True or False:• The Affordable Care Act is the currentlaw of the land.• The Affordable Care Act does not go intoeffect until January 1, 2014.• The U.S. Supreme Court upheld the ACAexactly as it was written in June of 2012.• The Affordable Care Act will beimplemented the same way in each state.
Overview of the ACA• Passed into lawMarch 23, 2010• Upheld (in its almostentirety) by the U.S.Supreme Court inJune, 2012• The law went intoeffect immediately• Major provisions gointo effect January 1,2014
Goal of the ACA: The Triple AimBetterhealthLowercostsBetterhealthcare
ACA Timeline2010• March 23rd Signed into law by President Obama• September 23rd Extends coverage to children under 26 to remain on parents’ plans2011• 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 coverage2012• January 1st Accountable Care Organizations begin providing services to individuals• March 1st Data collection and reporting to identify health disparities begins2013• January 1st Medicaid payments to physicians are increased• October 1st Open Enrollment for the Health Insurance Marketplace begins2014• 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 ofrace, ethnicity, gender/sexual identity, income or disabilitystatus• Using data to identify areas of need and drive improvementwithin the healthcare system• Providing comprehensive, holistic care to individuals thataddress unmet needs including those beyond thetraditional treatment setting• Improving health information technology to reduceduplication of services, improve exchange of information,reduce errors and improve individuals’ access toinformation• Strengthening the healthcare workforce including,increasing diversity and capacity in underserved areas• http://kff.org/health-reform/video/health-reform-hits-main-street/
State Implementation• The Affordable Care Act and the subsequent U.S. Supreme Court Decisionprovides states considerable discretion in how it is implemented at thestate level.• State decisions include:• Whether to expand Medicaid eligibility to 138% of the federal povertylevel• Whether to establish a state-based health insurance marketplace*, astate-federal partnership marketplace or defer to the federallyfacilitated marketplace• Choosing the benchmark plan for the Essential Health Benefits package& the benchmark plan for the Medicaid alternative plan for newlyeligible Medicaid enrollees• Participation in Health Home State Plan for individuals with chronicillnesses• Other funding opportunities (Bridge to Reform, Public Health &Prevention Fund grants, Centers for Medicare & Medicaid Innovationgrants, 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’splans• 657,000 children can not be denied coverage due to pre-existing conditions• Medicare Provisions• 2.3 million Medicare beneficiaries receiving primary care serviceswith no copay• Currently, Medicare beneficiaries receiving 50% discount onbrand name drugs in donut hole• By 2020 donut hole will be closed
MajorProvisionsof ACA thatAddress Disparitiesin PennsylvaniaACA Provision• Medicaid eligibilityexpansion of up to 133%federal poverty level(FPL)• Prohibits discriminationdue to pre-existingconditions• Increases funding forCommunity HealthCenters (CHC)Pennsylvania• 23% of individuals newlyeligible for Medicaid will befrom a racial or ethnic minority• 28% of American Indians;22.4% of African Americans;16.8% of Latinos and 10.9% ofAsian Americans inPennsylvania have pre-existingconditions• PA CHCs serve 547,100patients through 33 FQHCsand 229 delivery sites. 50% ofpersons who use CHCs are ofracial and ethnic minorities
The ACA: Access to Care• Individuals must obtain insurancecoverage by January 1, 2014 orpay a penalty.IndividualMandate• States can choose to expandMedicaid eligibility for individualsup to 138% of FPL.MedicaidExpansion• Individuals will be able to obtaininsurance coverage throughmultiple sources.HealthInsuranceMarketplace
ExpandingCoverageUndertheAffordableCareAct* 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 Level139-399%(Subsidies)400%+Private Non-GroupMedicaid*Employer-SponsoredInsuranceUninsured266 M Nonelderly
Individual Mandate• Most controversialprovision of the ACA• Requires individuals toobtain health insurance orpay a penalty• Penalties increase each year• Determined by each monthwithout insurance• Exemptions include:• “Unaffordable”• Religious• Incarceration• Undocumented statusYear Amount Owed2014 $95 per adult; $47 per child ( up to$285 per family or 1.0% of familyincome)2015 $325 per adult; $162. 50 per child (upto $975 or 2.0% family income)2016 $695 per adult; $347.50 per child (upto $2085 per family or 2.5% of familyincome)
Health Insurance Marketplace• States must establish by January 2014 or default tothe 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 TimelineSpring• NavigatorRFPReleasedJune• Navigatorapplicationsdue June 7• Call centerslaunchedJuly• NavigatortrainingbeginsAugust• NavigatorawardeesannouncedAug. 15th• Web portalopensOct 1• OpenenrollmentJan 1• Coveragebegins
Eligibility & Enrollment• Major changes toeligibility & enrollment• October 1, 2013 is openenrollment for Marketplace• Elimination of incomeverification• Screened for multiple optionsthrough one application• Income calculation now“modified adjusted grossincome” or MAGI• Federal government canprovide eligibilitydetermination
Source: Medicaid & CHIP Learning Collaborative. Available at: http://www.medicaid.gov/State-Resource-Center/MAC-Learning-Collaboratives/Downloads/Realtimebrief.pdf
Federally FacilitatedMarketplace:ImplementationIssuesin PA• Infrastructure• Pennsylvania returned Health Insurance Exchange Establishment fundingto 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 governmentmatching rate:• 100% first 3 years• Gradually decrease to 90% in2020 and beyond• Individuals and familieswith incomes up to 138%of the Federal PovertyLevel (FPL) will be eligible• Appx. $14,850 for anindividual• Appx. $30,650 for a family offour• Expected to enroll 11.6million people in 2014Photo from npr.org.
Medicaid Expansion in PA: The DebateFor Expansion• Increased access tocoverage & care• Significant fundingsource• 100% FMAP 2014,2015, 2016• 90% 2020 and beyond• Job creator• “The right thing todo”Against Expansion• Too much relianceon public system• Increased costs dueto administration &“woodwork effect”• Job killer• Political ideology
PA MedicaidExpansion:RecentActivity• Governor Corbett met withSec. Sebelius April 2nd• Considering alternativeoptions like the ArkansasPlan• Will not move forward until“more information fromHHS”• Legislation introduced in PASenate• Attempts to blockmovement of children fromCHIP to Medicaid
Medicaid ExpansionIssues withoutExpansion• Increase in individualsseeking services dueto• Elimination ofDisproportionateShare Hospital (DSH)payments could resultin a loss of $8.1 billionover next 10 years• Coverage gap forindividualsOpportunities withExpansion• Opportunity to expandinsurance coverage toappx. 650,000 PAresidents• Ensuring access to highquality health services• Maintaining efficiency
PA Coverage GapSource: PA Health Law Project, Medicaid Expansion in Pennsylvania Is Good ForFamilies (2013).
The ACA: Coverage of Care• Healthcare• Preventive services• Pre-existingconditions• Children’s coverage• Medical loss ratio• Medicare DonutHole• Mental Health &Substance Use• Essential HealthBenefits• Parity
Essential Health BenefitsWhat is essential?• Ambulatory patientservices• Emergency services• Hospitalization• Maternity and newborncare• Mental health andsubstance use disorderservices, includingbehavioral healthtreatment Rehabilitative andhabilitative services anddevices Laboratory services Preventive and wellnessservices and chronicdisease management Pediatric services,including oral and visioncare Prescription drugs
Essential Health Benefits• Mental Health & Substance Use services are among theten Essential Health Benefits (EHB) that must be coveredby insurers beginning in 2014.• Mental health parity applies to EHB in qualified healthplans and the Medicaid Alternative Plans for newlyeligible individuals.• Issues remain regarding:• Each of the PA benchmark plan options for the Health InsuranceMarketplace requires supplementation to meet HHS’ standards• The scope of services that must be offered• The federal-state cost share for states’ that choose to providecomprehensive coverage beyond the benchmark plan in MedicaidAlternative Plans
Mental Health Parity• Goal is to increase individuals’ access to mental health servicesand treatment by limiting insurance companies’ ability to denycare• IF an insurance company offers MH/SU services they must beoffered 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 finalregulations regarding this• Issues include:• The method of calculating parity between physical health andbehavioral health services• Enforcement and penalties of parity violations by insurers
State Benchmark Options:Health Insurance Marketplace• States can select from the following existing healthinsurance options to serve as the benchmark package forthe 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 theseoptions, the small group health plan with the largestenrollment 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 actas the State’s benchmark plan for the MedicaidAlternative Plan:• The Standard Blue Cross/Blue Shield Preferred Provider Optionoffered through the Federal Employees Health Benefit program;• State employee coverage that is offered and generally available tostate employees;• The commercial HMO with the largest insured commercial, non-Medicaid enrollment in the state; or• Secretary-approved coverage, which, as noted above, can includethe 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-outSources: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
Quality & PaymentReform:A Moveto Integrated Care• Patient Centered MedicalHomes (PCMH)• Health Homes• Accountable CareOrganizations• Establishment of NationalQuality Measures• Established the PatientCentered OutcomesResearch Institute (PCORI)• Health InformationTechnology• Innovation grant funding
Health Home• Health home provision (Sec. 2703 & Sec. 1945(e)) authorizesStates to build a person-centered care system that results inimproved outcomes and better services and value for StateMedicaid and other programs, including mental health andsubstance abuse agencies.• A health home is a provider or a team of health careprofessionals that provide integrated health care.• Designed to be person-centered system of care that facilitatesaccess to and coordination of• primary and acute physical health services• behavioral health care• long-term community-based services and supports.
Health Home TeamMental HealthProviderPrimary CareProviderSubstanceAbuseTreatmentProgramInpatient/Hospital EDUrgent CareMedicalSpecialists
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 LandscapeAs of April 2013-Graphic from CMS: http://bit.ly/11AVzuT
Accountable Care Organizations (ACO)• Providers collectively takeresponsibility for thequality and costs oftreatment• If providers can reducecosts while providing highquality care they receive ashare of the cost savings• Can be operated by healthsystems, health plans,hospitals, large physicianpractices or other medicalservice organizations• Population health approach= not just taking care of thesick but keeping peoplehealthy
Health Information Technology• HIT incentives extendedto physical healthproviders through“meaningful use”• Behavioral healthproviders largely left out;however:• HealthIT.gov BehavioralHealth Initiative• SAMHSApartnership/funding• Advocacy efforts includingthe Behavioral HealthInformation TechnologyAct
Innovation• The ACA established theCMS Innovation Center to“support the developmentand testing of innovativehealth care payment andservice delivery models.”• Pennsylvania Awarded$1.5 Million Grant fromthe Center for Medicareand Medicaid Innovationto Develop StateHealthcare InnovationModel• Current fundingopportunity forproviders:• Health Care InnovationAward Round II• Achieving Lower CostsThrough Improvement• LOI: June 28th• Applications: August15th
TakeawaysGet involved in advocacy effortsIncrease staff engagement & knowledgePrepare to help increased number of individuals access careCapitalize on funding opportunitiesPosition your services to be part of comprehensive care models
DBHIDS Health Reform PriorityAreasEligibility & Enrollment/ Medicaid ExpansionIntegrated Care ModelsHealth Information Technology/ReportingWorkforce DevelopmentEssential Health Benefits/ Parity
DBHIDS Resources• Resources on the web• Social mediaPublications• Monthly Newsletter• Biweekly PolicyUpdate• Regulations database• Information requests• Upcoming Events:• July 17th 12pm-2pmEligibility & EnrollmentStaff Training• June 25th 1pm-4pmHealth Home Forum• August 14th 12pm-2pmHealth Reform StaffTraining topic TBD
Contact Us• Shannon Mace Heller,Manager• Shannon.Mace@phila.gov• Shloka Joshi, Specialist• Shloka.Joshi@phila.gov• Kenya Smith-Johnson,Program Assistant• Kenya.Smith-Johnson@phila.gov• On the web:• http://dbhids.org/health-reform-health-equity-unit• Twitter:• @PhillyRecovery• @shannonmace• @shlokajoshi
ACA Resources• Philadelphia Department of Behavioral Health & IntellectualdisABILITY 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