THE PATIENT PROTECTION AND AFFORDABLE CARE ACT Susan Horky, LCSW

Components  Patient-related  Ensuring coverage  Increasing access  Fairness/transparency/getting value  Increasing quality  Systems efforts  Supporting prevention  Decreasing costs  Workforce development  Additional systemic changes

Ensuring insurance  No annual or lifetime caps  Can’t be kicked off insurance if sick or made mistakes on application  Can’t be denied coverage due to pre-existing condition

Ensuring insurance  Dependents remain on parents’ insurance till 26  Can’t be made to wait more than 90 days for coverage

Ensuring Insurance  People with insurance can keep their current insurance (or choose not to)  If you’re uninsured you can:  Obtain insurance through employer  Go to an exchange  [Obtain Medicaid]  Tax credits available for people < 400% FPL = $94,200 for a family of four

Tax credit  Generally available only for people who buy individual/family policies through an exchange  Available for people who have employer based health insurance IF The employees’ part of the premium is more than 9.5% of household income or If the plan covers less than 60% of medical costs

Ensuring insurance  Tax credits will insure that premiums will not exceed the percent indicated below, for various levels above poverty level:  A person who earns 150 percent of the poverty line (about $17,235) would be expected to pay no more than 3 percent of their income on premiums, or $517

Ensuring Insurance: Affordability  Sets limits to how much families must pay out of pocket  2013 limits are $6,250 for an individual and $12,500 for family  These amounts are indexed annually for inflation

Ensuring Insurance: Exchanges  Similar to buying car insurance, but online  Choose from different options, clearly laid out  Users won’t know if exchange is set up by state or federal government

Ensuring Insurance: Exchanges

Ensuring Insurance  “Navigators” will assist patients in navigating the insurance and healthcare systems  Navigator grants available to states, agencies, universities

Penalties for no coverage  Some people who choose not to have coverage will be required to pay a penalty  This is NOT the case if:  Your share of premiums (after federal subsidies and employer contributions) would total more than 8 percent of your income  Your income is below the income tax filing threshold, and so you’re not required to file taxes  You were uninsured for less than three months of the year (If over three, the penalty is pro-rated)  You choose not to get insurance for religious reasons

Penalties for no coverage  The Urban Institute estimates that approximately 6% of the population (roughly 18 million Americans) will even have to consider the question of whether to get insurance or pay a penalty  Penalty in 2015 will be $95.00  Proof will be filed with income tax  Penalty will be deducted from income

Ensuring Insurance  Small businesses (<50 employees) are specifically exempted from having to provide insurance  Large employers do have to have to provide insurance or pay a penalty, as then the cost of providing coverage to their employees is covered by tax payers

Small businesses-Incentives  Very small businesses (< 25 employees) can get tax credits to help with insurance if they choose to offer it  Small businesses with up to 100 employees will have access to state- based Small Business Health Options Program (SHOP) Exchanges  SHOP exchanges are estimated to reduce by 4% the costs small businesses pay in premiums

Grandfathered Insurance Policies  Grandfathered plans are those in existence prior to 2014 who apply for grandfathered status (partial ACA exemption)  Grandfathered plans lose their status if they significantly raise premiums, copays etc

Grandfathered plans  Get rid of lifetime insurance caps  Offer dependent coverage for young adults until age 26  Keep people on their insurance even if they made mistakes on application (rescission)  Provide preventive care without cost-sharing  Offer “essential health benefits" for individual and small group plans  Refrain from imposing annual dollar limits (for individual policies only)  Provide coverage to children under 19 if they have a pre-existing conditions (for individual policies only) Do have toDon’t have to

Essential health benefits (Required for individual and small group plans only)  Ambulatory patient services  Emergency services  Hospitalization  Maternity and newborn care  Mental health and substance use disorder services including behavioral health treatment  Prescription drugs  Rehabilitative and habilitative services and devices  Laboratory services  Preventive and wellness services and chronic disease management  Pediatric services, including oral and vision care..

Systems/Back-end Aspects of ACA AccessFairness QualityPrevention Workforce Development

Increasing access  Making healthcare choices more understandable  Choosing own PCP  No ER prior authorization required  Encouraging cultural competence  Workforce diversity grants  Health care professionals training for diversity

Increasing access  Significant focus on (and funding for) Federally Qualified Health Centers  Community Health Centers which serve a variety of Federally designated Medically Underserved Area/Populations (MUA or MUP).  Migrant Health Centers which provide culturally- competent and primary preventive medical care to migrant and seasonal agricultural workers,  Health Care for the Homeless Programs which reach out to homeless individuals and families and provide primary and preventive care and substance abuse services, and  Public Housing Primary Care Programs that serve residents of public housing and are located in or adjacent to the communities they serve.

Increasing access  School based health centers  Co-locating primary and specialty care in community- based mental health settings  Extension of family-to-family health information centers  Removing barriers and improving access to wellness for individuals with disabilities  Counting resident time in non provider settings.

Fairness/Value/Transparency  Low salaried individuals must have same insurance options as high salaried individuals  All people must be charged the same premiums for the same coverage except for:  Individual vs. family coverage  The insurance rating area in which the person lives  The age of the person (but cannot vary more than 3:1)  Whether or not the person uses tobacco (but cannot vary more than 1.5:1)

Fairness/Value/Transparency  All approved health insurance plans must have same components (within Silver, Gold and/or Platinum)  Amount patient pays of own healthcare costs (through deductibles and copays)  Bronze plan: 40%  Silver plan: 30%  Gold plan: 20%  Platinum plan: 10%

Fairness/Value/Transparency  80%-85% of premium incomes must be spent on healthcare  If insurance company spends more than 15%-20% premium incomes on administrative costs or profits, they must send rebates to the insured

Fairness/Value/Transparency  Each hospital must make public a list of the hospital's standard charges for items and services it provides  Each health insurance plan must have a clear plan for appealing their coverage decisions and standardized complaint forms  Nursing home compare Medicare website

Quality  Payments to hospitals will be linked to quality measures, including  Readmissions  Hospital acquired infections  Patient perceptions of care  Health outcomes  Patient safety/medical errors  Implementation of wellness programs

Quality  Technical assistance will be available to hospitals, to help improve quality  Healthcare professionals and hospitals will get bonuses for quality reporting  They will also be penalized for not doing quality reporting

Quality  Significant funding available to create innovative programs that improve quality:  Aging and disability resources centers  Medical Home projects  Integrated care around hospitalizations  MCH Home visiting projects  Research into postpartum depression  Train health professionals in quality initiatives and patient safety

Quality  Health care delivery system research  Medication management services in treatment of chronic disease.  Design and implementation of regionalized systems for emergency care  Trauma care centers and service availability  Program to facilitate shared decision-making  Presentation of prescription drug benefit and risk information  Patient navigator program  Improving women’s health  Community Health Teams

Quality  Funding for innovative programs, continued  Research into health disparities  Childhood Obesity Demonstration Project  Demonstration project concerning individualized wellness plan  Community transformation grants  Patient-Centered Outcomes Research

Prevention  Rebates on premiums if person uses employer- based fitness plan  No cost-sharing on preventive coverage for individual or group insurance purchased through exchanges  Clinical and community preventive services; Community education and outreach campaign about prevention  Nutrition labeling of standard menu items at chain restaurants.  No co-pays on ACIP recommended Immunizations

Prevention  Incentives for prevention of chronic diseases in patients with Medicaid  Coverage of comprehensive tobacco cessation services for pregnant women with Medicaid  Improving access to preventive services for eligible adults in Medicaid  Providers will be paid at Medicare rates for preventive services for Medicaid patients  Cultural competency, prevention, and public health and individuals with disabilities training

Workforce development  National health care workforce commission; Health care workforce assessment  Public health workforce recruitment and retention programs  State health care workforce development grants  Federally supported student loans  Nursing student loan program; Nurse education, practice, and retention grants; Advanced nursing education grants  Health care workforce loan repayment programs

Workforce Development  Mental and behavioral health education and training grants  Training opportunities for direct care workers  Training in family medicine, general internal medicine, general pediatrics, and physician assistants  Nurse-managed health clinics  National Health Service Corps  Allied health workforce recruitment and retention programs; Grants to promote the community health workforce

Additional Systems changes  Funding for innovative pilot programs that change how providers bill (thus reducing costs)  Decrease in DSH payments