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Affordable care act ver 2
This document provides an overview of key elements of the Affordable Care Act (ACA), including who is covered, what is covered, who pays for coverage, and how to get covered. It discusses the goals of universal coverage and affordable health plans. It also outlines provisions such as health insurance exchanges, Medicaid expansion, essential health benefits, accountable care organizations, and impacts on employers and individuals.
Affordable care act ver 2
- 1. Affordable Care Act March 2013 Janlee Wong, MSW NASW
- 2. Learning Objectives • Basic Health Care Policy Elements and the Affordable Care Act • Who is covered • What is covered • Who pays for coverage • How to get covered • Social worker role • Resources
- 3. Health Care Policy • Universal, single payer health care • ACA provides universal coverage (except for the unauthorized) • ACA does not provide single payer • Elements of the ACA are state electives – Medicaid expansion – Health Benefits Exchanges
- 4. Affordable Care Act (ACA) • Healthcare Reform or Obamacare • Signed into law March 2010, full implementation 2014 GOALS • Universal healthcare (excludes undocumented) • Affordable health plans – minimum benefit • Cost control through wellness, prevention, competition
- 5. Court and State Decisions • US Supreme Court upheld the “individual mandate” of the ACA (July 2012) • Struck down sanctions against states that fail to expand Medicaid
- 6. Who Is Covered • All are eligible (excluding the unauthorized) • Includes those with pre‐existing conditions •All required to have or purchase health insurance or pay a fine
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- 9. The Uninsured Unauthorized (5) 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.
- 10. Poor Outreach • The report also found that about 50% of those still uninsured five years after the ACA takes effect will qualify for coverage under the Medi‐Cal expansion or for health benefit exchange subsidies, but they will not be aware that they qualify because of poor outreach. Medi‐Cal is California's Medicaid program (5)
- 11. Clues (6) • Uninsured about 18.5% of CA Population • Uninsured immigrants with native born children: 27.9% • Uninsured natives with children: 12.9%
- 12. What is covered Essential Health Benefits 1. Ambulatory patient services 2. Emergency services 3. Hospitalization 4. Maternity and newborn care 5. Mental health and substance use disorder services, including behavioral health treatment 6. Prescription drugs 7. Rehabilitative and habilitative services and devices 8. Laboratory services 9. Preventive and wellness services and chronic disease management 10. Pediatric services, including oral and vision care
- 13. Plans • Standardized plans ‐ Bronze, Silver, Gold, Platinum (from 60‐40 to 90‐10 Premium‐ Copay) • No Rescissions, No Lifetime Limits & Restricted Annual Limits • Medical Loss Ratio, Consumers rebates, 80‐ 85% on healthcare and quality • Elimination of the Medicare Part D doughnut hole ($2,700 to $6,154)
- 14. Who Pays? • Insurance model: the high cost of the sick offset by low cost of the healthy • Young adults (up to age 26) covered by parents • Emphasizes and pays for prevention • Sets minimum benefit levels so health plans compete with each other on cost and quality • Creates a state run health benefit exchange market structure for individuals and business
- 15. Reducing Healthcare Costs While Expanding Coverage • Cover the healthy as well as the sick • Wellness and prevention, early diagnosis • Reductions in unnecessary testing and referrals • Reductions in preventable emergency room visits and hospitalizations • Reductions in infections and adverse events in hospitals • Reductions in preventable readmissions, • Use of lower‐cost treatments, settings, and providers
- 16. Plans are Income Tested • Households earning less than 250 percent of the federal poverty level can receive financial help if they enroll in a Silver plan; the less income they earn, the more financial assistance they can receive. • For example, individuals earning between 150 to 250 percent of the federal poverty level can expect to pay $20 to see their primary care physician, while those earning 100 to 150 percent would pay $4.
- 17. How to Get Coverage • Many employers will simply continue plans for employees • Employers with 50 or more FTE workers required to provide health insurance or pay a penalty • Expands Medicaid (Medi‐Cal) up to 133% of poverty ($14,404 indiv to $29, 327 family of 4) • Health Benefits Exchange (Covered California) • Accountable Care Organizations (ACOs)
- 18. Employers • For employers without employee plans: – For businesses with 50 or fewer full time employees, qualified plans available in Exchange – No penalties for 50 or less employers if health coverage not offered • Reactions
- 19. Employers With Over 50 FT Workers • May have to pay a penalty if not providing health insurance • Doesn’t apply to employees working 30 hours a week or less • Reactions
- 20. Business Incentives • Small Business Tax Credits: 2 million workers get their insurance from an estimated 360,000 small employers • Early Retiree Reinsurance Program (ERRP) partially reimburses employment‐based plans for health benefits for early retirees and their spouses, surviving spouses and dependents • Health Care Exchanges Available to Small Business
- 21. Sole Proprietors • Health care reform ends discrimination by insurance companies based on pre‐existing conditions and gender. The new law also eliminates lifetime caps, restricts annual caps and ends the practices by which health insurance companies retroactively end a policy when someone becomes sick. (1)
- 22. Sole Proprietors • Premium Subsidies and Cost Sharing Credits (Starting in 2014) – Subsidies and credits to lower premiums and cost‐sharing requirements are available to individuals and families with incomes below 400 percent of the federal poverty line (below $88,000 a year for a family of four) who purchase coverage in the newly established exchanges. (1)
- 23. Health Benefits Exchange “Covered California” • Quasi‐governmental organization, specifically an "independent public entity not affiliated with an agency or department.“ • Contracting with Plans: Contract with carriers so as to provide health care coverage choices that offer the optimal combination of choice, value, quality, and service.”
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- 28. Accountable Care Organizations (ACOs) • ACO is a network of hospitals, clinics, physician practices and other providers who work together to provide coordinated, integrated care for an assigned population of individuals and who receive financial compensation for meeting specific patient outcomes. • Goal: Reduce or control the growth of healthcare costs while maintaining or improving the quality of care
- 29. Accountable Care Organizations (ACOs) • The core is effective primary care delivered through a “medical home” • Primary care organizations can transform • Integrated coordinated care similar to the HMO model • Not surprising Kaiser picked as essential benefit plan
- 30. ACO Characteristics • a strong primary care/medical home foundation • multidisciplinary health care teams •targeted care coordination interventions (focused especially on individuals with multiple chronic conditions) • integration with behavioral health and substance use treatment • sophisticated information systems that include electronic medical records • formal partnerships with “medical neighbors”
- 31. Role of Social Worker • Social workers should be included in the interdisciplinary care teams across a broad array of health care settings • Social workers are likely the only professionals devoted to meeting the psychosocial needs of patients and families • Social workers extend the team to allow members to participate at the top of their licenses
- 32. Roles of Social Worker • Clinical social workers – mental and behavioral health services • Medical social workers – care coordination and case management, medically related social services, patient and family education, discharge planning, advance care planning, community outreach and engagement
- 33. Roles of Social Worker • Be a voice for social work in the health care plan’s development of ACOs • Advocate for comprehensive benefits including psychosocial services • Advocate for horizontal integration of health and human services benefits • Serve as a resource for identifying hard to reach populations
- 34. Social Work Advocacy NASW and California Deans and Directors got a social worker included on the California Workforce Investment Board, Health Workforce Development Council (8) • 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. • Change regulations to allow the services of Community Health Workers/Promotores to be reimbursable with government and private payers. • Develop supportive payment structure and policies targeted at increasing the attractiveness of primary care as a career path and retention of primary care providers. • Ensure adequate payment for primary care and preventive services with appropriate adjustments in payment incentives.
- 35. ACA Is Changing • Check various websites for up to date changes http://www.healthcare.gov/ http://www.chcf.org/publications/2010/05/the‐ affordable‐care‐act‐in‐california • Continued political turmoil: – 27 states are expanding Medicaid, 16 are not and 8 are undecided (Feb 2013) – 17 states have set up exchanges, 27 have not – Some continue to seek repeal or delay
- 36. Resources 1. http://www.cfra.org/node/2807 2. www.socialworkers.org 3. http://www.healthexchange.ca.gov 4. http://www.coveredca.com/ 5. http://www.californiahealthline.org/articles/ 2012/10/24/california‐considers‐strategies‐ for‐treating‐uninsured‐immigrants.aspx
- 37. Resources 6. http://www.cis.org/california‐education 7. http://www.ppic.org/main/publication_show .asp?i=818 8. http://www.cwib.ca.gov/res/docs/special_co mmittees/hwdc/meeting_materials/2013/H WDC%20Report%20‐ %20Draft%20012113.pdf