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The Affordable Care Act: Implementation in PA DBHIDS Health Reform & Health Equity
19 June 2013
Agenda
• Introductions
• Overview of the ACA
• Implementation in PA
• Access to Care
• Coverage of Care
• Quality of Care
• Discussion
• Resources
Disclaimer
We don’t have all the answers. . .
. . . but we want to know the questions.
There are no stupid questions.
Introductions
•Please provide your: •name
•place of work
•one question you have about the ACA
OVERVIEW OF THE ACA
True or False:
• The Affordable Care Act is the current law of the land.
• The Affordable Care Act does not go into effect until January 1, 2014.
• The U.S. Supreme Court upheld the ACA exactly as it was written in June of 2012.
• The Affordable Care Act will be implemented the same way in each state.
Overview of the ACA
• Passed into law March 23, 2010
• Upheld (in its almost entirety) by the U.S. Supreme Court in June, 2012
• The law went into effect immediately
• Major provisions go into effect January 1, 2014
Goal of the ACA: The Triple Aim
Better health
Lower costs
Better health
care
ACA Timeline
2010 • March 23rd Signed into law by President Obama
• September 23rd Extends coverage to children under 26 to remain on parents’ plans
2011 • January 1st $15 billion devoted to the Prevention & Public Health fund to administer public health grants
• January 1st Medical Loss Ratio rules go into effect requiring insurers to spend more on coverage
2012 • January 1st Accountable Care Organizations begin providing services to individuals
• March 1st Data collection and reporting to identify health disparities begins
2013 • January 1st Medicaid payments to physicians are increased
• October 1st Open Enrollment for the Health Insurance Marketplace begins
2014
• January 1st Individuals begin receiving coverage through Health Insurance Marketplace
• January 1st Medicaid eligibility is expanded to 138% in states that opted in to the expansion
• January 1st Annual limits on lifetime coverage are eliminated
Objectives of the ACA • Increasing access to care for ALL individuals regardless of
race, ethnicity, gender/sexual identity, income or disability status
• Using data to identify areas of need and drive improvement within the healthcare system
• Providing comprehensive, holistic care to individuals that address unmet needs including those beyond the traditional treatment setting
• Improving health information technology to reduce duplication of services, improve exchange of information, reduce errors and improve individuals’ access to information
• Strengthening the healthcare workforce including, increasing diversity and capacity in underserved areas
• http://kff.org/health-reform/video/health-reform-hits-main-street/
THE ACA: STATE IMPLEMENTATION
ACA State Implementation
State Implementation • The Affordable Care Act and the subsequent U.S. Supreme Court Decision
provides states considerable discretion in how it is implemented at the state level.
• State decisions include: • Whether to expand Medicaid eligibility to 138% of the federal poverty
level • Whether to establish a state-based health insurance marketplace*, a
state-federal partnership marketplace or defer to the federally facilitated marketplace
• Choosing the benchmark plan for the Essential Health Benefits package & the benchmark plan for the Medicaid alternative plan for newly eligible Medicaid enrollees
• Participation in Health Home State Plan for individuals with chronic illnesses
• Other funding opportunities (Bridge to Reform, Public Health & Prevention Fund grants, Centers for Medicare & Medicaid Innovation grants, etc.)
*Previously known as “health insurance exchange.”
ACA BENEFITS TO PENNSYLVANIANS
• To date:
• 7.7 million residents are without lifetime limits on coverage
• 32,100 young adults received coverage through parent’s plans
• 657,000 children can not be denied coverage due to pre-existing conditions
• Medicare Provisions • 2.3 million Medicare beneficiaries receiving primary care services
with no copay
• Currently, Medicare beneficiaries receiving 50% discount on brand name drugs in donut hole
• By 2020 donut hole will be closed
Major Provisions of ACA that Address Disparities in Pennsylvania
ACA Provision
• Medicaid eligibility expansion of up to 133% federal poverty level (FPL)
• Prohibits discrimination due to pre-existing conditions
• Increases funding for Community Health Centers (CHC)
Pennsylvania • 23% of individuals newly
eligible for Medicaid will be from a racial or ethnic minority
• 28% of American Indians; 22.4% of African Americans; 16.8% of Latinos and 10.9% of Asian Americans in Pennsylvania have pre-existing conditions
• PA CHCs serve 547,100 patients through 33 FQHCs and 229 delivery sites. 50% of persons who use CHCs are of racial and ethnic minorities
THE ACA: ACCESS TO CARE
The ACA: Access to Care
• Individuals must obtain insurance
coverage by January 1, 2014 or pay a penalty.
Individual Mandate
• States can choose to expand Medicaid eligibility for individuals up to 138% of FPL.
Medicaid Expansion
• Individuals will be able to obtain insurance coverage through multiple sources.
Health Insurance
Marketplace
Expanding Coverage Under the Affordable Care Act
* Medicaid also includes other public programs: CHIP, other state programs, Medicare and military-related coverage. The federal poverty level for a family of three in 2012 is $19,090. Numbers may not add to 100 due to rounding. SOURCE: KCMU/Urban Institute analysis of 2011 ASEC Supplement to the CPS.
18%
20%
6%
56%
54%
10%
37%
49.1 M Uninsured
<139% (Medicaid)
Federal Poverty Level
139-399% (Subsidies)
400%+
Private Non-Group
Medicaid*
Employer-Sponsored Insurance
Uninsured
266 M Nonelderly
Individual Mandate
• Most controversial provision of the ACA
• Requires individuals to obtain health insurance or pay a penalty
• Penalties increase each year • Determined by each month
without insurance
• Exemptions include:
• “Unaffordable”
• Religious
• Incarceration
• Undocumented status
Year Amount Owed
2014 $95 per adult; $47 per child ( up to $285 per family or 1.0% of family income)
2015 $325 per adult; $162. 50 per child (up to $975 or 2.0% family income)
2016 $695 per adult; $347.50 per child (up to $2085 per family or 2.5% of family income)
Health Insurance Marketplace
• States must establish by January 2014 or default to the Federal government
• Several requirements:
• User Friendly
• Phone, In-person, and online services
• Language accessibility
• Must screen and enroll public & private coverage
• Must establish “navigators”
• Transparency
• Self-financing by 2015
Enrollment Timeline
Spring
• Navigator RFP Released
June
• Navigator applications due June 7
• Call centers launched
July
• Navigator training begins
August
• Navigator awardees announced Aug. 15th
• Web portal opens
Oct 1
• Open enrollment
Jan 1
• Coverage begins
Eligibility & Enrollment
• Major changes to eligibility & enrollment • October 1, 2013 is open
enrollment for Marketplace
• Elimination of income verification
• Screened for multiple options through one application
• Income calculation now “modified adjusted gross income” or MAGI
• Federal government can provide eligibility determination
Source: Medicaid & CHIP Learning Collaborative. Available at: http://www.medicaid.gov/State-Resource-Center/MAC-Learning-Collaboratives/Downloads/Realtimebrief.pdf
Federally Facilitated Marketplace: Implementation Issues in PA
• Infrastructure
• Pennsylvania returned Health Insurance Exchange Establishment funding to the Federal government
• Education and Outreach
• 896,000 eligible for tax subsidies through Marketplace in PA
• Changes to eligibility calculation
• Movement to Modified Adjusted Gross Income (MAGI)
• $13 million in PA’s Dept. of Public Welfare (DPW) Budget
• Qualified Health Plan (QHP) selection (HHS to decide)
• Supplementation of default benchmark plan
• Medicaid determination
• State has the option of accepting federal determination as binding or not
• Navigators
• PA HB1522 limits & regulates use of navigators
Medicaid Expansion • Federal government
matching rate: • 100% first 3 years
• Gradually decrease to 90% in 2020 and beyond
• Individuals and families with incomes up to 138% of the Federal Poverty Level (FPL) will be eligible • Appx. $14,850 for an
individual
• Appx. $30,650 for a family of four
• Expected to enroll 11.6 million people in 2014
Photo from npr.org.
Medicaid Expansion in PA: The Debate
For Expansion
• Increased access to coverage & care
• Significant funding source • 100% FMAP 2014,
2015, 2016
• 90% 2020 and beyond
• Job creator
• “The right thing to do”
Against Expansion
• Too much reliance on public system
• Increased costs due to administration & “woodwork effect”
• Job killer
• Political ideology
PA Medicaid Expansion: Recent Activity
• Governor Corbett met with Sec. Sebelius April 2nd
• Considering alternative options like the Arkansas Plan
• Will not move forward until “more information from HHS”
• Legislation introduced in PA Senate
• Attempts to block movement of children from CHIP to Medicaid
Medicaid Expansion Issues without
Expansion • Increase in individuals
seeking services due to
• Elimination of Disproportionate Share Hospital (DSH) payments could result in a loss of $8.1 billion over next 10 years
• Coverage gap for individuals
Opportunities with Expansion
• Opportunity to expand insurance coverage to appx. 650,000 PA residents
• Ensuring access to high quality health services
• Maintaining efficiency
PA Coverage Gap
Source: PA Health Law Project, Medicaid Expansion in Pennsylvania Is Good For Families (2013).
THE ACA: COVERAGE OF CARE
The ACA: Coverage of Care • Healthcare • Preventive services • Pre-existing
conditions • Children’s coverage • Medical loss ratio • Medicare Donut
Hole
• Mental Health & Substance Use • Essential Health
Benefits • Parity
Essential Health Benefits What is essential? • Ambulatory patient
services
• Emergency services
• Hospitalization
• Maternity and newborn care
• Mental health and substance use disorder services, including behavioral health treatment
Rehabilitative and habilitative services and devices
Laboratory services
Preventive and wellness services and chronic disease management
Pediatric services, including oral and vision care
Prescription drugs
Essential Health Benefits • Mental Health & Substance Use services are among the
ten Essential Health Benefits (EHB) that must be covered by insurers beginning in 2014.
• Mental health parity applies to EHB in qualified health plans and the Medicaid Alternative Plans for newly eligible individuals.
• Issues remain regarding: • Each of the PA benchmark plan options for the Health Insurance
Marketplace requires supplementation to meet HHS’ standards
• The scope of services that must be offered
• The federal-state cost share for states’ that choose to provide comprehensive coverage beyond the benchmark plan in Medicaid Alternative Plans
Mental Health Parity • Goal is to increase individuals’ access to mental health services
and treatment by limiting insurance companies’ ability to deny care
• IF an insurance company offers MH/SU services they must be offered at parity with physical health services
• Lifetime limits and other durations must be the same
• Preexisting condition limitations must be the same
• However, the federal government has NOT released final regulations regarding this
• Issues include:
• The method of calculating parity between physical health and behavioral health services
• Enforcement and penalties of parity violations by insurers
State Benchmark Options: Health Insurance Marketplace • States can select from the following existing health
insurance options to serve as the benchmark package for the health insurance exchange: • One of the three largest small group insurance plans;
• One of the three largest state employee health plan options;
• One of the three largest federal employee health plan options; or
• The largest commercial HMO plan sold in the state
• If a state fails to choose a benchmark plan from these options, the small group health plan with the largest enrollment will act as the default benchmark plan.
Source: Kaiser, Health Reform Source. Available at:
http://www.kff.org/healthreform/quicktake_essential_health_benefits.cfm.
State Benchmark Options: Medicaid Alternative Plans • The state may choose the following existing plans to act
as the State’s benchmark plan for the Medicaid Alternative Plan: • The Standard Blue Cross/Blue Shield Preferred Provider Option
offered through the Federal Employees Health Benefit program;
• State employee coverage that is offered and generally available to state employees;
• The commercial HMO with the largest insured commercial, non-Medicaid enrollment in the state; or
• Secretary-approved coverage, which, as noted above, can include the Medicaid state plan -benefit package offered in that state.
Source: State Medicaid Director letter from CMS (20 November 2012). Available at: http://www.medicaid.gov/Federal-Policy-Guidance/downloads/SMD-12-003.pdf.
Coverage Issue: Carve-out
Sources: A Profile of Medicaid Managed Care Programs in 2010: Findings From a 50-State Survey. Kaiser Commission on Medicaid and the Uninsured, 2011. Health Center Reimbursement for Behavioral Health Services in Medicaid. National Association of Community Health Centers, 2010. Swartz M, Morrissey J. N C Med J. 2012;73:177–184. Available at: http://www.managedcaremag.com/archives/1212/1212.mental_health_carve.html%20
THE ACA: QUALITY OF CARE
Quality & Payment Reform: A Move to Integrated Care • Patient Centered Medical
Homes (PCMH)
• Health Homes
• Accountable Care Organizations
• Establishment of National Quality Measures
• Established the Patient Centered Outcomes Research Institute (PCORI)
• Health Information Technology
• Innovation grant funding
Health Home
• Health home provision (Sec. 2703 & Sec. 1945(e)) authorizes States to build a person-centered care system that results in improved outcomes and better services and value for State Medicaid and other programs, including mental health and substance abuse agencies.
• A health home is a provider or a team of health care professionals that provide integrated health care.
• Designed to be person-centered system of care that facilitates access to and coordination of
• primary and acute physical health services
• behavioral health care
• long-term community-based services and supports.
Health Home Team
Mental Health Provider
Primary Care Provider
Substance Abuse
Treatment Program
Inpatient/Hospital ED
Urgent Care
Medical Specialists
Health Home Services
• Comprehensive care management
• Care coordination
• Health promotion
• Comprehensive transitional care/follow-up
• Patient & family support
• Referral to community & social support services
National Landscape
As of April 2013-Graphic from CMS: http://bit.ly/11AVzuT
Accountable Care Organizations (ACO)
• Providers collectively take responsibility for the quality and costs of treatment
• If providers can reduce costs while providing high quality care they receive a share of the cost savings
• Can be operated by health systems, health plans, hospitals, large physician practices or other medical service organizations
• Population health approach = not just taking care of the sick but keeping people healthy
Health Information Technology
• HIT incentives extended to physical health providers through “meaningful use”
• Behavioral health providers largely left out; however: • HealthIT.gov Behavioral
Health Initiative
• SAMHSA partnership/funding
• Advocacy efforts including the Behavioral Health Information Technology Act
Innovation
• The ACA established the CMS Innovation Center to “support the development and testing of innovative health care payment and service delivery models.”
• Pennsylvania Awarded $1.5 Million Grant from the Center for Medicare and Medicaid Innovation to Develop State Healthcare Innovation Model
• Current funding opportunity for providers:
• Health Care Innovation Award Round II
• Achieving Lower Costs Through Improvement
• LOI: June 28th
• Applications: August 15th
Takeaways
Get involved in advocacy efforts
Increase staff engagement & knowledge
Prepare to help increased number of individuals access care
Capitalize on funding opportunities
Position your services to be part of comprehensive care models
DBHIDS HEALTH REFORM & HEALTH EQUITY
DBHIDS Health Reform Priority Areas
Eligibility & Enrollment/ Medicaid Expansion
Integrated Care Models
Health Information Technology/Reporting
Workforce Development
Essential Health Benefits/ Parity
DBHIDS Resources
• Resources on the web • Social media
Publications • Monthly Newsletter • Biweekly Policy
Update • Regulations database • Information requests
• Upcoming Events: • July 17th 12pm-2pm
Eligibility & Enrollment Staff Training
• June 25th 1pm-4pm Health Home Forum
• August 14th 12pm-2pm Health Reform Staff Training topic TBD
Contact Us
• Shannon Mace Heller, Manager
• Shloka Joshi, Specialist
• Kenya Smith-Johnson, Program Assistant
• On the web:
• http://dbhids.org/health-reform-health-equity-unit
• Twitter:
• @PhillyRecovery
• @shannonmace
• @shlokajoshi
Questions?
Thank you!
ACA Resources
• Philadelphia Department of Behavioral Health & Intellectual disABILITY Services, Health Reform & Health Equity Unit: http://dbhids.org/health-reform-health-equity-unit
• www.Healthcare.gov
• Kaiser Health Reform Source: http://kff.org/health-reform/
• Health Reform GPS: www.healthreformgps.org
• CMS, Streamlined Application: http://go.cms.gov/11SGmKF
• PA Health Law Project: http://www.phlp.org/home-page/reform
• PA Health Access Network: http://pahealthaccess.org/
• CMS Innovation Center: http://innovation.cms.gov/
• Pennsylvania benchmark plan: http://www.cms.gov/CCIIO/Resources/Data-Resources/Downloads/pennsylvania-ehb-benchmark-plan.pdf
