This presentation is an overview of the Affordable Care Act and how it has and will continue to impact physicians. The presentation is focused on the Florida market but most of the information can be applied to any state.

1. What to Expect with the
Affordable Care Act
Brief overview of what Florida physicians should changes they can expect with
the Affordable Care Act
Presented by: Andrew Eriksen, CMPE
Warning: If you suffer from depression, please leave the
room or take your medication.
S

2. Introduction
To be clear, this presentation is
intended to be an overview, not a
comprehensive analysis. The
goal of this presentation is to
equip you for changes that are
likely to impact your practice in
the coming months.
Please don’t misinterpret this as
a political presentation. I am
addressing facts and will let the
pundits bloviate over the
hypothetical.

3. What Changed?
S Too much to discuss in this presentation but here are few
things worth mentioning:
S Eliminated the preexisting condition clause, mandated
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certain preventative services such as
mammograms, requires that all health plans use at least
80% of premium dollars on actual care and eliminates the
lifetime/yearly benefit ceiling.
Subsidies provided to individuals based on household
income through the new insurance marketplace(once it
works)
Expanded Medicaid by raising the poverty line 133%
Requires health plans to cover participation in clinical trials
Instituted a penalty (or tax..) if you fail to obtain coverage

4. Insurance Marketplace
S
Created to promote competition and theoretically drive down costs
S
Health plans are not required to participate and individuals are not required to buy insurance through
the exchange.
S
Aetna, Avmed, BCBS, Coventry/First Health (now part of Aetna), Molina, Humana & Sunshine State
are participating in the exchange. 82 plans currently offered in Florida. Plans split into 4 categories:
Catastrophic, Bronze, Silver & Gold. Within these categories you have HMOs, EPOs, PPOs and
HSAs. HMOs are provide the greatest value to members which is where most patients will likely end
up. Only 6 of the 82 plans offered on the exchange are PPOs.
S
The proliferation of HMOs means lower reimbursements and an increased burden on the physicians.
Fee schedules for most exchange products are an average of 10%. The EPO plans offered by BCBS
rely on their HMO network but do not require a referral in most cases. They do however use the HMO
fee schedule which is about 10-15% lower than the PPO fee schedule.
S
With the proliferation of HDHPs, it would be wise to develop ways within the office to collect more of
what a patient owes prior to claim adjudication. This is commonly referred to as Real Time Claim
Adjudication. This may be unpopular with some of your patients, but it could save your office from a lot
of bad debt.

5. How has it helped?

6. Florida’s Exchange
Individual Monthly Health Insurance Premiums Before and After PPACA
Gross Annual Premium Comparison
HMO /
PPO
Offering
Plans On the
Federal
(1)
Exchange
(Yes/No)
Florida File
Log
Number(s)
Marketwide
Average Monthly
Premium per
Person Before
(2)
PPACA
Each Company’s
Statewide Average
Monthly Premium
per Person After
PPACA
Aetna Life Insurance Company
PPO
Yes
13-08779
$243
Blue Cross Blue Shield Of Florida
Cigna Health And Life Insurance
Company
PPO
Yes
13-09201
PPO
Yes
Coventry Health Care Of Florida, Inc.
HMO
Florida Health Care Plan, Inc.
Silver Plan Comparison
Percent
Change
Adjusted
Standard Risk
Rate
(3)
Premium
Each
Company’s
Statewide
Average Silver
Plan Premium
Percent
Change
$296
21.7%
$293
$422
44.2%
$243
$361
48.3%
$293
$384
31.2%
13-08574
$243
$377
55.3%
$293
$437
49.2%
Yes
13-08330
$243
$343
41.2%
$293
$366
25.1%
HMO
Yes
13-10554
$243
$324
33.3%
$293
$396
35.2%
Health First Insurance Company
PPO
Yes
13-11036
$243
$360
48.2%
$293
$373
27.5%
Health Options, Inc.
HMO
Yes
$243
$350
44.1%
$293
$400
36.7%
Humana Medical Plan, Inc.
HMO
Yes
13-09200
13-06858,
13-06046,
13-06203 &
13-10233
$243
$278
14.3%
$293
$315
7.6%
Molina Healthcare Of Florida, Inc
HMO
Yes
13-08632
$243
$412
40.8%
$293
$411
40.6%
Preferred Medical Plan
HMO
Yes
13-12081
$243
$331
36.3%
$293
$385
31.4%
Sunshine State Health Plan Inc
Average Change
HMO
Yes
13-08611
$243
$362
48.7%
39.3%
$293
$464
58.8%
35.2%
Company
(1) A plan available through the Federally-Facilitated Exchange (FFE) may or may not be available outside of the FFE.
(2) The before PPACA rates are determined using the “CY 2012 Accident and Health Gross Annual Premium” report trended at 8.9%. The comparison is done on
a marketwide basis.

7. Meet your New PatientMedicaid Reform
S
Approximately 1 million new lives in Florida due to the poverty level being
raised by 133%
S
Medicaid expansion eliminates straight Medicaid and turns over all current
members to the managed care plans. Florida is divided into 11 regions
with each region having approximately 3-6 managed care plans.
S
Opportunities for internal medicine trained physicians to attest and receive
Medicare rates. PCPs receive Medicare funds for participating but do not
have specialists to refer to. This creates obvious access issues which will
likely result in better payments for specialists in the near future.
S
Currently, Medicaid pays approximately 60% of Medicare to specialists.
There is a spreadsheet in Box folder with an analysis comparing Medicare
and Medicaid for our most common codes.
S
Sunshine State, Wellcare and UHC are and will continue to have the most
Medicaid members in Central Florida.

8. Regions in Florida

9. Medicaid Plans in Central
Florida

10. Medicare & Where your
Patients Went
S
P4P, Shared Savings and Captitated contracts are, and will continue to be, a focus for
Medicare and commercial payers. Captitation is utilized heavily within the Medicare
advantage market through shared risk agreements between IPAs and MSOs. They receive a
PMPM fee for each member and based on their performance, share in the profit or loss.
S
PCPs are required to be part of an IPA now for many Medicare advantage plans. Some of the
plans in Central Florida are Wellcare, Freedom/Optimum and PUP or Physicians United Plan.
S
Utilize ACOs to incentivize physicians to start thinking of ways to save money. While it’s a
noble concept and certainly nothing new, it carries with it the potential for severe access and
quality issues. ACOs have to save a minimum of 4% in order to share in the savings which
means we can expect them to be very aggressive if they want to see a return on their
investment. ER diversion is a primarily how they save but another easy way is to limit referrals
to specialists. Hospitals have combatted this issue by joining ACOs or creating their own ACO
with a group of their “preferred” physicians.
S
Access to specialists and ancillary services is being restricted through a Gate Keeper
mentality and financial incentives tied to saving Medicare dollars
S
http://www.americanthinker.com/2013/12/the_future_of_medical_specialists_under_the_afford
able_care_act.html

11. Closing
The financial burdens of medicine
have never been greater, but that
is not a reason to change the way
you practice. Patient
centered, outcome based
medicine, will always create value
for the payers and loyalty among
patients and referring physicians.