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Future of Healthcare - Indiana State Nurses Association

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Future of Healthcare - Indiana State Nurses Association

  1. 1. Indiana State Nurses Association • www.indiananurses.org – CNE, Career Center, Advocacy Tools – Legislative Conferences: 2/5, 2/20 • ISNAbler • bmiley@indiananurses.org @IndianaNurses Indiana State Nurses Association
  2. 2. Why Learn About the Affordable Care Act? • Join the Policy Discussion • Only 31% of those eligible for Medicaid and 35% of those eligible for subsidies know they qualify – KFF & Urban Institute survey using data from 9/2013 • 70% of WSJ/NBC News Poll respondents don’t understand the ACA • Nurses – Gallup’s most trusted profession for 12 consecutive years
  3. 3. Affordable Care Act Goals • Expand Health Coverage Eligibility – Employer Mandate (2015) – Medicaid Expansion (optional) • Easier to Obtain Coverage – Marketplaces • Improve Coverage – Insurers Must Be Nicer to Sick People – Medicare – Provider Incentives/Penalties
  4. 4. Make Insurers Be Nicer to Sick People Insurers Dropping Coverage, Charging High Fees • Regulate Insurance Rates & Offerings – More Sick People Have Insurance, Not Enough Healthy People Buy Insurance to Offset • Individual Mandate – Children can stay on parents’ policies up to age 26
  5. 5. Supreme Court Decision • Individual Mandate Constitutional – Walks like a Tax, Quacks like a Tax • Mandatory Medicaid Expansion Unconstitutional – Taking Away All Medicaid Funds if State’s Don’t Expand is Unduly Coercive • Remedy Makes Expansion Optional
  6. 6. Medicaid Expansion • Up to 138%* of the Federal Poverty Level • Federal Funding of New Enrollees – 100% for 2014-2016; scales down to 90% in 2020 • Would Apply to Approximately 348,900 Hoosiers • 100% Federal Poverty Level – Individual: $11,490 – Family of 4: $23,550
  7. 7. Mandates • Businesses Over 50 Employees (FTE) – Provide Affordable Health Coverage or Pay Penalty • Affordable = contribution < 9.5% of household income • 30 hour/week employees over 3, 6, or 12 months – Penalty = (# of workers – 30) x $2,000 • Individual: greater of $95 or 1% income – Must Have Health Coverage or Pay Tax • Exemptions if coverage gap < 3 months, low income, etc. – Enforcement limited to future refunds
  8. 8. Indiana’s Approach • Federally Run Marketplace • No Medicaid Expansion • Lawsuit by Schools Seeking to Prevent Employer Mandate Penalty – DC Court Rejected Similar Challenge • Seeking Repeal of 2.3% Medical Device Tax • Healthy Indiana Plan (HIP) – Federal Waiver Program, Expansion Possible
  9. 9. HIP Differences from Medicaid • Eligibility – Medicaid: pregnant, child, families, disability, 65+ – HIP: ages 19-64, not eligible for Medicaid • Reimbursement at Medicare Levels (higher) • Annual & Lifetime Caps on Benefits – $300,000 per year/$1 million lifetime • 45,000 Cap on Enrollment
  10. 10. HIP Differences from Medicaid • POWER Account – Contributions by Participants • Sliding Scale: Max 5% of annual income, Min $160/year • Unused Rollover – Contributions by State • $1,100 minus Individual Contribution • Unused Rollover Only if Preventive Services Utilized
  11. 11. Marketplaces • Healthcare.gov - Open Enrollment 10/1/13 – 3/31/14 • Individuals Receive Federal Tax Credits if Income is 100-400% FPL and Employer Doesn’t Offer Coverage • Prospective then reconciled or just at tax time • Amount scaled to second-cheapest silver plan • Determine eligibility for Tax Credits, Medicaid, CHIP • In.gov/healthcarereform • SHOP: Small Business Tax Credits Available Now,
  12. 12. Marketplace Plans • Metallic Categories By % of Costs Covered – Bronze: 60%, Silver: 70%, Gold: 80%, Platinum: 90% • Catastrophic Coverage: high deductible, low premium – Eligible if under 30 or hardship (including prior insurance plan canceled) • Regulated by State Dept. of Insurance
  13. 13. Indiana Marketplace Options 4 Providers, 241 Plans • Anthem – Community Health Network, Wishard Health Services, Suburban Health Organization • MDwise – IU Health, St. Vincent Health, Franciscan Alliance • Physicians Health Plan of Northern Indiana (north central & northwest) • Coordinated Care-Celtic (northeast)
  14. 14. Helping People with Marketplace • Navigators – No Fees to Consumers or Commission – Federal certification: 30 hours of training, exam, annual recertification & • Separate Indiana certification requirements – Cannot recommend specific plan • Application Counselors
  15. 15. Medicare • Beneficiaries do not use Marketplaces • Increases Preventive Services • Reduces Prescription Drug Costs in Part D Coverage Gap Deductible Initial Coverage Coverage Gap Catastrophic Coverage
  16. 16. Insurers • Minimum Required Medical Loss Ratio – % of Premiums Spent on Claims & Wellness – Small Group = 80%, Large Group = 85% – $22.6 million in rebates in Indiana for 2012 – Includes Medicare Advantage plans • No Lifetime or Annual Limits on Coverage
  17. 17. Insurers • • • • • Can’t Disqualify Based on Pre-existing Conditions Premiums Can’t Vary Based on Gender Premium Variance Based on Age < 300% Can’t Penalize for Clinical Trial Participation Non-grandfathered plans must cover Essential Health Benefits • Total Out-of-Pocket Expenses Capped in 2015 – $6,350 for individual; $12,700 for family (includes copays, deductibles, not premiums)
  18. 18. EHB Categories • • • • • • • • • • Ambulatory Patient Services Emergency Services Hospitalization Maternity & Newborn Care Mental Health & Substance Use Disorder Services Prescription Drugs Rehabilitative and Habilitative Services Laboratory Services Preventive & Wellness Services Pediatric Services, including Dental & Vision
  19. 19. Supreme Court 2014 Contraceptives • Preventive services for women include prescription contraceptives • Religiously affiliated nonprofits may request an accommodation requiring the insurer to bear the cost of the contraceptives • Supreme Court will decide whether for-profit companies can be required to cover contraceptives
  20. 20. Hospital Value Based Purchasing • Medicare Bonuses or Penalties – Inpatient Prospective Payment System • Process Measures • Patient Surveys • Readmission & Mortality Rates – Myocardial Infarction, Heart Failure, Pneumonia
  21. 21. CMS Innovation Center • Accountable Care Organizations • Bundled Payments for Care – Different Models for Episode of Care • Medical Home Approach
  22. 22. Nurse Programs • National Health Service Corps – Nurse Practitioner or Certified Nurse Midwife – Service Commitment to Health Professional Shortage Area • Nurse Corps Loan Repayment Program – Registered Nurse or Nurse Faculty – Service Commitment to Critical Shortage Area • Nurse Managed Health Clinics
  23. 23. ACA Takeaways • Goals – Expand Health Coverage Eligibility – Easier Access to Coverage – Efforts to Improve Coverage • Access to Coverage Does Not Equate to Access to Care
  24. 24. ACA Timeline • Oct. 1, 2013 – Marketplaces Open • Dec. 15, 2013 – Deadline to Obtain Coverage Starting Jan. 1, 2014 • Jan. 1, 2014 – Individual Mandate Begins • Mar. 31, 2014 – Open Enrollment Closes • Oct. 15 to Dec. 7, 2014 – Open Enrollment • Nov. 1, 2013 – SHOP Available on Marketplaces • Jan. 1, 2015 – Employer Mandate Begins, Out-ofPocket Cap
  25. 25. Info Resources • • • • • • • • healthcare.gov - US Dept. of Health/Human Serv. Marketplace Help Line: 1-800-318-2596 Marketplace.cms.gov – Provider info by CMS hrsa.gov – Grant programs from HRSA in.gov/fssa/healthcarereform – Program Table rwjf.org - Robert Wood Johnson Foundation kff.org - Kaiser Family Foundation Indiananurses.org – Indiana State Nurses Association

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