2011 news

CMS-HHS Announcement

This message’s aim is to inform about this year’s Seasonal Flu initiative. Walgreen’s Pharmacy is

partnering with HHS this season in an effort to promote seasonal flu vaccinations among minority

communities by supporting flu clinics throughout the Philadelphia, Montgomery, and Delaware counties area.

Our office has been asked to identify local, faith and community-based organizations that are interested

in having a flu clinic at their site.

Walgreen’s Pharmacy will come out to the site and will provide the vaccine, the pharmacist, educational materials

and any additional information, as per your request, at no cost. Walgreen’s pharmacists can immunize patients

18 and older. If given enough notice, Walgreen’s can schedule a nurse practitioner on site to administer vaccine to

patients under age 18. If they are unable to administer the vaccine on-site, patients will be given a voucher to be

used at any of the Take Care Clinics available in store.

If you are interested in hosting a flu clinic, we would need the following information:

Point of Contact
Site Address
Event Date or Dates
Event Start & End Times
Estimated # of immunizations
Estimated # of patients 65 or older
Estimated # of patients (under 18 years old)

If you have any questions, do not hesitate to contact me directly.
Thanks again for your time and I look forward to speaking with you soon.

Yvonne Maldonado
Program Assistant

DHHS/OASH/Office of Minority Health, Region III
The Public Ledger Building, Suite 436
150 S. Independence Mall West
Philadelphia, PA 19106
Phone: 215-861-4524
Email: yvonne.maldonado@hhs.gov

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Pafamilies-Systems of Care

Pennsylvania has been awarded a one-year System of Care Expansion Planning grant. This involves the development and implementation of a comprehensive statewide planning process that will determine how to establish Systems of Care in all areas of the Commonwealth. The planning effort will focus on youth ages 8-18 that have serious mental health needs, multi-system involvement and their families. The Expansion Planning process will build on and enhance efforts that have been underway for several years to integrate and more effectively provide services to youth and their families. This planning initiative will involve state and county child serving system leaders, in equal partnership with youth and family representatives, to incorporate the unique strengths and challenges from all areas of the state.

The goal and the main outcome of the planning process will be the development of a state plan that will identify the systems changes (regulation, funding, policy, structures) that need to occur to have the child welfare, juvenile justice, behavioral health, and education systems operate as one integrated whole in collaboration with strong and knowledgeable youth and family leaders. We anticipate hiring 8 planning group facilitators to assist with this work. These individuals will have strong facilitation and planning skills and the flexibility to work with a diverse group of individuals to gather input and develop group consensus on the system change recommendations to be included in the state plan. Six of these positions are geographically based, with a preference for individuals who have lived or worked in those areas. The two additional facilitators will support the family and youth leadership planning teams. These facilitators will work across the state, assuring youth and family voice and perspective in the planning process and the development of youth and family leadership to support the efforts to implement System of Care.

Individuals, that are available and interested in being considered for this work can be hired as part time, temporary employees, enter into a professional service agreement or continue in current employment through agreement and reimbursement to their current employer. Interested candidates can apply for the following positions (job opening numbers) at http://www.upmc.com/careersatUPMC/Pages/default.aspx

Youth Facilitator 2009221

Family Facilitator 2009222

Region I Facilitator 2009227

Region II Facilitator 2009229

Region III Facilitator 2009234

Region IV Facilitator 2009236

Region V Facilitator 2009238

Region VI Facilitator 2009240

For more information please contact Please contact Ellen DiDomenico, Expansion Planning Grant Project Director at edidomenic@pa.gov or 717.772.4131.

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OMHSAS Announcement

On November 15, 2011, Blaine L. Smith joined the Office of Mental Health and Substance Abuse Services as Deputy Secretary. Blaine comes to OMHSAS after 10 years in the behavioral health field, most recently as Executive Director for Central Pennsylvania Behavioral Health Collaborative in Blair County. Prior to that he served as Director of Finance for the Home Nursing Agency in Altoona and as Chief Fiscal Officer of the Blair County Mental Health/Mental Retardation and Drug & Alcohol Offices. Prior to his work in Blair County, he spent nearly 16 years in banking and finance.

Blaine and his wife, who is a kindergarten teacher, have 3 children.

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CMS-Final Rule Fact Sheet

The Centers for Medicare and Medicaid Services has just issued this ruling that requires insurance companies to spend 80%/85% of premium dollars on medical and health care, with a smaller percentage to be spend on administrative costs, along with issues of transparency, rebates, varying policies, etc.

Medical Loss Ratio: Getting Your Money's Worth on Health Insurance Final Rule Fact Sheet

Under the Affordable Care Act, consumers will receive more value for their premium dollar because insurance companies are required to spend 80 percent (individual and small group markets) or 85 percent (large group markets) of premium dollars on medical care and health care quality improvement, rather than on administrative costs, starting in 2011. If they don’t, the insurance companies must provide a rebate to their customers starting in 2012.
In December 2010, the Department of Health and Human Services (HHS) issued a regulation implementing this provision of the Affordable Care Act, known as the medical loss ratio (MLR). The MLR will make the insurance marketplace more transparent and make it easier for consumers to purchase plans that provide better value for their money.

In the 2010 rule, HHS requested comments on a number of the MLR provisions. HHS is now issuing a final rule amending these provisions of the regulation to provide certainty going forward.

What’s Changing?

The fundamental structure of the MLR policy is not changing. Beginning in 2011, the law requires insurance companies in the individual and small group markets to spend at least 80 percent of the premium dollars they collect on medical care and quality improvement activities. Insurance companies in the large group market must spend at least 85 percent of premium dollars on medical care and quality improvement activities. Insurance companies must report their MLR data to HHS on an annual basis so that residents of every State will have information on the value of health plans offered by different insurance companies in their State. Insurance companies that do not meet the MLR standard will be required to provide rebates to their consumers. Insurers will make the first round of rebates to consumers in 2012. Rebates must be paid by August 1^st each year.

The changes in this final rule largely address technical issues involved in the way issuers calculate and report their MLR and the mechanism for distributing rebates to enrollees in group health plans.

Rebates. In the previous rule, rebates in the group market would have been subject to tax. The final rule streamlines the rebate process for those enrolled in group policies. In particular, the final rule directs issuers to provide rebates to the group policyholder (usually the employer) through lower premiums or in other ways that are not taxable. This process will vary by plan type. Policyholders must ensure that the rebate is used for the benefit of subscribers. The final rule also requires that issuers provide notice of rebates to enrollees and the group policyholder. All enrollees must be given information about the MLR and its purpose, the MLR standard, the issuer’s MLR, and the rebate provided.
Insurers will be required to make the first round of rebates to consumers in 2012. Rebates must be paid by August 1st each year.

Provide MLR information to more consumers. Consistent with comments from consumer groups, the new regulation proposed a new notice requirement that will ensure all consumers receive information on either the amount of their rebate or their insurer’s MLR, regardless of whether there is a rebate, as well as how the insurer’s MLR has improved under the new law.

Special Circumstances Adjustments. Last year’s rule required accelerated reporting by issuers of mini-med and expatriate plans. This allowed HHS to receive and review data on their unique structures and determine how best to address the special circumstances of these plans in the context of the general MLR calculation. The first two quarters of the data have informed the final rule. The final rule continues the application of a methodological adjustment to the way the medical loss ratio is calculated for these plans to ensure that consumers do not lose coverage. Issuers of mini-med and expatriate policies must continue to report this experience separately, on an annual basis. Specifically:

Expatriate Policies. This final rule maintains for 2012 and future years the special circumstances adjustment of a multiplier of 2.0 to the MLR numerator for expatriate policies. This adjustment acknowledges the higher administrative costs and volatility of experience in these plans when compared to typical insurance plans, which primarily cover care in all parts of the world in a wide variety of health care systems.
Mini-med Policies. This final rule reduces the special circumstances adjustment from a multiplier of 2.0 to 1.75 for 2012, 1.5 for 2013, and 1.25 for 2014 for mini-med policies. In 2014, the use of annual dollar limits on coverage will be banned and we expect that these mini-med policies will cease to exist, as plans offered in the Affordable Insurance Exchanges will offer affordable coverage options to all Americans without annual coverage limits. This adjustment should minimize market withdrawal while incentivizing issuers to reduce their administrative expenses and operate more efficiently.

In addition, the rule states that HHS will post the mini-med MLR data that we have collected from the issuers in the spring of 2012 to further enhance transparency to consumers.

Other Changes in the MLR Calculation. The final rule makes other changes to the calculation of the MLR in areas where HHS requested comment in the interim final rule. Specifically, the final rule allows ICD-10 conversion costs of up to 0.3 percent of an issuer’s earned premium in the relevant State market to be considered quality improvement activities, for each of the 2012 and 2013 MLR reporting years. This final rule also levels the playing field within States by allowing an issuer to deduct from earned premiums the higher of either the amount paid in State premium tax or actual community benefit expenditures up to the highest premium tax rate in the State.

The MLR rule provides unprecedented accountability of health insurance companies. It will provide protection and value to approximately 74.8 million insured Americans. Estimates from last year indicate that, starting in 2012, up to 9 million Americans could receive rebates worth from $0.6 to $1.4 billion. However, the existence of the MLR requirement may have improved the pricing patterns of plans; some reports indicate that premium increases were tempered by the prospect of having to pay rebates. The rule, unchanged from the earlier publication, also allows insurers to include payments recovered through fraud reduction efforts in their calculation of incurred claims (up to the amount of fraudulent claims recovered), thereby encouraging plans to fight fraud. The final rule streamlines reporting and rebate requirements, and reduces the administrative burden on issuers and employers, while continuing to ensure that consumers receive maximum value for their health care dollar.

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