Mandates to MedicaidThe Future of Health Care State Bar of California, Business Law Section Health Care Committee Telesemi...
Mandates to Medicaid                                      The Future of Health Care          Minimum Essential Coverage   ...
Mandates to Medicaid                                                                               The Future of Health Ca...
Mandates to Medicaid                                                                                 The Future of Health ...
Mandates to Medicaid                                                                                    The Future of Heal...
Mandates to Medicaid                                    The Future of Health CareCollecting the Penalty• Waiver of crimina...
Mandates to Medicaid                                  The Future of Health Care          Essential Health BenefitsPAGE: 7
Mandates to Medicaid                                                                      The Future of Health CareWhat Ar...
Mandates to Medicaid                                                   The Future of Health CareWhat Could Be Essential He...
Mandates to Medicaid                                                                        The Future of Health CareWhat ...
Mandates to Medicaid                                     The Future of Health CarePrecious Metals (January 2013)• Platinum...
Mandates to Medicaid                                   The Future of Health Care           Health Insurance ExchangesPAGE:...
Mandates to Medicaid                                           The Future of Health CareThe Health Insurance Marketplace i...
Mandates to Medicaid                                                               The Future of Health CareHow Do Exchang...
Mandates to Medicaid                                                                                  The Future of Health...
Mandates to Medicaid                                                                                 The Future of Health ...
Mandates to Medicaid                                                                                The Future of Health C...
Mandates to Medicaid                                                                                       The Future of H...
Mandates to Medicaid                                                                                 The Future of Health ...
Mandates to Medicaid                                                   The Future of Health CareNew Regulations To Ensure ...
Mandates to Medicaid                                The Future of Health Care           Medicaid ExpansionPAGE: 21
Mandates to Medicaid                                      The Future of Health CareStatutory Authority for MedicaidPub. L....
Mandates to Medicaid                                                         The Future of Health CareWhat Is Medicaid?Hea...
Mandates to Medicaid                                                                                      The Future of He...
Mandates to Medicaid                                                                                  The Future of Health...
Mandates to Medicaid                                                                              The Future of Health Car...
Mandates to Medicaid                                           The Future of Health CareMedicaid Expansion (Nov. 2012)    ...
Mandates to Medicaid                                                         The Future of Health CareMedicaid Expansion (...
Mandates to Medicaid                                                                                 The Future of Health ...
Mandates to Medicaid                                                                                The Future of Health C...
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Health Care of the Future

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Part I (Mandates to Medicaid)

State Bar of California, Business Law Section
Health Care Committee

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Health Care of the Future

  1. 1. Mandates to MedicaidThe Future of Health Care State Bar of California, Business Law Section Health Care Committee Teleseminar: February 1, 2013 9:00 AM Presented by Craig B. GarnerPAGE: 1
  2. 2. Mandates to Medicaid The Future of Health Care Minimum Essential Coverage (Meeting the Mandate)PAGE: 2
  3. 3. Mandates to Medicaid The Future of Health CareStatutory Authority• The Patient Protection and Affordable Care Act (Pub. L. 111-148) +• Health Care and Education Reconciliation Act of 2010 (Pub. L. 111-152) +• Tricare Affirmation Act (Pub. L. 111-159) +• Clarification of Health Care Provided by the Secretary of Veterans Affairs (Pub. L. 111-173) =________________________________• 26 U.S.C. § 5000APAGE: 3
  4. 4. Mandates to Medicaid The Future of Health CareWhat Satisfies the Mandate?• Government sponsored programs (Medicare, Medicaid, CHIP, Tricare, Veterans, Peace Corps); or• Employer-sponsored plan; or• Plans in the individual market (Exchange, Basic Health Program or CO-OP); or• Grandfathered health plan; or• OtherPAGE: 4
  5. 5. Mandates to Medicaid The Future of Health Care Minimum EssentialThe Penalty Yes Coverage? 1. Self-funded student coverage 2. Foreign health coverage 3. Refugee medical assistance NEW WAYS TO QUALIFY (1/30/13) 4. Medicare Part C No 5. State high risk pools 6. AmeriCorp volunteers 1. Religious? 2. Not Present? Exception? Yes 3. In Jail? 4. Low Income? 5. Hardship? 6. Indian Tribe? No $695 (or less) PENALTY (in 2016) or not to Bronze Level of the greater of exceed Coverage 2.5% of household incomePAGE: 5
  6. 6. Mandates to Medicaid The Future of Health CareCollecting the Penalty• Waiver of criminal penalties• Limitations on liens and levies PAGE: 6
  7. 7. Mandates to Medicaid The Future of Health Care Essential Health BenefitsPAGE: 7
  8. 8. Mandates to Medicaid The Future of Health CareWhat Are Essential Health Benefits?• Ambulatory patient services• Emergency services• Hospitalization• Maternity and newborn care• Mental health and substance use disorder• Prescription drugs• Rehabilitative and habilitative services and devices• Laboratory services• Preventative and wellness services and chronic disease management• Pediatric services, including oral and vision care42 U.S.C. § 18022PAGE: 8
  9. 9. Mandates to Medicaid The Future of Health CareWhat Could Be Essential Health Benefits?• Emergency room visits• Ambulance services• Diabetes care management• Kidney dialysis• Physical therapy• Durable medical equipment• Prosthetics• Infertility treatment• Organ and tissue transplantationInstitute of Medicine, Essential Health BenefitsPAGE: 9
  10. 10. Mandates to Medicaid The Future of Health CareWhat Are the Levels of Coverage?• Bronze (60% of the full actuarial value of the benefits)• Silver (70% of the full actuarial value of the benefits)• Gold (80% of the full actuarial value of the benefits)• Platinum (90% of the full actuarial value of the benefits)• Catastrophic (29 years old or younger or exempt from Section 5000A)42 U.S.C. § 18022(d), (e)PAGE: 10
  11. 11. Mandates to Medicaid The Future of Health CarePrecious Metals (January 2013)• Platinum 30-day average = $1,585• Gold 30-day average = $1,673• Silver 30-day average = $31PAGE: 11
  12. 12. Mandates to Medicaid The Future of Health Care Health Insurance ExchangesPAGE: 12
  13. 13. Mandates to Medicaid The Future of Health CareThe Health Insurance Marketplace isdesigned to help you find insurancethat fits your budget, with less hassle.No matter where you live, you’ll beable to buy insurance. . . . New lawsmean plans must treat you fairly andcan’t deny you coverage because ofpre-existing conditions.Source: CMS ToolkitPAGE: 13
  14. 14. Mandates to Medicaid The Future of Health CareHow Do Exchanges Work?• Make comparison shopping easy• Lower barriers for new competition in the insurance market• Provide savings and choice through transparency• Determine individual tax credits/subsidies• Compete for enrollees• Focus on the uninsuredPAGE: 14
  15. 15. Mandates to Medicaid The Future of Health CareState-Based ExchangeEach individual state operates all Exchange activities, but a state may use federalgovernment services for the following activities:• Premium tax credit and cost sharing reduction determination• Exemptions• Risk adjustment program• Reinsurance programPAGE: 15
  16. 16. Mandates to Medicaid The Future of Health CareState Partnership ExchangeState operates activities for:• Plan management (and/or)• Consumer assistanceState may elect to perform or can use federal government Services for the followingactivities:• Reinsurance program• Medicaid and CHIP eligibility assessment or determination PAGE: 16
  17. 17. Mandates to Medicaid The Future of Health CareFederally-Facilitated ExchangeHHS operates, but state may elect to perform or can use federal government services forthe following activities:• Reinsurance program• Medicaid and CHIP eligibility assessment or determination PAGE: 17
  18. 18. Mandates to Medicaid The Future of Health CareExchange TransparencyAs part of the application process, each state should post certain sections from itsapplication on the appropriate state website, including:• Exchange board and governance structure• Stakeholder consultation plan• Outreach and education plan• Role of agents and brokers• Coordination strategy• Pre-Existing Condition Insurance Plan (PCIP) transition• Long-term operational cost plan PAGE: 18
  19. 19. Mandates to Medicaid The Future of Health CareCalifornia Health Benefit ExchangeThe California Health Benefit Exchange posts the following vision, mission and values onits website (www.healthexchange.ca.gov):• Consumer-focused• Affordability• Catalyst• Integrity• Partnership• Results PAGE: 19
  20. 20. Mandates to Medicaid The Future of Health CareNew Regulations To Ensure Fairness• Limit premium variation to age and tobacco use But what is tobacco use?• Accept all applicants and guarantee renewal Are there capacity limits?• Effective Rate Review Who will conduct the reviews?• Medical Loss Ratio Who will monitor? PAGE: 20
  21. 21. Mandates to Medicaid The Future of Health Care Medicaid ExpansionPAGE: 21
  22. 22. Mandates to Medicaid The Future of Health CareStatutory Authority for MedicaidPub. L. 103-448 + Pub. L. 110-90 +Pub. L. 104-226 + Pub. L. 111-3 +Pub. L. 105-12 + Pub. L. 111-5 +Pub. L. 105.33 + Pub. L. 111-148 +Pub. L. 106-113 + Pub. L. 111-152 +Pub. L. 106-169 + Pub. L. 111-309 +Pub. L. 108-448 + Pub. L. 112-78 +Pub. L. 109-91 +_____________________________42 U.S.C. § 1396dPAGE: 22
  23. 23. Mandates to Medicaid The Future of Health CareWhat Is Medicaid?Health insurance for individuals who qualify financially, as wellas families with dependent children, the aged, blind or disabled.• Medi-Cal• KanCare• SoonerCare• Hoosier Healthwise• MassHealth• SALUD!• TennCarePAGE: 23
  24. 24. Mandates to Medicaid The Future of Health CareMedi-Cal• Created in California during its 1975 Second Extraordinary Session• (First Extraordinary Session only considered Medi-Cal, while paying the Assembly and Senate $240,600)• Cal. Welf. & Inst. Code § 14000: “The purpose [of Medi-Cal] is to afford to qualifying health care and related remedial or preventative services, including related social services which are necessary for those receiving health care under [Medi-Cal].”• Includes 25% of California’s populationPAGE: 24
  25. 25. Mandates to Medicaid The Future of Health CareMedicaid Expansion77 Federal Register 17144 (Mar. 23, 2012) (Final Rule)• Implemented provisions of the Affordable Care Act related to Medicaid eligibility, enrollmentand coordination with the Exchanges, CHIP, and other programs• Simplified the eligibility rules in Medicaid and CHIP• Set the minimum Medicaid income eligibility level of 133 percent of the Federal Poverty Levelfor most non-disabled adults under age 65Proposed Rule (Jan. 14, 2013)• Reflects new statutory eligibility provisions•Proposes changes to provide states more flexibility to coordinate Medicaid and CHIP eligibility,appeals and other administrative procedures• Modernizes and streamlines existing rulesPAGE: 25
  26. 26. Mandates to Medicaid The Future of Health CareMedicaid Expansion and the Supreme Court• The United States Supreme Court held that Congress has the authority to offer fundingfor states to expand Medicaid by 2014 without imposing retroactive financial conditions.National Fed. of Indep. Bus. v. Sebelius, 132 S. Ct. 2566, 2606-07 (2012).• Congress never dreamed that any State would refuse to go along with the expansion ofMedicaid. Congress well understood that refusal was not a practical option. (Id. at 2665(Scalia, Kennedy, Thomas and Alito, JJ, dissenting).PAGE: 26
  27. 27. Mandates to Medicaid The Future of Health CareMedicaid Expansion (Nov. 2012) Not Participating Leaning Toward No Undecided Participating Leaning Toward YesPAGE: 27
  28. 28. Mandates to Medicaid The Future of Health CareMedicaid Expansion (Jan. 2013) After Election refers to views as of January 13, 2013. In states with newly elected governors, before election refers to the views of the outgoing governor, and after election refers to the views of the governor-elect. Source: Sommers, U.S. Governors and the Medicaid Expansion, New Engl. J. Med. (Jan. 2013)PAGE: 28
  29. 29. Mandates to Medicaid The Future of Health CareMedicaid Expansion By the Numbers• The Federal Government will pay 100% of added expense for newly eligiblebeneficiaries through 2016, 95% in 2017, 94% in 2018, 93% in 2019 and 90% in 2020and thereafter.• States must pay “qualified” physicians Medicaid fees at least equal to Medicare ratesstarting in 2013.• Pay increase applies to family physicians, internists and pediatricians (and in someinstances specialists) provided (1) they are Board-certified or (2) at least 60% of theMedicaid codes they billed in the previous year were primary care codes identified in theAffordable Care Act. PAGE: 29
  30. 30. Mandates to Medicaid The Future of Health CareQuestions?• www.healthcare.gov (U.S. Government)• www.healthreform.kff.org (The Henry J. Kaiser Foundation)• www.hhs.gov (The U.S. Department of Health and Human Services)• www.cms.gov (Centers for Medicare & Medicaid Services)• www.oshpd.ca.gov/reform (Office of Statewide Health Planning & Development)• www.chhs.ca.gov (California Health & Human Services Agency)• www.ppaca.me PAGE: 30
  31. 31. The End

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