Federal Reform Timeline

PPACA became law March 23 2010


Sept. 23, 2010 (6 months after signed into law)

GI for children under age 19

Preventive care mandate

Dependent coverage to age 26



Small employer tax credit (up to 35% of employer contribution)

Less than 25 employees

Average wage less than $50,000

Medical Loss Ratio reporting

No less than 85%

Medicare prescription drugs in ‘donut hole’

$250 rebate in 2010

50% coverage 2011 forward



Medical Loss Ratio standards and penalties

80% small group (50 or less) and individuals

85% groups over 50 (100+ in 2014)

If MLR less than target, must rebate to insureds

HAS, HRA, FSA Restrictions

No tax break for over the counter drugs without prescription

CLASS Act—Community Living Assistance Services and Support Act—Repealed



Sept. 23 and after:  Summary of Benefits & Coverage (SBC) required, all policies

No more than 4 pages, front and back (applies to Sec. 125, HSA’s also)

‘Comparative Effectiveness’ Tax to fund research

$2.00 per covered lives, starts 9/30/12, sunsets 9/30/19



Tax on High Income Earners ($200,000 sing. /$250,000 joint filers)

3.8% on most investment income

FSA’s $2500 annual limit on contributions


2014    When the real fun begins!

Insurance Reform

Denial of coverage for pre-existing conditions prohibited

Limits on benefits prohibited

‘Small Group’ up to 99 employees (was up to 50). Strict rating practices.

Employer Mandate for groups over 50

Fine is $2000 per employee per year—do the math

Individual Mandate

Fine is $695 per individual (3X for family: $2085) do the math!

‘Essential Health Benefits’ must be provided

Health Insurance Exchanges must be established (Cover Oregon)

Subsidies/tax credits available for individuals below 400% of FPL



Tax on Cadillac health plans

Oregon Health Insurance Reform

2012 Legislative Session

Approved Health Insurance Exchange business plan (HB 4164)

Oregon’s exchange called ‘Cover Oregon’

Creates a separate marketplace for individuals and small groups

Goal of Exchange:  provide access and choice

Subsidies available for those under 400% of Federal poverty line.

A public corporation like SAIF

Agents an important part of plan………so far.

Organization is scrambling to hit Jan. 1, 2014 deadline.

Must be self sustaining by Jan. 1, 2015 – Federal dollars run out

Resource:  ORHIX.org

Community Care Organizations Transformation (SB 1580)

An attempt to transform Ore. Health Plan

Regional CCO’s coordinate medical, dental, and mental health services

Long term plan is to apply this model beyond Medicaid/OHP (Exchange?)



Remains largely below the radar screen

Long term financial health??—2024 no longer sustainable (Medicare Trustees)

Pharmaceutical companies step up to offer 50% coverage in the ‘donut hole’.

Ongoing battle in Congress over physician reimbursement

Questions about ‘Advantage Plan’ reimbursement to carriers





The Road Ahead is a Rocky Road

Federal and State budget crisis

Health Care Reform is a political football

Lack of leadership: political, industry, providers.

Public lack of understanding

Tort reform?

Issue of cost of care has not been addressed