Louisiana Medical Loss Ratio Waiver Request Documents

The attached MLR application materials are courtesy of Jason Levine and David Hill.

Kevin Wrege, Esq.

Founder & President

Pulse Issues & Advocacy LLC

Office: 202-625-1787

Mobile: 202-253-4929

4410 Massachusetts Ave., NW, #150

Washington, DC 20016

s50bw_211032904190.pdf

state_mlr_adjustment_template_dec_2010_working_doc.pdf

Washington Post: Catania Endorses Biddle for Open At-Large Council Seat

Posted at 12:30 PM ET, 03/31/2011

Catania endorses Sekou Biddle in D.C. Council race

By Tim Craig

D.C. Council member David A. Catania on Thursday endorsed his colleague, Sekou Biddle, in the April 26 special election for an at-large seat on the council, a big get for Biddle as he seeks to distance himself from Council Chairman Kwame Brown and Mayor Vincent C. Gray.

Speaking on the politics program on WPFW 89.3, Catania (I-At large) called Biddle(D) a “very serious, thoughtful, honest man” and praised his work on education and mental health reform issues.

“Not only do I intend to vote for him, I endorse him,” Catania said in an rushed statement made in the closing seconds of the program.

After Brown was elected chairman, the D.C. Democratic State Committee selected Biddle in January to temporary fill Brown’s old at-large seat pending the special election later this month. But Biddle has struggled to gain his footing in a race that also features former council member Vincent B. Orange, GOP school board member Patrick Mara,Ward 8 activist Tom Brown and former Ward 1 advisory neighborhood commissioner Bryan Weaver.

In recent weeks, as the controversy mounted at city Hall, Biddle has been saddled by his close association to Gray and Brown, both of whom pushed the state committee to endorse him over Orange.

By securing the backing of Catania (I-At large), Biddle can try to redouble his efforts to highlight his independence and reach out to voters who are dismayed with Gray and Brown. On the council, Catania has emerged as a leading critic of both Gray and Brown,

A former Republican, Catania still has a good reputation in parts of Upper Northwest with high concentrations of GOP-leaning voters. Just as importantly for the Biddle campaign, Catania could help it rally support in the city’s large gay community. Catania, a key sponsor of the city’s same-sex marriage law, is one of two openly gay council members.

Catania’s endorsement of Biddle is a blow to Mara. Two years ago, Catania played a key role behind-the-scenes in helping Mara unseat former council member Carol Schwartz in the GOP primary. In his past races, Mara has also worked hard to try to win over gay voters.

Biddle is now being supported by Council members Yvette D. Alexander (D-Ward 7), Marion Barry (D-Ward 8), Mary M. Cheh (D-Ward 3) and Harry Thomas Jr. (D-Ward 5). Council member Muriel Bowser (D-Ward 4) is also backing, although Bowser told the Washington Post this week she also “loves” candidate Josh Lopez, a former advisor to Adrian M. Fenty.

The council members, each of whom have their own effective political operations, will likely help Biddle round up support in various neighborhoods in what is expected to be a low-turnout election. But the support, including Catania’s, could make it easier for the other candidates to portray Biddle as too connected to the city’s political establishment.

By Tim Craig | 12:30 PM ET, 03/31/2011

Kevin Wrege, Esq.

Founder & President

Pulse Issues & Advocacy LLC

Office: 202-625-1787

Mobile: 202-253-4929

4410 Massachusetts Ave., NW, #150

Washington, DC 20016

DC DISB Press Release on Health Care Reform 1 Yr. Anniversary

March 28, 2011

One Year Later: The Effects of the Health Reform Law

(Washington, DC) — A year ago on March 23, 2010, President Barack Obama signed the landmark Affordable Care Act into law. In just one year, the law has already given District of Columbia residents more freedom and control over their health care choices. Now, you and your family may be eligible for important new benefits that will ensure you get the care you need at a more reasonable cost.

The DC Department of Insurance, Securities and Banking (DISB) serves as a co-chair of the mayor-created four-member Health Reform Implementation Committee, which will advise the executive office on provisions to ensure a smooth execution of the legislation in the city.

“It is important for residents to know the provisions of the law that are available now, such as coverage for those with pre-existing conditions,” said Acting Commissioner William P. White. “I encourage them to visit the District’s health reform website at www.healthreform.dc.gov to read about how the law is changing the way we receive care.”

Here are some of the benefits District of Columbia residents receive because of the new law:

New Coverage Choices

· Most young adults can stay on their parent’s family plan until they turn 26. It does not matter whether you are married, living with your parents, in school, or financially independent. For more information on how to stay insured, call the customer service number for your parent’s insurer and explain your situation or visit Facebook.gov/YoungAdultCoverage to learn more.

· Most health plans cannot deny coverage to children under age 19 because of pre-existing conditions like cancer or cerebral palsy.

· If you have been uninsured because of a pre-existing condition, you may be eligible to be insured through the Pre-Existing Condition Insurance Plan. To find out about plans available in the District of Columbia, visit, https://www.pcip.gov/StatePlans.html or for general information, www.pcip.gov.

New Benefits if You Have Insurance

· If you are in a new insurance plan, insurance companies cannot charge you a deductible or copays for recommended preventive services, like mammograms, flu shots and other immunizations. Click here to find a list of preventive services that will be covered without cost sharing.

· Insurance companies are prohibited from capping the dollar amount of care you can receive in a lifetime, or cancelling your coverage due to a mistake on your application when you get sick.

New Benefits for People with Medicare

· Seniors and other people with Medicare can get many preventive services and an annual wellness visit with no deductible, co-insurance or co-payment. More than 150,000 seniors and individuals nationwide with disabilities with Medicare have received annual wellness visits in the first two months of the year.

· Seniors and others in the Medicare prescription drug coverage gap known as the "donut hole" now receive a 50 percent discount on covered brand name prescription drugs and 7 percent off prices for generic drugs. In 2010, nearly 4 million seniors and individuals with disabilities with Medicare received a one-time $250 rebate check to help with high prescription drugs costs.

This is only the beginning of a transformation of our health care system that puts the resident in the driver’s seat. For more information on how you can get these benefits, visit the US Department of Health and Human Services’ link, Better Benefits, Better Health Initiative.

Kevin Wrege, Esq.

Founder & President

Pulse Issues & Advocacy LLC

Office: 202-625-1787

Mobile: 202-253-4929

4410 Massachusetts Ave., NW, #150

Washington, DC 20016

New DC Medicaid Funding Formula Helps, Hurts Hospitals

New formula brings boon for some hospitals, loss for others

Premium content from Washington Business Journal – by Ben Fischer

Date: Friday, March 25, 2011, 6:00am EDT

After a failed partnership with the D.C. government that disintegrated into a fiery feud with politicians, Specialty Hospitals of America LLC never expected to benefit from a change in District policy. But it did.

The Hadley and Capitol Hill operations of the New Hampshire-based health care company saw their combined share of a form of Medicaid funding quadruple, from $454,000 to $1.9 million, under a new formula the District uses to distribute the funds to hospitals with high rates of unpaid bills.

D.C. received federal approval to make the change in 2010. The most striking effect is an extra $10 million in revenue for cash-strapped United Medical Center, now owned by the District after being seized from Specialty, according to an analysis by the office of D.C. Chief Financial Officer Natwar Gandhi. The new formula also caused Children’s National Medical Center and Washington Hospital Center to lose millions. Quarterly payments began reflecting the alterations at the end of 2010.

Peter Miller, CEO of Specialty Hospital of Washington-Hadley, said he was surprised to learn of the extra revenue when informed in January, and Eric Reiseberg, president of the parent company, was unaware of the increase as recently as March 22.

“Were we surprised? Yes, we were, no doubt about it,” Miller said.

D.C.-owned United Medical Center is projected to turn a profit for the first time in years in fiscal 2011, almost entirely due to the influx from the Medicaid fund.

Specialty Hospital officials were clamoring for changes to the formula and other Medicaid rules for months prior to the takeover, and Reiseberg said the company could have stabilized finances at UMC had the formula been fixed sooner.

“The number UMC received after we left was identical to what we’d requested,” Reiseberg said. District officials say the problems that led to the July foreclosure were too widespread to be fixed that easily.

The formula changes were designed to consider the percentage of charity care given to D.C. residents at each facility, rather than the total charity care given regardless of patients’ residence. The new formula, therefore, doesn’t account for uninsured patients from outside the District.

The hospitals getting the shorter end of the stick, however, are not pleased.

Officials at Children’s, which stands to lose $7.5 million annually, and Washington Hospital Center, which will lose $3 million annually, said the cuts are already jeopardizing their own missions to care for the poor.

“I don’t want to make threats, that’s not what we do, but I’ll be honest with you,” said Jacqueline Bowens, Children’s chief government and external affairs officer. “We are having some very tough decisions regarding our ability to be able to continue to provide services that are undercompensated.”

Tensions between private health care providers and the public sector are running high in D.C., Maryland and elsewhere, as hospitals and doctors lead a lobbying effort to keep government budget cuts away from public insurance plans. In those battles, industry representatives are fighting on the same side. In this controversy, they’re fighting for the same dollars.

“We certainly do not want to advocate against other hospitals in the District,” said Janis Orlowski, chief medical officer of Washington Hospital Center. “On the other hand, you want to make sure things are done fairly.”

D.C. Council Health Committee Chairman David Catania is satisfied with the current formula, said his aide, Ben Young.

Other winners in the change are Howard University Hospital, Providence Hospital and the Psychiatric Institute of Washington. The Hospital for Sick Children Pediatric Center in lost much of its funding as well.

Kevin Wrege, Esq.

Founder & President

Pulse Issues & Advocacy LLC

Office: 202-625-1787

Mobile: 202-253-4929

4410 Massachusetts Ave., NW, #150

Washington, DC 20016

Georgetown Business Association Meets with DISB on Health Insurance Exchange Issues

GBA legislative committee meets on health care insurance for small businesses

March 28, 2011 | by Joe Giannino

Georgetown businesses, like many across the country, are faced with difficult questions on health care and how to deal with new mandates imposed by Congress. Last week, GBA’s legislative committee met with Brendan Rose, Health Care Policy Analyst for the D.C. Department of Insurance, Securities and Banking (DISB) regarding the District’s Health Insurance Exchange. As DISB envisions it, when the exchange is complete, it will be an internet platform from which small businesses can select insurance options. The D.C. exchange is expected to go live on January 1, 2014.

The creation of the exchange is currently running on two tracks: (a) the legislative track, in which the D.C. Council is considering authorizing legislation to acquire additional federal funds to establish the exchange; and (b) the administrative track, in which the mayor’s office, based on recommendations from the DISB, will formulate how the insurance options will be offered, the requirements for an insurer to be listed on the exchange, and all of the other operational components of the exchange in order to send a final exchange program to be adopted by the D.C. Council.

Mr. Rose said that he and the committee have received voluminous input and suggestions from health care providers, insurers, and consumer advocates. However, the group he has not heard from is the business community. He very much wants to hear what small businesses have to say.

The time for the business community to be heard is now. Please send those concerns via email to Kathy.Darling. Your comments will included in the GBA Board ‘s coordinated response.

Kevin Wrege, Esq.

Founder & President

Pulse Issues & Advocacy LLC

Office: 202-625-1787

Mobile: 202-253-4929

4410 Massachusetts Ave., NW, #150

Washington, DC 20016

Consumer Groups, Producers Clash at NIAC Over Navigators’ Role in Exchange

Consumer Advocates, Brokers At Odds Over Navigators’ Role, Licensure Issues

Posted: March 28, 2011

Consumer advocates and insurance agents are at odds over the role that newly created “navigators” should play in insurance exchanges, particularly whether navigators should be required to obtain licenses. Advocates believe the distinction between brokers and navigators is clear and that navigators should not need to be licensed. But brokers and agents say existing consumer protections would be undermined if navigators don’t have to obtain a license to enroll people in plans.

The health reform law established the navigators and tasked them with carrying out certain function aimed at helping consumers better understand the policies available through the exchanges. Tasks include disseminating culturally and linguistically appropriate, unbiased information, fielding enrollee complaints and grievances, and facilitating enrollment. HHS is required to set standards pertaining to the navigators, but without formal regulations, many questions surround their exact role. The National Association of Insurance Commissioners produced a white paper earlier this month that aimed to identify and discuss the role of traditional brokers and agents compared with the expected role of navigators.

Questions explored include: Will the standards promulgated by HHS be floor or a ceiling? Should states have to license navigators? How will navigators be held accountable for errors?

In the section discussing licensing, the NAIC notes that the reform law does not preempt states requirements but that HHS can set standards — including licensure, if appropriate. Because states have licensing and certification processes that depend on local characteristic, flexibility is essential, the NAIC says.

All of the functions of a navigator are functions that agents would say they already perform, says Jessica Waltman of the National Association of Heath Underwriters. Waltman notes that the intent of the navigator program is to reach out to specific populations, and she says brokers fully support encouraging church, community and other groups to disseminate unbiased information about health plans. But only people who hold licenses should be able to actually enroll people in health plans, she says. She says only the individuals who conduct enrollment should require a license, rather than everyone who works for an entity that gets a grant to function as a navigator. Most state regulators agree, she says.

Waltman says HHS held a meeting last month to discuss these and other issues and believes the event helped both groups better understand each other’s position. Ultimately, she says, maintaining strong consumer protections is the key issue and one that both groups strive to achieve.

The Council of Insurance Agents and Brokers makes similar assertions in its comments on the NAIC while paper. If an individual or entity is providing general information or assistance regarding the availability of health plans, how to file a complaint or obtain an answer to a question about coverage, a license would not be necessary, the group says.. “However, once an individual or entity begins to offer more specific advice regarding the selection of coverage, provides claims advocacy services or becomes involved in the enrollment process, we would suggest that their activities mirror those performed by insurance producers and licensure is necessary,” the council’s comments state.

The council says its position is not influenced by concerns about competition, but rather is an “overarching public policy concern.” Absent a strong form of oversight, consumers may not have recourse if they are harmed as a result of navigators’ actions, the council writes.

Michael Miller of Community Catalyst, a consumer advocacy group, has a clear vision of what a navigator should be doing, such as helping people sort through their plans choices and figure out how to get questions answered. Miller said Community Catalyst would like to see the navigator program integrated with consumer assistance programs in the reform law, so that consumers would be able to get help with questions ranging from eligibility to care delivery.

Miller says brokers’ concerns are overblown. He says the overwhelming majority of people coming to an exchange will be eligible for Medicaid or subsidies — a group that brokers have not often dealt with. Therefore, they’re not likely to lose their place in the market, he says. Miller doesn’t think licensing is necessary.

A group of health care advocates, including representatives of from Families USA, the National Women’s Law Center and the Center for Budget and Policy Priorities, also say there is a clear distinction between navigators and producers. Agents and brokers solicit, negotiate and sell insurance, but these are not the duties of a navigator, they say. In many ways, the navigators’ role is analogous to the role that state assistance programs play with respect to Medicare, the group adds.

The advocates agree that the standards set by HHS should be a floor, not a ceiling, for certification and oversight of navigators — but with the caveat that states should be discouraged from creating standards so stringent that they could deter participation.

The advocates further say that they believe HHS should provide a template training program that states can adapt. “This would save time, but allow states to tailor information relevant to their Medicaid and CHIP programs and exchange. HHS can be helpful by supplying information that all navigators will need to understand regarding premium and cost-sharing assistance,” they write.

The advocates also say that rather than requiring each person acting as a navigator to receive a state license, standards could be set in grant agreements and it could be the responsibility of navigator entities to certify their employees or subcontractors, using training and testing materials provided by HHS and adapted by states.

The advocates agree that entities selected as navigators should be encouraged to carry liability insurance that would protect them, as well as consumers, in the event of errors. And they say there should be a complaint process for consumers who are dissatisfied with the performance of a navigator. Further, to guard against fraudulent operators that may try to move from state to state, the advocates suggest setting up a national registry.

The group also says compensation should be transparent. The advocates do not believe that funding navigators out of an exchange’s funding, collected mostly from fees on insurers, is an inherent conflict of interest. It would be a conflict, however, if a particular insurer were funding particular navigators, they say. — Amy Lotven

Washington Post: Council Hearing on Administration Hiring Practices

Mayor Gray’s hiring practices under microscope

By Tim Craig, Monday, March 28, 7:54 PM

Mayor Vincent C. Gray’s former chief of staff made several attempts to find a city job for Sulaimon Brown, eventually placing him in an agency with oversight over how the District spends funds on local and federal health-care programs, according to testimony from a D.C. Council hearing Monday probing the administration’s hiring practices.

The hearing, the first of two scheduled to try to unravel how several controversial hires were made, offered the most detailed picture to date of how Brown was hired as a $110,000-a-year special assistant despite six run-ins with law enforcement, including three charges in the District and one in Chicago.

Gerri Mason Hall, who was Gray’s chief of staff until her dismissal two weeks ago, instructed the Department of Health Care Finance on Jan. 31 to find a position to match Brown’s qualifications, the agency’s former chief of staff, Talib Karim, told the council.

“There was an auditor who she had identified for our agency,” Karim said, referring to Brown, who was later dismissed. “I was instructed to find a position for him.”

In his testimony before the Committee on Government Operations and the Environment, Karim said Brown was hired to work on a “special project” with the agency’s associate director for planning and policy. But after three weeks on the job, Karim said, agency leaders became concerned with Brown’s “poor performance and erratic behavior,” including “invading meetings he did not belong in.”

About the same time, Karim said, leaders started “receiving reports” that Brown was harassing female employees, including offering “a romantic gift to an intern with the agency.”

In an interview after his testimony, Karim alleged that Brown gave the intern a “love CD” on Valentine’s Day. Wayne Turnage, director of the health-care finance agency, told Brown on Feb. 24 that he was being fired.

Brown, who sat in the hearing room for part of the proceedings, declined to comment on Karim’s explanation of his termination.

“I won’t even dignify his comment with a response because it is off-base,” Brown said.

After Brown was fired, he alleged that Gray campaign officials last year had promised him a job if he stayed in the mayor’s race and continued his attacks former mayor Adrian M. Fenty (D). Brown said Lorraine Green, Gray’s campaign chairwoman, and campaign consultant Howard Brooks had given him cash payments during the campaign to continue his attacks on Fenty.

Gray (D), Green and Brooks have denied the allegations, and The Washington Post has not independently verified any payments.

The allegations came on the heels of reports that some top Gray administration officials had been awarded salaries that exceed limits set in the D.C. Code. The children of several top staffers and campaign officials — including Brooks, Green and Hall — were also were hired by the administration.

“This hearing is an attempt to get to the facts and lay them before the public and determine if laws were broken,” said D.C. Council member Mary M. Cheh (D-Ward 3).

Cheh, who chairs the committee, was joined at the hearing by council members David A. Catania (I-At Large), Muriel Bowser (D-Ward 4) and Marion Barry (D-Ward 8). Barry emerged as the sole defender of the administration, stating repeatedly that it is being held to an unfair standard.

“These are only allegations, and those of us on the council have a responsibility to not spread allegations as truth,” Barry said.

None of the witnesses said they had evidence that Gray had promised Brown a job.

All of the witnesses — including Reuben O. Charles, who headed Gray’s transition — also testified that they had no knowledge of Brown’s allegations that he had been paid by the Gray campaign last year.

But Judy Banks, head of the Department of Human Resources, testified that Hall set her son’s salary before she hired him, without an interview, as a special assistant for the Department of Parks and Recreation.

Cheh and other council members are hoping to gather more insight at the second hearing, tentatively scheduled for April 7.

Cheh said Green, Brooks and Hall have agreed to testify at that hearing. Brown has also been invited to testify, but he said he is uncertain whether to appear because he is already cooperating with a separate investigation by the U.S. attorney’s office.

“She needs to invite the mayor down here to testify, because he’s a key player in the whole thing,” Brown said, referring to Cheh. “For her to sit there and try to circumvent this, to put the mayor out of it, it’s ridiculous.”

During the hearing, Charles testified that he first met Brown the day after the Sept. 14 Democratic primary. Charles described Brown as “incredibly persistent” in his efforts to obtain a job.

“In many ways, he thought he was the most influential [person] to Vince Gray winning,” Charles said.

During the transition, Charles said, Brown became a nuisance and Green asked him to speak to Brown because he was “disrupting the flow” of the office.

Charles J. Willoughby, the city’s inspector general, testified that Hall contacted him Jan. 14 and asked him about a potential job opening in his office for Brown. When Willoughby told Hall that there were no openings, Hall asked him to “meet with him” as a “matter of courtesy.” The meeting was held the next week, but Willoughby said he reiterated to Brown that there were no openings.

When Brown received his job at the Department of Health Care Finance a week later, Banks said, Hall instructed her to process Brown with a salary of $110,000.

“We were told this was a special case,” Banks said.

craigt@washpost.com

Staff writer Nikita Stewart contributed to this report.

Kevin Wrege, Esq.

Founder & President

Pulse Issues & Advocacy LLC

Office: 202-625-1787

Mobile: 202-253-4929

4410 Massachusetts Ave., NW, #150

Washington, DC 20016