6. 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.
7. 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
8. Goal of the ACA: The Triple Aim
Better
health
Lower
costs
Better
health
care
9. 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
10. 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/
13. 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.”
14. 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
15. MajorProvisionsof ACA that
Address Disparitiesin 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
17. 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
18. 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 Level
139-399%
(Subsidies)
400%+
Private Non-
Group
Medicaid*
Employer-
Sponsored
Insurance
Uninsured
266 M Nonelderly
19. 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)
20. 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
21.
22. 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
23. 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
26. Federally FacilitatedMarketplace:
ImplementationIssuesin 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
27. 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.
28.
29. 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
30. PA MedicaidExpansion:
RecentActivity
• 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
31. 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
32. PA Coverage Gap
Source: PA Health Law Project, Medicaid Expansion in Pennsylvania Is Good For
Families (2013).
34. 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
35. 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
36. 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
37. 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
38. 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.
39. 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.
40. 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
42. Quality & PaymentReform:
A Moveto 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
43. 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.
44. Health Home Team
Mental Health
Provider
Primary Care
Provider
Substance
Abuse
Treatment
Program
Inpatient/Hos
pital ED
Urgent Care
Medical
Specialists
45. Health Home Services
• Comprehensive care management
• Care coordination
• Health promotion
• Comprehensive transitional care/follow-up
• Patient & family support
• Referral to community & social support services
47. 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
48. 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
49. 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
50. 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
52. DBHIDS Health Reform Priority
Areas
Eligibility & Enrollment/ Medicaid Expansion
Integrated Care Models
Health Information Technology/Reporting
Workforce Development
Essential Health Benefits/ Parity
53. 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
54. 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/heal
th-reform-health-
equity-unit
• Twitter:
• @PhillyRecovery
• @shannonmace
• @shlokajoshi
56. 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
