1. December 9th, 2011
Alan Morgan
Chief Executive Officer
National Rural Health Association

2. NRHA Mission
The National Rural Health Association is
a national membership organization
with more than 21,000 members whose
mission is to provide leadership on
rural issues through advocacy,
communications, education and research.

3. Children (up to age 26) can remain on
their parents’ health plan.

4. Small businesses can qualify for tax
credit (up to 35%) of the cost of premiums.

5. Insurance plans are barred from setting
lifetime caps on coverage, and can no
longer cancel policies when patients
get sick.

6. People with pre-existing medical conditions
are eligible for a new federally funded
“High Risk” insurance program. Eligible
residents of Virginia can apply for coverage
through the Pre-Existing Condition
Insurance Plan program run by the
U.S. Department of Health and
Human Services.

7. To qualify for coverage:
 You must be a citizen or national of the
United States or lawfully present in the
United States.
 You must have been uninsured for at least
the last six months before you apply.
 You must have a pre-existing condition or
have been denied coverage because of
your health condition.
To apply: https://www.pcip.gov/Apply.html

8. The Patient Protection & Affordable Care Act
(ACA)
 Addressing Key Challenges
 Improving Health Insurance Coverage
 Expanding the Rural Workforce
 Supporting the Rural Infrastructure
 Improving Public Health
 Improving Quality

9. The Affordable Care Act and Rural America
Solutions in ACA that will improve coverage:
 Immediate Consumer Protections
 Coverage for adult dependant children
 Changes to Medicare
 Expansion of Medicaid and CHIP

10. The Affordable Care Act
Key Patient “Protections”
 Access: Eliminates discrimination based on pre-existing medical
conditions.
 Exchanges: A competitive marketplace for easy-to-compare,
one-stop shopping of health insurance plans.
 Affordability: Premium tax credits for people less than 400% of
poverty level ($88,200 income for a family of four today) when
purchasing insurance through the exchange.
 Immediate Consumer Protections: No lifetime and restricted
annual limits, prohibition on rescissions, and temporary high
risk pool program for people who are uninsured and have a pre-
existing condition.

11. The Affordable Care Act and Rural America
 A Focus on Increasing Insurance Coverage
 Challenges
 More dependant on Individual Market
 Small Businesses as key employer
 Around one quarter of all rural adults are uninsured.
 High reliance on public insurance
 One-fifth of rural residents under age 65 have health
insurance from a public source, primarily Medicaid or
CHIP, compared to 17% of urban residents.
 40% of rural children have public coverage versus
30% of urban children.

12. The Patient Protection & Affordable Care Act (ACA)
The Pre-Existing Condition Insurance Plan (PCIP)
 Section 1101 of The Affordable Care Act (ACA) requires that
HHS establish a “temporary high risk health insurance
pool program”
 Provides immediate coverage for individuals with pre-
existing conditions until the Health Insurance Exchanges are
available in 2014
 Law required establishment within 90 days of enactment

13. The Affordable Care Act
Medicare
 Eliminates cost sharing for recommended preventive services
 Part D donut hole closed by 2020
– $250 rebate in donut hole (only in 2010)
– 50% brand-name discount (beginning 2011)
Medicaid
 Expands the Medicaid program to more Americans. This expansion will
increase access to care for low-income adults including many people living
with HIV/AIDS.

14. The Patient Protection & Affordable Care Act (ACA)
PCIP: Why This Matters in Rural America
Higher rates of Chronic
Disease and Disease
Burden
Lower Enrollment in
Group Insurance Market
Hospitals & Clinics Can Help Refer At-Risk Individuals to High-Risk Plans

15. The Patient Protection & Affordable Care Act (ACA)
2011 Plan Options & Out-of Pocket Costs
As in commercial coverage, PCIP enrollees pay monthly premiums and
deductibles for coverage
Federal Plans State Plans
Beneficiary
Responsibilities Standard Extended HSA-eligible
Option Option Option
Monthly premium $116 - $626 $156 - $842 $121 - $650 $69 - $1,806
Medical deductible $2,000 $1,000 $2,500 $0 - $5,000
Drug deductible $500 $250 Incl. in medical $100 - $500 or
incl.
Out-of-pocket limit $5,950 $5,950 $5,950 $5,950

16. The Patient Protection & Affordable Care Act (ACA)
Affordable Health Insurance Exchanges: Legislation
 Section 1311(b) and section 1321(b) of the Affordable
Care Act provide that each State has the opportunity
to establish an Exchange(s) that:
 (1) Facilitates the purchase of insurance coverage by
qualified individuals through qualified health plans (QHPs);
 (2) assists qualified employers in the enrollment of their
employees in QHPs; and
 (3) meets other requirements specified in the Affordable
Care Act.

17. The Patient Protection & Affordable Care Act (ACA)
Affordable Health Insurance Exchanges
 On July 11, 2011, HHS released two regulations relating to the
establishment of Affordable Health Insurance Exchanges:
 Establishment of Exchanges and Qualified Health Plans:
 Standards Related to Reinsurance, Risk Corridors and Risk
Adjustment:
 The proposed rules offer states flexibility, choices, competition and
clout for consumers and small businesses
 Comments on the Proposed Rule were due September 28, 2011

18. The Patient Protection & Affordable Care Act (ACA)
Affordable Health Insurance Exchanges:
Additional Regulations
 On August 12, 2011, CMS and the Treasury Department
proposed three regulations aimed at making it easier for
consumers to buy private health insurance through the
exchanges established in the ACA and reducing the
administrative burden on states establishing those
exchanges.
 Three proposed rules released by HHS and Treasury

19. The Patient Protection & Affordable Care Act (ACA)
Affordable Health Insurance Exchanges: State Legislation

20. The Patient Protection & Affordable Care Act (ACA)
Expanding the Rural Workforce
 Health Professions Education and Training
 Reauthorizes the National Health Service Corps
 Teaching Health Centers
 Redistribution of Unused Residency Slots

21. National Health Service Corps
The Affordable Care Act Builds on:
Significant Program Expansion
• $300 million in expansion funds for the NHSC from the Recovery Act
• More than 6,700 clinicians presently serving
• 7,358 Primary Care Providers estimated in 2010 vs. 4,760 in 2009
• Over 8,600 NHSC-Approved sites; 46% Community Health Centers
Recent Program Improvements
• Simplifying the NHSC site application and approval process.
• Examining NHSC disciplines to ensure the primary care workforce needs
are supported.
• Assessing NHSC program implementation with the goal of driving more
people into primary health care careers to meet public needs.

22. National Health Service Corps and
the Affordable Care Act
 Over 2,800 new Loan Repayment awards and over 200 scholarships are
expected in FY 2011.
 Authorizes and appropriates $1.5 billion for the NHSC through 2015.
 FY2011: $290 million
 FY2012: $295 million
 FY2013: $300 million
 FY2014: $305 million
 FY2015: $310 million

23. The Patient Protection & Affordable Care Act (ACA)
Improving Public Health
 Public Health and Prevention Fund
 Community Prevention Initiatives
 Building the Public Health Infrastructure
 Expanding Public Health Research and Training

24. Prevention and Public Health Fund
Primary Care, Prevention, and Wellness Workforce and Public
Health Training
 Public Health Training Centers Program
 Advanced Nursing Education Expansion Program
 Expansion of Physician Assistant Training Program
 Primary Care Residency Expansion
 Nurse Managed Health Clinics
 State Health Care Workforce Planning Grants
 State Health Care Workforce Implementation Grants
Obesity Prevention and Fitness
 Healthy Weight Collaborative
 Nutrition, Physical Activity and Screen Time in Child Care Settings

25. The Patient Protection & Affordable Care Act (ACA)
Improving Quality
 Center for Medicare & Medicaid Innovation (CMMI)
 Medicare Shared Savings Program: Accountable Care
Organizations (ACOs)

26. Health Reform Initiatives
Partnership for Patients
 Reduce harm caused to patients in hospitals.
We will accelerate the reduction of preventable harms to inpatients starting now, so that by the
end of 2013 we will observe a 40% reduction in preventable harm compared to 2010. Based on
our calculations, this would mean almost two million fewer injuries to patients and more than
60,000 lives saved.
 Reduce preventable hospital readmissions.
We will advance efforts to decrease preventable hospital readmissions within 30 days of
discharge, so that by 2013 all readmissions would be reduced by 20% compared to 2010. This
would mean prevention of more than 1,600,000 hospital readmissions.
Achieving these two goals will not only save lives and greatly reduce injuries to millions of
Americans, it will also result in savings of billions of dollars that help put the nation on
the path to having a more sustainable health care system.

27. Health Reform Initiatives
Hospital-Acquired Conditions: Opportunities for Improvement
 The goal of the Initiative is a 40% reduction of preventable HACs in three years.
Condition/Adverse Event (examples) Total Cases (2010) Preventable Cases (2010)
Central Line-Associated Blood Stream Infection 41,000 20,500
Pressure Ulcer 250,000 125,000
Surgical Site Infection 290,000 101,500
Adverse Drug Event 1,900,000 950,000
Injury from Fall 200,000 50,000
Ventilator-Associated Pneumonia 40,000 20,000
All Other Hospital Acquired Conditions
For example:
- Delay in administration of aspirin leads to hemorrhage 2,240,589 985,859
- Misplacement of feeding tube leads to choking
- Failure to manage diabetic symptoms leads to coma
Total - ALL Hospital Acquired Conditions 5,982,768 2,623,150

28. Rural Programs and the Affordable Care Act
Supporting the Rural Infrastructure
 Payment Extensions
 340B Changes
 Value-Based Purchasing Demonstration for Critical Access Hospitals
 Low-Reimbursed Rural Hospital Payments
 Frontier Wage Index & Practice Expense Floor
 Low-Volume Adjustment Changes
 Medicare-Dependent Hospital Extension
 Expansion of the Regional Extension Assistance Center for HIT
(REACH) Demonstration

29. Rural Programs and the Affordable Care Act

30. The Affordable Care Act
Supporting and Expanding the Rural Infrastructure
Rural Payment Extensions
 Low-Reimbursed Rural Hospital Payments
 Frontier Wage Index
 Low-Volume Adjustment Changes
 Medicare-Dependent Hospital Extension
Increase Payments for Rural Physicians
 Bonus Payments for Primary Care and General Surgery

32. Join NRHA Today!
 www.ruralhealthweb.org
 Click button: Become a Member
 Access to Social Networking: NRHA
Connect
 Regulatory and Legislative Guides
 E-news and Rural Roads
 Much, Much More

33. THANK YOU
Alan Morgan
Chief Executive Officer
National Rural Health Association