Affordable Care Act Nurse Practitioner Association of Southwestern Pennsylvania May 15, 2013 H EALTH C ARE.GOV Aryanna Abouzari, Esq. Executive Officer U.S. Department of Health & Human Services, Region III Pennsylvania, Delaware, District of Columbia, Maryland, Virginia, West Virginia

Critical Need for Health Reform 48.6 million uninsured Americans 48.6 million uninsured Americans $3 trillion spent annually on healthcare $3 trillion spent annually on healthcare 17.9 % of our economic output tied up in the health care system 17.9 % of our economic output tied up in the health care system Without reform, by 2040, 1/3 of economic output tied up in health care Without reform, by 2040, 1/3 of economic output tied up in health care

Affordable Care Act Overview Creates Consumer Protections Creates Consumer Protections Prevents denials of coverage for pre-existing conditions Prevents denials of coverage for pre-existing conditions Make health insurance more affordable for middle class families and small businesses with tax credits Make health insurance more affordable for middle class families and small businesses with tax credits Expands access to care through Marketplaces and Medicaid expansion Expands access to care through Marketplaces and Medicaid expansion

Highlights for Providers Increases the number of Primary Care Practitioners – Provides new investments to increase the number of primary care practitioners, including doctors, nurses, nurse practitioners, and physician assistants Increases the number of Primary Care Practitioners – Provides new investments to increase the number of primary care practitioners, including doctors, nurses, nurse practitioners, and physician assistants Projected to place more than 16,000 health professionals over next 5 years Projected to place more than 16,000 health professionals over next 5 years Community Health Centers - Increases funding for Community Health Centers to allow for nearly a doubling of the number of patients seen by the centers over the next 5 years Community Health Centers - Increases funding for Community Health Centers to allow for nearly a doubling of the number of patients seen by the centers over the next 5 years 231 community health centers in PA eligible for funding231 community health centers in PA eligible for funding 671,646 patients treated in 2010 at federally supported health centers in the U.S.671,646 patients treated in 2010 at federally supported health centers in the U.S.

Highlights for Nursing Workforce Nurse Education, Practice, Quality & Retention Nurse Education, Practice, Quality & Retention Nursing Workforce Diversity Nursing Workforce Diversity Nurse Faculty Loan Program Nurse Faculty Loan Program Advanced Nursing Education Program Advanced Nursing Education Program Advanced Education Nursing Traineeships Advanced Education Nursing Traineeships Nurse Anesthetist Traineeships Nurse Anesthetist Traineeships

Center for Medicare and Medicaid Innovation Developing payment and delivery system reforms, focused on: Developing payment and delivery system reforms, focused on: Expanding team-based care coordination Expanding team-based care coordination Rewarding providers for care outside of traditional face-to-face visits Rewarding providers for care outside of traditional face-to-face visits Focusing on aggressive management of chronically ill patients Focusing on aggressive management of chronically ill patients Expanding access to home-based care Expanding access to home-based care $10 billion in funding for FY $10 billion in funding for FY Opportunity to scale up: authority to expand successful models to the national level Opportunity to scale up: authority to expand successful models to the national level

Center for Medicare and Medicaid Innovation Partnership for Patients Partnership for Patients Accountable Care Organizations Accountable Care Organizations Bundled Payments for Care Improvement Bundled Payments for Care Improvement Community-based Care Transitions Program Community-based Care Transitions Program Value Based Purchasing Value Based Purchasing Graduate Nurse Education Demonstration Graduate Nurse Education Demonstration

Health Insurance Marketplace Sometimes called “Exchanges,” the Marketplace is required by the ACA to be created by January 1, 2014 Sometimes called “Exchanges,” the Marketplace is required by the ACA to be created by January 1, 2014 New “marketplace” where small businesses and individuals can select and enroll in a private health insurance plan New “marketplace” where small businesses and individuals can select and enroll in a private health insurance plan Consumers will have Consumers will have the same level of benefits and coverage available to members of Congressthe same level of benefits and coverage available to members of Congress more choice and selection in health plansmore choice and selection in health plans

Three models available Three models available State-Based State-Based Federal-State Partnership Federal-State Partnership Federally-Facilitated Federally-Facilitated States can apply for Marketplace establishment funding at any time and be awarded grants through 2014 States can apply for Marketplace establishment funding at any time and be awarded grants through 2014 HHS to operate marketplaces for States that have not elected to do so HHS to operate marketplaces for States that have not elected to do so Marketplace Implementation

Health Insurance Marketplace Regional Snapshot PA – No enabling legislation; Federally-facilitatedPA – No enabling legislation; Federally-facilitated DE – No enabling legislation; Federal-State PartnershipDE – No enabling legislation; Federal-State Partnership MD – Passed enabling legislation; State-basedMD – Passed enabling legislation; State-based DC – Passed enabling legislation; State-basedDC – Passed enabling legislation; State-based WV – Passed enabling legislation; Federal-State PartnershipWV – Passed enabling legislation; Federal-State Partnership VA – No enabling legislation; Federally-facilitatedVA – No enabling legislation; Federally-facilitated

Financial Assistance Premium tax credits Premium tax credits Will reduce the premium amount the consumer owes each monthWill reduce the premium amount the consumer owes each month Available to eligible consumers with household incomes between 100% and 400% of the FPL ($44,680 for an individual and $92,200 for a family of 4 in 2012), and who don’t qualify for other health insurance coverageAvailable to eligible consumers with household incomes between 100% and 400% of the FPL ($44,680 for an individual and $92,200 for a family of 4 in 2012), and who don’t qualify for other health insurance coverage Based on household income and family size for the taxable yearBased on household income and family size for the taxable year Paid each month to the insurerPaid each month to the insurer

Financial Assistance Cost-sharing reductions: Cost-sharing reductions: Reduce out-of-pocket costs (deductibles, coinsurance, copayments) Reduce out-of-pocket costs (deductibles, coinsurance, copayments) Generally available to those with income 250% FPL or below ($27,925 for an individual and $57,625 for a family of 4 in 2012)Generally available to those with income 250% FPL or below ($27,925 for an individual and $57,625 for a family of 4 in 2012) Consumer must enroll in a “silver-level” planConsumer must enroll in a “silver-level” plan

Quality Insurance The ACA requires plans inside the Marketplace to meet particular actuarial value (AV) targets The ACA requires plans inside the Marketplace to meet particular actuarial value (AV) targets Bronze = 60% AVBronze = 60% AV Silver = 70% AVSilver = 70% AV Gold = 80% AVGold = 80% AV Platinum = 90% AVPlatinum = 90% AV “Metal Levels” will enable consumers to compare plans with similar levels of coverage, promote competition on premiums, and allow plans flexibility to design cost sharing structures “Metal Levels” will enable consumers to compare plans with similar levels of coverage, promote competition on premiums, and allow plans flexibility to design cost sharing structures

Essential Health Benefits Essential Health Benefits Ambulatory patient servicesAmbulatory patient services Emergency servicesEmergency services HospitalizationHospitalization Maternity and newborn careMaternity and newborn care Mental health and substance use disorder services, including behavioral health treatmentMental health and substance use disorder services, including behavioral health treatment Prescription drugsPrescription drugs Rehabilitative and habilitative services/devicesRehabilitative and habilitative services/devices Laboratory servicesLaboratory services Preventive and wellness services and chronic disease managementPreventive and wellness services and chronic disease management Pediatric services, including oral and vision carePediatric services, including oral and vision care Quality Insurance

Enrollment Process Consumer submits application to the marketplace Consumer submits application to the marketplace OnlineOnline PhonePhone MailMail In PersonIn Person The marketplace verifies and determines eligibility for The marketplace verifies and determines eligibility for enrollment in a Qualified Health Plan (QHP)enrollment in a Qualified Health Plan (QHP) tax credits and cost-sharing reductionstax credits and cost-sharing reductions Medicaid or CHIPMedicaid or CHIP Consumer enrolls in a QHP or Medicaid/CHIP Consumer enrolls in a QHP or Medicaid/CHIP Online plan comparison tool available to inform health plan choiceOnline plan comparison tool available to inform health plan choice Tax credit is sent to insurer (if eligible) to reduce consumer premium owedTax credit is sent to insurer (if eligible) to reduce consumer premium owed

Enrollment Assistance Help available in each Marketplace Help available in each Marketplace Toll-free call centerToll-free call center WebsiteWebsite Navigator programNavigator program Certified Application CounselorsCertified Application Counselors Community-based organizationsCommunity-based organizations Agents and brokersAgents and brokers

Initial Open Enrollment Period October 1, 2013 – March 31, 2014 October 1, 2013 – March 31, 2014 Enroll during the Initial Open Enrollment Period Your coverage is effective* On or before December 15, 2013 January 1, 2014 Between the 1 st and 15 th day of January – March First day of the following month Between the 16 th and the last day of December – March First day of the following month

Resources: Affordable Care Act website – Affordable Care Act website – Health Insurance Marketplace – Health Insurance Marketplace –marketplace.cms.gov Center for Consumer Information & Insurance Oversight website – Center for Consumer Information & Insurance Oversight website – Affordable Care Act Spanish Affordable Care Act Spanish website –

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