Affordable Care ActJanlee Wong, MSW

NASW CaliforniaOctober 2014

Google: slideshare Janlee Wong

Course Objectives

• Understand what the Affordable Care Act is and how it is implemented in California

• How it affects you• How it covers the uninsured• How it reforms both service delivery and

financing incentives• What are the roles of social workers and how

to get involved (advocacy)

California has the eighthlargest proportion ofuninsured in the nationand the largest totalnumber of uninsured. Onlythree states (Massachusetts,Hawaii, and Minnesota) haveuninsured rates under 10%.

*All numbers reflect the non-elderly population, under age 65.Source: Employee Benefit Research Institute estimates of the 2009 – 2011 Current Population Survey, March Supplements.

What is the ACA

• Affordable Care Act or “Obamacare”• First successful major national reform enacted

since Medicare (1935) and Medicaid (1965)• First step towards “universal” healthcare• Expands “single payer” Medicaid (MediCal)• NASW policy goal is universal single payer

healthcare system

ACA Market Reforms (31)• Insurers are prohibited from setting lifetime limits on essential health benefits, such as hospital stays, beginning with new policies issued. Approximately 12 million people in California are no longer subject to these limits as a result of the act, according to federal estimates.• Insurers are no longer allowed to re-examine a customer’s initial application to cancel, or “rescind,” their coverage due to unintentional mistakes or minor omissions.• Dependent children up to age 26 must be offered coverage under a parent’s insurance plan. Federal data indicates that more than 435,000 young adults in California have gained coverage as a result of this provision of the act.• Insurers may not exclude children under the age of 19 from coverage due to a pre-existing medical condition.• Insurers are now required to spend the vast majority of premium dollars on medical care and quality improvement activities, and a smaller, limited amount on overhead expenses such as marketing, profits, salaries, administrative costs and agent commissions.

ACA Accomplishments (9)(12)

• More uninsured covered (fell from 20% to 15% nationwide)

• More Latino uninsured covered (fell from 36% to 23% - 2013-2014) In CA Latinos make up 60% of the uninsured

• 25% reduction in uncompensated hospital care ($5.7 billion)

ACA Reduces Readmissions (26)

2007 2008 2009 2010 2011 2012 201316.5

17

17.5

18

18.5

19

19.5

Medicare Hospital Readmissions

Medicare Hospital Readmissions

Getting California Covered

• 2.6 million Californians qualify for federal financial assistance

• Another 2.7 million Californians will benefit from guaranteed covered coverage

• Estimated 2.3 million California residents will enroll in a health plan through the Exchange (Covered California) by 2017

Getting California Covered

• 2014, employers with 25 or fewer employees – possible eligibility for tax credits

• 2014, employers with 50 or fewer employees can buy plans in the Exchange

• 2015, employers with 100 or fewer employees can buy plans in the Exchange

Income & ACA

$9 per hour min. wage =$15,750 annually, $13 per hour = living wage in US$15 per hour min. wage = $26,250 annually or twice the federal poverty threshhold

Income & ACA

MediCal (Medicaid)

• Another almost 1.5 million Californians are eligible for expanded Medi-Cal, which will be open to all individuals under 65 with incomes of up to $16,000 for an individual and about $32,500 for a family of four

• End of categorical rules, eligibility based on income, • Bye bye asset test (except for foster care children,

SSI/SSDI, elderly)• Spend down continues

Special Medi-Cal Eligible Populations

• Homeless• Aged out transitional foster youth• Parolees, probationers

– Oakland, Alameda county expects to enroll some 18,000 Medicaid-eligible inmates and detainees in the coming years

Dual Eligibles (26)

• Coordination of Care (new “duals” offices) • Prescription Drugs (elimination of cost sharing, Part D

for home and community based care clients)• Medicare Advantage Plans (improved quality

measures)• Long-Term Care and Chronic Illness (Medical Homes)

Poor Outreach

• 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)

Enrollment: Social Workers Can HelpNov. 15 to Feb. 15, 2015

• Champions for Coverage. Marketplace.cms.gov/technical-assistance-resources/assisterprograms/champion-apply.hmtl

• Enroll America: www.enrollamerica.org• Certified Application Counselor:

marketplace.cms.gov, “About Assister Programs”

• Local Help Directory: localhelp.healthcare.gov

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.”

• For individuals and families ineligible for Medicaid but below 400% of poverty

Healthcare Marketplace

• For those who don’t get insurance through their employer

• Not qualified for Medi-Cal• Want low cost affordable health insurance

plans• Want subsidies (tax credits) depending on

income (below 144% of poverty) or below $25 per hour for an individual

Exchange (Marketplace)Individual Mandate

• Conservative ideas from the Heritage Foundation (let insurers compete and consumers can choose)

• First implemented in the Massachusetts Health Connector exchange

• ACA: Consumer choice; plans have the same basic benefits; managed care features – restricted networks, high out of network care costs, tax subsidies (credits)

Competition (13)

• California saw reduced insurer participation from 12 to 10 carriers on its exchange

• Some think it doesn't suggest disenchantment, but rather that weaker players are dropping out of a very competitive market.

• Nationally, HHS Secretary Burwell reported there will be a 25% increase in the number of insurers participating in the exchanges.

Walmart, Target, Home Depot

• ACA labeled a “job killer” because employers would rather lay off employees than pay for health care for part timers.

• Companies have cut benefits for part-timers but not laid them off.

• Walmart cut benefits for 30,000 employees, Home Depot, 20,000

• Most cut health for part-timers but many of their employees pay less for ACA benefits than in company plans

Limited Networks, Providers

• Health insurers offer limited or restricted networks of providers in their plans

• Many lack accurate information on who are their providers

• The drastic shortage of primary care physicians has not materialized

• Care is limited in rural, remote areas

Exchange Marketplace Report Card (21)

• Sufficient numbers of enrollees? Met its goal of 8 million enrollments through the exchanges during the 2014 coverage season (21)

• Attract enough healthy young people to offset the cost of older or sicker enrollees? Meeting goal (22).

• Sufficient interest by insurance companies? More insurers interested. (23)

• Continued challenges: Consumer skepticism, partisan opposition and court challenges (21)

Goal:40% (22)

18 state run exchanges, 8 state/Fed partnerships

Which plans were selected 2015 (25)1. Anthem Blue Cross of California 2. Blue Shield of California 3. Chinese Community Health Plan 4. Health Net 5. Kaiser Permanente 6. L.A. Care Health Plan7. Molina Healthcare8. Sharp Health Plan9. Valley Health Plan10. Western Health Advantage

1. Ambulatory patient services2. Emergency services3. Hospitalization4. Maternity and newborn care5. Mental health and substance use disorder services, including behavioral health treatment6. Prescription drugs7. Rehabilitative and habilitative services and devices8. Laboratory services9. Preventive and wellness services and chronic disease management10. Pediatric services

Accountability• Have sufficient clinicians — doctors, hospitals and other providers — to meet

the needs of the consumers who enroll in their plan• Ensure that each enrollee has had a preventive health and wellness visit

during the first year of enrollment • Identify and proactively manage all “at-risk” enrollees• Determine enrollees’ health status and proactively develop a plan to manage

their individual health care needs• Promote the use of best practice models for continuity of care and care

coordination that are proven to improve quality of care• Be transparent about plan performance at the point of enrollment, specifically

regarding standard measures of prevention, access and clinical effectiveness• Be certified by the National Committee for Quality Assurance or URAC

(formerly known as the Utilization Review Accreditation Commission) to meet quality standards

Pediatric Dental

• Covered California, the state's health insurance exchange, has said it will offer five stand-alone pediatric dental plans for 2014 as well as what's called a "bundled" plan in which insurers pair a stand-alone dental plan with a medical plan.

Pediatric Dental

• Anthem Blue Cross of California.• Blue Shield of California.• Delta Dental of California.• Liberty Dental Plan of California.• Premier Access Dental and Vision.• Small Business Health Options Program Shop

(SHOP) plans

Vision

• Vision benefits will be available for children embedded in health plans.

• Covered California is considering combining pediatric vision and dental plans in the future

Affordability

• Effective Jan. 1, 2014, insurance companies may consider only three factors to determine the cost of your premium: age, geography and family size. Your health history may no longer be considered in setting premiums.

Subsidies and the Exchange

• 5 million Californians qualify to get insurance on the Exchange.• Half of them are eligible for government subsidies, which are

federal tax credits that will offset the cost of their monthly premium

• The subsidies are available to those who earn $15,850 to about $46,000 a year. A family of four is eligible if they earn between $32,500 to $94,200 a year

• The more you make, the smaller the subsidy. The less you make the more assistance you’ll get

• Based on your adjusted gross income plus any tax-exempt income you might have.

What Metal?

• Platinum plans have the highest premium, yet pay 90% of covered health care expenses. Bronze plans have the lowest premium, but pay only 60% of covered health expenses. It’s important to think about how much health care you will need when choosing a level.

• Shop and Compare:https://www.coveredca.com/shopandcompare/#healthplans

Health Benefits Exchange PlansBronze, Silver, Gold & Platinum (2015)

Bronze 60 Silver 70 Gold 80 Platinum90

Healthcare Cost Coverage 60% 70% 80% 90%

Copay Primary Care Visit $60 $45 $30 $20

Deductible Individual to Family

$5,000 - $10,000

$2,000 - $4,000

None None

Specialty Care Visit $70 $65 $50 $40

Urgent Care Visit $120 $90 $60 $40

Meds Generic $15 $15 $15 $5

Lab 30% $45 $30 $20

ER $300 $250 $250 $150

Max Out of Pocket Individual to Family

$6,250 to $12,500

$6,250 to $12,500

$6,250 to $12,500

$4,000 to $8,000

Monthly Premium MonthlyFamily of 2*

$896 $1,128 $1,336 $1,484

*Ages 60 years old; Burbank area, LA Care Health Plan

Web Live Demonstration

• Covered California

Does the ACA Affect You?• Maybe, I already have health insurance through my

employer, family member or programs such as Medicare and Medicaid. (85%)

• Yes, my employer doesn’t provide health insurance• Yes, I’m below 400% of poverty, ineligible for

Medicaid (due to income) and don’t have health insurance

• Yes, I was previously ineligible for Medicaid but now I am eligible

• No, I’m undocumented

Covered CA Affordable? +4.2% (24)

• The overall weighted average increase is 4.2 percent• 16% of Covered California consumers (217,000 people) will

see the premium of their health plan stay constant or decrease (with most decreases of 1 percent to 3 percent, but some decreases of up to 14 percent)

• 35 % (489,000 people) will see premiums increase a small amount — less than 5 percent

• 36% (495,000 people) will see premium increases of 5 percent to 8 percent (with most of those being about 6 percent)

• 13 % (186,000 people) will see premium increases of more than 8 % (with almost 90 percent of these in the 8-10 percent range)

Covered CA Premium Increase +4.2%

Premium Increase

1-3%<5%+5-8%>9%

Consumer Assistance and Outreach

• Grants to community groups and a comprehensive advertising campaign aimed at attracting new consumers and encouraging them to enroll in the state’s health benefit exchange

• Network of Certified Enrollment Counselors, Certified Insurance Agents and county eligibility workers

Covered California Certified Enrollment Entities• American Indian Tribe or Tribal Organizations• Chambers of Commerce• City Government Agency• Community Clinics• Community Colleges and Universities• Faith-Based Organizations• Labor Unions• Non-Profit Community Organizations• Ranching and farming organizations• Resource partners of Small Businesses• School Districts• Tax Preparers• Trade, industry, and professional organizations

For complete list: http://hbex.coveredca.com/enrollment-entities/PDFs/Navigator-Funding.pdf

Role of Social Worker - Policy

• 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

• Social workers are experienced in outreach to disadvantaged populations

Roles of Social Worker - Practice

• Directors, Managers, Elected and appointed officials• 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

• Outreach, community organizers, advocates

Models of Care

• Accountable Care Organizations• Integrated comprehensive acute care• Integrated comprehensive primary care• Coordinated medical and behavioral health

care

Characteristics

• A strong primary care/medical home/health 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”

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

Accountable Care Organizations (ACOs) (29)

• There were more than 600 ACOs nationwide at the start of the year, and they are being touted as a key strategy for curbing U.S. health-care costs. The fundamental idea is that doctors and hospitals are rewarded for keeping and making patients healthy, rather than a “fee for service” approach where they earn more for prescribing lots of tests or scheduling appointments regardless of how a patient fares.

Industry ACO Example (29)

• UW Medicine as well as Providence Health & Services and Swedish Health Services have each recruited a network of hospitals and clinics and formed their own ACOs. Boeing has separate contracts with each to provide care for Puget Sound-area employees beginning next year.

• These employer-driven ACO arrangements, with no insurance company involved, are believed to be among the first in the nation to use this approach and could serve as models elsewhere.

Integrated Comprehensive Primary CareSouthwest Virginia Community Healthcare Systems, Inc

Patient visit Prim. Care Physician (PCP)

PCP screens for behavioral health issue

Referral to behavioral

health consultant

PCP continue

with medical

visit

NegativePositive

Medical Home (28)

• The medical home is the model for 21st century primary care, with the goal of addressing and integrating high quality health promotion, acute care and chronic condition management in a planned, coordinated, and family-centered manner.

Medical Home Building Blocks (28)

1. Care Partnership SupportEmpowers children, youth and families to manage their health and healthcare

2. Clinical Care InformationAssures delivery of effective, efficient clinical care & patient self-management support

3. Care Delivery ManagementPromotes clinical care that is consistent with patient and family preference and scientific evidence

4. Resources & LinkagesMobilizes community resources to meet patient and family needs

5. Practice Performance MeasurementAddresses the organization and promotion of safe and high quality care

6. Payment & FinanceMatches quality care and NCQA recognition with payment / solid return on investment

Medical Home Implementation (28)

• Riverside County Public Health Department plans to implement a patient centered medical home at its primary care clinics.

• Ventura County's Medi-Cal beneficiaries are expected to be assigned to medical homes through Gold Coast Health Plan

• Los Angeles County community clinics will be transformed into PCMHs through L.A. Care Health Plan

Social Work AdvocacyNASW 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.

Advocate Role 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

Look Out For

• Be on the look out for creep back to bias against those with pre-existing conditions or chronic diseases (high drug costs, limited networks and specialty hospitals, services)

US Supreme Court Cases

• Individual mandate is legal (it’s a tax)• States can’t be forced to open exchanges• Allows closely held private corporations

to be exempt from contraceptive mandate due to religious beliefs of the owners (Hobby Lobby). Employers must let workers know if they remove coverage

Lower Court Cases (10)

• Judge Ronald White, a George W. Bush appointee, invalidated an Internal Revenue Service rule interpreting the Patient Protection and Affordable Care Act to allow the premium tax credits in states that have not established their own exchange. “The court holds that the IRS Rule is arbitrary, capricious, an abuse of discretion or otherwise not in accordance with law,” White wrote.

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.

Senate Bill 1005

• SB 1005 by Sen. Ricardo Lara (D-Bell Gardens) would create the California Health Exchange Program for All Californians, which would be overseen by Covered California. The federally funded exchange is not allowed to cover the undocumented so state funds would be used for that portion of the population covered in the new exchange.

• Passed Senate Health Committee, May 2014.

My Health LA (27)

• Los Angeles County will provide access to a primary care doctor for nearly 150,000 uninsured Los Angeles County residents, including many who are ineligible for Obamacare coverage because they lack legal immigration status.

• My Health L.A., as the $61-million program for the uninsured is called, will assign uninsured patients to a "medical home" at one of around 150 community clinics

GlossaryAccountable Care Organizations ACO

• 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.

GlossaryActuarial Value

• A health insurance plan’s actuarial value is the percentage of total average costs for benefits that a plan covers. All Covered California health insurance plans have an actuarial value assigned to them: Bronze, Silver, Gold or Platinum.

• As the metal category increases in value, so does the percent of medical expenses that a health plan covers. This means the Platinum plans cover the highest percentage of health care expenses.

• These expenses are usually incurred at the time of health care services — when you visit the doctor or the emergency room, for example. The health insurance plans that cover the greatest percentage of health care expenses also usually have higher premium payments.

GlossaryCopayment

• A fixed amount (for example, $15) you pay for a covered health care service, usually when you receive the service. The amount can vary by the type of covered health care service.

GlossaryCost Sharing

• The share of costs covered by your insurance that you pay out of your own pocket. This term generally includes deductibles, coinsurance and copayments, or similar charges, but it doesn’t include premiums, balance billing amounts for non-network providers, or the cost of non-covered services.

GlossaryCoinsurance

• Your share of the costs of a covered health care service, calculated as a percentage (for example, 20 percent) of the allowed amount for the service.

• You pay coinsurance plus any deductible you owe. • For example, if the health insurance plan’s allowed

amount for an office visit is $100, and you have met your deductible for the year, your coinsurance payment of 20 percent would be $20.

• The health plan pays the rest of the allowed amount.

GlossaryMedical Homes (31)

A mode of care that includes(A) personal physicians; (B) whole person orientation; (C) coordinated and integrated care; (D) safe and high-quality care through evidence informed medicine, appropriate use of health information technology, and continuous quality improvements; (E) expanded access to care; and (F) payment that recognizes added value from additional components of patient-centered care. 5

GlossaryOut of Pocket Limit

• The most you pay during a policy period (usually a year) before your health insurance or plan begins to pay 100 percent of the allowed amount.

• This limit never includes your premium, balance-billed charges or health care your health insurance plan doesn’t cover.

• Some health insurance plans don’t count all of your copayments, deductibles, coinsurance payments, out-of-network payments or other expenses toward this limit.

GlossaryPremium and Assistance

Premium • The amount that must be paid for your health insurance or plan. You

or your employer, or both, usually pay it monthly, quarterly or yearly. Premium Assistance • Also known as the Advanced Premium Tax Credit, this is financial

assistance eligible consumers may receive when enrolling in a Covered California health insurance plan, to assist them in paying their monthly premium costs.

• The amount of premium assistance an individual may receive is determined based on his or her income as a percentage of the federal poverty level. Tax credits are also available to small businesses with fewer than 25 full-time-equivalent employees to help offset the cost of providing coverage.

GlossarySubsidy

• Cost-sharing subsidies and premium assistance reduce the cost of premiums and out-of-pocket expenses for health coverage that qualifying individuals and families purchase through Covered California.

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

Resources

1. http://www.cfra.org/node/28072. www.socialworkers.org3. http://www.healthexchange.ca.gov4. http://www.coveredca.com/5. http://

www.californiahealthline.org/articles/2012/10/24/california-considers-strategies-for-treating-uninsured-immigrants.aspx

Resources

6. http://www.cis.org/california-education7. http://

www.ppic.org/main/publication_show.asp?i=818

8. http://www.cwib.ca.gov/res/docs/special_committees/hwdc/meeting_materials/2013/HWDC%20Report%20-%20Draft%20012113.pdf

Resources9 http://www.advisory.com/daily-briefing/2014/09/26/hhs-coverage-expansion-is-cutting-uncompensated-care%20costs-at-hospitals

11 http://www.advisory.com/daily-briefing/resources/primers/medicaidmap#lightbox/0/

12 http://www.latimes.com/health/la-na-obamacare-latinos-20140925-story.html

13 http://www.modernhealthcare.com/article/20140927/MAGAZINE/309279977&utm_source=AltURL&utm_medium=email&utm_campaign=am&AllowView=VXQ0UnpwZTVBL2FaL1I3TkErT1lBajNja0U4VUErUmFFQk1IQXc9PQ==?mh

10 http://www.modernhealthcare.com/article/20140930/NEWS/309309919?AllowView=VDl3UXk1T3dDZlNCbkJiYkY0M3hlMHFxajBVZEMrOD0=&utm_source=link-20140930-NEWS-309309919&utm_medium=email&utm_campaign=mh-alert

Resources

23 http://www.nytimes.com/2014/05/26/your-money/health-insurance/insurers-once-on-the-fence-plan-to-join-health-exchanges-in-15.html?_r=0

24 https://www.coveredca.com/PDFs/CC-health-plans-booklet-2015.pdf

25 http://kff.org/health-reform/issue-brief/affordable-care-act-provisions-relating-to-the/

21 http://www.bloombergview.com/quicktake/health-insurance-exchanges

22 http://www.washingtonpost.com/blogs/wonkblog/wp/2014/04/04/facing-obamacare-deadline-more-young-people-signed-up-in-march/

Resources26 U.S. Department of Health & Human Services News Division 202-690-6343 media@hhs.gov www.hhs.gov/news May 07, 2014

27 http://www.latimes.com/local/lanow/la-me-ln-remaining-uninsured-los-angeles-20141006-story.html

28 http://www.pediatricmedhome.org/

29 http://seattletimes.com/html/localnews/2023842772_acoboeingprovidenceuwxml.html

30 https://www.cms.gov/eHealth/downloads/Webinar_eHealth_December6_HealthITInnovation.pdf

31 Patient Protection and Affordable Care Act §3502(c).t