchasing coalitions have continually evolved their performance measurement requirements and the FEHB Program needs to do the same,

Last week the Pharmaceutical Research and Manufacturers of America (“Phrma”)  named John J. Castellani, formerly head of the Business Roundtable, to be its new President.

The FEHBlog discovered that on June 24, 2010, the Congressional Research Service published a report on Federal Employee Benefits and Same Sex Partnerships.  

HHS, the Labor Department and the IRS released today the interim final rule implementing the Affordable Care Act’s preventive care mandate.  Here is a link to the list of preventive care services that non-grandfathered plans must cover under this mandate with no-cost sharing when received from an in-network provider.

There is no obligation on health plans to provide these services out of network.  Business Insurance explains that

The regulations * * * make clear that regular cost-sharing requirements can be imposed on an office visit when a recommended preventive service is billed as a separate charge.
In addition, treatment resulting from a preventive service can be subject to cost-sharing requirements if the treatment is not itself a recommended preventive service.
Regulators estimate that the new requirements will increase group health care plans’ costs by an average of 1.5% a year.
Mike Thompson, a principal with PricewaterhouseCoopers L.L.P. in New York said, though, the cost impact will be much lower for employers that already provide coverage for many preventive services.

As mentioned yesterday, the FEHB plan already offers generous in-network preventive services coverage.

Government HIT News reports that HHS released today its meaningful use regulations that hospitals and other health care providers must follow in order to receive electronic healthcare record funding under last years stimulus act. Modern Healthcare.com takes a look at the regulations (which weigh in at 864 pages) from the providers’ perspective. Interestingly, America’s Health Insurance Plans issued a statement on how health plans are helping bring the medical community into the 21st Century.

The FEHBlog expects that the First Lady, Dr. Jill Biden, and HHS Secretary Sebelius will be releasing the next set of Affordable Care Act implementing regulations tomorrow afternoon. Those regulations will implement the preventive care mandate that applies to non-grandfathered plans beginning with plan years that take effect on or after September 23, 2010. FEHB plans currently provide a wide range of preventive care services with no enrollee cost sharing when the services are performed by a health plan network provider.  

AHIP’s Hi-Wire ran an interesting piece about how health plans are using Medicare Part B’s pricing schedule (known as the resource based relative value schedule (RBRVS)) to price commercial health plan reimbursements to providers.

Elizabeth Curran, Head of National Contracting Policy and Medicare Strategy for Aetna, believes that adopting the Resource-Based Relative Value Scale (RBRVS) used by Medicare makes a lot of things easier because everyone understands it, especially providers.
Mark Austin, Senior Vice President of Network Management at Blue Cross Blue Shield of Tennessee, finds that employers and business groups speak in the language of Medicare rates. He also noted that as more and more payers shift to some form of RBRVS, it becomes a lot easier to compare reimbursement plans.
Jessalyn Greene, Director of Reimbursement Strategy for Scott and White Health Plan, cautioned that geographic differences can force variances to the methodology. She finds that many rural areas will see best use of RBRVS for their Medicare populations.

Given Ingenix’s exit from this business under a settlement with the NY Attorney General, this trend makes a lot of sense to the FEHBlog.

Congress returns to work this week following the Fourth of July recess during which Donald Berwick MD was appointed administrator of the Centers for Medicare and Medicaid Services.

The FEHBlog is anxiously awaiting the next Affordable Care Act implementing regulation, the preventive care mandate (new Public Health Service Act (“PHSA” Section 2713), which was submitted to the Office of Management and Budget for final review on June 29. The FEHBlog hears that the regulation implementing the disputed claim review procedures mandate is in the on deck circle (new PHSA Section 2719). Neither of these mandates is applicable to grandfathered group health plans.

The Politico Pulse presented an interesting Affordable Care Act tidbits last Friday:

NEXT REG BATTLE – [The National Association of Insurance Commissioners] NAIC is wading into another hazardous regulatory task: writing the form that health insurers will provide in March, 2012 to subscribers and applicants to outline benefits and costs [pursuant to new PHSA Section 2715]. Regulators must boil down complex benefit information into brief, intelligible summaries [maximum of 4 pages 12 point font]. Regulators, administration officials and insurers began the task Thursday in the first of what will be biweekly, 90-minute conference calls. NAIC has four prototype documents, obtained by PULSE, being used as a baseline. Three are from a FTC study and one drawn up by the Oregon Insurance Division (Miller’s home state): http://politi.co/dzIJ6T , http://politi.co/cViAHG , http://politi.co/dffqcx , http://politi.co/9XmNsJ

MLR REDUX? PPACA gives NAIC until March 2011 to write the consumer-focused forms but HHS has asked the group to deliver early, sometime in the fall. NAIC plans to comply, but recall the last time something similar happened… [Plans must begin to use one year later — grandfathered plans also are subject to this mandate.]

ABOUT THOSE MLR [medical loss ratio] DEFINITIONS – The head of the NAIC subcommittee working on the definitions says that, while the group makes progress, the end is not in sight. “We still have the December 31 deadline, which we anticipate meeting,” Steve Ostlund, chair of the NAIC’s Accident & Health Working Group said on a call Thursday. He expects to meet the deadline well ahead of time, but won’t put a new estimate on the group wrapping up its work. “It’s not going to go on forever.” [The group is implementing the minimum medical loss ratio requirements stated in new PHSA Section 2718, which applies to insured plans whether or not grandfathered.]

I enjoy reading the Pulse every weekday morning.

HHS has upgraded the www.healthcare.gov website and it has created a health information privacy website which according to an HHS press release will “help visitors easily access information about existing HHS privacy efforts and the policies supporting them. The site emphasizes HHS’ deep commitment to privacy in the collection, use, and exchange of personally identifiable information. This new resource provides Americans with confidence that their personal information is secure and underscores HHS’ goal of greater openness and transparency in government.” 

Although it’s not an FEHB decision, the FEHBlog did note with interest a Business Insurance article reporting that “A 2004 District of Columbia law that would have made pharmacy benefit managers “fiduciaries” was ruled invalid Friday by a three-judge panel of a federal appeals court.” The court concluded that the FEHBA’s private sector analog ERISA preempted the DC law. Here’s a link to the opinion.

HHS released a proposed rule implementing various provisions of the HITECH Act which beefed up the HIPAA Privacy and Security Rules applicable to health plans, health care providers, healthcare clearinghouses and their business associates.  According to the HHS release (because I have not read the 234 page proposed rule yet)

The proposed rule announced today would strengthen and expand enforcement of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy, Security, and Enforcement Rules by:

• expanding individuals’ rights to access their information and to restrict certain types of disclosures of protected health information to health plans. 

• requiring business associates of HIPAA-covered entities to be under most of the same rules as the covered entities;

• setting new limitations on the use and disclosure of protected health information for marketing and fundraising; and

• prohibiting the sale of protected health information without patient authorization.

HHS is inviting public comment on the proposed rule for 60 days beginning on July 14.

The Boston Globe reports that a federal district judge in that state, Joseph L. Tauro, ruled today that the federal Defense of Marriage Act (“DOMA”) is unconstitutional.  DOMA requires that the term spouse when used in a federal statute (as it is in Section 8902 of the FEHB Act defining a covered family member) must be limited to an opposite sex partner.  The individual plaintiffs in this case include federal and postal employees who wanted FEHB coverage for their same sex spouses (as same sex marriage is lawful in Massachusetts).  The Judge concluded that DOMA runs afoul of the Tenth and Fourteenth Amendments to the Constitution. We will have to see what happens now. Probably an appeal. A copy of the Court’s opinion in the Gill case is available here and its opinion in the Massachusetts case is here.

The Hartford Courant reports that America’s Health Insurance Plans, AHIP, announced that the board elected Vicky Gregg to a one-year term as chair. Gregg is president and chief executive officer of BlueCross BlueShield of Tennessee. She succeeds Jay Gellert, president and CEO of Health Net Inc. of Woodland Hills, California.

The President will be making a Congressional recess appointment in order to place Harvard professor Donald Berwick in charge of the Centers for Medicare and Medicaid Services according to Modern Healthcare.com. The recess appointment allows Dr. Berwick to hold the post for the remainder of the next Session of Congress (December 2011) without Senate confirmation.

Speaking of Medicare today is the date for implementation of the Provider Enrollment, Chain and Ownership System, or PECOS created as a result of the Affordable Care Act, according to a CMS press release. A stamp honoring Pecos Bill is to your left.

“CMS issued an interim final regulation on May 5, 2010 implementing provisions of the Affordable Care Act that permit only a Medicare enrolled physician or eligible professional to certify or order  home health services, durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) , and certain items and services under Medicare Part B.  The new law applies to orders, referrals and certifications made on or after July 1.

“While the regulation will be effective July 6, 2010, CMS will not implement automatic rejections of claims submitted by providers that have attempted to enroll in PECOS.  However, until the automatic rejections are operational, providers should not see any change in the processing of submitted claims, they will continue to be reviewed and paid as they have historically been reviewed and paid.”

The Kaiser Family Foundation has a helpful preview of the health care issues — Medicaid funding for the States, resuscitation of the COBRA/TCC premium subsidy, and the Medicare Part B physician reimbursement schedule — facing Congress when it returns from its recess next week. It’s all about the Benjamins.

The Labor Department’s Employee Benefits Security Administration, which enforces ERISA, the FEHBA’s private sector analog, has its own healthcare reform website. Posted on that site are model notices for ERISA governed plans to use when implementing certain Affordable Healthcare Act immediate reforms, such as the expansion of dependent child coverage up to age 26. That particular change takes effect for the FEHB Program on January 1, 2011.

Happy Independence Day! The Congress is in recess until next week.

The next Affordable Care Act implementing regulation will be the “Interim Final Rules for Group Health Plans and Health Insurance Issuers Relating to Coverage of Preventive Services under the Patient Protection and Affordable Care Act” which according to reginfo.gov, is currently receiving Office of Management and Budget review. I understand that the rule governing the Affordable Care Act’s internal and external disputed claim procedures is waiting to step into the on deck circle. Both sets of regulations apply to plans which remain grandfathered under the recently issued regulations.

Last week, on June 30, the Federal Workforce subcommittee of the House Oversight and Government Reform Committee held a hearing on the federal government’s use of temporary employees.  The Federal Times reports that

The federal government employs about 180,000 temporary workers, and is unsure how many lack health insurance. Those workers can purchase health insurance under the Federal Employees Health Benefits Program after they have completed one year of temporary service, but the government does not pay for any portion of the premiums. Temporary workers are also ineligible for federal life insurance or retirement benefits.

The federal government needs to better understand how many of its temporary workers lack health care coverage, Del. Eleanor Holmes Norton, D-D.C., said.

Angela Bailey, deputy associate director for recruitment and diversity at the Office of Personnel Management, said current law prevents the government from offering full FEHBP benefits to temporary workers.

Finally, last week URAC released preliminary results of an ongoing survey of medical management practices.  The URAC press release explains that “Preliminary results from a new survey by URAC, a national leader in health care accreditation, reveals that the medical management industry is continuing to focus resources on health information technology, but the ability of consumers to access their information on-line remains low due to the cost of developing appropriate web-portals and other business and security-related concerns.”

“We’re not unsympathetic to this issue,” Bailey said. “We would be more than willing to work with the subcommittee with regard to health benefits for these federal employees.”

The U.S. Labor Department posted an important and helpful clarification to its unnecessarily complex mental health reform rule today which reads as follows:

Since the interim final regulations were issued, some plans and issuers have stated that it is common with respect to outpatient benefits for plans and issuers to require a copayment for office visits (e.g., physician or psychologist visits) but coinsurance for other outpatient services (e.g., outpatient surgery, facility charges for day treatment centers, laboratory charges, or other medical items.)

For purposes of determining parity for outpatient benefits (whether in-network or out-of network), can a plan or issuer establish any sub-classifications, similar to the special rule for multi-tier prescription drugs?

Until the issuance of final regulations, the Agencies have determined that they will establish an enforcement safe harbor under which the Agencies will not take enforcement action against a plan or issuer that divides its benefits furnished on an outpatient basis into two sub-classifications for purposes of applying the financial requirement and treatment limitation rules under MHPAEA: (1) office visits, and (2) all other outpatient items and services. After the sub-classifications are established, the plan or issuer may not impose any financial requirement or treatment limitation on mental health or substance use disorder benefits in any sub-classification (i.e., office visits or non-office visits) that is more restrictive than the predominant financial requirement or treatment limitation that applies to substantially all medical/surgical benefits in the sub-classification using the methodology set forth in the interim final rules. Other than as permitted under this enforcement policy, and except as permitted under the interim final rules for multi-tier prescription drug formularies, sub-classifications are not permitted when applying the financial requirement and treatment limitation rules under MHPAEA. Accordingly, and as stated in the preamble to the interim final rules, separate sub-classifications for generalists and specialists are not permitted.

I was among many folks who asked for this clarification. I made my request at the OPM AHIP carrier conference in March.

This FAQ suggests to me, however, that the regulatory agencies don’t plan to accept the public comments suggesting that the compliance date (plan years beginning on or after today) be postponed one year.

Today, the Administration replaced the healthreform.gov website with the new healthcare.gov website. According to the HHS press release,

HealthCare.gov  is the first central database of health coverage options, combining information about public programs, from Medicare to the new Pre-Existing Conditions Insurance Plan, with information from more than 1,000 private insurance plans.  Consumers can receive information about options specific to their life situation and local community.
In addition, the website will be a one-stop-shop for information about the implementation of the Affordable Care Act as well as other health care resources.  The website will connect consumers to quality rankings for local health care providers as well as preventive services.

OPM’s analogous FEHBP website is opm.gov/insure.