New HHS Web Page To Track HHS ACA Relief & Reform

The Department of Health and Human Services recently launched a new web page on HHS.gov highlighting the regulatory and administrative actions the Department is taking to relieve the burden of the current healthcare law and support a patient-centered healthcare system in response to President Trump’s January 20, 2017 Executive Order Minimizing the Economic Burden of the Patient Protection and Affordable Care Act Pending Repeal (the “Executive Order”).

In the Executive Order, President Trump among other things:

  • Confirmed the Trump Administration’s policy to seek the prompt repeal of the Patient Protection and Affordable Care Act (Public Law 111-148), as amended (the “ACA”); and
  • Announced the Trump Administration’s directivepending the planned ACA repeal to ensure that the law is being efficiently implemented, take all actions consistent with law to minimize the unwarranted economic and regulatory burdens of the ACA, and prepare to afford the States more flexibility and control to create a more free and open healthcare market.

In furtherance of these policies, the Executive Order also directed the Secretary of HHS and and the heads of all other executive departments and agencies (agencies) with authorities and responsibilities under the ACA to the maximum extent permitted by law:

  • To exercise all authority and discretion available to them to waive, defer, grant exemptions from, or delay the implementation of any provision or requirement of the ACA that would impose a fiscal burden on any State or a cost, fee, tax, penalty, or regulatory burden on individuals, families, healthcare providers, health insurers, patients, recipients of healthcare services, purchasers of health insurance, or makers of medical devices, products, or medications;
  • To exercise all authority and discretion available to them to provide greater flexibility to States and cooperate with them in implementing healthcare programs;
  • To encourage the development of a free and open market in interstate commerce for the offering of healthcare services and health insurance, with the goal of achieving and preserving maximum options for patients and consumers.

HHS intends to use the new web page to announce new measures as adopted by HHS in furtherance of the Executive Order with a planned emphasis in particular upon actions to

  • Lower costs and increase choices by providing relief from the burdensome regulations and fostering competition in insurance markets;
  • Work to ensure a stable transition period;
  • Offer states greater flexibility of their Medicaid programs to meet the needs of their most vulnerable populations; and
  • Increase the opportunities for patients to get the care they need when they need it.

According to statements on the new web page, HHS intends to purse these objectives by “going through every page of regulations and guidance related to the Affordable Care Act to determine whether or not they work for patients and whether or not they are making our health care system better.”

Check out and follow these developments here.

About The Author

Recognized by LexisNexis® Martindale-Hubbell® as a “AV-Preeminent” (Top 1%/ the highest) and “Top Rated Lawyer,” with special recognition  as “LEGAL LEADER™ Texas Top Rated Lawyer” in Health Care Law and Labor and Employment Law; as among the “Best Lawyers In Dallas” for her work in the fields of “Health Care,” “Labor & Employment,” “Tax: Erisa & Employee Benefits”  and “Business and Commercial Law” by D Magazine, the author of this update is widely known for her 29 plus years’ of work in health care, health benefit, health policy and regulatory affairs and other health industry concerns as a practicing attorney and management consultant, thought leader, author, public policy advocate and lecturer.

Throughout her adult life and nearly 30-year legal career, Ms. Stamer’s legal, management and governmental affairs work has focused on helping health industry, health benefit and other organizations and their management use the law, performance and risk management tools and process to manage people, performance, quality, compliance, operations and risk. Highly valued for her rare ability to find pragmatic client-centric solutions by combining her detailed legal and operational knowledge and experience with her talent for creative problem-solving, Ms. Stamer supports these organizations and their leaders on both a real-time, “on demand” basis as well as outsourced operations or special counsel on an interim, special project, or ongoing basis with strategic planning and product and services development and innovation; workforce and operations management,  crisis preparedness and response as well as to prevent, stabilize and cleanup legal and operational crises large and small that arise in the course of operations. Her experience encompasses  helping health industry clients manage workforce, medical staff, vendors and suppliers, medical billing, reimbursement, claims and other provider-payer relations, business partners, and their recruitment, performance, discipline, compliance, safety, compensation, benefits, and training ;board, medical staff and other governance;   compliance and internal controls; strategic planning, process and quality improvement; change management;  assess, deter, investigate and address staffing, quality, compliance  and other performance;  meaningful use, EMR, HIPAA and other data security and breach and other health IT and data; crisis preparedness and response; internal, government and third-party reporting, audits, investigations and enforcement; government affairs and public policy; and other compliance and risk management, government and regulatory affairs and operations concerns.

The American Bar Association (ABA) International Section Life Sciences Committee Vice Chair, a Scribe for the ABA Joint Committee on Employee Benefits (JCEB) Annual OCR Agency Meeting, former Vice President of the North Texas Health Care Compliance Professionals Association, past Chair of the ABA Health Law Section Managed Care & Insurance Section, past ABA JCEB Council Representative, past Board President of Richardson Development Center (now Warren Center) for Children Early Childhood Intervention Agency, past North Texas United Way Long Range Planning Committee Member, and past Board Member and Compliance Chair of the National Kidney Foundation of North Texas, Ms. Stamer has worked closely with a diverse range of physicians, hospitals and healthcare systems, DME, Pharma, clinics, health care providers, managed care, insurance and other health care payers, quality assurance, credentialing, technical, research, public and private social and community organizations, and other health industry organizations and their management deal with governance; credentialing, patient relations and care; staffing, peer review, human resources and workforce performance management; outsourcing; internal controls and regulatory compliance; billing and reimbursement; physician, employment, vendor, managed care, government and other contracting; business transactions; grants; tax-exemption and not-for-profit; licensure and accreditation; vendor selection and management; privacy and data security; training; risk and change management; regulatory affairs and public policy and other concerns.

As a core component of her work,  Ms. Stamer has worked extensively throughout her career with health care providers, health plans and insurers, managed care organizations, health care clearinghouses, their business associates, employers, banks and other financial institutions, management services organizations, professional associations, medical staffs, accreditation agencies, auditors, technology and other vendors and service providers, and others on legal and operational compliance, risk management and compliance, public policies and regulatory affairs, contracting, payer-provider, provider-provider, vendor, patient, governmental and community relations and matters including extensive involvement advising, representing and defending public and private hospitals and health care systems; physicians, physician organizations and medical staffs; specialty clinics and pharmacies; skilled nursing, home health, rehabilitation and other health care providers and facilities; medical staff, accreditation, peer review and quality committees and organizations; billing and management services organizations; consultants; investors; technology, billing and reimbursement and other services and product vendors; products and solutions consultants and developers; investors; managed care organizations, insurers, self-insured health plans and other payers; and other health industry clients to establish and administer compliance and risk management policies; comply with requirements, investigate and respond to Board of Medicine, Health, Nursing, Pharmacy, Chiropractic, and other licensing agencies, Department of Aging & Disability, FDA, Drug Enforcement Agency, OCR Privacy and Civil Rights, Department of Labor, IRS, HHS, DOD, FTC, SEC, CDC and other public health, Department of Justice and state attorneys’ general and other federal and state agencies; JCHO and other accreditation and quality organizations; private litigation and other federal and state health care industry investigation, enforcement including  insurance or other liability management and allocation; process and product development, contracting, deployment and defense; evaluation, commenting or seeking modification of regulatory guidance, and other regulatory and public policy advocacy; training and discipline; enforcement, and a host of other related concerns for public and private health care providers, health insurers, health plans, technology and other vendors, employers, and others.and other compliance, public policy, regulatory, staffing, and other operations and risk management concerns.

Past Chair of the ABA Managed Care & Insurance Interest Group and, a Fellow in the American College of Employee Benefit Counsel, the American Bar Foundation and the Texas Bar Foundation, Ms. Stamer also has extensive health care reimbursement and insurance experience advising and defending health care providers, payers, and others about Medicare, Medicaid, Medicare and Medicaid Advantage, Tri-Care, self-insured group, association, individual and group and other health benefit programs and coverages including but not limited to advising public and private payers about coverage and program design and documentation, advising and defending providers, payers and systems and billing services entities about systems and process design, audits, and other processes; provider credentialing, and contracting; providers and payer billing, reimbursement, claims audits, denials and appeals, coverage coordination, reporting, direct contracting, False Claims Act, Medicare & Medicaid, ERISA, state Prompt Pay, out-of-network and other nonpar insured, and other health care claims, prepayment, post-payment and other coverage, claims denials, appeals, billing and fraud investigations and actions and other reimbursement and payment related investigation, enforcement, litigation and actions.

Heavily involved in health care and health information technology, data and related process and systems development, policy and operations innovation and a Scribe for ABA JCEB annual agency meeting with OCR for many years who has authored numerous highly-regarded works and training programs on HIPAA and other data security, privacy and use, Ms. Stamer also is widely recognized for her extensive work and leadership on leading edge health care and benefit policy and operational issues including meaningful use and EMR, billing and reimbursement, quality measurement and reimbursement, HIPAA, FACTA, PCI, trade secret, physician and other medical confidentiality and privacy, federal and state data security and data breach and other information privacy and data security rules and many other concerns.  Her work includes both regulatory and public policy advocacy and thought leadership, as well as advising and representing a broad range of health industry and other clients about policy design, drafting, administration, business associate and other contracting,  risk assessments, audits and other risk prevention and mitigation, investigation, reporting, mitigation and resolution of known or suspected violations or other incidents and responding to and defending investigations or other actions by plaintiffs, DOJ, OCR, FTC, state attorneys’ general and other federal or state agencies, other business partners, patients and others.

Ms. Stamer has worked extensively with health care providers, health plans, health care clearinghouses, their business associates, employers and other plan sponsors, banks and other financial institutions, and others on risk management and compliance with HIPAA, FACTA, trade secret and other information privacy and data security rules, including the establishment, documentation, implementation, audit and enforcement of policies, procedures, systems and safeguards, investigating and responding to known or suspected breaches, defending investigations or other actions by plaintiffs, OCR and other federal or state agencies, reporting known or suspected violations, business associate and other contracting, commenting or obtaining other clarification of guidance, training and enforcement, and a host of other related concerns. Her clients include public and private health care providers, health insurers, health plans, technology and other vendors, and others. In addition to representing and advising these organizations, she also has conducted training on Privacy & The Pandemic for the Association of State & Territorial Health Plans, as well as HIPAA, FACTA, PCI, medical confidentiality, insurance confidentiality and other privacy and data security compliance and risk management for Los Angeles County Health Department, MGMA, ISSA, HIMMS, the ABA, SHRM, schools, medical societies, government and private health care and health plan organizations, their business associates, trade associations and others.

A former lead consultant to the Government of Bolivia on its Pension Privatization Project with extensive domestic and international public policy and governmental and regulatory affairs experience, Ms. Stamer also is widely recognized for regulatory and policy work, advocacy and outreach on healthcare, education, aging, disability, savings and retirement, workforce, ethics, and other policies.  Throughout her adult life and career, Ms. Stamer has provided thought leadership; policy and program design, statutory and regulatory development design and analysis; drafted legislation, proposed regulations and other guidance, position statements and briefs, comments and other critical policy documents; advised, assisted and represented health care providers, health plans and insurers, employers, professional. and trade associations, community and government leaders and others on health care, health, pension and retirement, workers’ compensation, Social Security and other benefit, insurance and financial services, tax, workforce, aging and disability, immigration, privacy and data security and a host of other international and domestic federal, state and local public policy and regulatory reforms through her involvement and participation in numerous client engagements, founder and Executive Director of the Coalition for Responsible Health Policy and its PROJECT COPE: the Coalition on Patient Empowerment, adviser to the National Physicians Congress for Healthcare Policy, leadership involvement with the US-Mexico Chamber of Commerce, the Texas Association of Business, the ABA JCEB, Health Law, RPTE, Tax, Labor, TIPS, International Life Sciences, and other Sections and Committees, SHRM Governmental Affairs Committee and a host of other  involvements and activities.

A popular lecturer and widely published author on health industry concerns, Ms. Stamer continuously advises health industry clients about compliance and internal controls, workforce and medical  staff performance, quality, governance, reimbursement, privacy and data security, and other risk management and operational matters. Ms. Stamer also publishes and speaks extensively on health and managed care industry regulatory, staffing and human resources, compensation and benefits, technology, public policy, reimbursement and other operations and risk management concerns. Her insights on these and other related matters appear in the Health Care Compliance Association, Atlantic Information Service, Bureau of National Affairs, The Wall Street Journal, Business Insurance, the Dallas Morning News, Modern Health Care, Managed Healthcare, Health Leaders, and a many other national and local publications.

A Fellow in the American College of Employee Benefit Counsel, the American Bar Foundation and the Texas Bar Foundation, Ms. Stamer also shares her thought leadership, experience and advocacy on these and other related concerns by her service in the leadership of the Solutions Law Press, Inc. Coalition for Responsible Health Policy, its PROJECT COPE:  Coalition on Patient Empowerment, and a broad range of other professional and civic organizations including North Texas Healthcare Compliance Association, a founding Board Member and past President of the Alliance for Healthcare Excellence, past Board Member and Board Compliance Committee Chair for the National Kidney Foundation of North Texas; former Board President of the early childhood development intervention agency, The Richardson Development Center for Children (now Warren Center For Children);  current Vice Chair of the ABA Tort & Insurance Practice Section Employee Benefits Committee, current Vice Chair of Policy for the Life Sciences Committee of the ABA International Section, Past Chair of the ABA Health Law Section Managed Care & Insurance Section, a current Defined Contribution Plan Committee Co-Chair, former Group Chair and Co-Chair of the ABA RPTE Section Employee Benefits Group, past Representative and chair of various committees of ABA Joint Committee on Employee Benefits; a ABA Health Law Coordinating Council representative, former Coordinator and a Vice-Chair of the Gulf Coast TEGE Council TE Division, past Chair of the Dallas Bar Association Employee Benefits & Executive Compensation Committee, a former member of the Board of Directors of the Southwest Benefits Association and others.

Ms. Stamer also is a highly popular lecturer, symposium and chair, faculty member and author, who publishes and speaks extensively on health and managed care industry, human resources, employment and other privacy, data security and other technology, regulatory and operational risk management. Examples of her many highly regarded publications on these matters include “Protecting & Using Patient Data In Disease Management: Opportunities, Liabilities And Prescriptions,” “Privacy Invasions of Medical Care-An Emerging Perspective,” “Cybercrime and Identity Theft: Health Information Security: Beyond HIPAA,” as well as thousands of other publications, programs and workshops these and other concerns for the American Bar Association, ALI-ABA, American Health Lawyers, Society of Human Resources Professionals, the Southwest Benefits Association, the Society of Employee Benefits Administrators, the American Law Institute, Lexis-Nexis, Atlantic Information Services, The Bureau of National Affairs (BNA), InsuranceThoughtLeaders.com, Benefits Magazine, Employee Benefit News, Texas CEO Magazine, HealthLeaders, the HCCA, ISSA, HIMSS, Modern Healthcare, Managed Healthcare, Institute of Internal Auditors, Society of CPAs, Business Insurance, Employee Benefits News, World At Work, Benefits Magazine, the Wall Street Journal, the Dallas Morning News, the Dallas Business Journal, the Houston Business Journal, and many other symposia and publications. She also has served as an Editorial Advisory Board Member for human resources, employee benefit and other management focused publications of BNA, HR.com, Employee Benefit News, Insurance Thought Leadership and many other prominent publications and speaks and conducts training for a broad range of professional organizations.

For more information about Ms. Stamer or her health industry and other experience and involvements, see here or contact Ms. Stamer via telephone at (469) 767-8872 or via e-mail here.

About Solutions Law Press, Inc.™

Solutions Law Press, Inc.™ provides human resources and employee benefit and other business risk management, legal compliance, management effectiveness and other coaching, tools and other resources, training and education on leadership, governance, human resources, employee benefits, data security and privacy, insurance, health care and other key compliance, risk management, internal controls and operational concerns. If you find this of interest, you also be interested reviewing some of our other Solutions Law Press, Inc.™ resources here such as:

If you or someone else you know would like to receive future updates about developments on these and other concerns, please be sure that we have your current contact information including your preferred e-mail by creating  your profile here.

©2017 Cynthia Marcotte Stamer. Non-exclusive right to republish granted to Solutions Law Press, Inc.™  All other rights reserved.   For information about republication or other use, please contact Ms. Stamer here.

Speak Up Now On Health Reform 2017

Voters’ election of President-elect Donald Trump and a Republican Majority put health care reform squarely back on the table even as leaders debate if repeal or reform, and if reform, what reform Americans want.

Voters’ election of President-elect Donald Trump and a Republican Majority put health care reform squarely back on the table even as leaders debate if repeal or  reform, and if reform, what reform Americans want.

The increasingly evident cracks and extraordinary cost of the Patient Protection and Affordable Care Act (ACA) reforms  make clear reform is needed.  Contrary to the exuberant claims of the victors, however, the  election results are not so overwhelming that they provide a clear mandate for healthcare reform or a clear pathway for what to replace it with. If healthcare reform this time around is to do any better than the last, boaters need to become very involved and very specific about what they like and don’t like and very realistic terms and leaders need to listen and act on that input to come up with the most pragmatic and specific plan possible quickly.

As Americans gear up for the next round of debate there are some basic realities we all must confront.

Pie in the sky, idealistic policies aren’t a real option and only promise more waste and disillusionment.

As the healthcare reform debate resumes,  voters and leaders considering these matters must look forward, not back.
Voters and leaders need to focus on discrete, SPECIFIC, reforms that best promote patient-empowered decision making and communicate their wishes clearly to Congressional and state elected officials. We must get beyond buzz words and hype to talk about what, how, when, who chooses, who does the work, how they get paid and other very concrete matters.

Because  the reforms enacted over the past 7 years disassembled the old system,  the old system no longer exists.  Consequently,  repeal alone isn’t a real option, even for those who dream of the “good old days.”

Also, Congress cannot undo Obamacare or fix healthcare with one magic vote.  Even  those who call for Congress on day one to repeal the ACA need to realize that the instant repeal will not undo the healthcare reform’s that were enacted because these reforms are hardwired into the state insurance laws and regulations that were implemented in response to the ACA.

Further, even  if repeal would magically bring back the old system, going back to those old days doesn’t necessarily mean problem solved.  Obamacare passed because the old system had problems.  Coverage was still expensive and there were many people uninsured.  The difference now is that a lot of the money is going for a huge regulatory nightmare that strips off money for Care to pay for infrastructure and regulators.  As a result regardless of whether you repeal and replace or you systematically work through the laws the process will need to be specific and address the particular individual action items to fix the system. Any other process just replace this one mess with another.

Additionally, this is an American opportunity, that transcends partisanship.  Healthcare requires statesmanship from our leaders and citizens.  We are at war against disease and death.  We must work as a team to fight this universal enemy.

We all bleed red and death eventually claims us all.  Life, death and the care of the health of our nation is a shared need and a shared responsibility.  Death, disability and illness come to all families regardless if income, race, sex, religion, or other classification that too often is used to distinguish and divide us.  Health care is about helping families and communities care for loved ones dealing with the challenges of illness and eventually death.  If we must argue over these distinction within our society, let’s do it somewhere else besides health care.

Resources are limited.  We can’t give everything to everybody and someone has to pay the bill.   Be cautious about financing by having the “haves” pick up the cost for the “have less.” Too often the have-nots suffer from reduced wages or employment from these Robin Hood financing strategies.

Also paying for it matters.  Reforms that break the budget are unreliable and therefore aren’t sustainable.  Bang for the buck matters.

Americans must stop treating health care professionals as religious martyrs. Physicians care for patients and pay a huge price dealing with the physical, financial and lifestyle demands to do so.   Physicians and other healthcare professions deserve and must get paid commensurate with the skill, responsibility and accountability Americans expect.  We must question why Americans have no problem with a talented athlete with a high school education earning millions of dollars in the NBA but feel a doctor who spends 8-10 years and a half a million dollars or more earning the right to care for patients, who is paid far less, earns too much. Healthcare isn’t free and legislating unreasonably low reimbursement drives quality providers out of healthcare, undermines quality, availability or both.   Americans that ignore this reality can and should look forward to being cared for by less educated, less skilled physicians.

Finally healthcare isn’t one size fits all and wellness and disease management at best slows, but cannot defeat death.  Each individual and his or her family will experience a different path of life, illness and health, and ultimately death.  These are personal matters that require personal choice to match these unavoidable personal responsibilities.

To help ensure you and your family retain the choices most important to you and understand the choices that this round of health care reform will product, you must embrace your right and responsibility to plan for and deal with these challenges by getting informed and participating.

Here’s some reading to get started: the leading proposals of the Republican Majority leaders:

Share your thoughts about what our health care system should look like going forward, how these proposals relate and the other reforms you believe Congress should make to build a better healthcare system for today that can survive into the future by joining the discussion  in the Solutions Law Press, Inc. Coalition for Responsible Health Care Policy LinkedIn Group.

Hyper-Technical Health Reforms Threatening American Family’s Health Care Quality

Like most American families with school aged children, our family’s annual flurry of back-to-school preparations includes an annual visit to our child’s pediatrician. Since we generally must take time off work to fit in the pediatrician’s visit around the flurry of work, carpool and other demands of daily living, like most families blessed with relatively healthy children, we tend to remember to schedule the visit when prompted by a minor health concern and/or to save up our requests for prescription refills and questions and concerns about minor or chronic health care issues to discuss with the pediatrician while he conducts his annual check of our sons’ height, weight, blood sugar, eyesight, immunizations and other basic health concerns normally included in an annual well child checkup. Unfortunately, the opportunity for parents to use a single office visit to the pediatrician for a single fee to get caught up with our pediatrician on all current and recurring health care questions and concerns about our child while the pediatrician also conducts an annual checkup appears to be the latest healthcare casualty of Obamacare.

Government Audit Zealots Putting Coding Before Patient Care

Like most American families with school aged children, our family’s annual flurry of back-to-school preparations includes an annual visit to our child’s pediatrician.  Since we generally must take time off work to fit in the pediatrician’s visit around the flurry of work, carpool and other demands of daily living, like most families blessed with relatively healthy children, we tend  to remember to schedule the visit when prompted by a minor health concern and/or to save up our requests for prescription refills and questions and concerns about minor or chronic health care issues to discuss with the pediatrician while he conducts his annual check of our sons’ height, weight, blood sugar, eyesight, immunizations and other basic health concerns normally included in an annual well child checkup.   Unfortunately, the opportunity for parents to use a single office visit to the pediatrician for a single fee to get caught up with our pediatrician on all current and recurring health care questions and concerns about our child while the pediatrician also conducts an annual checkup appears to be the latest healthcare casualty of Obamacare.

The Obama Administration touts the “Preventive Care” mandates of Obamacare as a key reform that promises to bring down patient suffering and the cost of health care through early detection by requiring group and individual health plans to pay for 100% of a physician’s charge for an annual checkup for each individual without applying any co-payment or deductible,  Obamacare often challenge the value of Obamacare’s preventive care mandates on the grounds that Obamacare doesn’t require health plans to cover and health plans often provide no or limited coverage for many procedures needed to treat conditions detected through these checkups.  Beyond concerns about gaps and limitations on coverage to treat conditions identified through the annual physicals contemplated by Obamacare, however, hyper technical coding and billing requirements for physicians when performing and submitting charges for checkups covered by the preventive care benefit also are raising concerns.

Billing and coding rules approved by the Obama Administration require physicians performing preventive care checkups to separately deliver code and bill preventive care services separate from sick or other care the physician provides to the patient.  While these rules are designed to prevent physicians from inappropriately billing sick or other charges for care that does not qualify for coverage under the preventive care mandate, current coding and billing procedures are pressuring physicians to engage in practices that discourage patients from bringing up emerging health concerns or other health care issues during annual checkups.  For instance, our pediatrician’s office warned us that bringing up other health conditions or concerned during the annual checkup could cause us to incur added charges by handing us a paper when I signed my son for his annual pediatrician’s visit last week containing the following new policy on “Charges for Illnesses During Well Checkups:”

 Charges for Illnesses During Well Check-ups

The passage of The Affordable Care Act (the A.C.A.), or “Obamacare”, made several very positive changes in insurance coverage for children: pre-existing conditions are outlawed and preventative health care, or check-ups, are covered without copay or deductible.

However, a check-up does not include management of common pediatric illnesses such as ear infections, bronchitis, injuries, asthma, etc. In accordance with national guidelines and our contract with your insurance company, these illnesses are coded separately from the check-up and are paid separately. Unfortunately, most insurers are paying for management of an illness during a check-up as a separate encounter and applying copays and deductibles to those charges.

There are only three options when a child scheduled for a check-up has an illness or injury:  have the family reschedule the “sick” visit for another time and pay the copay or deductible at that visit; reschedule the check-up for another time and take care of the illness or injury now; go ahead and take care of the problem during the check-up. The cost to you, the family, is the same, but it is much more convenient to do both during the check-up.

This is a difficult issue and we encourage you to discuss this with our insurance department if you have further questions.

While I applaud providers that make an effort to alert patients about potentially unexpected uncovered healthcare costs like the notification from my pediatrician that our family could incur added charges for asking the pediatrician to address an illness or other health concern during  any annual checkup, I am concerned about the likely unintended chilling effect of the notice, much less the regulations that promoted it, could have on the free flow of information between patients and their physicians and the resulting quality of care delivered during the checkup.

Certainly, my pediatrician’s office delivery of this warning against asking the pediatrician to treat an illness or provide other care in addition to performing the scheduled checkup unless I was prepared to pay added charges prompted me to reconsider the list of topics I planned to discuss during the meeting.  Fortunately, I felt I could afford the potential additional charges that I was likely to incur to get advice on the questions on my list;  however, many American families are not so fortunate.

During the appointment, I discussed both my planned list of concerns and questions, as well as the new policy, with my new pediatrician.  In the course of the appointment, we each also bemoaned the waste of the ACA preventive care mandate forcing health plans to make heavy expenditures to screen patients for a host of disease,  when public and private plans frequently provide little if any coverage to help patients and their families pay for the costs of following on testing, much less treatment that patients would need to treat the condition detected through the checkup covered by the preventive care screening as well as a host of other new challenges for patients and providers fueled by Obamacare.  Both of us agreed that the disruption of the continuity and quality of communication necessary to the patient physician relationship was one of the most significant of these adverse side effects.

Of course, the chilling affect of notifications or other discussions about added care costs are most likely to affect the care decisions of budget-strained parents or patients.  Warnings or other discussions about potential uncovered charges tend to make budget sensitive or otherwise cost-conscious patients or parents think twice about seeking care.  Patients or parents of patients concerned about care costs are likely to be reluctant to bring up health concerns or share other symptoms with a pediatrician or other physician during an annual checkup for fear the discussion might trigger additional unbudgeted charges for the visit in a manner that could undermine the reliability of the checkup, cause a patient or parent to delay seeking care of an emerging condition, or prompt a patient or parent to delay scheduling an annual wellness exam.

However, it is not just budget conscious patients and families that are likely to suffer as a result of the chilling effect of policies or practices that discourage the free flow and open discussion of information between patients and providers, the patient-physician relationship and quality of care.  On the contrary, any policy that requires or encourages a patient or a doctor to fail to exchange and freely discuss information, questions or concerns about current or recent symptoms, illnesses or injuries inherently undermines the quality and value of the encounter. Since any reliable checkup or other treatment generally must include gathering and consideration of information about current or recent illnesses, injuries, symptoms and concerns, a policy or practice that discourages patients and their caregivers from openly sharing, physicians or other caregivers from holistically collecting,  or patients, caregivers and physicians and other health care providing from openly discussing past, current or recent symptoms, illnesses or injuries during a checkup or any other visit inherently undermines the value of the checkup as well as the overall quality of care provided to the patient. The Obama Administration, as well as patients and their caregivers, health care providers, employers, health plans and American communities all share an interest and must work together to identify and insist that appropriate steps be taken to ensure that health care billing, coding or other laws, regulations and practices do not allow excessive emphasis on billing accuracy to undermine care quality generally.

Do you share these or other concerns about how Obamacare or other federal or state reforms are affecting the patient-physician relationship or other aspects of our health care system, its quality, affordability or access?  How are you as a patient or family member of a patient, employer, healthcare provider, or health plan or insurer dealing with these encounters or concerns?  If you found this article helpful and are interested in learning about or joining the discussion of health care, aging and disability related public policy reforms as well as  practical practices, tools, information and ideas for helping disabled, aging or ill individuals, their families and other caregivers, and communities to anticipate, plan for and meet the challenges of living with or caring for ill, disabled or aging individuals, register to follow the resources and discussions of Project COPE: Coalition for Patient Empowerment here and join and participate in the sharing of information, exchange of discussion and prespectives, tools, opportunities for collaboration and participation, and other resources available through our involvement in our Coalition For Responsible Health Care Policy LinkedIn Group. You also be interested in reviewing one or more of other recent articles published on the Coalition For Responsible Health Care Policy  electronic publication available here, our electronic Solutions Law Press Health Care Update publication available here, or our HR & Benefits Update electronic publication available here.  You also can get access to information about how you can arrange for training on “Building Your Family’s Health Care Toolkit,”  using the “PlayForLife” resources to organize low-cost wellness programs in your workplace, school, church or other communities, and other process improvement, compliance and other training and other resources for health care providers, employers, health plans, community leaders and others here. If you or someone else you know would like to receive future updates about developments on these and other concerns, please be sure that we have your current contact information – including your preferred e-mail by creating or updating your profile here.

About Project COPE: The Coalition On Patient Empowerment & Its Coalition on Responsible Health Policy

 

Project COPE: The Coalition on Patient Empowerment (Project COPE) & the Coalition on Responsible Health Policy (Coalition) are Solutions Law Press, Inc.™-sponsored public policy and community service projects that seek to empower ill, disabled and aging individuals, their families and other caregivers, employers, health care and other disability services providers, employee benefit plans, insurance and other payers, communities and community service organizations, government agencies and programs and other stakeholders individually, and our society collectively to better understand, identify, plan for, constructively collaborate and work together and respond to the challenges and responsibilities of meeting the needs of ill, disabled and aging individuals in our society encouraging and promoting better awareness, understanding, collaboration and teamwork, public and private policies and practices, skills, resources, support and tools and other understanding, collaboration and actions that better empower ill disabled or aging Americans, their families and caregivers, healthcare and disability service providers, employers, insurers, communities and community organizations, government agencies and officials and policymakers and other stakeholders as well as our society as a whole to understand, plan for and cope with the challenges and responsibilities they face in responding to illness, aging and disabilities.

Project Cope and the Coalition recognize the challenges or, and how our society addresses the needs and challenges of caring for the ill, disabled, and aging members of our society often has broad reaching impacts on ill, disabled and aging individuals and their family or other caregivers, as well as friends and neighbors, taxpayers, employers, benefit plans and insurers, health care and disability service providers, communities and community organizations, social service and other governmental agencies, and others all are impacted by, bear responsibility for, and play a critical role in planning for, providing and helping to cope individually and collectively with illness, aging and disabilities in our families and communities.

The Coalition For Responsible Health Care Policy focuses on public policy, regulatory, tax, enforcement and other government actions that shape and impact the care and treatment of aging, ill and disabled people in our communities and others caring for or dealing with them.  The Coalition exists in recognition of the significant direct and indirect impact that Federal and state health, disability, employee benefit, insurance, employment, tax, social security, civil rights and a host of other laws, regulations, funding, enforcement and other government policies and actions have in shaping the responsibility for, experience, availability, quality, cost and financing, delivery and other elements of the care and treatment of ill, aging and disabled Americans, their families and caregivers, healthcare and disability services providers, employers, insurers, their communities and community organizations, taxpayers, social and other government agencies and other stakeholders and the ability of stakeholders to predict, plan and pay for and cope with the challenges of illness, aging and disabilities.  The Coalition seeks to promote the development and implementation of synergistic statutory, regulatory, funding, enforcement and other healthcare, disability, aging and other policy by encouraging constructive awareness, understanding, involvement, vetting and input, consensus building, and other participation among other stakeholders throughout the process through a variety of activities including:

  • Publishes and share various blogs, updates, alerts, articles, whitepapers, presentations, assessments, commentary, data, toolkits, proposed strategies, opportunities and strategies and other resources or perspectives from Solutions Law Press, Inc.™ authors or other sources identified by Solutions Law Press, Inc. editors and contributors identify as relevant to existing or proposed public policies, proposals, and other developments or events with material implications on the responsibilities, options, costs or funding, delivery, access or other matters of concern of disabled, aging or ill Americans, their families and caregivers, healthcare and disability services providers, employers, insurers, communities or community organizations, taxpayers and other stakeholders relating to planning for, financing, delivering care or services, or other support or responsibilities relation to the care, treatment or other matters relating to ill, aging or disabled individuals and their family or other caregivers;
  • Hosts, offers or facilitates access to Solutions Law Press, Inc.™ or other thought leaders or other speakers or resources, and provides other collaboration, consultation, and assistance to others to design, host, identify and secure resources, disseminate information or otherwise organize and present present briefings, teleconferences, webinars, seminars, panel and other dialogues or discussions, meetings with regulators, elected officials or other leaders, and other events and activities offering thought leadership, education, opportunities for dialogue or other input, or perspectives or other stakeholder information, tools or resources in relation to existing or proposed health, disability and other legislative, regulatory, enforcement or other public policy activities and proposals potentially or actually impacting various stakeholders in relation to planning for, providing, financing or other aspects of involvement relating to the care or other support for ill, aging, disabled individuals
  • Encourages, provides and shares information about opportunities for stakeholders to receive or engage in respectful, constructive sharing, discussion and collaboration on various public policy proposals and concerns by joining and participating in the discussion in the Coalition For Responsible Health Care Policy Linkedin Group or other discussion platforms, activities or events that Solutions Law Press, Inc.™ hosts, participates, or identifies
  • Offers fee-based education, training, coaching, consultation and other services and resources to assist stakeholders to plan or present events or other activities; assess, develop and draft legislative or regulatory proposals, comments, testimony or other policy positions; identify and develop strategic relationships alliances or other points of collaboration with stakeholders, regulators, elected officials or others; and other governmental affairs, public relations and other assistance and support with monitoring, providing input and responding to regulatory and other public policy developments and concerns; and other governmental and public affairs and public relations consultation, thought leadership, resources and services;

While acknowledging the importance of striving to improve public policies impacting responsibility for and the financing and delivery of care of ill, disabled and disabled individuals within our communities and society, at the end of the day, public policy can only do so much.  The best public policy solution only facilitates, obstructs or assigns responsibility or blame for financing the cost, caring for and dealing with the ill, disabled and aging in our families, workplaces and communities among the various individuals and organizations within our society.  At the end of the day, ill, disabled and aging individuals and their families and caregivers, their employers, healthcare and disability service providers, governmental agencies and communities still are left to deal with the day to day realities of dealing with and fulfilling their assigned responsibilities to care for ill, aging and disabled individuals and their families.

Project COPE focuses on empowering ill, disabled and aging individuals, their families and caregivers, employers, health care and disability services providers, communities and community services agencies, government and government agencies and others to better and more effectively plan for and cope with their own challenges and responsibilities by developing and promoting the use of understanding, practical tools and resources, communication, organization, collaboration and teamwork and other skills and abilities that aid them to better cope with the realities of their responsibilities and roles for caring for or dealing with ill, disabled or aging individuals or their family or caregivers including:

  • Educating and helping individuals and organizations to understand their own and the abilities, resources, responsibilities and challenges of the others involved in caring for or dealing with ill, disabled or aging individual and his family and caregivers;
  • Developing, sharing and encouraging the use of resources like our “Building Your Family’s Health Care Toolkit” training and tools, “PlayForLife” resource for helping to plan low-cost wellness programs in your workplace, school, church or other communities, health care teamwork and communication, and other process improvement, compliance and other training and education, needs assessment and planning, practical organizational, skill building, care coordination and management, communication and other tools and strategies that help patients and their caregivers, employers, health care providers, payers, communities, governmental leaders and other develop and improve their own understanding and coping skills for dealing with illness, disability or aging;
  • Working with all parties to improve their understanding and knowledge, effective communication, teamwork, collaboration to better plan for and cope with their own challenges and responsibilities of planning for and caring for themselves or others impacted by illness, aging or disability and work together collaboratively to meet these challenges and leverage these opportunities individually and collectively; and
  • Hosting,  helping to organize, providing or helping to identify speakers or other resources for conferences, workshops, and other events and activities that help to promote communication, organization, collaboration, planning and other skills and understanding that providers, patients and their caregivers, employers, health plans, communities, the government or others can use to better plan for or meet needs and challenges associated with caring for ill, aging or disabled individuals;
  • Working with disease management organizations, health care providers and organizations, employers, insurers and communities to understand and better meet various challenges of dealing with illness, aging or disability on their responsibilities and activities; and
  • A host of other activities.

You also can get access to information about how you can arrange for training on “Building Your Family’s Health Care Toolkit,”  using the “PlayForLife” resources to organize low-cost wellness programs in your workplace, school, church or other communities, and other process improvement, compliance and other training and other resources for health care providers, employers, health plans, community leaders and others here. If you or someone else you know would like to receive future updates about developments on these and other concerns, please be sure that we have your current contact information – including your preferred e-mail by creating or updating your profile here.

For important information about this communication click here.

©2016 Cynthia Marcotte Stamer.  Nonexclusive right to republish granted to Solutions Law Press, Inc. All other rights reserved.

OIG Says CMS Mismanaged HealthCare.gov ACA Federal Marketplace Implementation

The Centers for Medicare & Medicaid Services (CMS) and other public and private organizations should use key lessons for the successful design and deployment of website and other operating systems revealed in a report of the findings of the Department of Human Services (HHS) Office of Inspector General (OIG) investigation into what lead to the notoriously poor launch and other problems in the Healthcare.gov health insurance marketplace website and operating system that the Patient Protection & Affordable Care Act (ACA) directed HHS to establish and administer to facilitate the purchase of private insurance by citizens living in states that declined to establish a state health insurance marketplace in response to ACA.

According to just released OIG Report OEI-06-14-00350, “many missteps” committed by the Department of Health & Human Services (HHS) and its Centers for Medicare & Medicaid Services (CMS) lead to the widespread crashes of the Healthcare.gov website and other widespread problems with the Healthcare.gov enrollment tools necessary for millions of Americans to enroll in new health insurance coverage options created as part of the ACA. The report not only helps to explain what went wrong, but also provides key insights for HHS as well as other public and private organizations of common management issues that often derail the design and deployment of website or other technologies required to execute key organizational goals.

The Centers for Medicare & Medicaid Services (CMS) and other public and private organizations should use key lessons for the successful design and deployment of website and other operating systems revealed in a report of the findings of the Department of Human Services (HHS) Office of Inspector General (OIG) investigation into what lead to the notoriously poor launch and other problems in the Healthcare.gov health insurance marketplace website and operating system that the Patient Protection & Affordable Care Act (ACA) directed HHS to establish and administer to facilitate the purchase of private insurance by citizens living in states that declined to establish a state health insurance marketplace in response to ACA.

According to just released OIG Report OEI-06-14-00350, “many missteps” committed by the Department of Health & Human Services (HHS) and its Centers for Medicare & Medicaid Services (CMS) lead to the widespread crashes of the Healthcare.gov website and other widespread problems with the Healthcare.gov enrollment tools necessary for millions of Americans to enroll in new health insurance coverage options created as part of the ACA.  The report not only helps to explain what went wrong, but also provides key insights for HHS as well as other public and private organizations of common management issues that often derail the design and deployment of website or other technologies required to execute key organizational goals.

Problems in the completion and operation of the Healthcare.gov website at its launch on October 1, 2013 and for some time created significant challenges for U.S. families residing in states that elected not to sponsor a state-sponsored health insurance marketplace in response to the ACA. Among other things, HealthCare.gov users attempts to use the Healthcare.gov website were disrupted by a host of website outages and technical malfunctions. After corrective action by CMS and contractors, HealthCare.gov performance improved and facilitated health plan enrollment for millions of consumers. The problems at launch raised concerns about the effectiveness of CMS management of the Federal Marketplace. The findings set forth in the report resulted from an OIG study conducted to gain insight into CMS implementation of the Federal Marketplace, focusing primarily on HealthCare.gov.

The report details the results of OIG’s review and analysis of the chronology of events and identifying factors that contributed to the Healthcare.gov website’s breakdown at launch, its recovery following corrective action, and implementation of the Federal Marketplace through the second open enrollment period based on interviews of 86 current and former HHS and CMS officials, staff, and contractors involved with the website and OIG’s review of “thousands of HHS and CMS documents,” including management reports, internal correspondence, and website development contracts.

Based on this review and analysis, OIG found that “HHS and CMS made many missteps throughout development and implementation that led to the poor launch of HealthCare.gov.” According to the report, the “most critical” misstep was “the absence of clear leadership, which caused delays in decisionmaking and a lack of clarity in project tasks.” The report also criticized HHS and CMS for:

  • Devoting too much time to developing policy, which left too little time for developing the website;
  • Failing to properly manage its key website development contract;
  • Allowing CMS’s organizational structure and culture to create poor coordination between policy and technical work and otherwise to hamper progress; and
  • CMS continuing to follow a “failing path despite signs of trouble” and “making rushed corrections that proved insufficient.

While highly critical of the initial mismanagement, OIG also complimented HHS and CMS for quickly learning and using certain key lessons for more effectively managing major technology projects to respond to and start correcting deficiencies in the Healthcare.gov site.  These core practices include:

  • Leadership. Assign clear project leadership to provide cohesion across tasks and a comprehensive view of progress.
  • Communication. Promote acceptance of bad news and encourage staff to identify and communicate problems.
  • Alignment. Align project and organizational strategies with the resources and expertise available.
  • Execution. Design clear strategies for disciplined execution, and continually measure progress.
  • Culture. Identify and address factors of organizational culture that may affect project success.
  • Oversight. Ensure effectiveness of IT contracts by promoting innovation, integration, and rigorous oversight.
  • Simplification. Seek to simplify processes, particularly for projects with a high risk of failure.
  • Planning. Develop contingency plans that are quickly actionable, such as redundant and scalable systems.
  • Integration. Integrate policy and technological work to promote operational awareness.
  • Learning. Promote continuous learning to allow for flexibility and changing course quickly when needed.

By learning from these lessons, OIG reports that CMS took corrective action and is using these lessons to address problems with Healthcare.gov and to improve its operations and services.  OIG notes that after the launch, CMS and contractors pivoted quickly to corrective action, reorganizing the work to improve execution. Key factors that contributed to recovery of the website included adopting a “badgeless” culture for the project, wherein all CMS staff and contractors worked together as a team, and a practice of “ruthless prioritization” that aligned work efforts with the most important and achievable goals. CMS recovered the website for high consumer use within 2 months, and adopted more effective organizational practices.

OIG calls on CMS to continue progress in applying lessons learned from HealthCare.gov to avoid future problems and to maintain improvement across the agency.  In response to the report and these recommendations, CMS concurred with OIG’s call for continued progress, stating that it will continue to employ the lessons learned and that since OIG’s review, it has implemented several initiatives to further improve its management.  As CMS works to improve Healthcare.gov, other public and private organizations should leverage the lessons learned from CMS’ experience to improve their own technology and IT design and implementation.

About Project COPE: The Coalition On Patient Empowerment &  Coalition on Responsible Health Policy

What do you think about the status and direction of the U.S. health care system and its reforms?  Do you share Dr. Koriwchak’s concerns?  Have other concerns?  Do you have ideas about how to improve the understandability of medication warnings or research findings for patients or other ideas about how to improve healthcare or health care policy?  Share your ideas in the  PROJECT COPE: Coalition On Patient Empowerment LinkedIn Group.  If you have knowledge, experience or other resources that could help patients, families, communities, or the government better understand or cope with  Asperger’s or other health care conditions, costs of care, or other challenges affecting Americans and the American health care system, we encourage you to get involved and share your insights.

As American leaders continue to struggle to deal with these and other mounting problems impacting the U.S. health care system, the input of individual Americans and businesses and community leaders is more critical than ever.  Get involved in helping to shape improvements and solutions to the U.S. health care system and the Americans it cares for by sharing your ideas and input through the Coalition For Responsible Health Care Policy  and exchanging information and ideas for helping American families deal with their family member’s illnesses, disabilities and other healthcare challenges through PROJECT COPE: Coalition On Patient Empowerment.

Sharing and promoting the use of practical practices, tools, information and ideas that patients and their families, health care providers, employers, health plans, communities and policymakers can share and offer to help patients, their families and others in their care communities to understand and work together to better help the patients, their family and their professional and private care community plan for and manage these  needs is the purpose of PROJECT COPE.

The Coalition and its PROJECT COPE arise and run on the belief that health care reform and policy must be patient centric and patient empowering.  The best opportunity to improve access to quality, affordable health care for all Americans is for every American, and every employer, insurer, and community organization to seize the opportunity to be good Samaritans.  The government, health care providers, insurers and community organizations can help by providing education and resources to make understanding and dealing with the realities of illness, disability or aging easier for a patient and their family, the affected employers and others. At the end of the day, however, caring for people requires the human touch.  Americans can best improve health care by not waiting for someone else to step up:  Step up and help bridge the gap when you or your organization can. Speak up to help communicate and facilitate when you can.  Building health care neighborhoods filled with good neighbors throughout the community is the key.

The outcome of this latest health care reform push is only a small part of a continuing process.  Whether or not the Affordable Care Act makes financing care better or worse, the same challenges exist.  The real meaning of the enacted reforms will be determined largely by the shaping and implementation of regulations and enforcement actions which generally are conducted outside the public eye.  Americans individually and collectively clearly should monitor and continue to provide input through this critical time to help shape constructive rather than obstructive policy. Regardless of how the policy ultimately evolves, however, Americans, American businesses, and American communities still will need to roll up their sleeves and work to deal with the realities of dealing with ill, aging and disabled people and their families.  While the reimbursement and coverage map will change and new government mandates will confine providers, payers and patients, the practical needs and challenges of patients and families will be the same and confusion about the new configuration will create new challenges as patients, providers and payers work through the changes.

We also encourage you and others to help develop real meaningful improvements by joining PROJECT COPE: Coalition On Patient Empowerment and by sharing ideas, tools and other solutions and other resources. The Coalition For Responsible Health Care Policy provides a resource that concerned Americans can use to share, monitor and discuss the Health Care Reform law and other health care, insurance and related laws, regulations, policies and practices and options for promoting access to quality, affordable healthcare through the design, administration and enforcement of these regulations.

You also may be interested in one or more of the following other recent articles published on the Coalition for Responsible Health Care Reform electronic publication available here, our electronic Solutions Law Press Health Care Update publication available here, and/or our HR & Benefits Update electronic publication available here.

You also can get details about how to arrange for your employees or other communities to participate in training on “Building Your Family’s Health Care Toolkit,”  using the “PlayForLife” resources to organize low-cost wellness programs in your workplace, school, church or other communities, and other process improvement, compliance and other training and other resources for health care providers, employers, health plans, community leaders and others here.

NOTE:  This article is provided for educational purposes.  It is does not provide legal advice, establish any attorney-client relationship or provide or serve as a substitute for legal advice to any individual or organization.  Readers must engage properly qualified legal counsel to secure legal advice about the rules discussed in light of specific circumstances.ANY STATEMENTS CONTAINED HEREIN ARE NOT INTENDED OR WRITTEN BY THE WRITER TO BE USED, AND NOTHING CONTAINED HEREIN CAN BE USED BY YOU OR ANY OTHER PERSON, FOR THE PURPOSE OF (1) AVOIDING PENALTIES THAT MAY BE IMPOSED UNDER FEDERAL TAX LAW, or (2) PROMOTING, MARKETING OR RECOMMENDING TO ANOTHER PARTY ANY TAX-RELATED TRANSACTION OR MATTER ADDRESSED HEREIN.  ©2016 Cynthia Marcotte Stamer, P.C. Non-exclusive license to republish granted to Solutions Law Press.  All other rights reserved.

 

National Infant Immunization Week Great Time To Review Your Family’s Immunizations

April 18–25 is National Infant Immunization Week. Publicity over measles, rotavirus, pertussis, polio, rubella, various flu strains and the much rarer Ebola and other viruses have helped remind Americans that immunizations play a critical role in protecting their families and others in their communities from potentially deadly or disabling diseases disease.

Decisions about what immunizations you and your family members should or should not get should be tailored to your individual health risk profile, in consultation with your physician taking into account the latest medical evidence and risk data.   While some immunizations make sense for the majority of individuals, other vaccinations may be unnecessary or inappropriate for others.  Decisions about what immunizations to get and when can depend on a wide range of factors unique to the individual health, lifestyle, community and situation of the individual, the contagious disease and other risk profiles of the communities in which they live and a host of other factors.

Cost of immunizations often is one of the concerns that family members ask about when considering whether and when to get immunizations for themselves or their families.  The cost of many immunizations often is covered in whole or part by health insurance.  This is particularly true in the case of infant or child immunizations, where insurer or other payers recognize the value of cover or are subject to federal or state mandates to provide benefits for the immunization.  For the uninsured or in the case of various other immunizations, free or reduced cost vaccinations for many of the most widely recommended immunizations also often are available from public health departments, public health or other health clinics, at community or other health fairs or from other sources.  Check with your local public health department, physician, community hospital or health plan about the potential availability of these sources and options.

Each individual should educate him or herself about the available immunizations using reliable, peer reviewed credentials and then work with his physician to decide which immunizations are advisable or necessary for their family members. While discussion of options, questions and concerns with friends or others, it is important to keep in mind that these impressions and opinions often may rely upon assumptions that rely on historical practices, outdated or disproven understandings, unique circumstances or other factors that may make the decisions or opinions of the non-physician inaccurate or inappropriate for you or your family.

To help prepare to discuss your family’s immunization profile and choices with your physician or other qualified medical profession, you may want to check out some of the resources on Immunization & Vaccination in the U.S. Government Bookstore here.

About Project COPE: The Coalition On Patient Empowerment & Its  Coalition on Responsible Health Policy

Do you have feedback or other experiences to share about medical debit, ACA or other health care challenges?  Have ideas for helping improve our system, helping Americans cope with these and other health care challenges or other health care matters? Know other helpful resources or experiences that you are willing to share?  Are you concerned about health care coverage or other health care and disability issues or policy concerns?  Join the discussion and share your input by joining Project COPE: Coalition for Patient Empowerment here.

Sharing and promoting the use of practical practices, tools, information and ideas that patients and their families, health care providers, employers, health plans, communities and policymakers can share and offer to help patients, their families and others in their care communities to understand and work together to better help the patients, their family and their professional and private care community plan for and manage these  needs is the purpose of Project COPE, The Coalition on Patient Empowerment & It’s Affiliate, the Coalition on Responsible Health Policy.

The best opportunity to improve access to quality, affordable health care for all Americans is for every American, and every employer, insurer, and community organization to seize the opportunity to be good Samaritans.  The government, health care providers, insurers and community organizations can help by providing education and resources to make understanding and dealing with the realities of illness, disability or aging easier for a patient and their family, the affected employers and others. At the end of the day, however, caring for people requires the human touch.  Americans can best improve health care by not waiting for someone else to step up:  Step up and help bridge the gap when you or your organization can. Speak up to help communicate and facilitate when you can.  Building health care neighborhoods filled with good neighbors throughout the community is the key.

The outcome of this latest health care reform push is only a small part of a continuing process.  Whether or not the Affordable Care Act makes financing care better or worse, the same challenges exist.  The real meaning of the enacted reforms will be determined largely by the shaping and implementation of regulations and enforcement actions which generally are conducted outside the public eye.  Americans individually and collectively clearly should monitor and continue to provide input through this critical time to help shape constructive rather than obstructive policy. Regardless of how the policy ultimately evolves, however, Americans, American businesses, and American communities still will need to roll up their sleeves and work to deal with the realities of dealing with ill, aging and disabled people and their families.  While the reimbursement and coverage map will change and new government mandates will confine providers, payers and patients, the practical needs and challenges of patients and families will be the same and confusion about the new configuration will create new challenges as patients, providers and payers work through the changes.

We also encourage you and others to help develop real meaningful improvements by joining Project COPE: Coalition for Patient Empowerment here by sharing ideas, tools and other solutions and other resources. The Coalition For Responsible Health Care Policy provides a resource that concerned Americans can use to share, monitor and discuss the Health Care Reform law and other health care, insurance and related laws, regulations, policies and practices and options for promoting access to quality, affordable healthcare through the design, administration and enforcement of these regulations.

Other Helpful Resources & Other Information

We hope that this information is useful to you.   If you found these updates of interest, you also be interested in one or more of the following other recent articles published on the Coalition for Responsible Health Care Reform electronic publication available here, our electronic Solutions Law Press Health Care Update publication available here, or our HR & Benefits Update electronic publication available here .  You also can get access to information about how you can arrange for training on “Building Your Family’s Health Care Toolkit,”  using the “PlayForLife” resources to organize low-cost wellness programs in your workplace, school, church or other communities, and other process improvement, compliance and other training and other resources for health care providers, employers, health plans, community leaders and others here. If you or someone else you know would like to receive future updates about developments on these and other concerns, please be sure that we have your current contact information – including your preferred e-mail by creating or updating your profile here. You can reach other recent updates and other informative publications and resources.

Some examples of these publications include:

For important information about this communication click here.

©2015 Solutions Law Press, Inc.  All rights reserved.

Calculating & Reporting Your ACA Individual Shared Responsibility Payment

Beginning January 1, 2014, the individual coverage mandate rules of the Patient Protection & Affordable Care Act (ACA) generally required most American citizens to maintain health coverage meeting the “minimum essential coverage” mandates of ACA or pay an “individual shared responsibility payment.” With the deadline for filing 2014 individual tax returns rapidly approaching, Americans now generally will be required to show their fulfillment of or exemption from this mandate or pay the “individual shared responsibility” payment that ACA imposes as a penalty for failing to meet its individual coverage mandates when filing their 2014 individual tax returns

The Health Care Law and Taxes: Reporting Coverage, Exemptions and Payments

Beginning January 1, 2014,  the individual coverage mandate rules of the Patient Protection & Affordable Care Act (ACA) generally required most American citizens to maintain health coverage meeting the “minimum essential coverage” mandates of ACA or pay an “individual shared responsibility payment.”  With the deadline for filing 2014 individual tax returns rapidly approaching, Americans now generally will be required to show their fulfillment of  or exemption from this mandate or pay the “individual shared responsibility” payment that ACA imposes as a penalty for failing to meet its individual coverage mandates when filing their 2014 individual tax returns.

Internal Revenue Service (IRS) rules now require individual Americans to report minimum essential coverage meeting ACA’s requirements, report or claim a coverage exemption, or make an individual shared responsibility payment when filing their 2014 federal income tax return. If an individual is not required to and does not want to file a tax return, however, IRS rules stay he does need to file a return solely to report his minimum essential coverage or to claim an exemption.

If a taxpayer and his dependents all had minimum essential coverage  for each month of the tax year, the taxpayer should show this on his 2014 tax return by simply checking a box on Form 1040, 1040A or 1040EZ.

Individuals who obtained a coverage exemption from the Marketplace or who qualify for an exemption must claim the exemption by filing Form 8964 with their tax return.

For any month a taxpayer or his dependents did not have coverage or a coverage exemption, IRS rules will require the individual to make a shared the responsibility payment. The payment will be reported on Form 1040, line 61 in the Other Taxes section and on the corresponding lines on Form 1040A and 1040EZ.

The Internal Revenue Code specifies that the required individual shared responsibility payment generally equals the greater of:

  • 1 percent of the taxpayer’s household income that is above the tax return filing threshold for your filing status, or
  • The taxpayer’s family’s flat dollar amount, which for 2014 is $95 per adult and $47.50 per child, limited to a family maximum of $285,
  • But capped at the cost of the national average premium for a bronze level health plan available through the Marketplace in 2014.

Many taxpayers who elected not to buy the required minimum essential coverage necessary to avoid the individual shared responsibility payment reportedly are experiencing painful surprise about the amount of their required shared responsibility payment when completing their 2014 individual tax returns.

It appears that many Americans were unaware of or did not fully appreciate that their required individual shared responsibility payment could be up to 1 percent of their family income.  Rather, they may have assumed that their family’s required individual shared responsibility payment would be only $95 per adult and $47.40 per child up to a family maximum of $285.

Depending on the income of the individual taxpayer, however, the actual individual shared responsibility is likely to be much higher.

For 2014, the annual national average premium for a bronze level health plan available through the Marketplace is $2,448 per individual ($204 per month per individual), but $12,240 for a family with five or more members ($1,020 per month for a family with five or more members). See Rev. Proc. 2014-46.

Many taxpayers who elected not to buy the required minimum essential coverage necessary to avoid the individual shared responsibility payment reportedly are experiencing painful surprise about the amount of their required shared responsibility payment when completing their 2014 individual tax returns.  It appears that many Americans were unaware of or did not fully appreciate that their required individual shared responsibility payment could be up to 1 percent of their family income.  Rather, they may have assumed that their family’s required individual shared responsibility payment would be only $95 per adult and $47.40 per child up to a family maximum of $285.  Depending on the income of the individual taxpayer, however, the actual individual shared responsibility is likely to be much higher. 

Taxpayers interested in more information about the ACA individual shared responsibility payment, its exemptions and reporting, should check out the information on Claiming and Reporting an Exemption and Individual Shared Responsibility Provision – Reporting and Calculating the Payment pages on IRS.gov for more information about figuring and reporting the payment.

About Project COPE: The Coalition On Patient Empowerment &  Coalition on Responsible Health Policy

As American leaders continue to struggle to deal with these and other mounting problems impacting the U.S. health care system, the input of individual Americans and businesses and community leaders is more critical than ever.  Get involved in helping to shape improvements and solutions to the U.S. health care system and the Americans it cares for by sharing your ideas and input through the Coalition For Responsible Health Care Policy  and exchanging information and ideas for helping American families deal with their family member’s illnesses, disabilities and other healthcare challenges through Project COPE: Coalition for Patient Empowerment here.

Sharing and promoting the use of practical practices, tools, information and ideas that patients and their families, health care providers, employers, health plans, communities and policymakers can share and offer to help patients, their families and others in their care communities to understand and work together to better help the patients, their family and their professional and private care community plan for and manage these  needs is the purpose of

The Coalition and its Project COPE arise and run on the belief that health care reform and policy must be patient focused, patient centric and patient empowering.  The best opportunity to improve access to quality, affordable health care for all Americans is for every American, and every employer, insurer, and community organization to seize the opportunity to be good Samaritans.  The government, health care providers, insurers and community organizations can help by providing education and resources to make understanding and dealing with the realities of illness, disability or aging easier for a patient and their family, the affected employers and others. At the end of the day, however, caring for people requires the human touch.  Americans can best improve health care by not waiting for someone else to step up:  Step up and help bridge the gap when you or your organization can. Speak up to help communicate and facilitate when you can.  Building health care neighborhoods filled with good neighbors throughout the community is the key.

The outcome of this latest health care reform push is only a small part of a continuing process.  Whether or not the Affordable Care Act makes financing care better or worse, the same challenges exist.  The real meaning of the enacted reforms will be determined largely by the shaping and implementation of regulations and enforcement actions which generally are conducted outside the public eye.  Americans individually and collectively clearly should monitor and continue to provide input through this critical time to help shape constructive rather than obstructive policy. Regardless of how the policy ultimately evolves, however, Americans, American businesses, and American communities still will need to roll up their sleeves and work to deal with the realities of dealing with ill, aging and disabled people and their families.  While the reimbursement and coverage map will change and new government mandates will confine providers, payers and patients, the practical needs and challenges of patients and families will be the same and confusion about the new configuration will create new challenges as patients, providers and payers work through the changes.

We also encourage you and others to help develop real meaningful improvements by joining Project COPE: Coalition for Patient Empowerment here by sharing ideas, tools and other solutions and other resources. The Coalition For Responsible Health Care Policy provides a resource that concerned Americans can use to share, monitor and discuss the Health Care Reform law and other health care, insurance and related laws, regulations, policies and practices and options for promoting access to quality, affordable healthcare through the design, administration and enforcement of these regulations.

You also may be interested in one or more of the following other recent articles published on the Coalition for Responsible Health Care Reform electronic publication available here, our electronic Solutions Law Press Health Care Update publication available here, or our HR & Benefits Update electronic publication available here.

You also can get details about how to arrange for your employees or other communities to participate in training on “Building Your Family’s Health Care Toolkit,”  using the “PlayForLife” resources to organize low-cost wellness programs in your workplace, school, church or other communities, and other process improvement, compliance and other training and other resources for health care providers, employers, health plans, community leaders and others here.

For Advice, Training & Other Resources

Should your business need legal advice about the taxability of or other requirements on tips, gratuities or other compensation,  assistance assessing or resolving potential past or existing compliance exposures, or monitoring and responding to these or other workforce, benefits and compensation, performance and risk management, compliance, enforcement or management concerns, the author of this update, attorney Cynthia Marcotte Stamer may be able to help.

Board Certified in Labor & Employment Law, Past Chair of the ABA RPTE Employee Benefit & Other Compensation Arrangements Group, Co-Chair and Past Chair of the ABA RPTE Welfare Plan Committee, Vice Chair of the ABA TIPS Employee Benefit Plans Committee, an ABA Joint Committee On Employee Benefits Council representative, Past Chair of the ABA Health Law Section Managed Care & Insurance Section, a Fellow in the American College of Employee Benefit Counsel, ABA, and State Bar of Texas, Ms. Stamer has more than 25 years’ experience advising health plan and employee benefit, insurance, financial services, employer and health industry clients about these and other matters. Ms. Stamer has extensive experience advising and assisting health plans and insurers about ACA, and a wide range of other plan design, administration, data security and privacy and other compliance risk management policies.  Ms. Stamer also regularly represents clients and works with Congress and state legislatures, EBSA, IRS, EEOC, OCR and other HHS agencies, state insurance and other regulators, and others.   She also publishes and speaks extensively on health and other employee benefit plan and insurance, staffing and human resources, compensation and benefits, technology, public policy, privacy, regulatory and public policy and other operations and risk management concerns. Her publications and insights appear in the Health Care Compliance Association, Atlantic Information Service, Bureau of National Affairs, World At Work, The Wall Street Journal, Business Insurance, the Dallas Morning News, Modern Health Care, Managed Healthcare, Health Leaders, and a many other national and local publications.

You can review other recent human resources, employee benefits and internal controls publications and resources and additional information about the employment, employee benefits and other experience of the Cynthia Marcotte Stamer here. If you or someone else you know would like to receive future updates about developments on these and other concerns, please be sure that we have your current contact information – including your preferred e-mail – by creating or updating your profile at www.cynthiastamer.com or by registering to receive these and other updates here.  Recent examples of these updates include:

NOTE:  This article is provided for educational purposes.  It is does not provide legal advice, establish any attorney-client relationship or provide or serve as a substitute for legal advice to any individual or organization.  Readers must engage properly qualified legal counsel to secure legal advice about the rules discussed in light of specific circumstances.ANY STATEMENTS CONTAINED HEREIN ARE NOT INTENDED OR WRITTEN BY THE WRITER TO BE USED, AND NOTHING CONTAINED HEREIN CAN BE USED BY YOU OR ANY OTHER PERSON, FOR THE PURPOSE OF (1) AVOIDING PENALTIES THAT MAY BE IMPOSED UNDER FEDERAL TAX LAW, or (2) PROMOTING, MARKETING OR RECOMMENDING TO ANOTHER PARTY ANY TAX-RELATED TRANSACTION OR MATTER ADDRESSED HEREIN.  ©2015 Cynthia Marcotte Stamer, P.C. Non-exclusive license to republish granted to Solutions Law Press.  All other rights reserved.

Mass. Connector & Other State Exchanges Problems Another Sign of Cracks In Obama Care?

While most Americans are familiar with the well-publicized issues and higher than projected premium costs of coverage offered to Americans enrolling in health care coverage through the federal healthcare marketplace Healthcare.gov created under the health care reforms of the Patient Protection & Affordable Care Act (ACA), many Americans are just beginning to recognize the growing problems and concerns emerging with state exchanges in those states that elected to enact their own exchange. As the Supreme Court prepares to hear arguments in the challenge to the use of ACA subsidies to pay for coverage purchased through the federal healthcare.gov marketplace in King v. Burwell on Wednesday, March 4, 2015, the growing evidence of rapidly emerging funding and other challenges affecting state run exchanges raise concerns about the solvency and reliability of coverage promised and purchased through those state run exchanges. What are your thoughts?

While most Americans are familiar with the well-publicized issues and higher than projected premium costs of coverage offered to Americans enrolling in health care coverage through the federal healthcare marketplace Healthcare.gov created under the health care reforms of the Patient Protection & Affordable Care Act (ACA), many Americans are just beginning to recognize the growing problems and concerns emerging with state exchanges in those states that elected to enact their own exchange.  As the Supreme Court prepares to hear arguments in the challenge to the use of ACA subsidies to pay for coverage purchased through the federal healthcare.gov marketplace in King v. Burwell on Wednesday, March 4, 2015, the growing evidence of rapidly emerging funding and other challenges affecting state-run exchanges raise concerns about the solvency and reliability of coverage promised and purchased through those state run exchanges.

During the Congressional debates leading up to the enactment of ACA, for instance, ACA advocates touted the Massachusetts health care mandates and reform law of Massachusetts as part of the model for ACA and evidence of the potential benefits offered by enactment of ACA.  Now Massachusetts officials are blaming ACA for serious underfunding and other problems in their state’s health care connector.

Massachusetts Governor Charlie Baker recently cited the Health Connector and its challenges in enrolling Massachusetts residents in health insurance plans as part of the Affordable Care Act that forced the state to temporarily transition hundreds of thousands of state residents into the commonwealth’s Medicaid program as a primary reason for the state’s projected $1.5 billion budget deficit.  He now has asked for the resignations of four Massachusetts Health Connector board members:  MIT professor Jonathan Gruber,  Covered California actuarial consultant John Bertko; Massachusetts Nonprofit Network CEO Rick Jakious and Spring Insurance Group CEO George Conser.

The Massachusetts experience is not unique.  Other states also are experiencing significant funding and other problems dealing with the ACA mandates and implementation.  See, e.g.,  Funding Woes Imperil Future of State Run Exchanges;  State Insurance Exchanges Face Challenges In Offering Standardized Choices Alongside Innovative Value-Based Insurance.

This mounting evidence of serious cost, financing and other concerns in state-run exchanges creates new reason for concern about the future of ACA’s health care reforms even for those citizens of states whose eligibility for subsidies is not challenged by the King v. Burwell Supreme Court challenge.  These and other budget overruns and operational challenges raise serious questions about the ability of the federal government or the states to fund the promises currently made by ACA in its present form.  Congress and state governments almost certainly will be forced to deal with these broader challenges regardless of the outcome of King v. Burwell.   As American leaders continue to struggle to deal with these and other mounting problems impacting the U.S. health care system, the input of individual Americans and businesses and community leaders is more critical than ever.  Get involved in helping to shape improvements and solutions to the U.S. health care system and the Americans it cares for by sharing your ideas and input through the Coalition For Responsible Health Care Policy  and exchanging information and ideas for helping American families deal with their family member’s illnesses, disabilities and other healthcare challenges through Project COPE: Coalition for Patient Empowerment here.

About Project COPE: The Coalition On Patient Empowerment &  Coalition on Responsible Health Policy

Do you have ideas or experiences to share about medical debit, ACA or other health care challenges?  Have ideas for helping improve ACA and other health care policies impacting the US health care system, helping Americans cope with these and other health care challenges or other health care matters? Know other helpful resources or experiences that you are willing to share?  Are you concerned about health care coverage or other health care and disability issues or policy concerns?  Join the discussion and share your input by joining Project COPE: Coalition for Patient Empowerment here.

Sharing and promoting the use of practical practices, tools, information and ideas that patients and their families, health care providers, employers, health plans, communities and policymakers can share and offer to help patients, their families and others in their care communities to understand and work together to better help the patients, their family and their professional and private care community plan for and manage these  needs is the purpose of

The Coalition and its Project COPE arise and operate on the belief that health care reform and policy must be patient focused, patient centric and patient empowering.  The best opportunity to improve access to quality, affordable health care for all Americans is for every American, and every employer, insurer, and community organization to seize the opportunity to be good Samaritans.  The government, health care providers, insurers and community organizations can help by providing education and resources to make understanding and dealing with the realities of illness, disability or aging easier for a patient and their family, the affected employers and others. At the end of the day, however, caring for people requires the human touch.  Americans can best improve health care by not waiting for someone else to step up:  Step up and help bridge the gap when you or your organization can. Speak up to help communicate and facilitate when you can.  Building health care neighborhoods filled with good neighbors throughout the community is the key.

The outcome of this latest health care reform push is only a small part of a continuing process.  Whether or not the Affordable Care Act makes financing care better or worse, the same challenges exist.  The real meaning of the enacted reforms will be determined largely by the shaping and implementation of regulations and enforcement actions which generally are conducted outside the public eye.  Americans individually and collectively clearly should monitor and continue to provide input through this critical time to help shape constructive rather than obstructive policy. Regardless of how the policy ultimately evolves, however, Americans, American businesses, and American communities still will need to roll up their sleeves and work to deal with the realities of dealing with ill, aging and disabled people and their families.  While the reimbursement and coverage map will change and new government mandates will confine providers, payers and patients, the practical needs and challenges of patients and families will be the same and confusion about the new configuration will create new challenges as patients, providers and payers work through the changes.

We also encourage you and others to help develop real meaningful improvements by joining Project COPE: Coalition for Patient Empowerment here by sharing ideas, tools and other solutions and other resources. The Coalition For Responsible Health Care Policy provides a resource that concerned Americans can use to share, monitor and discuss the Health Care Reform law and other health care, insurance and related laws, regulations, policies and practices and options for promoting access to quality, affordable healthcare through the design, administration and enforcement of these regulations.

Other Helpful Resources & Other Information

We hope that this information is useful to you.   If you found these updates of interest, you also be interested in one or more of the following other recent articles published on the Coalition for Responsible Health Care Reform electronic publication available here, our electronic Solutions Law Press Health Care Update publication available here, or our HR & Benefits Update electronic publication available hereYou also can get access to information about how you can arrange for training on “Building Your Family’s Health Care Toolkit,”  using the “PlayForLife” resources to organize low-cost wellness programs in your workplace, school, church or other communities, and other process improvement, compliance and other training and other resources for health care providers, employers, health plans, community leaders and others here. If you or someone else you know would like to receive future updates about developments on these and other concerns, please be sure that we have your current contact information – including your preferred e-mail by creating or updating your profile here. You can reach other recent updates and other informative publications and resources.

Examples of some of these publications include:

For important information about this communication click here.

©2015 Cynthia Marcotte Stamer.  Limited non-exclusive license to republish granted to Solutions Law Press, Inc.  All rights reserved.