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Providers and Agencies Prepare for 501(r)

This year will likely see the final release of Internal Revenue Service’s regulations for hospitals to maintain their tax-exempt status. In the meantime, the IRS has advised professionals in the health care and collection industries to follow the proposed guidelines to determine if they are in compliance.

During a Jan. 21 online seminar for the Healthcare Financial Management Association, Michael Engle, a partner with BKD CPAs and Advisors in Kansas City, Mo., discussed preparation for the regulations.  Requirements for a hospital to maintain its nonprofit status, set by the IRS and mandated by the Affordable Care Act, include:

• Establishing written financial assistance and emergency medical care policies. 

• Limiting amounts charged for emergency or other medically necessary care to individuals eligible for assistance to not more than amounts billed to people with insurance for the care.

• Determining if an individual is eligible for financial assistance before using extraordinary collection practices.

• Conducting a community health needs assessment and adopt an implementation strategy at least once every three years.  

Engle said hospitals are also required to make their financial assistance policies widely available to the public, and a plan needs to be in place to aid with that process.  “Very few (hospitals with) financial policies today have ideas how they are going to make it widely available,” he said.

Because the regulations specify that hospitals are responsible for actions of their agencies, it is essential that hospitals and collection agencies work closely.  “If the agency breaks the law, the hospital is considered as having broken the law as well,” Engle said.  At this time, if a hospital is trying to comply with the regulations and makes a mistake, it is not grounds for the IRS to remove its tax-exempt status, according to Engle. 

Instead, the proposed regulations are in place to allow hospitals to correct any mistakes.  Hospitals should rely on following the proposed regulations until the IRS publishes a final rule, said Roberta Schultz, director of operations at Minnesota-based revenue cycle management company ProSource.  Schultz is quite familiar with the proposed regulations, as they are similar to requirements that have been in place in Minnesota for several years.

“The regulations revolve around ensuring accounts are billed properly to all third-party payers, self-pay amounts are validated as correct and truly owed and patients are aware of financial assistance,” Schultz said. “Patients must be given the opportunity to apply for charity care, and uninsured patients should be given the same discount as the facilities ‘most favored payer.’” 

Schultz said it is important that patients know what their financial options are and for hospitals and collection agencies to document communication.  “You need to have a very compliant agency that understands and has technology and (an) electronic process in place to ensure that accounts are handled appropriately,” she said.  Schultz advises hospitals to use consistent “patient due diligence” to comply with the IRS regulations.  Patient account records should include details about dates when bills are sent, dates of patient contact and, most importantly, Schultz said, if they were informed about the hospital’s financial assistance policy and given an application.

Hospitals could verbally notify patients about the financial assistance policies through a recording on their phone line or through providing copies at their location and online.  As Engle mentioned, collaboration between collection agencies and hospitals is important in following the regulations.  Schultz said technology can help ensure an agency has access to hospitals’ systems to answer and record actions, and to allow providers to view that information.

“There is a technology answer to just about all of the requirements of the regulations, but it takes a lot of investment, time and complete understanding before the technology is effective,” she said.  

http://1.usa.gov/1fCTPWL (IRS regulations)

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Legislation: Medicare Reform Bill Seeks to Lower Costs and Improve Care

Several lawmakers have introduced legislation aimed to improve care of chronically ill patients and decrease costs through Medicare. The “Better Care, Lower Cost Act of 2014,” includes provisions to pay health care providers based on their patients’ outcomes instead of under a fee-for-service system.

Sen. Ron Wyden (D-Ore.) is leading the legislation with support from Sen. Johnny Isakson (R Ga.), Rep. Erik Paulsen (R-Minn.) and Rep. Peter Welch (D-Vt.).  According to Wyden’s bill summary, the legislation “removes the barriers that prevent Medicare providers from building on existing successful delivery models, and provides a framework for encouraging innovating chronic care delivery across the country.”

Sixty-eight percent of Medicare beneficiaries suffered from two or more chronic conditions in 2010 to account for 93 percent of Medicare spending, approximately $487 billion each year, according to data from the Centers for Medicare and Medicaid Services on the site.  Ninety-eight percent of hospital readmissions involve people with Medicare and multiple chronic conditions.

One goal of the legislation is to have critical support available for health care providers including team based care, telemedicine networks to increase access in rural areas and case management services known to increase medical compliance, according to the bill summary.  “The point of our bipartisan legislation is to break government’s shackles on innovation so that these providers are the norm rather than the exception,” Wyden said.

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ICD 10 Cost Estimates Higher Than Expected

Physicians implementing required updates to their medical coding system by Oct. 1, 2014, will likely pay more than the previously estimated costs, according to new research conducted for the American Medical Association.  The system, ICD-10, is replacing ICD-9 for reporting medical diagnoses and inpatient procedures. All entities covered by the Health Insurance Portability and Accountability Act must implement the new system by the Oct. 1 deadline.

In 2008 research by Nachimson Advisors and Physicians EHR for the AMA concluded that it would cost $83,290 for a small medical practice to implement ICD-10, compared to about $2.7 million for a large practice.  New research shows the ICD-10 process requires physicians to upgrade their electronic health records and practice management systems software, which produces the billing information to submit to a health plan for payment.

In addition to software changes, costs to physicians include training, assessment, vendor upgrades, remediation and productivity losses.  Expenses for a small practice to use ICD-10 could range from $56,639 to $226,105, according to the new research. A large practice could pay between $2 million and $8 million.

The ICD-10 transition could also affect medical practices’ finances due to a possible disruption in the payment reimbursement process. While it will be difficult to determine the extent of the impact until after Oct. 1, 2014, researchers predict there could be denial of claims for reimbursement due to inaccuracies in the policies updated for ICD-10.

“A poorly executed ICD-10 implementation effort will increase those risks and expose practices to large costs in 2014 and beyond,” AMA’s new report states. “Planning must take place now so those risks can be mitigated and practices can continue to operate effectively.”

 More information: http://bit.ly/1gSa724

 

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ICD-10 Readiness Lags

    

With the Oct. 1, 2014, ICD-10 transition date approaching, many in the health care industry have not yet adequately prepared for the new coding system.  Health care payers and providers are significantly behind on preparing to use a new coding system required by the Centers for Medicare and Medicaid Services’ Oct. 1 deadline, according to KPMG, a U.S. audit, tax and advisory firm.

The new system, ICD-10, is a replacement for ICD-9, which is used to document medical diagnoses and inpatient procedures.  All entities covered by HIPAA must implement the new system by Oct. 1. It will create consistency between the health care system in the United States and other industrialized countries.

Codes in the ICD-10 allow for more specific patient diagnoses, and the system also makes it easier if new codes need to be added.  KPMG completed a poll to gauge preparedness for the change in the health care industry and found that 74 percent of participants had not, or had no plans to conduct testing involving outside entities such as health plans, providers and trading entities.  Additionally, 50 percent of the participants said they have not reviewed the impact of the coding update on their cash flow. 

“As Oct. 1 inches closer, health care organizations have their work cut out to properly absorb the impact that the new coding will have on their businesses,” said Wayne Cafran, an advisory principal with KPMG. “With estimates by those who did measure the impact tallying anywhere from $1 million to more than $15 million, health care organizations are in for a rude awakening when they finally realize what (impact) the new standards will have on their bottom lines.”

 

 

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ACA International and HFMA Announce Best Practices for Resolving Patient Medical Accounts

  

A Medical Debt Collection Task Force led by the Healthcare Financial Management Association, ACA International and a group of diverse stakeholders, including medical providers and consumer advocates, recently announced new best practices to help make paying of medical bills an easier and fairer proposition for consumers.

“Many consumers are struggling with medical bills today,” said ACA International CEO Pat Morris. “These best practices are a balanced step forward for all of the stakeholders involved to better resolve patient medical accounts.”

The Medical Debt Task Force sought to identify common methods for resolving the patient portion of medical bills and provide a framework for educating patients about available financial assistance programs and the account resolution process.  These new best practices are intended to be voluntary guidelines and complement existing federal, state and local laws governing the recovery of patient medical debt.

Health care providers and their business partners using the best practices will be able to:

1. Lay the groundwork for successful account resolution by educating patients and following best practice for communication prior to the time of service.

2. Make bills and all communications clear, concise, correct and patient friendly. 

3. Establish policies for account resolution and ensure that they are followed internally and by business affiliates.

4. Be consistent in key aspects of account resolution—from billing disputes to payment application.

5. Coordinate account resolution activities with business affiliates to avoid duplicative patient contacts.

6. Exercise good judgment about the best ways to communicate with patients and bills.

7. Start the account resolution clock when the first statement is sent to the patient.

8. Report back to the credit bureaus when and account is resolved (in the event that an account is reported to a credit bureau).

9. Track all consumer complaints.

10. Use best practices, principles, and guidelines to inform their organizational approach to medical account resolution. 

“The best practices bring consistency, clarity and transparency to talking with patients about their health care costs,” said former U.S. Secretary of Health and Human Services Michael Leavitt. “They provide guidance for when, how and by whom communication should take place about financial issues—such as insurance coverage, financial counseling, patient financial responsibility, and any existing balance the patient may have.” 

Representing ACA on the Medical Debt Task Force were Director of Federal Government Affairs Lucia Lebens, Board Member Tom Gavinski of I.C. System, Tina Hanson of State Collection Service, Eric Mock of Medical Business Bureau, and Pam Kirchner of BCA Financial Services.

The following are included among a broader list of best practices. More information on these best practices is available at http://www.hfma.org/medicaldebt.

Improve Patient Education and Communication. Take responsibilityfor educating patients about theirpayment options and responsibilities.  Be proactive about communicatingavailable financial assistance policiesand procedures. Health care providersshould educate consumers about theaccount resolution process beforeproviding a service or at the time ofservice. The discussion of optionsshould also include attempting toqualify patients for coverage by thirdparty payers.

Make bills patient-friendly. All financial communication should be clear, concise, correct, and patient friendly.  It will help patients be able to know what to do when they receive a bill and ensure that the statement correctly documents the financial aspects of their care. 

Establish policies for account resolution and ensure that they are followed. Make sure that keyaccount resolution activities aregoverned by your organization’s board approvedpolicies. Providers shouldhave a clear policy about financialassistance, including how to apply,required supporting documentation,eligibility criteria and steps theymay take to resolve accounts. Theaccount resolution policy should alsoinclude the economic profile of thecommunity and be available to allpatients.

Report back to credit bureaus when and account is resolved. If a past-dueaccount is reported to a credit bureau,the reporting entity should report backto the bureau when the account issatisfied. 

Track all consumer complaints.  This information should beshared between the businessaffiliate and the provider toimprove customer service, hastenaccount resolution, and avoidreoccurring grievances.

Use established HFMA and ACA best practices, principles and guidelines to inform your organization’s approach to medical account resolution. Thisincludes HFMA’s BestPractices for PatientCommunications;HFMA’s PatientFriendly BillingProject; ACA’s HealthCare ServicingGuidelines andACA’s Code ofEthics.

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ICD-10: A Dramatic Change to the Health Care Revenue Cycle

On Oct. 1, 2014, the Centers for Medicare and Medicaid Services is implementing a new coding system that will have a significant impact on all aspects of the health care revenue cycle.  ICD-10 is replacing ICD-9 as the system to report medical diagnoses and inpatient procedures. All HIPAA-covered entities will be required to make the transition.

At ACA International’s Fall Forum & Expo in November, Day Egusquiza, president of AR Systems Inc. in Twin Falls, Idaho, talked about why the transition is taking place, and how it will affect various players in the health care industry.  “We have to think this is bigger than just coding,” Egusquiza said. “All of us are impacted.”

The biggest change between ICD-9 and ICD-10 will be the level of specificity with the codes. According to the American Medical Association, ICD-9 uses approximately 13,000 codes, and each code contains three to five characters. Under ICD-10, there will be approximately 68,000 codes, and each code will contain up to seven characters.

This new system will allow for more specific diagnoses and will also allow for more flexibility if new codes need to be added. It will bring the U.S. up to speed with other industrialized countries, virtually all of which currently use ICD-10, Egusquiza said. “We kind of need to join the rest of the industrialized countries,” she noted.

The U.S. has been slow to adopt ICD-10, Egusquiza said, because it has private payers that also need to be up to speed on the codes. In many other countries, where the government pays for health care, this level of complexity is removed.  Getting the U.S. up to speed on ICD-10 will require a coordinated effort between providers, payers and everyone else in the health care revenue cycle.

On the front end, providers might now have multiple ways to code a diagnosis, whereas before they had just one choice. For example, under ICD-9, a hospital might have a code for someone who fell inside his home. But under ICD-10, a more specific code could allow a diagnosis for someone who fell inside his home, and specifically inside the kitchen.

However, in this example, it seems unlikely that an emergency room doctor will ever ask a patient which room he fell in. Likewise, providers probably don’t care to know that level of detail, either. Egusquiza said it’s important that medical coders don’t live in a vacuum, and realize that even though more specific codes might be available in ICD-10, they might not always be useful. In fact, they could slow down the process and even lead to payment claim denials.

“We have to get into the conversation to say, ‘The payers don’t want it, you don’t have to give it, why are you asking?’” Egusquiza said. “That’s why we have to get a little reality check.”  With ICD-10 implementation only eight months away, people who work in the health care revenue cycle should do tests of the new system. Because of the big increase in the number of codes available, there will likely also be new rejection codes related to bills. Figuring these out will be critical, Egusquiza said.

This process is all coming during a very busy time for the industry, as reform due to the Affordable Care Act is in full swing. However, being up to speed on ICD-10 will be essential to keeping the health care revenue cycle running smoothly.  “ICD-10 in the middle of health care reform is tough,” Egusquiza said. “People who work in health care are in the midst of a dynamic change.”

 

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News & Notes

 

Price Increases, Not Demand Are Responsible for Rise in U.S. Medical Spending

Price increases—not demand for services or an aging population—are responsible for most of the increase in medical spending the U.S. has experienced since 2000, according to a recent study published in the Journal of the American Medical Association.   Medical price increases produced 91 percent of spending increases during that time period.

Federal Officials Change ‘Use-or-Lose’ Rule for FSA’s

The move allows employers to decide whether they’ll let their employees carry over up to $500 of their unused flexible spending account balances year to year.  It will be up to employers whether they make the change, and when.

Survey: Many Unprepared for Health Care Costs in Retirement

Among the 1,000 non-retired adults age 50-64 who were surveyed by AARP, only about one-third (36 percent) have tried to estimate how much money they will need to save and have set money aside to cover these expenses in the future. Less than two in 10 (16 percent) are very confident that they can afford the costs of health care in retirement.

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Financial Focus for U.S. Not-for-Profit Hospitals Shifts Toward Value

The April 2013 issue of Pulse discussed an emerging trend inhealth care of tying reimbursement tothe quality of a hospital’s care ratherthan the quantity of care given. A newreport confirms the increasing scope ofthis concept.

As reimbursements shift towardrewarding value in health care, theability to deliver quality care at anaffordable cost is becoming increasinglyimportant to the financial strengthand credit quality of a not-for-profithospital, according to the new Moody’sInvestors Service report, ““Not for-Profit Hospitals: The Pursuit of Value.”

“After decades of following volume basedincentives, measuring and provingvalue will become necessary for healthcare systems to maintain operatingstability and distinguish themselves asmarket leaders,” said Moody’s AssociateManaging Director Lisa Goldstein.

Long-term trends, such as excessivecost inflation, and the near-term reformsin government policies are driving theshift toward a new quality-based businessmodel, according to the rating agency.

Moody’s details four specific objectives hospital managers are pursuing as they respond to the shift in business model:

• Achieving breakeven performance with Medicare rates.

• Building scale through nontraditional methods.

• Improved patient experience.

• Cultivating informed leadership.

In response to the shift, Moody’s recently added several new indicators that measure a hospital’s quality and demand for services, including number of unique patients, covered lives, employed physicians, Medicare readmission rates, all payer readmission rates and risk-based revenues.

Private and government payers are also increasing their emphasis on value by introducing risk-based contracts that create incentives for hospitals to achieve certain quality and cost targets or, in some cases, face financial penalties.

“Individuals and businesses have become more discerning in their health care purchases since the recession,” Goldstein said. “Both payers and purchasers will accelerate their demand for high-value healthcare products with the start of mandated insurance exchanges in 2014.”

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CMS Provides Hospital Charge Comparison Data

On May 8, 2013, the Centers for Medicare and Medicaid Services released data aimed at providing consumers with information about what hospitals charge. The data, available at http://tinyurl.com/blv4cwg, reflects significant variation across the country and within communities in what hospitals charge for common inpatient services.

“Currently, consumers don’t know what a hospital is charging them or their insurance company for a given procedure, like a knee replacement, or how much of a price difference there is at different hospitals, even within the same city,” said Health and Human Services Secretary Kathleen Sebelius. “This data and new data centers will

help fill that gap.” The data includes information comparing the charges for services that may be provided during the 100 most common Medicare inpatient stays. Hospitals determine what they will charge for items and services provided to patients and these “charges” are the amount the hospital generally bills for an item or service.

These amounts can vary widely. For example, average inpatient charges for services a hospital may provide in connection with a joint replacement range from a low of $5,300 at a hospital in Ada, Okla., to a high of $223,000 at a hospital in Monterey Park, Calif.

Even within the same geographic area, hospital charges for similar services vary significantly. For example, average inpatient hospital charges for services that may be provided to treat heart failure range from a low of $21,000 to a high of $46,000 in Denver, and from a low of $9,000 to a high of $51,000 in Jackson, Miss. To make these data useful to consumers, HHS is also providing funding to data centers to collect, analyze, and publish health pricing and medical claims reimbursement data.

The data centers’ work helps consumers better understand the comparative price of procedures in a given region or for a specific health insurer or service setting. Businesses and consumers alike can use this data to drive decision-making and reward cost-effective provision of care. At least one organization, Moody’s Investors Service, questioned the usefulness of the data.

The rating agency issued a report that publication of the database of hospital charges will have minimal impact on the credit quality of hospitals and health systems for the time being. Longer-term, however, the wide range of pricing for similar services the database presents is likely to strengthen the hand of those calling for greater regulation of hospital pricing and billing practices, a credit negative for the industry.

“The credit impact to individual hospitals and health systems is minimal in the near term, as most insurers and purchasers of health care services already understand charges bear little relationship to actual negotiated rates with payers, which are substantially discounted from charges,” said Daniel Steingart, CFA, a Moody’s assistant vice president and analyst, in the report, “Publication of Hospital Charges Highlights Poor Transparency in Hospital Pricing.”

“Longer-term credit implications are negative for hospitals, however, especially those that are truly higher

cost,” Steingart said. “As governments deal with ongoing budget challenges and patients pay higher out-of-pocket costs, there will be increasing pressure on hospitals to operate with low revenue growth and rationalize their public pricing data. There is substantial risk the persistence of unexplainable differences in hospital charges will invite greater regulation of the industry and supports our negative sector outlook.”

Moody’s also took issue with the data that was chosen for the report. Because hospitals charge significantly more than what is actually reimbursed, the data does not provide any information on actual prices paid. Longer term, however, it is conceivable that a hospital system will adopt price transparency as a marketing strategy, according to Moody’s.

The agency speculated that possible changes in regulation could include states requiring additional disclosure on actual prices paid, inviting greater federal or state scrutiny of the industry. “Such a development would have a material impact on hospitals’ marketing and billing strategies and be credit negative for hospitals slow to adapt,” Moody’s said in a written statement.

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Four in 10 Americans Don’t Believe the Affordable Care Act is Law

Forty-two percent of Americans are unaware that the Affordable Care Act is still the law, according to a new poll by the Kaiser Family Foundation. This includes 12 percent who think Congress repealed the law and 7 percent who believe the Supreme Court overturned the law. Other findings:

• Nearly half the public (49 percent) said they do not have enough information about the health reform law to understand how it will affect their own family.

• The share of the public who says they lack enough information to understand how the Affordable Care Act will affect their family is higher among two groups the law is likely to benefit most—the uninsured (58 percent of whom said they lack enough information) and low-income households (56 percent of whom said they lack enough information).

• When it comes to information sources about the law, Americans most commonly cite friends and family (named by 40 percent), newspapers, radio news or other online news sources (36 percent), and cable news (30 percent).

About one in 10 report getting information from a health insurer, a doctor, an employer or a nonprofit organization. Similar shares say they have gotten information from “federal agencies such as the Department of Health and Human Services” (9 percent) or “state agencies such as your state Medicaid office or health department” (8 percent).

View the full report at http://tinyurl.com/bx39xtb.

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Policies Give States More Flexibility to Establish Affordable Insurance Exchanges

On March 12, 2012, the U.S. Department of Health and Human Services (HHS) announced its new policies to assist states in building Affordable Insurance Exchanges. Starting in 2014, these one-stop market places will allow consumers and small businesses to choose a private health insurance plan and offer the public the same kinds of insurance choices as members of Congress.

The policies provide states with the guidance and certainty they need as they continue to work to build these marketplaces for their residents for operation in 2014. The policies offer guidance about the options on how to structure Exchanges in two key areas:
- Setting standards for establishing Exchanges, setting up a Small Business Health Options Program (SHOP), performing the basic functions of an Exchange and certifying health plans for participation in the Exchange; and
- Establishing a streamlined, web based system for consumers to apply for and enroll in qualified health plans and insurance affordability programs.

The final rule builds on the flexibility and resources provided by HHS already to build state-based Exchanges.


Written by Pulse

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Supreme Court Divided on Health Care Reform

The Supreme Court recently heard oral arguments regarding constitutional challenges to the Patient Protection and Affordable Care Act (PPACA). The oral arguments extended for three days (March 26-28, 2012). The primary focus of the Supreme Court's review concerned the constitutionality of the PPACA's individual mandate, which requires consumers obtain health insurance by 2014, or face a penalty. The Court also discussed the applicability of federal tax law and state Medicaid expansion.

On the first day of oral arguments the Court evaluated whether the Anti-Injunction Act prevents challenges to the Affordable Care Act. The Anti-Injunction Act generally prohibits pre-enforcement legal challenges to the assessment and collection of taxes. Because the PPACA requires consumers to purchase health insurance or pay a penalty with their tax return, the Court discussed whether the Anti-Injunction Act deprives courts of jurisdiction to hear challenges regarding the individual insurance mandate. Neither the government nor opponents of the PPACA asserted the Anti-Injunction Act applied.

During oral arguments, the Court was skeptical of the Anti-Injunction Act's application. Justices Breyer and Ginsburg suggested the penalty associated with the individual mandate is not a "tax" within the meaning of the Anti-Injunction Act, given that the individual mandate is not intended to be a revenue source.

The second day of oral arguments focused on the constitutionality of the individual health insurance mandate, which requires most Americans to purchase health insurance by 2014. The discussion of constitutionality fixated on how to characterize the decision not to purchase insurance coverage. The government asserted the individual mandate is constitutional because it is a valid exercise of Congress' power under the Commerce Clause. Opponents to the law argued the individual mandate does not regulate commerce; rather, it forces people into the stream of commerce by requiring them to purchase health care coverage or pay a penalty.

The Court's opinion was split. Some Justices suggested the individual mandate was a permissible exercise of Congress' authority to regulate interstate commerce, while others felt the individual mandate would make it difficult to draw a "limiting principle" beyond which the government cannot go. Justice Kennedy stated there was a "very heavy burden of justification" to show where the Constitution authorizes Congress to change the relation of the individual to the government. Importantly, however, both Justice Kennedy and Roberts alluded that even if the mandate forced consumers into commerce to subsidize health insurance, the health insurance market may be unique enough to justify that unusual treatment.

On the third day of oral arguments, the Court addressed two issues:
- What parts of the PPACA will survive if the individual mandate is declared unconstitutional?
- Is the PPACA's requirement that states expand Medicaid eligibility constitutional?

The government argued that only two provisions of the law-a prohibition against insurers discriminating against people with pre-exiting conditions and a limitation on how insurers set rates-depended on the mandate and asserted the rest of the law should stand. Several Justices expressed skepticism concerning whether the PPACA should be invalidated as a whole if the individual mandate was ruled unconstitutional. Justices Kennedy, Scalia, Alito and Roberts, however, considered whether any provision of the PPACA could survive without the individual mandate.

The last issue considered by the Court was the constitutionality of the PPACA's state Medicaid expansion. Twenty-six states challenged the constitutionality of the PPACA's requirement, which requires states expand their Medicaid eligibility to cover individuals up to 133 percent of the Federal Poverty Level, starting in 2014. States argued the federal government was unconstitutionally "coercing" them into expanding Medicaid eligibility as a condition for qualifying for federal funds to help pay for Medicaid. Some Justices expressed concern whether states actually have a choice to accept the new Medicaid funding, while others appeared to reject the coercion argument.

The Justices attended a confidential conference on March 30, 2012, to vote on the outcome of the challenges to the PPACA. It is expected the Court will issue its written decision at the end of its current term, near the end of June 2012.

For more information on the PPACA hearings or to listen to the transcripts visit: http://www.supremecourt.gov/docket/ PPAACA.aspx.



Written by Pulse

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