HCR-Update: State Strategies; Claims Appeals Rules

Thanks to our partners at UBA, we have more information surrounding Health Care Reform.  Read below to learn the latest.

HHS and Treasury Propose Rules for States to Adopt Innovative Strategies to Meet the Goals of PPACA; Comments Accepted

The Departments of Health and Human Services (HHS) and Treasury have proposed new rules outlining the steps states may pursue in order to receive a state innovation waiver under the Patient Protection and Affordable Care Act (PPACA). The Act gives states the flexibility to receive a state innovation waiver (beginning in 2017 -- some elected officials would like to see this date changed to 2014) so they may pursue their own innovative strategies to ensure their residents have access to high-quality, affordable health insurance. The proposed regulation describes the content of the waiver application and how such proposals may be disclosed to the public, monitored and evaluated.

State innovation waivers are designed to allow states to implement policies that differ from those in PPACA so long as they:

• Provide coverage that is at least as comprehensive as the coverage offered through health insurance exchanges -- new competitive, private health insurance marketplaces
• Make coverage at least as affordable as it would have been through the exchanges
•  Provide coverage to at least as many residents as otherwise would have been covered under PPACA
• Do not increase the federal deficit

States could use a variety of strategies to innovate through a waiver, provided they meet the above requirements. For example, they could develop a new system for providing tax credits, which links small business tax credits to the tax credits for moderate-income families. Or they could change the benefit levels or add new benefit levels for health plans offered in the exchanges, providing consumers and employers even more choices.

• The proposed rule says that an application must include the following:
• The provisions of the law that the state seeks to waive
• An explanation of how the proposed waiver will meet the goals related to coverage expansion affordability, comprehensiveness of coverage and costs
• A budget plan that does not increase the federal deficit, with supporting information
• Actuarial certifications and economic analysis to support the state's estimates that the proposed waiver will comply with the comprehensive coverage requirement, the affordability requirement and the scope of coverage requirement; and
• Analyses of the waiver's potential impact on provisions that are not waived, access to health care services when residents leave the state, and deterring waste, fraud and abuse
• Under the proposed rule, states with waivers submit quarterly and annual reports. They track measures in the four key areas: affordability, comprehensiveness of coverage, the number of people covered and impact on the federal deficit.

A summary of the proposed rules is available at http://www.healthcare.gov/news/factsheets/stateinnovation03102011a.html.

EBSA Provides Additional Grace Period for Health Care Reform's Claims Appeals Regulations
The Department of Labor's Employee Benefit Security Administration has extended and modified an enforcement grace period for some of the new standards required under the Patient Protection and Affordable Act (ACA) for health care internal claims and appeals and external reviews until plan years beginning on or after Jan. 1, 2012. Technical Release 2011-1 is intended to give group health plans more time to change plan or policy procedures and to modify computer systems in order to comply with the new interim final claims regulations issued on July 23, 2010, and Aug. 23, 2010, to implement Public Health Service Act (PHSA) Sec. 2719. The Department of Health and Human Services, the Internal Revenue Service, and EBSA jointly issued these 2010 regulations, and they intend to issue amendments to these rules soon.

Specifically, this Technical Release 2011-01 extends the enforcement grace period until plan years beginning on or after Jan. 1, 2012 with respect to the following:

• A plan or issuer must notify a claimant of a benefit determination (whether adverse or not) with respect to a claim involving urgent care as soon as possible, taking into account the medical exigencies, but not later than 24 hours after the receipt of the claim by the plan or issuer
• Notices must be provided in a culturally and linguistically appropriate manner, as required by the statute, and as set forth in the 2010 interim final regulations)
• If a plan or issuer fails to strictly adhere to all the requirements of the 2010 interim final regulations, the claimant is deemed to have exhausted the plan's or issuer's internal claims and appeals process, regardless of whether the plan or issuer asserts that it has substantially complied, and the claimant may initiate any available external review process or remedies available under ERISA or under state law

During the grace period, the Department of Labor and the IRS will not take any enforcement action against a group health plan, and HHS will not take any enforcement action against a self-funded non-federal governmental health plan, with respect to these provisions. Similarly, HHS is encouraging states to provide similar grace periods with respect to insurers, and HHS will not cite a state for failing to substantially enforce PHS Act section 2719(a) in these situations.

Will Congress Repeal Health Care Reform?

Attempts to Repeal the Health Care Reform Law
In January, the House passed repeal legislation by a vote of 245 to 189, with three Democrats crossing the aisle to vote with their Republican colleagues. The Senate also voted on repeal in February. However, that attempt was defeated, with Senators voting along party lines. Sixty votes were required for repeal; the measure failed 47 to 51.

It is possible that further attempts to repeal the health care reform law will be introduced in Congress.

Potential Health Care Reform Changes
Because full repeal of the health care reform law will be difficult, Republicans have indicated that they will use other strategies to prevent the law from being fully implemented in its current form. These strategies include replacing, rather than repealing, parts of the law, or repealing the law “piece by piece,” using approaches like blocking funding or regulations.

Provisions of the law that may be revised or repealed include:

• The requirement for businesses to report payments in excess of $600 on a Form 1099;
• The employer responsibility provisions, which provide that employers can face penalties for not providing a certain level of health coverage to employees.
• The individual responsibility requirement, which imposes penalties on individuals who do not obtain coverage;
• The Cadillac Plan tax on high-cost, employer-sponsored health plans;
• The tax on manufacturers of medical devices; and
• Cuts to Medicare.

Republicans have also suggested changes to the planned health insurance exchanges, which will take effect in 2014, to give states more power in designing the exchanges. However, members of the GOP have also said that they may want to keep some of the law’s provisions that are popular with consumers. Some experts have warned that keeping some parts of the law while repealing others may not be practical.

Democrats are standing behind the health care package and some exit polls show that the public is split on whether health care reform should be repealed. However, party leaders, such as President Obama and Senate Majority Leader Harry Reid (D-Nevada) have indicated a willingness to revise some portions of the law, especially if changes will bring faster and more effective reform to the health care system.

What’s Next?

Despite the various attempts to repeal the law, and potential future changes, the health care reform law as we know it is the law. Employers and health plan sponsors should make sure they are implementing the requirements as they become effective. If any changes are made to parts of the law that have already taken effect, there will likely be time for employers and plan sponsors to put changes into place.

Healthcare Reform: Major Updates and Look Ahead at 2011!

As we approach the one-year anniversary of the enactment of the Patient Protection and Affordable Care Act (“ACA”), we thought it would be a good idea to review the changes that have occurred as well as look forward to what can be expected in 2011. While there are many aspects of ACA, we’ll limit this discussion to those elements that could have significant impact on municipal employers.

Published Regulations

• Grandfathered Status. Interim Final Regulations (IFRs) were released last June and Final Regulations are scheduled to be released by the end of 2011. An employer that makes very little or no changes to their medical plan that was in effect on March 23, 2010 (the date ACA was signed into law), can postpone some of the mandated benefits required by ACA, fulfilling the promise that “if you like your health insurance plan you can keep it”. When the IFR was released, Federal regulators predicted that, on average, 82% of large employers (100+ employees) would retain their grandfathered status in 2011, while 70% of small employers would. Results since September would seem to indicate that many more employers than anticipated are making plan changes that result in their loss of grandfathered status.
• Preventive Care Benefits Provided Without Cost-Sharing . IFRs were released last July and Final Regulations are scheduled to be released in April of this year. This is the most significant mandate required when a plan loses its grandfathered status. Applicable benefits are based on the recommendations of the U.S. Preventive Services Task Force, but since many of those recommendations are vague, insurance carriers and self-funded plans are challenged to develop specific plan provisions. Hopefully the Final Regulations will provide some clarity.
• Removal of Lifetime Dollar Limits. One of the few clearly-defined mandates in ACA, making this change seems to have had little financial or administrative impact to employer plans.
• Dependent Children Eligible Until Age 26 . While Final Regulations are scheduled for release in April, this mandate also seems to have presented minimal administrative challenges for employers and insurance carriers. Not enough data is available yet to gauge this mandate’s effect on enrollment or plan costs.
• Non-Discrimination Testing Applicable to Insured Plans. This mandate applies to insured plans that lose their grandfathered status, and was designed to be very similar to the testing applied to self-funded programs since the 1980s. Plans are tested to ensure they don’t disproportionately favor highly-compensated employees, both in terms of availability and participation. If the plan is found to be discriminatory, the employer is subject to substantial excise taxes. Originally set to apply to plan years beginning after September 23, 2010, federal regulators were besieged with questions that weren’t addressed in the existing rules. Recognizing the need for more concise guidance, they have postponed enforcement of the testing and penalties until after they publish more clearly defined regulations, which are expected in September 2011.
• Consumer Operated and Oriented Plans (“CO-OP Plans”).  HHS has just published a request for input concerning these non-profit alternatives to traditional insurance programs for the individual and small group markets.  Loans and grants are scheduled to be dispersed starting in July 2013 for these programs and HHS is looking for feedback as to the structure, sponsorship and operational requirements that would help ensure sustainable success.  It’s expected that there be at least one CO-OP plan in each state and a plan could be regional (I.e., cross state lines).

Other Regulations Expected to Be Released in 2011

• Uniform Explanation of Benefits, Coverage Facts and Standardized Definitions (March). Establishes national definitions and standard formats for communicating plan details to participants. This must be provided to all participants by March 2012. Coincident with providing this information, beginning in April 2012 plans/carriers must provide a summary of material modifications a minimum of 60 days prior to the effective date of any such plan changes.
• Requirements to Implement American Health Benefits Exchanges (March). Will lay out the requirements, processes and timetables to establish the State Exchanges for the individual and small group markets. If a state is unable or unwilling to follow these rules, HHS will set up and run an exchange for that state. Iowa has already been working for several years on creating this type of program and it is hoped the new Federal regulations will have minimal impact on that effort.
• Transparency Reporting Rule (March). Plans/carriers must provide information on claims payment policies, number of claims denied and rating practices. Upon request from a covered individual, must provide the amount of cost-sharing for a specific item or service by a plan participating provider.
• Community Living Assistance Services and Supports (CLASS) Act (September). Enrollment and eligibility regulations are expected to be spelled out for the Federally-administered long-term care program. Many industry and policy experts have raised concerns regarding the sustainability of the program as set up in the ACA legislation. In fact, the bipartisan National Commission on Fiscal Responsibility and Reform established last fall by President Obama proposed eliminating the CLASS Act and legislation to do so was introduced in both the last and the current Congress. Given this environment, it’s quite possible this specific portion of ACA will not be implemented.

Court Challenges to the ACA

Sixteen filings have been entered in U.S. District Courts since the ACA was signed into law last March. So far, the score is:

• 2 judges have ruled the ACA constitutional
• 2 judges have ruled it to be unconstitutional ( either in whole or in part)
• 12 judges have dismissed challenges

In each of the four rulings, the losing parties have indicated their intent to file petitions with the appropriate Appellate Court. Many legal and legislative experts expect the issue will ultimately be decided by the Supreme Court. In the meantime, most carriers and employers are making the plan revisions mandated by the ACA, while recognizing they may eventually need to make even more changes based on future court decisions.

Over the Counter Drugs Q&A

Health care reform changes the rules for reimbursement of over-the-counter drugs through HSAs, HRAs, MSAs and FSAs. These questions and answers from the IRS clarify the new rules.

Q. How are the rules changing for reimbursing the cost of over-the-counter medicines and drugs from health flexible spending arrangements (health FSAs) and health reimbursement arrangements (HRAs)?
A. Section 9003 of the Affordable Care Act established a new uniform standard for medical expenses. Effective Jan. 1, 2011, distributions from health FSAs and HRAs will be allowed to reimburse the cost of over-the-counter medicines or drugs only if they are purchased with a prescription. This new rule does not apply to reimbursements for the cost of insulin, which will continue to be permitted without a prescription.

Q. How are the rules changing for distributions from health savings accounts (HSAs) and Archer Medical Savings Accounts (Archer MSAs) that are used to reimburse the cost of over-the-counter medicines and drugs?

A. In accordance with Section 9003 of the Affordable Care Act, only prescribed medicines or drugs (including over-the-counter medicines and drugs that are prescribed) and insulin (even if purchased without a prescription) will be considered qualifying medical expenses and subject to preferred tax treatment.

Q. When will the changes become effective?
A. The changes are effective for purchases of over-the-counter medicines and drugs without a prescription after Dec. 31, 2010. The changes do not affect purchases of over-the-counter medicines and drugs in 2010, even if they are reimbursed after Dec. 31, 2010.

Q. How do I prove that I have purchased an over-the-counter medicine or drug with a prescription so that I can get reimbursed from my employer's health FSA or an HRA?
A. If your employer’s health FSA or HRA reimburses these expenses, you would provide the prescription (or a copy of the prescription or another item showing that a prescription for the item has been issued) and the customer receipt (or similar third-party documentation showing the date of the sale and the amount of the charge). For example, documentation could consist of a customer receipt issued by a pharmacy that reflects the date of sale and the amount of the charge, along with a copy of the prescription; or it could consist of a customer receipt that identifies the name of the purchaser (or the person for whom the prescription applies), the date and amount of the purchase, and an Rx number.

Q. How does this change affect over-the-counter medical devices and supplies?
A. The new rule does not apply to items for medical care that are not medicines or drugs. Thus, equipment such as crutches, supplies such as bandages, and diagnostic devices such as blood sugar test kits will still qualify for reimbursement by a health FSA or HRA if purchased after Dec. 31, 2010, and a distribution from an HSA or Archer MSA for the cost of such items will still be tax-free, even without a prescription.

Q. Will I need a prescription to use my health FSA, HRA, HSA or Archer MSA funds for insulin purchases after Dec. 31, 2010?
A. No. You can continue to use your health FSA, HRA, HSA or Archer MSA funds to purchase insulin without a prescription after Dec. 31, 2010.

Q. I use health FSA funds for my copays and deductibles. Will I still be able to reimburse those expenses with health FSA funds after Dec. 31, 2010?A. Yes. Copays and deductibles continue to be reimbursable from a health FSA after Dec. 31, 2010. Similarly, funds from an HRA can continue to be used for these expenses and a distribution from an HSA or Archer MSA for these purposes will be tax-free.

Q. My company gives me two extra months beyond the end of the year to submit claims for health FSA expenses incurred during the year. What happens if I purchase over-the-counter medicines or drugs without a prescription in 2010 but do not submit the claim for those expenses until January 2011? Will they qualify for reimbursement?
A. Yes. The new restriction on plan reimbursements for the cost of over-the-counter drugs without a prescription applies only to purchases that are made after 2010.

Q. My company’s health FSA includes a provision for a grace period, so that if I don’t spend all of the money in my health FSA by Dec. 31, I can still use the amount left at the end of the year to reimburse expenses I incur during the first 2 ½ months of the following year. If I buy over-the-counter medicines or drugs without a prescription during the 2 ½ month grace period of 2011, can I still use the amount left in my health FSA from 2010 to reimburse those expenses?
A. No. The change applies to any purchases made on or after Jan. 1, 2011. Thus, even if your employer’s plan includes the 2 ½ month grace period provision, the cost of over-the-counter medicines and drugs purchased without a prescription during that grace period in 2011 will not be eligible to be reimbursed by a health FSA.

Q. If my health FSA or HRA issues a debit card that I use to pay for over-the-counter medicines or drugs, will I still be able to use the card to purchase over-the-counter medicines or drugs after Dec. 31, 2010?
A. Generally, yes, if you have a prescription for the medicine or drug. For expenses incurred in 2010, you may continue to use an FSA or HRA debit card to purchase over-the-counter medicines or drugs (whether or not you have a prescription) at pharmacies and from mail order and web-based vendors that sell prescription drugs. Starting after Jan. 15, 2011, you may continue to use an FSA or HRA debit card to purchase over-the-counter medicines or drugs at these vendors, so long as you obtain a prescription for the medicine or drug, the prescription is presented to the pharmacist, and the medication is dispensed by the pharmacist and given an Rx number.

For further information, including guidance on purchases of over-the-counter medicines and drugs from health care providers other than pharmacies and mail order and web-based vendors (such as physicians or hospitals), see IRS Notice 2011-5. For guidance on debit card purchases at “90 percent pharmacies,” see IRS Notice 2010-59.

Q. If I use HSA or Archer MSA funds to reimburse the cost of over-the-counter medicines or drugs purchased after Dec. 31, 2010, without a prescription, what taxes will I incur?
A. If you have an HSA or Archer MSA, the amount of the distribution for expenses that are not qualifying medical expenses will be includable in your gross income and subject to an additional tax of 20 percent.

Smoking Cessation, ACA and MHPAEA

The topic of smoking cessation has hit our radar a few times recently and we decided to dig a little deeper.  Remember that in no way are we providing legal advice, just helping to navigate topics concerning employee benefits.

• We need to separate the social aspect of stop-smoking programs from the legal requirements. Don’t confuse someone’s desire to provide coverage because it’s the “right thing to do” with the mandates required of insured/self-funded plans.
• The Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) does not require that smoking cessation be provided as part of a health plan. In fact it doesn’t mandate any specific service be provided – only that if a service is provided as of the plan year on or after July 1, 2010, then that service must continue to be provided. If provided, benefit levels for the MH/SA service cannot be less than benefit levels for medical/surgical benefits under the plan.
• MHPAEA applies only to plans (insured or self-funded) with more than 50 employees.
• Since most plans exclude services for smoking cessation, they can continue to exclude those services and still be in compliance with MHPAEA.
• The ACA mandates that non-grandfathered plans must provide specific preventive services at no cost sharing on the part of the employee/patient. Those services are designated by recommendations from the United States Preventive Services Task Force (USPSTF). Two of the services address tobacco use:
• That clinicians ask all pregnant women about tobacco use and provide augmented, pregnancy-tailored counseling to those that smoke.
• That clinicians ask all adults about tobacco use and provide tobacco cessation interventions for those who use tobacco products.
• Much of the current debate revolves around the word “interventions”:
• If pregnant women should receive counseling, shouldn’t that also be the extent of the intervention for other smokers?
• The recommendation doesn’t require that all interventions be provided. Does counseling alone meet that recommendation, just as it does for pregnant women?
• The preventive care interim regulations indicate that treatment resulting from a preventive care screening can be subject to cost-sharing. Since nicotine addiction is a recognized medical condition, isn’t any intervention (including counseling and drug therapies) a “treatment”?
• ACA requires that beginning 1/1/2014, smoking cessation drugs will be eligible under Medicaid. This is the only specific reference to smoking cessation drugs in either MHPAEA or ACA.
• Given all the confusion and contradictions, it’s not surprising that there will be different solutions to this issue. Hopefully some clarity will come out of the final regulations (regulators aren’t required to meet specific deadlines for these), but no one should expect perfectly clear answers even then.

IRS DELAYS APPLICATION OF NONDISCRIMINATION RULES

On December 22, 2010, the Internal Revenue Service announced (in Notice 2011-1) that insured group health plans will not be required to comply with the nondiscrimination requirements under health care reform until some time after the IRS issues regulatory guidance on those requirements.

The Affordable Care Act provides that insured group health plans (other than certain "grandfathered" plans) must satisfy the requirements of Code Section 105(h)(2), which prohibits discrimination in favor of "highly compensated" participants in terms of either (i) eligibility to participate, or (ii) the benefits provided under the plan. The Act specifically provides that the terms "employer" and "highly compensated individual" (or "HCI") have the meanings given under Section 105(h). Prior to the Affordable Care Act, the nondiscrimination requirements of Section 105(h) applied solely to self-insured (i.e., self-funded) plans.

However, the consequences of violating the nondiscrimination requirements are quite different for insured plans. Code Section 105(h) currently provides that, if a self-insured plan discriminates in favor of one or more HCIs, those individuals will be taxed on some or all of the benefits that they receive under the plan (i.e., those individuals will "lose" the benefit of non-taxable health care reimbursements).

By contrast, if an insured plan violates the nondiscrimination rule, there are no tax consequences to the affected HCIs. Instead, the employer/plan sponsor is subject to an excise tax equal to $100 per day per non-highly compensated individual who is discriminated against. The employer may also be subject to a lawsuit by one or more federal agencies (or by the non-highly compensated individuals discriminated against) for the benefits that the non-highly compensated individuals did not receive.

Under the health care reform statute, these new requirements are to apply to non-grandfathered insured plans for plan years beginning on or after September 23, 2010. Thus, absent relief, these new rules would have applied to calendar-year insured plans beginning on January 1, 2011 (and they already apply to certain fiscal-year plans). However, Notice 2011-1 provides that insured plans will not be subject to the new rules -- and will not be subject to the $100 per day per affected non-HCI penalty for violation of the rules -- until plan years that begin after the IRS issues guidance on the application of these rules.

The IRS has also requested additional comments on how the Section 105(h) "eligibility" and "benefits" tests should be applied to insured plans. This additional comment period closes on March 11, 2011.

A Look at the Impact on Workers’ Compensation

A guest blog from Risk Management Specialist, Stuart Haker.

Healthcare reform has been arguably the most ferociously debated topic in recent years. Employers all over the United States are scrambling to learn what the impact of the Patient Protection and Affordable Care Act will be on their processes, compliance procedures, and bottom line. The trouble is that even the “experts” don’t know for sure what the answers are, as much is yet to be defined. One thing that has become apparent is the potential effect the Act may have on workers’ compensation.

The Act is designed to ensure that all Americans are covered by health insurance and at a capped level of premium. In order to achieve 100% coverage for Americans, approximately 1/3 of the uninsured will be moved into Medicaid programs and the remaining uninsured individuals would purchase insurance through Government health insurance exchanges. This means providers could be forced to ramp up the level of “cost shifting” to maintain operating revenues necessary to treat the increased number of insured patients. Cost shifting occurs when hospitals and doctors receive reimbursement rates from Medicare and Medicaid that are lower than the cost of providing care. To compensate for underfunded services provided, healthcare providers increase how much they charge other patients. Cost shifting is a troubling symptom of the Act as it will have a powerful effect on both private health plans and workers’ compensation carriers.

Currently, workers’ compensation makes up 2% of revenues on average for healthcare providers. However, providers are currently obtaining 16% of their margin from providing workers’ compensation treatment. The medical cost of workers’ compensation is expected to increase as providers will be forced to lean on the high margin services to make up for Governmental reimbursement losses. We are already seeing the early stages of the cost increase in Iowa as the Iowa insurance division announced that the National Council on Compensation Insurance Inc. has made a rate filing for employers to incur a 4.7% increase in workers' compensation insurance rates effective January 1, 2011.

In an environment where governmental intervention is leading to increased costs, a greater focus must be made on utilizing proven methods to minimize usage of the workers’ compensation system to maintain a healthy bottom line. In a commercial insurance program, the one area in which an employer can truly control costs is workers’ compensation. For example, a general liability policy may pay a $10,000 claim and renew with a decreased premium due to market conditions whereas a ‘work comp.’ policy factors the losses against the State rate structure to penalize employers with a poor loss experience and discount the top performers.

In risk management programs focused on reducing the cost of human capital, risk managers implement a workers’ compensation model that integrates three critical components.

1. Human Resources: HR processes need to be put into place to maintain compliance with State and Federal rules in keeping work comp predators off of your jobsite. Ensure that current employees are guided through the work comp system most effectively. And minimize the likelihood that employees will be putting themselves into future claim scenarios.
2. Prevention through Safety: Creating a “Culture of Safety” is essential to encourage the workforce to operate without injury on a daily basis. In order to change culture, everyone from the CEO to the part-time employees must buy in to working together to be safe. Culture change is not easy, but it is obtainable and the results are impossible to argue with.
3. Financial Modeling: In workers’ compensation, unlike group health insurance, employers have choices. There is not an 800 pound gorilla company that dominates the marketplace. Because of this, employers can align themselves with a carrier that provides the best network discounts, and buys into the employer strategy of financing claims using most cost effective methods.

The one certainty that we know is that the Patient Protection and Affordable Care Act will have an effect on your business. Taking a proactive approach to mitigate the negative effects of the legislation will only lead to future profits.

When hockey great Wayne Gretzky was asked to explain the success he had in his career, he responded, “I skate to where the puck is going to be, not where it has been.” Being proactive with your employees’ wellness is no different. Workers’ compensation can be a frustrating puzzle with an enormous cost, but through strategic planning and measured implementation, it can be a puzzle that leads to a profitable picture.

Stuart Haker, Senior Risk Advisor

319-739-1417, shaker@truenorthcompanies.com

Specializing in commercial risk management solutions, Stuart partners with his clients to design and implement long-term risk management strategies. Stuart advises on the reduction of client expenses through enterprise risk planning and the systematic deployment of firm resources on a proactive basis. As a part of his business, Stuart focuses on controlling the costs associated with worker's compensation plans.

Stuart is a member of several local organizations whose mission is to stimulate leadership and growth in the area, including Board participation, Rotary and he is a graduate of the Leadership for Five Seasons professional program.