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The Financial Professional's Guide to Healthcare Reform

Book Description

A comprehensive reference guide interpreting and applying healthcare reform law for consultants, appraisers, accountants, and attorneys

The Financial Consultants'Guide to Healthcare Reform provides an historical backdrop on how the healthcare system got to its present state including the Massachusetts Reform and Medicare Advantage along with an explanation of the principal types of health insurance in the United States and how "insurance" actually works. A review and explanation of each of the reform provisions follows, including an analysis of what the implications are for providers, consumers and business and what responses each of these communities might have to the Reform. Using the authors' insights and firsthand experiences in U.S. healthcare finance, this book explains the new healthcare law for individuals and businesses alike, what to expect from it and what actions they need to take to comply.

  • Interprets and applies the health care reform law

  • Provides examples of what the impact of the law might look like

  • Extensive use of sidebars to provide in-depth analysis or background on particular topics of import, where the reader may need more detail to understand the context of Reform's changes.

  • Written for consultants, appraisers, accountants, and attorneys

  • Written by major figures in the world of healthcare valuation and consulting

  • The Financial Consultants' Guide to Healthcare Reform provides a complete handbook to healthcare reform for financial consultants, both for understanding this important legislation as well as for planning responses to it.

    Table of Contents

    1. Cover
    2. Series Page
    3. Title Page
    4. Copyright
    5. Foreword
    6. Preface
    7. Acknowledgments
    8. Chapter 1: Introduction
      1. A Brief Recap of the History of Reform
      2. Balanced Budget Revision Act and Benefits Improvement and Protection Act
      3. Failure of Managed Care
      4. Provider Integration and Consolidation
      5. Summary of the Healthcare Market in 2000
      6. Other Market-Based Studies
      7. Summary
    9. Chapter 2: Massachusetts
      1. The Time Line of Massachusetts Reform
      2. Early Reform Legislation in Massachusetts
      3. The Intervening Years
      4. Components of the 2006 Massachusetts Legislation
      5. Key Features of Massachusetts Reform
      6. Recounting the Results of Reform in Massachusetts
      7. Special Commission on the Health Care Payment System
      8. State Government Reports Tracking the Results of Reform
      9. Massachusetts Quarterly Reports
      10. Massachusetts Attorney General's Report
      11. Recent Legislative Changes through August 2010
      12. What Can We Learn from the Massachusetts Experience?
    10. Chapter 3: Insurance Reforms
      1. What is Insurance?
      2. Components of Health Insurance and Healthcare Entitlement
      3. Health Insurers
      4. How Do Health Insurers Provide Health Insurance?
      5. Understanding Actuarial Risk
      6. How Does Self-Insurance Work?
      7. Regional and Industry Factors in Health Insurance
      8. The Reform of Health Insurance
      9. Minimum Essential Coverage
      10. Consumer Protection Provisions
      11. Grandfathered Health Insurance Plans
      12. Medical Loss Ratios
      13. Cost Containment
      14. Rating and Other Reforms in the Small Group and Individual Market
      15. Mini-Med Plans
      16. Insurance Exchanges
      17. The Massachusetts Experience
      18. Chapter Summary
      19. Appendix 3.1: Selected Legislative Text for Insurance Exchanges
      20. Appendix 3.2: CMS Proposed Regulations—Glossary of Health Insurance and Medical Terms
      21. Appendix 3.3: Using the Massachusetts Health Connector
    11. Chapter 4: Medicare Advantage Plans
      1. How Many Medicare Beneficiaries are in Medicare Advantage Plans?
      2. Geographic Distribution of Medicare Advantage Enrollees
      3. History of Medicare Advantage and Its Predecessors
      4. Changes from the Reform
      5. Implications for the Provider Community
      6. Implications for Insurers
      7. Implications for Medicare Advantage Beneficiaries
      8. Appendix 4.1: PPACA Sections Affecting Medicare Advantage
    12. Chapter 5: Medicaid Expansion
      1. Introduction and Overview
      2. Medicaid Enrollment and Spending
      3. Eligibility Changes
      4. Key Expansion Groups
      5. Community First Choice Option
      6. Benefits
      7. Financing the Changes
      8. Implications and Responses for Low-Income Uninsured and Taxpayers
      9. Appendix 5.1: Table of Medicaid Provisions in the PPACA
      10. Appendix 5.2: Subtitle D—Medicare Part D Improvements for Prescription Drug Plans and MA-PD Plans
    13. Chapter 6: Mandates, Subsidies, Penalties . . . and Taxes
      1. The Individual Mandate
      2. Subsidy Eligibility
      3. Tax Credits and Subsidies
      4. Subsidies
      5. Employer Requirements
      6. The Role of the Tax Code and the Internal Revenue Service
      7. Inexplicable Changes to Flexible Spending Accounts: Notices 2000–59 and 2011–5
      8. Itemized Deductions for Medical Expenses
      9. Reporting of Health Benefits on Form W-2
      10. Methods of Calculating the Cost of Coverage
      11. Health Insurance Information Provided by Employers to All Employees
      12. Annual Return to IRS on Coverage
      13. Tax Treatment of HealthCare Benefits Provided With Respect to Children Under Age 27: Notice 2010–38
      14. Tax Credit for Employee Health Insurance Expenses of Small Employers: Notices 2010–44 and 2010–82
      15. Consumer Operated and Oriented Plan (CO-OP Program)
      16. Funding of Patient-Centered Outcomes Research: Notice 2011–35
      17. Excise Tax on High-Cost Employer-Sponsored Health Coverage
      18. Added Medicare Tax on the Upper-Middle Class and High-Income Individuals
      19. Increased Medicare Part B Premium
      20. Increased Medicare Part D Premium
      21. Internal Revenue Code Changes for Tax-Exempt Hospitals
      22. Implications and Responses for Small Business
      23. Implications and Responses for Larger Business
      24. Implications and Responses for Individual Taxpayers and Consumers
      25. Some Thoughts for Lenders and Small-Business Investors
      26. Appendix 6.1: Table of Internal Revenue Service Notices
      27. Appendix 6.2: Table of Regulations (Treasury Decisions)
    14. Chapter 7: Delivery System Reforms
      1. Overview of Delivery System Reforms
      2. Quality Measures
      3. Hospital Readmissions Reduction Program
      4. Payment Adjustments for Conditions Acquired in Hospitals
      5. Payment Bundling
      6. Revisions of Market Basket Updates and Incorporation of Productivity Improvements into Market Basket Updates
      7. Independent Payment Advisory Board
      8. Medicare Geographic Payment Disparities
      9. Medicare and Medicaid Disproportionate Share Hospital Payment Program
    15. Chapter 8: Accountable Care Organizations
      1. Historical Parallels
      2. Precursor to ACOs: Physician Group Practice (PGP) Demonstration
      3. Center for Medicare and Medicaid Innovation
      4. The Proposed Regulations of March 31, 2011, and the Final Regulations of October 20, 2011
      5. Eligibility and Governance
      6. Agreement Requirement
      7. Primary Care Providers and the Assignment of Beneficiaries to the ACO
      8. Data Sharing
      9. Future Regulatory Changes
      10. Quality and Other Reporting Requirements
      11. Calculating the Performance Score for Each Measure within a Domain
      12. Shared Savings Determination
      13. Loss Factors Specific to the Two-Sided Model
      14. Claims Run-Out
      15. ACO Distribution of Shared Savings
      16. Public Reporting of Shared Savings
      17. Termination of the ACO Agreement
      18. Overlap with Other Shared Savings Initiatives
      19. Pioneer ACOs
      20. Advanced Payment ACO Model
      21. Antitrust Issues
      22. The Internal Revenue Service and ACOs
      23. Implications for Beneficiaries
      24. Implications for Providers
      25. Some Thoughts for Lenders and Small-Business Investors
    16. Chapter 9: Healthcare Workforce
      1. Innovations in the Healthcare Workforce
      2. Increasing the Supply of the Healthcare Workforce
      3. Healthcare Workforce Education and Training
      4. Support of the Existing Healthcare Workforce
      5. Primary Care Reimbursement and Other Workforce Improvements
      6. Improving Access to Healthcare Services
    17. Chapter 10: Transparency and Program Integrity
      1. Physician Ownership and Other Transparency
      2. Nursing Home and SNF Transparency
      3. Nationwide Background-Check Program
      4. Patient-Centered Outcomes Research
      5. Medicare, Medicaid, and CHIP Integrity Provisions
      6. Additional Medicaid Program Integrity Provisions
      7. Additional Program Integrity Provisions
      8. Elder Justice Act
      9. Healthcare Fraud Enforcement
    18. Chapter 11: Section 340B Expansion
      1. Overview of the 340B Program and Reforms
      2. Expansion of Covered Entities
      3. Program Integrity Provisions
      4. Regulations Implementing 340B Legislation
    19. Chapter 12: Medical Tort Litigation Demonstration Program
      1. ACA Demonstration Program Provisions
      2. Health Act
    20. Chapter 13: Other Provisions
      1. Physician Quality Reporting System
      2. Physician Feedback Program
      3. Misvalued Codes Under the Physician Fee Schedule
      4. Modification of Equipment Utilization Factor for Advanced Imaging Services
    21. About the Authors
    22. Index