Monday, August 29, 2011

Webinar on wellness compliance issues

Senn Dunn invites you to participate in an Assurex Global webinar on September 29 from 2:00 to 3:30 PM EST.
Reserve your seat now at:
Employer sponsored wellness plans come in many different shapes and sizes. Many wellness initiatives raise significant compliance concerns for employers. This session will discuss a variety of wellness related compliance issues including:

• When is a wellness program considered a “health plan” and what does that mean to the employer?
• HIPAA wellness non-discrimination rules
• Other compliance issues such as HIPAA privacy and tax consequences of some wellness-related incentives

Please note: times for AG webinars vary and are listed for the Eastern time zone.

Presented by: Bob Radecki, President, Benefit Comply, LLC
Bob Radecki has more than 25 years experience in the HR and employee benefits industry helping employers deal with difficult benefit and compliance matters. Previously, Bob founded and served as President of A.E. Roberts Company, a nationally recognized compliance consulting and training firm. He has served as the principal HIPAA consultant to a number of health insurance companies, and is recognized as a leading expert on a variety of benefit compliance issues including COBRA, FMLA, Health Reform and more. Bob has been the featured speaker at numerous industry events and conferences, and has published a number of articles concerning various compliance issues.

After registering you will receive a confirmation email containing information about joining the Webinar.

Friday, August 19, 2011

HHS announces proposed rules for uniform benefit summaries

On Wednesday August 17th, HHS released a Notice of Proposed Rulemaking for uniform benefit summaries as required by the Affordable Care Act (ACA).  HHS has adopted the format proposed by the NAIC for the standardized Summary of Benefits and Coverage.  Accoding to ACA, the Summary of Benefits and Coverage must include the following four components:
  • A four-page Benefit Summary (double sided)

  • Medical Scenarios called "Coverage Examples" for maternity, breast cancer treatment and managing diabetes

  • A standard glossary of medical and insurance terms

  • A phone number and website where individuals can get additional information including documents such as Certificates, Summary Plan Descriptions (SPDs) and policies

The new standardized summaries must be provided beginning with individuals enrolling in a medical plan on or after March 23, 2012.  This provision applies to individual and employer-sponsored medical plans, regardless of grandfathered status or funding.  For fully-insured plans, the insurer is responsible for producing and distributing the summaries.  For self-insured plans, the employer is responsible.

People enrolled in a health plan must be notified of any significant changes to the terms of coverage reflected in the Summary of Benefits and Coverage at least 60 days prior to the effective date of the change. This timing applies only to changes that become effective during the plan or policy year but not to changes at renewal (the start of the new plan or policy year).

Summaries are required to be provided both before and after enrollment and may be delived in paper and/or electronic format.  The penalty for willful non-compliance is up to $1,000 per enrollee.

For more information, please view Cigna's Informed on Reform briefing on this topic.

Tuesday, August 16, 2011

Health reform law headed for Supreme Court following split Appeals Court rulings

On Friday August 12th, the three-judge panel of the US Court of Appeals for the 11th Circuit ruled by a 2-1 vote that the individual mandate in the Affordable Care Act is unconstitional.  This decision comes on the heels of the 6th Circuit Court's ruling on June 29th, which found the individual mandate constitutional and a valid exercise of power under the Commerce Clause of the US Constitution.

As the courts are now split on this issue, it will most likely be headed to the Supreme Court, perhaps as early as next session.  President Obama says he is confident the Supreme Court will uphold the individual mandate as long as the justices follow existing laws and precedents.  However, there is some speculation that the Obama administration will attempt to delay a Supreme Court ruling on the case until after the 2012 election.

Tuesday, August 2, 2011

BCBSNC launches new treatment cost estimator

Blue Cross and Blue Shield of North Carolina launched a new Treatment Cost Estimator designed to help  members make informed health care decisions by providing data on the costs of elective procedures. The tool, found on, replaces the previous cost estimation tool and adds cost information to the provider search tool.

The tool provides average costs for 59 common elective procedures. BCBSNC believes this information will help members become informed consumers and take an active role when they have choices to make about their health care. Additional information and more medical procedures will be added to the tool later this year.

Frequently Asked Questions
The following questions and answers can be used to help your clients understand and use the new Treatment Cost Estimator:

What is the Treatment Cost Estimator tool?
The new Treatment Cost Estimator is a web-based tool that provides members with information about the relative cost of 59 elective procedures. This tool gives our customers an estimated range of what a procedure may cost and provides them with information about how the cost may vary based on the physician/hospital they choose.

Can the tool be used for all BCBSNC plans?
Cost comparison information is not available to members on the following plans:
  • Medicare Advantage (Blue Medicare)
  • Medicare Supplement
  • FEP
  • Dental-only
What data is used to calculate the cost estimations?
Blue Cross and Blue Shield of North Carolina has joined other Blue plans across the country in providing new cost range information for various types of treatments and procedures based on network claims data.

The costs listed in the tool represent a range of the average treatment costs at a particular hospital. This tool calculates costs using a methodology which is broken into two components:
  • There are several steps involved in generating costs of a procedure at a particular facility. First, we collect claims data and categorize the information into cases of care. Cases of care represent a collection of services such as the doctors’ charges, the hospital charges, lab tests, etc. related to a particular procedure. Second, the cases are reviewed to remove any outliers/exceptions that may skew the averages. Third, cost bands/ranges are created for each procedure based on these averages.
  • Each office visit is assigned a code to specifically identify the procedure/service that is being provided. Costs are assigned to each procedure code; along with a standard rate based on the location (Zip Code) of the where the service takes place. This cost value is displayed within the application.
Is the tool intended to provide medical advice and exact payment information?
The cost information provided is intended to be used as a reference tool for our members’ convenience and is not a substitute for medical advice from or treatment by a medical professional for specific medical conditions.

Estimates are not intended to be an exact calculation of claim payment and do not contain all health benefit plan terms, conditions, limitations and exclusions that may apply to a member’s coverage. Also, estimates are not a guarantee of payment or prior approval for a particular service.

Members should not avoid getting health care nor should they make health care decisions based on the cost estimates displayed on this website. Only patients and their doctors can decide which medical decision is best for them.

Why is there such a wide variation in price for a certain procedure?
Doctors’ and hospitals’ rates may vary based on differences in selected treatment plans based on individual needs. This information is intended to be used as a reference tool for our members’ convenience and discussion with their doctors.

Why is BCBSNC introducing the tool?
Health plan designs increasingly require consumers to make informed decisions about their health care, and consumers do not always have the information to determine what they will be required to pay or why. The goal of introducing this type of tool is to support members as they consult with their physician and make decisions about where to seek the health services they need.

How do I use the new tool?
Blue Cross and Blue Shield of North Carolina members need to log into Member Services online at to get treatment cost information. Once logged in with their Member ID and secure password, members can use our doctor or facility search to see cost ranges associated with specific practices or facilities.

Members may also use the Treatment Cost Estimator in Member Services to see the general cost range for 59 elective procedures, without selecting a specific physician or hospital.

For doctor or facility searches:
  1. and click on Find a Doctor at the top right of the web page.
  2. Complete the fields to search for a doctor or facility.
  3. Select a type of facility to choose a type of treatment or procedure.
  4. Select your treatment from the category menu under “Get Treatment Cost Estimates.”
  5. Click “Search” and look for the cost range information on the right side. You may open or close the search field area after the results are visible.
For general treatment costs:
  2. Make sure the first three letters of your Member prefix are correct in the first field
  3. Enter your ZIP code.
  4. Select a type of treatment or procedure from the drop down menu.
  5. Click “Search” for results. You may open or close the search field area after the results are visible.
How does the functionality change the tool I have been using?
In the provider search tool, in addition to obtaining name, location and distance to a provider, you will also be able to access relative cost information which represents the allowed amount for the service. You can use this information to get a general cost comparison depending on the physician or hospital you choose.

Will my provider have access to the information?
The tool is available to all BCBSNC members who are registered on Member Services. BCBSNC has notified all impacted providers regarding this information. Please feel free to share the information with your physician if you have questions and would like to discuss options for where you should have treatment.

Does the cost displayed include all services related to my treatment?
The treatment costs you see represent a collection of services such as the doctors’ charges, the hospital charges, lab tests, etc. related to a particular procedure. The cost generally includes all services related to your treatment; however, some follow-up care may not be included depending on your treatment plan.

Can I use the tool even if BCBSNC is not my primary insurer?
The purpose of this tool is to provide cost comparison information between facilities. The relative value may not be as high if BCBSNC is not the primary insurer.

How often is the tool updated?
The tool is updated every 6 months in April and October. Additional procedures will be added to the tool by the end of the year.

Monday, August 1, 2011

HHS releases new guidelines for women's preventive services

Based on the July 2011 Institute of Medicine (IOM) report, Clinical Preventive Services for Women: Closing the Gap, HHS released new required health plan coverage guidelines for women's preventive services effective August 1, 2011. Accordingly, non-grandfathered plans and issuers are required to provide coverage without cost sharing consistent with these guidelines in the first plan year (in the individual market, policy year) that begins on or after August 1, 2012.

This requirement is part of a broad expansion of coverage for preventive services under the Affordable Care Act (ACA). 

Preventive services to be covered include well woman visits, screenings for gestational diabetes, HPV testing, contraceptive methods and counseling, breastfeeding support and supplies, among other services.  For more details on the new guidelines, refer to the Women’s Preventive Services: Required Health Plan Coverage Guidelines page of