Affordable care act ca 2104


Published on

  • Be the first to comment

  • Be the first to like this

No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide

Affordable care act ca 2104

  1. 1. Affordable Care Act California Implementation Janlee Wong, MSW NASW California Chapter April 2014
  2. 2. ACA Goals • Universal coverage – By January 2014, 92% of Californians will be eligible for coverage (1) – 2.6 million unauthorized immigrants will not (2) • Affordable Health Plans – Expand Medi-Cal (Medicaid) in Low Income Health Plan (LIHP) (500,000) (2) – Offer plans in Healthcare Exchange (Covered CA) • Cost Controls
  3. 3. California has the eighth largest proportion of uninsured in the nation and the largest total number of uninsured. Only three states (Massachusetts, Hawaii, and Minnesota) have uninsured rates under 10%. *All numbers reflect the non- elderly population, under age 65. Source: Employee Benefit Research Institute estimates of the 2009 – 2011 Current Population Survey, March Supplements.
  4. 4. The Uninsured Unauthorized (3) A recent report by the UC-Berkeley Center for Labor Research and Education and the UCLA Center for Health Policy Research on California residents who will remain uninsured after the ACA takes effect found that: • 66% of the remaining uninsured will be Latino; • 60% of the remaining uninsured will have limited English proficiency; and • 62% of the remaining uninsured will live in Southern California.
  5. 5. Immigrants • The ACA does not change the current eligibility standard preventing most documented immigrants from enrolling in Medicaid or the Children's Health Insurance Program if they have resided in the U.S. for fewer than five years. States are permitted to cover such immigrants in the programs at their own expense, and Medicaid will cover emergency care for all immigrants.
  6. 6. Immigrants • Undocumented immigrants are not eligible for public health insurance programs, and the ACA in most cases will further exclude them from new coverage opportunities, including state health insurance exchanges and Medicaid expansions. • Lawful immigrants who have lived in the U.S. for less than five years may participate in health insurance exchanges and obtain subsidies if income-qualified, but in most states, they still will not be able to qualify for full Medicaid coverage.
  7. 7. Immigrants • In California under the state's Medicaid program -- "services for undocumented immigrants, including prenatal care, pregnancy-related services, nursing home care, and limited breast and cervical cancer treatment," are provided through Medi-Cal • The Deferred Action for Childhood Arrivals program was created by President Obama in 2012 to grant immigrants who came to the country illegally as children — sometimes called Dreamers — legal status and work authorization for two-year periods. • Laurel Lucia, a policy analyst at the UC Berkeley Labor Center and author of the report released Tuesday, said California is one of the few states that lets youth with deferred action status enroll inMedicaid.
  8. 8. ACA Implementation In CA Goals 1. Expand Coverage in Public Programs 2. Simplify and Streamline Eligibility and Enrollment 3. Protect Health Insurance Consumers 4. Create a New Marketplace for Private Health Insurance
  9. 9. Goal 1: Expand Coverage in Public Programs 1. Expand Medi-Cal 2. Determine Coverage Options for Low Income Individuals 3. Use Financial Incentives to Improve Access and Quality
  10. 10. Objective 1: Medi-Cal Expansion • Current Coverage: Infants and pregnant women (200% Federal Poverty Level - FPL) • Children (ages 1-5 - 133% FPL), ages 6-19 (100% FPL) • Low-income parents, elderly, people with disabilities • ACA expansion: parents of dependent children, foster youth to age 26, non-elderly and childless adults (133% FPL)
  11. 11. Summary - Individuals
  12. 12. Summary - Families
  13. 13. 3. Use Financial Incentives to Improve Access and Quality (1) • Primary care rate enhancement (required). 100% federal financing in 2013 and 2014 • Raises Medi-Cal reimbursement rates to parity with Medicare for certain evaluation and management services provided by primary care physicians. • 120% increase in reimbursement
  14. 14. Preventive Services w/o Copays • 1% increase in federal matching payments if the state covers certain recommended immunizations and preventive services without charging Medicaid beneficiaries a share of the cost. • Adults get 15 services covered for preventive care, women get 22 and kids get 26 covered services. These services include some of the most important types of prevention like immunizations, mammograms and wellness visits. Medicare patients also gain some new benefits under the ACA as the 2010 preventive health mandates apply to them as well.
  15. 15. Goal 2: Simplify and Streamline Eligibility and Enrollment (1) Objectives 1. Improve Consumer Experience – Consumer Application/enrollment: in person, mail or online 2. Promote and support enrollment – Assisters and Navigators provide consumers with one-on-one assistance in enrollment
  16. 16. 1. Improve Consumer Experience • “No wrong door” – Medi-Cal enrollment, 58 counties with in person, mail telephone and online, certified assisters • CalHEERS – California Healthcare Eligibility, Enrollment, & Retention System (Accenture) • Covered CA website: fact sheets, subsidy calculator and consumer phone number • Simple Income Eligibility Determination: Single income standard, no assets test
  17. 17. 2. Promote and support enrollment Assisters/Navigators (6) • Assister Enrollment Entities (AEE) – Organizations approved by the Exchange to provide one-on-one consumer assistance – AEEs can be registered in either the Navigator Program or the In-Person Assistance Program but not both. – American Indian/Tribal Organizations, Attorneys, Tax Preparers, Trade/Prof. Org., Com Clinics, Colleges, Cities, Unions, Chambers of Commerce, Non-Profits, Schools, Ranch or Farm Organizations (partial list)
  18. 18. 2. Promote and support enrollment Navigators/Assisters (6) • In-Person Assistance Program (IPA) – Operated by AEE – Hires Assisters to provide one-on-one assistance – AEE paid $58 per enrollment • Navigator Program – Operated by AEE – Hires Navigators – Awarded grants for outreach, education and enrollment assistance one-on-one to consumers
  19. 19. Goal 3: Protect health Insurance Consumers • Objectives: 1. Enforce new health insurance coverage rules – Today, CA limits use of pre-existing conditions limits, and requires annual policy renewal – January 2014: All ACA provisions apply 2. Ensure health insurance premium value 3. Limit impact adverse risk on rate payers
  20. 20. 1. Enforce new health insurance coverage rules • Grandfathered 2010 plans by individuals and small businesses exempt from ACA • CA established Pre-Existing Condition Plan Managed Risk Medical Insurance Board (MRMIB) in 2010 • Will transition MRMIB into Exchange or Private Market Jan. 1, 2014 • Small group reform enacted 2012 • Individual plan reform pending legislation
  21. 21. 2. Ensure health insurance premium value 1. Establish minimum set of “essential health benefits” (EHB) for individual and small employer coverage 2. State Review of proposed premium increases 3. Medical Loss Ratio: health plans spend a minimum percentage of 80-85% of premium on care – Statutory authority enacted 2012
  22. 22. Essential Health Benefits (EHB) (7) • Benchmark plan established in 2012 (patterned after Kaiser Small Group HMO • Includes mental health/substance abuse • Includes Pediatric Dental/Vision supplemental • Currently plans covered by Dept. of Managed Care must cover EHB, but not Dept. of Insurance plans • Jan 1, 2014: Plans in and outside Exchange must cover EHB
  23. 23. 2. State Review of proposed premium increases (8) • Implemented 2011, CA Depts of Managed Health Care and Insurance • Department of Managed Health Care posting rate information, including findings of an unreasonable rate increase, on the Department’s public website. • Department of Insurance posting public access to rate filings. • Since January 1, 2011, the Department of Insurance rate review process resulted in some rate reductions and adjustments estimated to save policyholders a total of at least $40 million.
  24. 24. 3. Medical Loss Ratio • 2012 – “Anthem Blue Cross, Blue Shield of California and Kaiser Permanente distribute more than $50 million in rebates across some 1 million California customers.” – June 2, 2012, Los Angeles Times (9)
  25. 25. 3. Limit impact adverse risk on rate payers 1. Traditional Reinsurance 2. Risk Adjustment 3. Risk Corridors Legislation to establish a state program failed in 2012 and the federal government will administer this program
  26. 26. Goal 4: Create a New Marketplace for Private Health Insurance 1. Operate the Exchange – CA obtained conditional certification for “Covered CA” Jan. 2013 and full certification by Oct. 2013 2. Offer coverage through qualified health plans – 11/2012 RFPs for platinum, gold, silver, bronze and catastrophic benefit plans – 6/2013 Contracting with selected insurers – 10/1/2013 enrollment Oct. 2013
  27. 27. Accountable Care Organizations (ACO) (12) Experiment or Experience? • ACO goal: improve care and reduce costs • Method: Collaboration among provider groups, hospitals, and others— in an environment of aligned financial incentives — to improve coordination, care delivery, and efficiency • Providers and ACOs share in savings resulting from coordinated care • Serves as “insurer and provider”
  28. 28. ACO Characteristics • Choice of providers, often the same existing providers • Can work within existing health plans including Medicare, Aetna, etc. • Coordinated care from prevention to acute and post acute • Information Technology System that reports frequently on healthcare utilization • Shared savings
  29. 29. Accountable Care Organizations (11) • Medicare Shared Savings Program (MSSP) ACOs are designated to coordinate care for Medicare fee-for- service beneficiaries. • Medicare Advanced Payment Model* is a special version of the MSSP ACO model to support infrastructure development. • Medicare Pioneer ACOs* were among the first Medicare-designated ACOs and take on more risk than the MSSP model. • Look-Alike ACOs contract with commercial health plans to coordinate care in a similar model to those above.
  30. 30. San Diego ACOs (13) • North Coast Medical ACO (MSSP) Medicare ACO- Shared Savings Program • San Diego Independent ACO (MSSP) Medicare ACO- Shared Savings Program • Sharp HealthCare (Aetna) Look-alike ACO-Contract w/Health Plan For Non-State • Sponsored Program • Sharp Healthcare (Blue Flex) Look-alike ACO-Contract w/Health Plan For Non-State • Sponsored Program • Sharp HealthCare ACO (Pioneer) Medicare ACO- Pioneer
  31. 31. San Diego ACOs Summary (13) • Total ACOs Operating in the County 5 • Total Individual ACO Hospital Partners in the County 9 • Number of PCPs Involved in the ACOs 1,284 • Number of Specialists Involved in the ACOs 2,792 • Total Individual Medical Groups/Clinics Utilized in the County by the ACOs 48 • Estimated Lives to Be Served within the Specific ACO Activity 68,000
  32. 32. Care Coordination (14) What is it? Wrap around? • Medical – Medication management – Utilization review/data analysis – Emergency room management – Follow up for specialized care • Social – Consumer empowerment – Psychosocial assessment – Person in Environment approach – Social and behavioral health services – Cultural humility, advocacy
  33. 33. Texas Promotor(a) (17) • Communication skills • Interpersonal skills • Service Coordination skills • Capacity-building skills • Advocacy skills • Teaching skills • Organizational skills • Knowledge base on specific health issues
  34. 34. Community Health Workers Workforce Innovations (17) Grand-Aides® • CNA/CMA Training • Primary care and chronic care • Home visits • Telemedicine • Medication Management • Social issues Texas Promotor(a) • Communication skills • Interpersonal skills • Service Coordination skills • Capacity-building skills • Advocacy skills • Teaching skills • Organizational skills • Knowledge base on specific health issues
  35. 35. CA Workforce Investment Board Health Workforce Development Council (18) “Standardize, strengthen and expand curricula and training programs to increase access and consistent competencies for Community Health Workers/Promotores, Medical Assistants, Social Workers, Nurses, Direct Care Workers and other workers.”
  36. 36. Enrollment by Plan 369 332 13 0.976 238 210 32 10.6 10.4 1.6 3.2 000s Total
  37. 37. Medicare Shared Savings Program (MSSP) Accountable Care Clinical Services (Orange) Accountable Care Clinical Services/Preferred ACO Affiliated Physicians Medical Group ACO Akira Health APCN-ACO ApolloMed ACO Applecare Medical Group Cedars-Sinai Accountable Care John Muir Physician Network Meridian Holdings Meritage ACO North Coast Medical ACO Premier ACO Physicians Network San Diego Independent ACO Torrance Memorial Integrated Physicians UCLA ACO Medicare Advanced Payment Model Golden Life Healthcare National ACO Medicare Pioneer Brown & Toland Physicians HealthCare Partners ACO Heritage California ACO Monarch HealthCare Sharp HealthCare Look Alike ACOs Access Medical Group/St. John's Health Center/NantWorks AllCare IPA/Doctors Medical Center Brown & Toland Physicians Brown & Toland Physicians/California Pacific Medical Center Greater Newport Physicians/Hoag Hospital HealthCare Partners Associates Medical Group Hill Physicians/Dignity Health - Sacramento Hill Physicians/Dignity Health - County Employees Hill Physicians/Dignity Health - UC Employees John Muir Health Palo Alto Medical Foundation Physicians Medical Group of Santa Cruz/Dominican Hospital Primecare Medical Network Santa Clara County IPA Sharp HealthCare St. Joseph Health Appendix: California ACOs
  38. 38. References 1. 2. igrant_population_by_state.html 3. treating-uninsured-immigrants.aspx 4. 5. ge_Plan_(Update).pdf 6. ders%20Webinar%20Draft%20Regs-FINALSlide%20Deck05032013.pdf 7. 8. 9. 10. HeritageACO.pdf 11. 12. 13. 14. df 15. 16. es%20for%20SWers.pdf 17. 18. 0Report%20-%20Draft%20012113.pdf
  39. 39. References • health-care-many-not-eligible-for-medicaid-expansion • n_california_qualified_to_be_covered_by_medicaid.html • •