He alth Car e Ac c ountability Or dinanc e (HCAO) Sug g e ste d - - PowerPoint PPT Presentation
He alth Car e Ac c ountability Or dinanc e (HCAO) Sug g e ste d Re visio ns to Minimum Sta nda rds SF De pa rtme nt o f Pub lic He a lth No ve mb e r 6, 2012 Bac kgr ound - HCAO ffe c t: Sinc e 2001. In E s: CCSF Co ntra c to rs
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Minimum Standar
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Co nve ne d b y DPH to re vie w & re c o mme nd
17 o rg a niza tio ns we re re pre se nte d. T
He a lth Co mmissio n ha s the a utho rity to
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Goals inc lude :
Co mpre he nsive ra ng e o f se rvic e s Affo rda b le fo r the e mplo ye e – minimize
Affo rda b le fo r the e mplo ye r Ac c e ssib le fo r the e mplo ye r – pla ns must
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Minimum Standar ds Re quir e me nt 2011 Standar ds/ 2013 Standar ds
Standard 1: Type of Plan Required Any type of plan that meets the Minimum Standards as described below. Standard 2: Employee Premium Contribution The employer must pay 100% of the employee’s health coverage premium. Standard 3: Annual Out-of-Pocket (OOP) Maximum In-Network: No higher than a $4,000 maximum, including all types
etc.). Out-of-Network: Not specified. Standard 7: Coinsurance Percentages 20% in-network 50% out-of-network Standard 8: Copay for Preventive Care Visits & Services In-Network services are not subject to a deductible, copay, or coinsurance (per health reform rules). Preventive care services from an out-of-network provider are subject to the plan’s out-of-network requirements. Standard 9: Copayments for Physician Office Visits for Primary Care, Perinatal/Maternity $30 maximum. Out-of-Network: Not specified.
Minimum Standar ds Re quir e me nt 2011 Standar ds/ 2013 Standar ds
Standard 10: Services:
hospital service
procedures
ray, labs, etc.)
including delivery services and postpartum care
Speech Therapy
These services must be covered. When coinsurance is applied to services: 20% in-network 50% out-of-network When copayments are applied for these services: Not specified. Standard 11: Mental Health Services
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Inpatient & Outpatient Alcohol & Substance Abuse Services
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Inpatient & Outpatient These services must be covered. When coinsurance is applied to services: 20% in-network 50% out-of-network When copayments are applied for these services: Not specified Standard 12: Emergency Room Services & Ambulance Limited to treatment of medical emergencies. The in-network deductible and coinsurance also apply to emergency services received from an out-of-network provider.
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Minimum Standar ds Re quir e me nt 2011 Standar ds 2013 Re c omme ndations
Sta nda r d 4: Pr e sc r iption Dr ug De duc tible In- Ne twor k: No hig he r tha n a $4,000
ma ximum, inc luding a ll type s o f e mplo ye e c o st-sha ring (de duc tib le , c o pa yme nts, c o insura nc e , e tc .).
Out- of- Ne twor k: No t spe c ifie d. In- Ne twor k: No hig he r tha n a
$300 ma ximum.
Out- of- Ne twor k: No t spe c ifie d. Sta nda r d 5: R e g ula r (Me dic al Se r vic e s) De duc tible In- Ne twor k: No hig he r tha n a $4,000
ma ximum, inc luding a ll type s o f e mplo ye e c o st-sha ring (de duc tib le , c o pa yme nts, c o insura nc e , e tc .).
Out- of- Ne twor k: No t spe c ifie d. In- Ne twor k: No hig he r tha n a
$2,000 ma ximum. If a n e mplo ye r o ffe rs a pla n with a de duc tib le hig he r tha n $2,000, the e mplo ye r must fund a He a lth Re imb urse me nt Ac c o unt (HRA) o r He a lth Sa ving s Ac c o unt (HSA) fo r the a mo unt e xc e e ding the $2,000 ma ximum de duc tib le (e .g ., e mplo ye r- funde d HRA o r HSA o f $500 fo r a pla n with a $2,500 de duc tib le ).
Out- of- Ne twor k: No t spe c ifie d. Sta nda r d 6: Pr e sc r iption Dr ug Cove r a g e
No t spe c ifie d. Co ve ra g e o f no n-fo rmula ry drug s no t re q uire d. Must pro vide pre sc riptio n drug c o ve ra g e , inc luding c o ve ra g e
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Appro ve s the 2013 Minimum Sta nda rds o n 1/ 1/ 13 Suppo rts re c o nside ra tio n o f Sta nda rds fo r 2014
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