October 01, 2012 (CaliforniaHealthline) by George Lauer – As many as four million Californians could remain uninsured after all national health reforms are in place, and about half of them will be eligible for subsidized coverage but not enrolled, ac

cording to a new report.

National reform will bring health coverage to millions of previously uninsured Californians through the expansion of Medi-Cal and creation of subsidized insurance through the new Health

Benefit Exchange. However, millions still will fall through the cracks, say authors of a joint report from the UC-Berkeley Center for Labor Research and Education and the UCLA Center for Health Policy Research. According to the authors, 3.1 million to four million Californians still will be uninsured after health reform fully takes effect.

“The number of remaining uninsured doesn’t surprise us, but I suspect it will surprise others,” said Ken Jacobs, chair of the UC-Berkeley Labor Center and one of the report’s authors.

“Both the overall number and the mix of who those people are … important data and should serve as a wake-up call for the need to maintain the safety net system in California,” Jacobs said.

Among the findings and predictions in the report, “Who Will Remain Uninsured?”:

•Half of all remaining uninsured, or two million Californians, will be eligible for Medi-Cal or exchange subsidies but will remain unenrolled due to lack of awareness about the programs, challenges in the enrollment process or an inability to afford subsidized coverage;
•Nearly 40% of the remaining uninsured will not be able to afford coverage;
•More than 70% of the remaining uninsured will be exempt from the federal tax penalty; approximately 3% of all Californians will owe a tax penalty in 2019 due to not obtaining minimum coverage;
•Latinos will make up two-thirds of the remaining uninsured; and
•Californians with limited English proficiency will account for about 60% of the uninsured.
•Report Recommends Extra Effort in Latino Community
Authors of the report recommend that state officials make an extra effort to connect with the Latino community.

Chad Silva, policy director for Latino Coalition for a Healthy California, agreed.

“The California Departments of Health Care Services and Managed Health Care and the Health Benefit Exchange need to engage community-based stakeholder groups who are already working with this population,” Silva said. “Groups such as ours, who have ties with many of these groups, can help to facilitate the dialogue and linkages,” he said.

Silva said there is some doubt

in the Latino community about whether outreach efforts by the state’s new insurance exchange will be adequate.

“It is our understanding that the exchange plans to allocate $250,000 for a statewide outreach effort. This would not be sufficient to engage a population the size of Fresno,” Silva said.

“It is concerning that they underestimate how hard it will be to engage the Latino community, especially those residing in rural communities in isolated areas. The report highlights some of the issues: language, age, class, etc., that would make engagement difficult if the right people are not treated as partners in this process,” Silva said.

“All of this is exacerbated by their compressed timeline,” Silva added. “People and things can get missed when done very quickly. We need to be diligent, and help the exchange help themselves.”

The Health Benefit Exchange this week begins a nomination process to identify and select stakeholders to participate in advisory groups.

‘Safety Net Will Still Be Needed’

Report authors recommend that California officials take steps to ensure a strong post-ACA safety net.
“The most important take-away from this report I think,” UC-Berkeley’s Jacobs said, “is to urge governments at every level — federal, state and county — to maintain whatever they’re doing after ACA arrives. It’s fair to assume most programs won’t need as much money or attention because a lot of the people who use those programs now will be insured, but it won’t be everyone — not by a long shot.”
Jacobs added, “Programs like Family PACT and LIHP and others will still serve an important role — maybe not as big a role, but still important.”
Family PACT provides family planning services to low-income Californians, and LIHP — the Low Income Health Program — is part of the state’s 1115 Medicaid waiver known as the “Bridge to Reform.” Both programs are administered by the state Department of Health Care Services.
The report also suggests state officials might consider creating new safety-net programs once the ACA is in place and the state’s needs change.
“We don’t really have anything I mind at this point,” Jacobs said. “That is more a long-range recommendation that California be thinking of new possibilities.”
Undocumented Immigrants Part of the Mix
The report predicts that after health care reforms are in place almost three-quarters of California’s uninsured will be U.S. citizens or documented immigrants. That means as many as one million undocumented immigrants may be among the uninsured.
That meshes with estimates by Latino Coalition for a Healthy California, Silva said, adding that it’s a difficult group to count.
“This is not a population that tends to want to be counted due to fear [of] reprisals,” Silva said.
“We agree with the conclusions made in the report that point to strengthening the safety net, in particular the clinics, which can be federally qualified, FQHC look-alikes. The state needs to avail itself of every federal opportunity to fund the clinics and increase funding to assure that health care is provided to all,” Silva said.
Silva said the report’s findings support a broader approach to health care that goes beyond insurance.
“I think the conclusions and recommendations in this report would tend to support investments into wellness and health at the community level,” Siva said. “Clearly, insurance coverage is not going to do enough to address health disparities and health equity. It is clear that millions will be left out for one reason or another. The best way to address this is to not focus on insurance coverage but to focus on preventing disease.”
Silva said investing in clinics and taking advantage of federal programs that support creating healthier communities, such as safe routes to schools and community transformation grants, would help.
“If the environment in which we live is healthier as the result of smarter planning, more open spaces, greater access to healthier foods, the community as a whole benefits. This report supports the idea that we need to be thinking about this differently. Insurance coverage only deals with one side of the equation. The greater impact can be realized by investing in health and wellness,” Silva said.

Health care reform at-a-glance W-2 reporting requirements.

The Affordable Care Act (ACA or health care reform law) requires employers to report the cost of employer-sponsored health benefits. This is a new, separate entry on the W-2 form. Here’s

w

hat you need to know:

Who the provision applies to:

The W-2 reporting provision applies to grandfathered and non-grandfathered plans, both fully insured and self-funded groups.
The requirement applies to anyone who is still receiving benefits from the employer, including COBRA participants and retirees (even though retiree-only plans are exempt from the health care reform law).

What the provision requires:

Employers must report the cost of coverage under an employer-sponsored group health plan. Employers must start reporting for tax years on or after January 1, 2011 (meaning it would be reported on employees’ W-2 forms they receive in 2012).
However, there will be transition relief available for certain employers and types of coverage. (See this question for more information about transition relief.)

Costs to be included in the calculation:

The ACA didn’t specify the costs to be included in the W-2 calculation. Instead, it stated that the rules will be similar to those of Internal Revenue Code section 4980B(f) – the method for calculating applicable premiums for COBRA continuation coverage. Based on that description, IRS guidance states that the following types of coverage will be included in the W-2 calculation:
 Medical plans, including limited benefit plans
 Prescription drug plans
 Dental and vision coverage provided as part of the medical plan
 Hospital indemnity or specified illness (insured or self-funded) paid pre-tax or by employer
 Health Flexible Spending Arrangement (FSA) for the plan year in excess of employee’s cafeteria plan salary reductions for all qualified benefits
 Employee physicals
 Domestic partner coverage
 Employee assistant programs (required if employer charges a COBRA premium)
 On-site health clinics (required if employer charges a COBRA premium)
 Wellness programs(required if employer charges a COBRA premium)
 Medicare supplement insurance
Due to transition relief, there are some optional coverage types that employers can choose or choose not to include in reporting the cost of health care benefits. (See this question for a list of those coverage types.)

Even though the W-2 calculation will be based on COBRA rules, employers should not assume that the W-2 amount will be the same as the COBRA amount for two reasons:
 The W-2 reporting requirement extends to plans that don’t ordinarily count toward the COBRA premium
 The COBRA calculation allows for an administrative fee and the W-2 calculation does not

Questions and answers:
Q: Does this mean employees will pay taxes on their health insurance?
A: No. There is nothing about the reporting requirement that causes or will cause excludable employer-provided health coverage
to become taxable. The purpose of the reporting requirement is to provide employees useful and comparable consumer
information on the cost of their health care coverage.

Q: Must an employer issue a W-2 form with the aggregate cost of applicable employer-sponsored coverage to an
individual to whom the employer is not otherwise required to issue a W-2 form, such as a retiree or other former
employee receiving no compensation required to be reported on a W-2 form?
A: No. The IRS Notice 2012-9 stated that an employer is not required to issue a W-2 form reporting the aggregate reportable
cost to an individual to whom the employer is not otherwise required to issue a W-2 form.

Q: Where will this information appear on the W-2 form?
A: The IRS has determined that the value of health care coverage will appear in Box 12 with Code DD to identify the amount.
You can view the draft form on the IRS website.

Q: Are there any types of coverage I don’t have to include?
A: According to IRS guidance, employers do not need to include these amounts in the W-2 calculation:
 Accident insurance
 Automobile medical payment insurance
 Disability insurance
 Credit-only insurance
 Employee contributions to health care flexible spending accounts and health savings accounts (reported elsewhere on
W-2)
 Health Flexible Spending Arrangement (FSA) funded solely by salary-reduction amounts
 Health Saving Arrangement (HSA) contributions by employer or employee
 Archer Medical Savings Account contributions by employer or employee
 Long-term care insurance
 Plans paid for with after-tax dollars
 Stand-alone dental and vision coverage
 Workers’ compensation insurance

Q: Do I need to adjust the calculation if an employee is

only covered for part of the month?
A: The provision doesn’t indicate how to calculate for partial-month coverage. We expect further clarification is forthcoming.

Q: What transition relief is being provided?
A: For certain employers and types of coverage listed below, the requirement to report the cost of coverage will not apply for the
2012 W-2 forms (the forms required for the calendar year 2012 that employers generally are required to provide employees in
January 2013) and will not apply for future calendar years until the IRS publishes guidance giving at least six months of advance
notice of any change to the transition relief. However, reporting by certain employers and types of coverage may be made on a
voluntary basis.

Q: Which employers and types of coverage does it apply to and how long does it last?
A: The transition relief applies to the following:
(1) employers filing fewer than 250 W-2 forms for the previous calendar year (for example, employers filing fewer than 250 2011
W-2 forms (meaning Forms W-2 for the calendar year 2011, which generally are filed with the SSA in early 2012) will not be
required to report the cost of coverage on the 2012 W-2 forms (which generally are filed with the SSA in early 2013). For
purposes of this relief, the number of W-2 forms the employer files includes any forms it files itself and any filed on its behalf by
an agent under § 3504 (see Q&A-3 of Notice 2012-9 for more information). In addition, for purposes of this relief, the employer is
determined without the application of any aggregation rules;

(2) multi-employer plans;
(3) Health Reimbursement Arrangement (HRA) contributions;
(4) dental and vision plans that either
 are not integrated into another group health plan or
 give participants the choice of declining the coverage or electing it and paying an additional premium (see Q&A-20 of Notice 2012-9 for more information);
(5) self-insured plans of employers not subject to COBRA continuation coverage or similar requirements;
(6) employee assistance programs, on-site medical clinics, or wellness programs for which the employer does not charge a premium under COBRA continuation coverage or similar requirements; and
(7) employers furnishing W-2 forms to employees who terminate before the end of a calendar year and request a Form W-2 before the end of that year.

If your company’s major medical plan includes prescription drug coverage, you are required to provide disclosure notices to Medicare Part D eligible individual

Medicare Part D Notifications must be sent by October 15th each year.

If you send t

he notices by e-mail, you must include the

statement: “If you would like a printed copy, please let us know and we will be happy to provide you with one”.

CMS recently revised its model disclosure notices, and you ilmainen kasino will need to change any notices you have sent in the past. The revised notices reflect a change in the Medicare Part D annual coordinated election period (ACEP), which now runs from October 15 to December 7. As a result of the change, your company must now provide its annual creditable and non-creditable coverage disclosure notices by October 15 of each year.

The CMS website is very helpful. http://www.cms.gov/creditablecoverage/

Monday, Sep. 17, 2012
Goal Power
By Dr. Mehmet Oz

I am terrified of heights. Climbing to the top of a telephone pole three stories tall in the Arizona desert is not my idea of a good time. It didn”t help much that I would be wearing a helmet–a

three-story drop is a three-story drop, no matter what you”ve got on your head. It should have helped that I”d be wearing a safety cable, but that made no difference either. If you know anything about how the brain works, you know that what you understand in your reasoning lobes and what you feel in your emotional lobes are two very different things. And when it came to the idea of standing atop a swaying, creaking pole with the desert floor swimming below, my emotional lobes won in a landslide.

I had gone to Arizona with a crew from The Dr. Oz Show and a group of 50 women who had been offered a surprise trip and were taken directly from the studio in New York during the taping because they desperately wanted to make changes in their lives. Maybe one wanted to quit smoking; maybe another wanted to lose weight or exercise more or go back to school or get out of a lousy job. The point is they were stuck, rooted between the world of “I know I should do this” and the world of “I”m actually doing it”–a place where many of us can spend a lot of fruitless and frustrating time.

The three-story pole was a three-story metaphor. Take a step forward–or actually a step straight up–in Arizona and maybe we could all take other, even scarier steps elsewhere in our lives. I was paired with Pam, a 33-year-old IT worker from Long Island who had been obese as a child and hasn”t wanted to be singled out since for fear of embarrassment. So in the spirit of taking the counterintuitive step, she agreed to go first and be singled out for a very positive reason. I stood at the bottom of the pole, watching her go up and dreading the moment when she would reach the tiny platform at the top, which was big enough for only two, because that would mean I had to go. When I began the climb, it was just what I expected, by which I mean the whipping wind and the receding ground and my sweaty palms on the rungs were just awful. But there was a power in enduring that awfulness.

Pam shouted down encouragement, and as I neared the little platform, she reached out, took my hand and helped me take the final step. My real fear, it seemed, had not been of heights but of lack of control. Trusting Pam was the antidote. I flung an arm around her in a celebratory hug. The climb may have been terrible, but completing it

was sublime.

You Know You Should

There”s a strange, discordant pathology to the state of being stuck. Nobody who starts smoking plans to be hooked for life. Nobody who”s obese secretly wants to stay that way. When a doctor or family member pleads with us to make lifesaving changes, we mean it when we say, “I know, I know, I should. I will.” What”s left unsaid is the killer caveat: “Just not today.”

Over the years, I have had more conversations like this with patients than I can count, so many that the phrase “I know I should” has become a bright red flag–a sad predictor that I will probably one day crack open those patients” sternums in the operating room, trying to undo the damage that poor choices and unhealthy lifestyles have done to their hearts. Why these people spend their lives moving stubbornly toward major, potentially life-threatening surgery when they could avoid it with just a few wise moves is a riddle that has always dogged me.

But perhaps it shouldn”t. Getting people to make meaningful changes in their lives is much more complicated than explaining to them what to eat for dinner, how often to exercise and which kinds of tests they should get from their doctors. The psychology of health is every bit as complex as the biology, and to create seismic shifts in behavior, we have to probe the subconscious.

Psychologists divide behavior into the ego syntonic and the ego dystonic. Ego syntonic is when we embrace a mere fear as absolute truth and the unhealthy behavior that results as justified–as with an anorexic who truly believes she is overweight despite a doctor”s scale saying otherwise. Ego dystonic is when, for example, a person with obsessive-compulsive disorder knows that worrying about germs isn”t healthy but can”t stop anyway. When it comes to behavior, the ego-dystonic sort ought to be easier to fix: you already understand what has to be done. But if that were so, far fewer of my patients would have to make that long trip to the cardiac OR.

There are lots of ways to move the needle on the dystonic problem. A colleague and frequent collaborator of mine, psychologist John Norcross, is one of

the authors of a groundbreaking book, Changing for Good, which, as the title suggests, explains not only how to repair what”s not working in your life but also how to make those fixes stick. It does this with the help of what”s known as the transtheoretical model, which has been around since the late 1970s but is no less powerful now and even has special utility when two-thirds of Americans are overweight or obese and 600,000 of us are killed by cardiovascular disease per year.

The transtheoretical model divides the process of making changes into five key stages: precontemplation, contemplation, preparation, action and maintenance. Precontemplation is in many ways the most dangerous; you have no plans to make any changes and may not even be aware you have a problem. This is often the state of the early-stage alcoholic who clearly has a problem but has not yet lost a job or cracked up a car and can thus pretend everything”s fine. It”s less common in cases of obesity or smoking. There are too many reminders, from the warnings on cigarette packs to the pains in your chest to the numbers on the scale.

Much trickier are the contemplation stage, in which you begin to recognize the problem and weigh taking action, and the preparation stage, when you intend to act imminently. People who get stuck at “I know I should” generally get marooned on the shores of one of these states of mind.

So how to get unstuck? Here”s where psychology and a little spirituality can help. Throughout time, religion has been about not just worship but also life lessons, self-improvement and redemption, with earthly accountability to the community and congregation to help keep us in line. It”s hard to cheat a neighbor who sits next to you in church. It”s hard to skip an exercise class organized by your congregation. Alcoholics Anonymous was launched in the 1930s with a 12-step model based on the same idea. Here, too, getting the support and, if necessary, the scolding of a group leads to better results than what AA members call white-knuckle sobriety–when someone who puts the cork in the bottle relies on sheer tooth-gritting willpower to resist pulling it back out.

A 2012 study in the journal Obesity explored the power of the collective, looking at the weight-loss rate among people in groups who succeeded at a 12-week diet. The participants were 12,000 people who took part in the 2009 Shape Up Rhode Island fitness campaign. They divided themselves into 987 five-to-11-person teams, stayed in regular communication over the Internet and competed with other teams to see who could lose the most at the end of 12 weeks.

In general, the researchers found there was a kind of virtuous loop among the most successful groups. The more pounds any individual member of a high-weight-loss group dropped, the likelier it was that other members would follow suit and shed more pounds too. At the end of the study, members of the most motivated and successful groups lost 5% of their body weight–a healthy and maintainable target that members of a lot of the other groups missed. Crunching the data, the researchers concluded that any person from the 5% group would have lost only 3.8% of body weight if moved to a less successful group. In other words, it wasn”t just the quality of the individual”s resolve; the quality of the group”s mattered too.

A 2008 study published in the New England Journal of Medicine took a similar approach, looking at the dynamics of smoking behavior in a large social network. Harvard”s Dr. Nicholas Christakis, the lead author of the paper (and a TIME Ideas contributor), is a pioneer in the young field of social networks and public health. He and others have found that a whole range of health issues, from depression to smoking to obesity, can be powerfully influenced by the other people in your social web, including–remarkably–some you”ve never met.

There”s no telepathy involved in that. Perhaps you decided to quit smoking because you saw a friend succeed at it. But she quit because her husband, whom you know slightly, had done so. And he quit because he was following the example of an office friend you don”t know at all. Twang one strand in the web and it can cause vibrations everywhere. The 2008 study explored more direct, first-person contact, but the results were still striking: people whose spouse quit smoking were 67% less likely to start or continue smoking; they were 36% less likely if a friend quit, 34% if a work colleague quit, and 25% if a sibling did.

Achieving a goal doesn”t always have to be a collective effort. Sometimes it can be simply a matter of breaking the job up into a lot of minigoals. Part of AA”s genius is its “one day at a time” dictum. You don”t have to quit drinking for the rest of your life; just do it today. Tomorrow you can make the same choice again. String together enough such days and you”ve put down the bottle for good.

In a 2007 study, a randomized clinical trial for postmenopausal women with Type 2 diabetes, investigators tested the effectiveness of the Mediterranean lifestyle–a regimen that includes regular exercise as well as a diet based on fruits, vegetables, olive oil, nuts, beans and lean meats, particularly fish and other seafood. The study found that the incremental approach works. Subjects who set short-term goals–increasing exercise sessions in five-minute increments, for instance–were doing better at the end of two years than a control group of people who simply adopted the program and, all too often, abandoned it later.

The Accountability Factor

Medication compliance is another critical area that can be improved by intervention and goal setting. From 50% to 75% of all hypertension patients currently prescribed drugs don”t have their pressure under control because they fail to take the meds dependably. A 2006 study conducted by the National Heart, Lung and Blood Institute and published in the journal Disease Management used the transtheoretical model to try to improve those numbers in a sample group of 1,227 patients. All the subjects were in the pre-action phase: not complying but planning to. And all were given the assistance of both an onscreen and a paper transtheoretical workbook that used questionnaires and other tools to explore why they were stuck and what it would take to get them to move. Significantly, participants were surveyed three times during the study, meaning there was follow-up and accountability in the mix. A year after the study was done, 73% of those who had received counseling were compliant with their drug regimens, compared with just under 58% for a control group. At 18 months it was 69% to 59%. That”s not 100%, but imagine slowing the No. 1 killer in the U.S. by simply getting resistant patients to take their statins and beta blockers.

I”m not pretending any of this is easy. Inaction is a powerful coping mechanism. Justification and rationalization are ways to handle feeling desperate, out of options, out of control. The National Institute of Mental Health published a revealing article in 2010 on the phenomenon known as emotional inertia–a sort of fixed state of depression, low self-esteem, anxiety or other condition that rarely seems to change even in the face of circumstances that warrant change. Using a series of role-playing games in which subjects were asked to work through a family problem, investigators found that when the need to act was most pressing, subjects dug into their habitual moods more than ever. The urgency paradoxically pushed them to cling more closely to the thing they knew, even if it was bad and unhealthy. I see this in some of my patients, who are so demoralized by their failure to lose weight or quit smoking that as soon as they leave my office, they seek comfort in a sundae or a cigarette.

In fairness, that is the nature of all of us. Human beings can be remarkably static creatures; it”s practically woven into our DNA. Why move from the familiarity of the campfire circle and step into the scary wilderness, even if wonderful, life-giving things might be there? Doctors, however, like to look at things another way. To us, life is never static. Everything is either growing or dying. When you delay your diet until tomorrow or wait to quit smoking until your next birthday, you are choosing, in a day-to-day way, to follow the route of the dying.

Taking action, of course, is the very hardest of the transtheoretical steps–the moment you stand up from the campfire, dust off your pants and begin walking toward the woods. Difficult as it is, though, it can be the start of an inexorable forward momentum. As Newton taught, a body in motion stays in motion. I often remind my patients of a favorite and familiar riddle: If you see 10 birds on a wire and five decide to fly, how many are left? The answer is 10. Deciding and doing are not the same.

I learned that fact anew at the base of that pole in Arizona. I traveled west that day having already decided to climb the blasted thing. But I hadn”t done anything at all until I actually put my foot on the lowest rung.

September 6, 2012

Guidance on waiting period and determining full-time status for shared

responsibility of employers On August 31, 2012, two notices were issued. The first was issued by the Department of Health and Human Services (HHS) on the 9

0-Day Waiting Period Limitation. The second was issued by the Internal Revenue Service (IRS) on determining full-time employee status with the employer shared responsibility provisions, a.k.a. the “Employer Mandate.” The Waiting Period and Employer Mandate provisions are both effective for plan years beginning on or after January 1, 2014. Waiting Period The HHS guidance defines the Waiting Period Limitation

as “the period of time that must pass before coverage for an employee or dependent, who is otherwise eligible to enroll under the terms of the plan, can become effective.” Effective for plan years beginning on or after January 1,

2014, the waiting period can be no more than 90 days. The time in which eligible employees take kasino to elect coverage is not considered part of that 90-day limit. Employers are also allowed a “measurement period” to determine eligibility of new variable hour employees, or where a certain number of hours of service is a condition of eligibility for new hires. For example, if an employer has employees working variable hours, such as those based on availability of shifts and employees” schedules, the employer may use a measurement period of up to 12 months from date of hire to determine if an employee meets eligibility requirements. This measurement period is not considered part of the waiting period. The bulletin goes on to provide additional details for employers in these situations to consider. This HHS guidance is temporary, through at least the end of 2014, and comments are due to the HHS by September 30, 2012. Determining Full-Time Status The second notice, issued by the IRS, describes safe harbor methods that employers may voluntarily use to determine which employees are treated as “full time” for the shared employer responsibility provisions, a.k.a the “Employer Mandate.” Employers may

apply these safe harbor methods to ongoing and newly hired employees. Due to the complexity and detail of the

IRS notice, and how the methods may be applied to a particular employer, we encourage clients to review what might be applicable in the guidance with their own legal counsel. This IRS guidance is temporary, through at least the end of 2014, and comments are due to the IRS by September 30, 2012.