RandeeAbramsonJaime AngaritaAlan CampbellBethany Carr

Lynn ClementsRichard Dotson

Lucinda GallagherWendy Johnson

Thomas LongmanJames LuffmanWilliam MaloneyRoger Michels

Christine MorenoMario Nowogrodzki

Pat PattersonRobert RankinRichard Shapiro

Poornima Srinivasan

Rich RasmussenVice President for Membership Relations/Florida Hospital Assn.

George Elias Jr, EsquireAttorney & Counsleor at Law/George Elias, Jr., Esquire

160 Viewpoints on Health Care in 2013

Rich Rasmussen

Rich RasmussenVice President

Membership Relations for the Florida Hospital Association (FHA)

Rich Rasmussen serves as Vice President for Membership Relations for the Florida Hospital Association (FHA). His responsibilities include: enhancing membership value in the association including recruiting new members, managing the Florida Hospital Association Political Action Committee (FHAPAC), and serve as a member of the association’s advocacy team, lobbying on behalf of Florida’s hospitals. As part of his advocacy role, he serves as the President of the Coalition to Health Healthcare in Florida. He also is responsible for supervising the emergency management functions for the Association and works directly with the Rural Hospital, Chief Information Officer and Psychiatric Services Councils in the FHA. Prior to this role, Rich

position he held for seven years.

Rich came to FHA in 2000 following the merger of the Association and the Association of Community Hospitals and Health Systems of Florida (CHHS), where he served as Vice President, a position he held for ten

media, marketing and public relations, membership communications, and advocacy. He received his Broadcast Journalism degree from Florida Southern College in 1986. His hospital advocacy career began after serving as Press Assistant to the United States Senate Budget Committee under the Chairmanship of the late Senator Lawton Chiles.

In addition to his professional responsibilities, Rich is also a member of the Florida Public Relations Association; Florida Society for Healthcare Public Relations and Marketing; and the Society for Healthcare Strategy and Market Development. Rich served on a number of community boards including the American Red Cross, Tallahassee Urban League, Big Brothers/Big Sisters, and as District Captain of the United States Coast Guard Auxiliary. A father of three, Rich is active in the St. Paul’s United Methodist Church in Tallahassee.

September 2012

160 View Points on HealthCare in 2013

Rich RasmussenVice President for Membership Relations

• Affordable Care Act• State changes to Medicaid• Pressures to Lower Healthcare Costs• How Market is Responding

Economic

UninsuredAccess

Payment

Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 1999-2010. Bureau of Labor Statistics, Consumer Price Index, U.S. City Average of Annual Inflation (April to April), 1999-2010; Bureau of Labor Statistics, Seasonally Adjusted Data from the Current Employment Statistics Survey, 1999-2010 (April to April).

Worker ContributionEmployer ContributionNote: The average worker contribution and the average employer contribution may not add to the average

total premium due to rounding.

Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 2005-2011.

$10,880

$15,073

$1,416Worker Contribution Increase

52%

34%

39%

Medicare3,307,686

18%

Medicaid2,898,568

15%

CommercialInsurance8,728,628

46%

KidCare240,057

1%

Uninsured3,742,417

20%

• Passed March 2010• Expand coverage to 32 million

• Mandate to purchase coverage• Insurance reforms• Delivery systems reforms• Regulatory oversight• Improve quality & patient safety

• In 2014, individuals required to obtain coverage or face a penalty

• Business encouraged to provide coverage• Tax credits for small• Penalties for large

• Expansion of Medicaid• Subsidies to help low income

• No cancellation of coverage• No lifetime benefit limits or unreasonable annual limits.• No pre-existing condition exclusions

• under age 19 effective Sept 2010• Adults – 2014

• High Risk Pool • Community rate setting (not health status)• Free preventive care• Dependent coverage up to age 26

• Limits on rate increases• Medical loss ratio requirements

– Rebates if MLR not met• Uniform explanation of coverage documents and

standard definitions (3/23/12)• Health plan reporting requirements

– Initiatives to improve quality, care coordination, disease management, readmission initiatives, patient safety, wellness and health promotion

• State or Federally run– Individuals without affordable employer based coverage– Premium and cost-sharing support tax credits– Small business exchange

• Essential health benefits package requirements– What should be included

• Benefit options and cost sharing– Bronze, silver, gold, platinum

• Rating system for health plans

Accountable Care Organizations

Bundling Pilots

CMS Center for Innovation

Value-Based Purchasing

Geographic Variation

Medical Homes

Gainsharing

The Patient Protection & Affordable Care Act

• Law as a whole is constitutional and is upheld

• Individual Mandate is a tax

• Medicaid Expansion provision is limited, but not completely invalidated

• Medicaid expansion has to be construed as optional, not a mandatory requirement.

• Threatening with the removal of existing federal Medicaid matching funds, if they do not expand Medicaid, was considered “unduly coercive”.

• Insurance reforms and market place• Delivery system reforms

– ACOs– Bundled payments– Medical homes

• Payment Reforms– value-based payment modifiers, sanctions on avoidable

readmission and hospital acquired infections

• $10 Billion Center for Medicare and Medicaid Innovation

• Reimbursement reductions (including $155 Billion hospital Medicare and DSH reductions)

• PPACA passed the first hurdle, but there are more to go before the law is certain

• If Gov. Romney wins the Presidency, Republicans keep control of the House and the Republicans gain control of the Senate (at least 51 seats), parts of PPACA could be repealed or de-funded, such as the Individual Mandate

• If President Obama wins re-election, PPACA will stand, as he will veto any repeal legislation

• Currently, Florida has 3.9 million residents uninsured

• If Medicaid Expansion was fully implemented, 1.9 million more would be covered under Medicaid

• Florida will still have 2 million uninsured, even if Medicaid is expanded

• 537,000 Floridians will be eligible for the health exchange subsidies, and will be subject to the Individual Mandate

• Currently under Disproportionate Share Hospital (DSH) statute, Florida receives $53 per uninsured resident, while New Hampshire receives $1,204 per uninsured. Florida receives the same amount of DSH funding ($200 million) for its’ 4 million uninsured, as Connecticut does for its’ 300,000 uninsured residents.

• Florida Governor Rick Scott –– Refuses to expand Medicaid– Will not set up state health insurance

exchange– Not access grants to beef up insurance

oversight– Praying for a change in the White House

and repeal• What will the GOP-controlled State

Legislature do?

• Will those between 22 percent and 133 percent of the Federal Poverty Level be subject to the Individual Mandate if they are not covered by Medicaid Expansion?

• Hospitals nationwide took a $155 Billion cut to Medicare and DSH payments over ten years in exchange for more Americans insured. If Florida does not expand Medicaid, will the $10.7 Billion cut for Florida’s share still stand?

• Make the economic case for Medicaid expansion• Continue planning for implementation• Continue our commitment to provide better

coordinated, high-quality, affordable care for the patients we serve

• Focus on improving quality and cost efficiency• Continue to work with policymakers on both

sides of the aisle to shape the future of the health care delivery system and lower the uninsured rate.

$15,073 $15,567

8.0% 16.2%

*Private paySources: AHCA FHURS Data, 2010

Hidden Health Tax: Americans Pay a Premium, Families USA, Milliman, May 2009Kaiser/HRET Employer Health Benefits 2011 Annual Survey

• Move to a DRG based payment system• Medicaid managed care

– Long-term care– Medical care

• Funding issues– IGTs/LIP– Budget challenges

6

1

9

2

3

57

8

10

11

4

Region Counties

Numberof

RequiredPlans1

ManagedCare Plans

withContracts2

ManagedCare

Contractswith

Hospitals

Managed CareContracts in

Negotiations

Number ofHospitals in

SurveyRegion 1 Escambia, Okaloosa, Santa Rosa &

Walton2 15 24 33 11

Region 2 Bay, Calhoun, Franklin, Gadsden, Gulf,Holmes, Jackson, Jefferson, Leon, Liberty,Madison, Taylor, Wakulla & Washington

2 15 37 19 12

Region 3 Alachua, Bradford, Citrus, Columbia,Dixie, Gilchrist, Hamilton, Hernando,Lafayette, Lake, Levy, Marion, Putnam,Sumter, Suwannee & Union

3 to 5 16 85 7 18

Region 4 Baker, Clay, Duval, Flagler, Nassau, St.Johns & Volusia

3 to 5 13 72 11 17

Region 5 Pasco & Pinellas 2 to 4 13 137 3 18Region 6 Hardee, Highlands, Hillsborough, Manatee

& Polk4 to 7 14 149 5 23

Region 7 Brevard, Orange, Osceola & Seminole 3 to 6 12 102 8 22

Region 8 Charlotte, Collier, DeSoto, Glades, Hendry,Lee & Sarasota

2 to 4 14 88 8 18

Region 9 Indian River, Martin, Okeechobee, PalmBeach & St. Lucie

2 to 4 21 218 8 19

Region 10 Broward 2 to 4 22 223 15 16Region 11 Miami Dade & Monroe 5 to 10 21 198 11 22

1,333 128 196

Delivery System

Numberof

Plans

Numberof

Counties

Non ReformCounty

Enrollment as ofFebruary 1, 2012

Reform CountyEnrollment as ofFebruary 1, 2012

StatewideEnrollment

Health MaintenanceOrganization (Nonreform)

18 39 1,004,446 0 1,004,446

Health MaintenanceOrganization (Reform)

9 5 0 157,494 157,494

FFS Provider ServiceNetwork

4 6 10,807 143,181 153,988

Capitated ProviderService Network

2 31 101,112 0 101,112

Nursing Home Diversion 17 41 14,950 2,333 17,283

Fee For Service N/A 67 906,992 138,761 1,045,753

MediPass N/A 67 584,167 3,669 587,836

• Formation of ACOs– Physician based– Health plan-Providers, Aetna, Cigna

• Consolidation– Devita/MedPartners– WellPoint/Amerigroup– Other strange bedfellows– Hospital-Physician groups

• Health spending has flattened– Recession?– Changing consumer behavior?– Policy changes targeting unnecessary care– Reducing variation?– Increased value (i.e. safer care)?– Adopting accountable care concepts?– MLR rebates?

• Health plans getting aggressive– Tiering or redirecting– Pay for Performance– New policies– What will be sold in the exchange– Partnerships

• Eye on provider costs– Massachusetts rate controls

• Employers demanding changes• Focus on “Population Health”

– Mandated contracting– Out-of-Network focus on provider charges

• Hospital-based physician• What is the rate?

– Utilization – postpone or healthier?– Downstream impact of govt cuts on health plan rates– Can we really manage health?

The Three-Legged Stool and the Other Docs You Can Stand On

George Elias, Jr., Esq.

Attorney & Counselor at Law George Elias, Jr. Esquire, P.A.

George Elias, Jr. is a graduate of Case-Western Reserve University at Cleveland, OH (B.B.A.) and received his law degree from George Washington University in Washington D.C. (Juris Doctor with Honors in 1955). Upon graduating, selected as one of 30 law graduates in the U.S. for appointment to the Attorney General’s Honor Law Program, Tax Division, U.S. Department of Justice in Washington, D.C. Entering the private practice of law in 1965, Mr. Elias concentrated his practice in the areas of drafting wills, trusts and estate and tax planning documents, probate and guardianship administration, trust law and administration, probate and trust litigation, elderly and disability law. He is certified as a civil actions Mediator in the Dade County courts. He also has extensive legal experience in negotiating and drafting commercial/hospital and residential architectural/construction contract documents.

Mr. Elias has been responsible for the administration of hundreds of decedents' estates, trusts and guardianships during more than 35 years of practice. His broad range of experience enables him to offer advice to efficiently and effectively probate estates, administer trusts, prosecute and defend litigation involving wills and trusts, and protectively handle the affairs of incapacitated persons, all in compliance with the duties and obligations of law.

Mr. Elias holds membership in the Real Property, Probate and Guardianship Sections of both The Florida Bar and the American Bar Association. He is also a member of the Dade County Bar Association, wherein he served as Chairman of the Tax Committee (1967), and Chairman of the Probate and Guardianship Committee (1988). He was the Founder, Lecturer and Permanent Chairman of the Dade County Bar Association's "Annual Surviving Spouse Seminar" (1984–1994).

Additionally, Mr. Elias serves on the governing Boards of several charitable institutions, including St. Jude Children's Research Hospital in Memphis, TN, its Executive Management Board (1970 to present), serving as CEO/Chairman of the Board (1988-1990), and member (and Chairman (1990-1997)) of the Building Committee (1986 to present), overseeing hospital construction exceeding $500 Million. He also served on the Boards of Trustees and Directors and Secretary of the Miami Heart Institute, Miami Beach, FL (1965-1991), and the Papanicolaou Cancer Research Institute, n/k/a Sylvester Comprehensive Cancer Center (1984-1990).

CHRISTINE M. MORENO ATTORNEY-CPA

TEL: 772/ 288-1020

The Basics of What Most Clients Need

None of the Materials contained herein, and None of the information conveyed orally during this presentation, can be used or relied upon for penalty protection.

Christine M. Moreno, Attorney-CPA, practices law throughout the State of Florida, with her law office in Stuart, Florida.

A graduate of Barry Univ & U of M Law School, and Mayor of North Miami in 1981. Christine was past President of the North Dade South Broward FICPA Chapter and remains a Director. Chris has served as Past Chair of the Accounting Show Committee.

Christine holds a CGMA designation and advises individuals on their business, estate, real estate, probate and tax matters. Her practice does notinclude preparing or filing tax returns.

Estate Documents should comply with the state laws of the Taxpayer’s domicile

Domicile is crucial factor in determination of State’s Death Tax, other crucial factors include location of Taxpayer’s property

1. Is Taxpayer’s desires met with current estate Documents?

2. Are estate documents in compliance with state law?

3. Are Safe guards in place in event of death or disability, to insure proper administration?

Key Items to Verify in Review of Will:

1. General Form: Two Witnesses & NotaryWas it properly executed?

2. 4-Corners: Does Will Read Properly?Taxpayer’s intent accomplished?

3. Distributions Occur on Date of Death for Probate Assets only (not jointly held assets)

Simple Wills: Devise probate assets as of date of death

Testamentary Wills: Contain provisions for creation of Trust, to distribute probate assets over a period of time to designated beneficiaries

BEWARE: Powers of Appointment(General POAs versus Special or Limited POAs)

Trusts are either Revocable or IrrevocableGrantor/Settlor can amend Revocable until Grantor dies or is incapacitated, at which time the trust becomes irrevocable

Irrevocable is usually non-amendable (usually a life insurance trust or a charitable trust is irrevocable)

Pour-Over Will is provided with Trust and “Pours Over” into the Trust any assets not already placed in Trust. So, Residuary Beneficiary is usually the Trustee of the Trust.

Most Important Document for Most Florida residents

Allows Taxpayer to select Attorney-in-Fact to act for Taxpayer in event of unavailability or incapacity

Attorney-in-Fact is held to duties of Fiduciary

Remember: A copy is as Good as an Original

HIPPA requirements mandate written authorization by patient prior to release of medical information and records to third parties (even spouses)

Must be signed by Patient with two witnesses, Notarization is recommended

Governor’s Office provided form for designation of healthcare surrogate by patient.

It is advisable to also include successor or alternate designations, in the event of unavailability.

Keep up to date with correct addresses and contact numbers.

Give copy to Primary Doctor as well as Surrogate.

Schiavo Case is ever in our minds (Living Will)

Right to decline medical procedures, including forced nutrition & hydration, when it will only prolong artificially the natural process of dying

This is not a Do Not Resuscitate (“DNR”)

Copy to Primary Physician &

First Leg Is: Simple Will

Second Leg Is: Durable POA

Third Leg Is: Healthcare Surrogate and related medical docs

Good Night, Sweet Prince

Learn more about membership. | msc@ficpa.org | www.ficpa.org(800) 342-3197 (in Florida) | (850) 224-2727

“ I renew because of the invaluable networking opportunities that being a member of the F ICPA provides. From being involved with your local chapter to attending networking events, the F ICPA is an organization that is

known and respected across many industries.”

Monica Ospina, CPA, ABV, CFF Cherry, Bekaert & Holland, LLP

Coral Gables Member since 2007

“ I renew my F ICPA membership because of the signif icant access to education, current events, and the

networking it provides.”

Ray Monteleone, CPA President, Paladin Global Partners

Fort Lauderdale Member since 1979

“ Ibeced

“ I’m renewing my F ICPA membership because it keeps me professionally and socia lly connected to my fellow peers in the profession.”

David White, CPA Carr Riggs & Ingram LLC

Tallahassee Member since 2010

FICPA Membership: Connect, Learn and ThriveProud to be a Member

Keep Your Organization Moving Forward

For more information, please contact the FICPA at onsite@ficpa.org

or call (800) 342-3197 (in Florida) or (850) 224-2727 extension 412.

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