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Monday, August 26, 2013

The Family and Medical Leave Act (FMLA): An Overview

Gerald Mayer
Analyst in Labor Policy

The Family and Medical Leave Act of 1993 (FMLA), as amended, is intended to help employees balance work and family life. The act provides eligible employees with two types of job-protected leave: regular leave and military family leave. In turn, military family leave consists of qualifying exigency leave and military caregiver leave. 

Eligible employees.
Under the FMLA, an eligible employee is an employee who has worked for the employer for at least 12 months (the 12 months need not be consecutive), has worked a minimum of 1,250 hours in the 12 months preceding the start of FMLA leave, and is employed at a worksite where 50 or more employees are employed by the employer within 75 miles of that worksite. 

Covered employers.
The FMLA covers both private and public sector employers. The FMLA covers private employers who employed at least 50 employees for at least 20 weeks in the preceding or current calendar year. Public agencies are covered by the FMLA regardless of the number of employees. To be eligible for FMLA leave, public employees must meet the above employee eligibility requirements of the act. Public agencies include the federal government and state and local governments. A “state” includes the District of Columbia and the territories and possessions of the United States. 

Job-protected leave.
After returning from FMLA leave, employees generally have the right to return to the same, or an equivalent, job with the same pay, benefits, and working conditions. Paid versus unpaid leave. FMLA leave is generally unpaid leave. An employee may, however, substitute accrued paid leave for FMLA leave. Private employers may require an employee to substitute accrued paid leave for unpaid leave. While an employee is on FMLA leave, an employer must maintain the employee’s group health insurance coverage. 

Regular FMLA leave
. An eligible employee may take up to 12 weeks of leave for the birth and care of a child; to care for an adopted or foster child; to care for a spouse, a child under age 18, or a parent with a serious health condition; or because the employee is unable to work because of his or her own serious health condition.

The 12 weeks of FMLA leave need not be continuous. If there is a medical need, an employee may take “intermittent” leave or work a part-time schedule. Although it is not required, an employer may agree to allow an employee to take intermittent or part-time leave for the birth or care of a child or to care for an adopted or foster child. 

Military family leave
. Eligible employees may take two types of military family leave. The first type of leave is for a qualifying exigency. Qualifying exigencies include a “short notice deployment” (which is a notice that a member of the employee’s family will be deployed in seven days or less); time for the employee to arrange for childcare, make financial or legal arrangements, or attend official ceremonies; time to care for a parent of a military member if the parent is incapable of self-care; and up to 15 days of leave for the employee to spend time with a member of the military who is on temporary leave for rest and recuperation during a deployment.

The second type of military family leave is military caregiver leave. An employee who is the spouse, son or daughter (of any age), parent, or next of kin of a covered servicemember with a

serious injury or illness can take up to 26 weeks of leave during a 12-month period to care for the servicemember. 

Airline flight crews
. The FMLA has special rules that apply to airline pilots, flight attendants, and other airline crewmembers. A member of an airline flight crew is eligible for FMLA leave if he or she worked (1) at least 504 hours during the previous 12-month period for the employer and (2) at least 60% of the minimum number of hours that the employee was scheduled to work in any given month or, for an employee who is in “reserve status,” at least 60% of the hours that an employee was paid for any given month. The hours that airline flight crews work include the hours spent in flight and the hours that a crewmember is on duty but not in flight. The hours that a crewmember is on duty may include hours between flights or hours during which a crewmember is on reserve status waiting to be called to duty.

Date of Report: August 5, 2013
Number of Pages: 14
Order Number: R42758
Price: $29.95

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Medical Loss Ratio Requirements Under the Patient Protection and Affordable Care Act (ACA): Issues for Congress

Suzanne M. Kirchhoff
Analyst in Health Care Financing

The 2010 Patient Protection and Affordable Care Act (ACA, P.L. 111-148, as amended) requires certain health insurers to provide rebates to their customers for each year that the insurers do not meet a set financial target called a medical loss ratio (MLR). At its most basic, an MLR measures the share of a health care premium dollar spent on medical benefits, as opposed to company expenses such as overhead or profits. For example, if total premiums collected are $100,000, and $85,000 is spent on medical care, the MLR would be 85%. The ACA sets the minimum required MLR at 80% for the individual and small group markets and at 85% for the large group market. In general, the higher the MLR, the more value a policyholder receives for his or her premium payment. Congress imposed the MLR in an effort to provide “greater transparency and accountability around the expenditures made by health insurers and to help bring down the cost of health care.” Insurers that fail to meet these minimum standards must provide rebates to policyholders.

The Department of Health and Human Services (HHS), with input from state insurance commissioners who are the main regulators of health insurance, issued rules for implementing the MLR. These rules provided greater details for calculating the MLR and issuing rebate payments. ACA allows companies to include quality improvements along with medical benefits when calculating the MLR. In addition, state and local taxes and some licensing fees are subtracted (i.e., disregarded) from expenses in the MLR formula. ACA’s requirements are different from those imposed by state laws, which generally compare only medical claims to premiums. Though a number of states have their own MLRs, the ACA is now the minimum standard that must be met nationwide by certain health insurers. About 8.6 million U.S. consumers were due more than $500 million in ACA MLR rebate payments by August 2013, for an average award of $98 per qualifying household. Employers or insurers can provide the rebates, which are based on activity in 2012, via a check, an electronic deposit in a bank account, a reduction in insurance premiums, or by spending the funds for the benefit of employees.

The MLR is based on the aggregate performance of a health plan, not on individual policy history. Even if a beneficiary had no medical claims during a given year, he or she would not receive a rebate if the broader plan met the MLR requirements. In addition, many Americans were enrolled in health plans that were not covered by the ACA MLR provisions in 2012. The ACA MLR provisions cover only fully funded health plans, which are plans where insurance companies assume the full risk for medical expenses incurred. The requirements do not extend to self-funded plans, which are health care plans offered by businesses in which the employer assumes the risk for, and pays for, medical care. Non-profit insurers and some Medicare Advantage plans were not covered by the ACA MLR standards during the first two years the law was in effect, though these insurers will be subject to MLR provisions in 2014. In addition, some states won special exceptions for individual insurance policies, based on an HHS determination that meeting the MLR requirement would harm a state’s insurance market.

Several issues have been raised about the MLR provisions since the ACA was enacted. These include considerations regarding the treatment of insurance agent and broker bonuses and commissions, and the impact of the MLR on insurers that provide high deductible plans.

Date of Report: August 9, 2013
Number of Pages: 33
Order Number: R42735
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Thursday, August 22, 2013

Medicare Immunosuppressive Drug Coverage for Kidney Transplant Recipients

Scott R. Talaga
Analyst in Health Care Financing

End-stage renal disease (ESRD) is substantial and permanent loss in kidney function. Persons with ESRD require either a regular course of dialysis treatment (a process that removes harmful waste products from an individual’s blood stream) or a kidney transplant to survive. The Medicare program provides coverage for health care services for the vast majority of individuals diagnosed with ESRD, regardless of age.

In 2010, roughly 489,000 Medicare beneficiaries received ESRD-related services—less than 1% of the total Medicare population. According to the United States Renal Data System (USRDS), in 2010, Medicare expenditures for the ESRD-related services totaled $32.9 billion, or roughly 6.3% of total Medicare expenditures.

The Medicare program consists of four parts: Part A (Hospital Insurance, or HI), Part B (Supplementary Medical Insurance, or SMI), Part C (Medicare Advantage), and Part D (outpatient prescription drug coverage). Under Part A, Medicare-covered ESRD-related services include dialysis treatments upon admission to a hospital, inpatient services in an approved hospital for covered kidney transplants, and the cost of care for the individual donating a kidney. Under Part B, Medicare-covered ESRD-related services include dialysis treatments in a dialysis facility or at home, physicians’ services for kidney transplant procedures, and certain prescription drugs—including immunosuppressive drugs (for individuals who received a Medicare-covered transplant). Under Part D, beneficiaries can also enroll in a prescription drug plan to receive coverage for drugs that treat ESRD-related symptoms and any additional outpatient prescription drugs. Coverage of immunosuppressive drugs for individuals whose transplant was not covered by Medicare may be covered under Part D.

Individuals who have received a kidney transplant usually require immunosuppressive drugs for the rest of their life to minimize the risk of their immune system rejecting the donor kidney. In 2010, Part B expenditures for immunosuppressive drugs totaled $345 million. Under Part B, Medicare provides payment for immunosuppressive drugs based on manufacturers’ reported average sales price (ASP), for each drug, plus a 6% handling and storage payment. Since 2009, the ASP for commonly used immunosuppressive drugs has decreased by over 50%—most likely due to the use of generics.

For ESRD beneficiaries, Medicare covers a lifetime of dialysis treatments. For Medicare-eligible individuals with a functioning kidney transplant, Medicare covers the cost of the transplant and 36 months of follow-up care (which includes immunosuppressive medication). According to the USRDS, at the end of 2010, approximately 41% of individuals under the age of 65 who had a functioning kidney transplant and thus no longer required dialysis were not covered by Medicare. Since the 105
th Congress, legislation has been introduced in each Congress to provide some form of Medicare coverage for post-transplant recipients who are no longer entitled to Medicare following 36 months of a successful kidney transplant. Individuals who are not covered by Medicare who require immunosuppressive drugs and do not have health insurance may have to pay the cost of immunosuppressive drugs out-of-pocket. In 2014, individuals who are not covered by Medicare and who have a functioning kidney transplant may have greater access to immunosuppressive drug coverage from private health plans due to provisions in the Patient Protection and Affordable Care Act and a recent decline in the price of commonly used immunosuppressive drugs.

Date of Report: July 16, 2013
Number of Pages: 16
Order Number: R43154
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Wednesday, August 21, 2013

Post-Traumatic Stress Disorder and Other Mental Health Problems in the Military: Oversight Issues for Congress

Katherine Blakeley
Analyst in Foreign Affairs

Don J. Jansen
Analyst in Defense Health Care Policy

Military servicemembers suffering from post-traumatic stress disorder (PTSD), traumatic brain injury (TBI), and depression, as well as military suicides, continue to be a major concern of Congress. Numerous legislative provisions have been enacted over the past years to address these issues. Members will likely seek to offer legislation in the 113th Congress to address this complex set of issues. This report is intended to provide assistance in understanding the issues associated with psychological health in the active duty forces, potential congressional responses, and what questions may remain unanswered.

Key points in this report include the following:

• mental disorders such as PTSD are poorly understood and in most cases cannot be physically identified but, rather, must be diagnosed using symptoms reported by the servicemember;

• estimates of the prevalence of mental health conditions in any given population may be greatly affected by the methodology used;

• diagnoses of mental health conditions among active duty servicemembers have increased substantially relative to non-deployed servicemembers. This increase may be due to the psychological toll of exposure to conflict, but may also be due in part to increased and improved screening methods as well as Department of Defense (DOD) efforts to reduce the stigma associated with seeking mental health treatment that might dissuade some servicemembers from reporting mental health concerns or accessing care; and

• reliable evidence is lacking as to the quality of mental health care and counseling offered in DOD facilities. A 2012 Institute of Medicine (IOM) study recommended that DOD undertake efforts to measure the effectiveness of efforts to improve quality, such as training providers in evidence-based practice, that are not integrated into the system of mental health care offered in DOD treatment facilities.

Significant areas for potential congressional oversight activities regarding psychological health in the active duty forces include the following:

• research into the causes and physical manifestations of psychological health conditions, screening tools, and treatments;

• the effectiveness of screening and treatment efforts;

• servicemembers’ access to mental health care, including efforts to reduce the stigma of seeking mental health care, waiting times for care, staffing levels of mental health treatment professionals, mental health care available in remote or deployed settings, and care available to de-activated Reserve and Guard members;

• the quality of mental health care available to servicemembers, including the use of appropriate and effective treatments by qualified mental health treatment professionals;

• oversight of ongoing program evaluation efforts, including evaluation of the variety of suicide-prevention, stigma-reduction, and transition assistance programs within the services and DOD; and

• the costs of mental health care for active duty servicemembers, including present costs through the Defense Health Program, as well as the future costs of mental health care once servicemembers are no longer part of the active duty forces.

Date of Report: August 8, 2013
Number of Pages: 74
Order Number: R43175
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