spotlight on reform: affordable care act and covered ca · overview of affordable care act •...

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Spotlight on Reform:Affordable Care Act and Covered CA

Tom Rogers, DDS, MPH, MA Associate Professor,

LLU School of Dentistry Faculty Scholar,

LLU Institute for Health Policy and Leadership

July 2, 2014

Brought to you byLoma Linda University

Institute for Health Policy and

Leadership

lluhpolicyinstitute.org

GRW

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Outline• Brief review of need for Affordable Care Act (ACA)

• Overview of the ACA

• Background information on Covered CA

• What is it?

• Who is eligible?

• How are insurance plans organized?

• How are rates determined?

• Data on Covered CA enrollment

• Implications for healthcare providers

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WhyReformHealthCareinUS?

• Accesstocare

• Cost

• Qualityofcare

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Access(insurancecoverage)

• 50millionuninsured(16%)– Up14millioninpast10years

• 55%haveemployer-basedinsurance(downfrom64%in1999)– 25millionunderinsured

• 15%Medicare

• 16%Medicaid

5Source:UniversityofIowaPublicPolicyCenter

UninsuredbyincomeinUS

• Uninsured>1year:

- 43%oflowerincomepersons

- 4%ofhigherincomepersons

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Quality/Outcomes• Qualityimportantasitrelatedtocost

• Twotypesofquality:– Technicalquality(thisisassumed)

– Appropriatenessofcare

• Outcomes– Focusingonimprovingcareandreducingcostsforhighestusers

– Couldbedrivingsysteminfuture• Asitrelatedtocostandcompetition


Health Care Costs– G7Countries

7000

6000

5000

4000

3000

2000

1000

01980 1984 1988 1992 1996 2000 2004

Average spending on health per capita ($US )

United StatesGermanyCanadaFranceAustraliaUnited Kingdom

Healthvs.HealthCare

• LifeexpectancymostcommonlyreportedstatforstateofhealthandsuccessofHCsystem

– Problematicbecausecausesaremulti-factorial

• Manyofthedeterminantsofhealthareoutsideoftraditionalhealthcaredelivery

• Overallsystemrequiresintegration

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DeterminantsofHealth

• Whateffectsourhealth:– Lifestylefactors– 51%

– Environmentalfactors– 10%

– Humanbiology– 20%

– Healthcaredelivery– 10%

• WheredoesUSinvest:– Lifestylefactors– 1.2%

– Environmentalfactors– 1.8%

– Humanbiology– 7%

– Healthcaredelivery- 90%

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Source:UniversityofIowaPublicPolicyCenter

OverviewofAffordableCareAct• Signedintolaw2010byPresidentObama,intendedto:

• Increasehealthcarecoverage

• Reducehealthcarecostsandimproveaffordability

• Improvequalityofhealthcareandpopulationhealth

• Primarilyorientedtowardindividualsandsmallbusinesses

• Providefinancialassistance,informof:– Premiumassistanceandcost-sharingsubsidiesforindividuals– Taxincentivesforsmallbusinesses– ExpansionofMedicaid

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Market-basedreform

• Slightlyright-of-centerapproach– SimilarelementstoproposalsbyRichardNixon,RobertDole,BillClinton,andMittRomney

• Left-of-centerapproach:singlepayersystem

• Majoreffectoflawinvolvesprivateinsuranceexpansion

– EspeciallyinstatesoptingoutofMedicaidexpansion


Key Changes Mandated by the

ACA

• Young adult coverage: up to age 26 can be

covered under parents’ plans

• Preventive care coverage: no out-of-pocket

costs for preventive services rated A or B by

USPSTF à 71 million Americans with private

health insurance and 8 million Californians

benefitted

• Guaranteed coverage: no denials for pre-

existing conditions à over 16 million non-

elderly Californians (including 2.2 million

children) have some type of pre-existing health

condition

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Key Changes Mandated by the

ACA (cont)

• Nolifetimeorannuallimità 12millioninCAalonebenefitted

• Noratesbasedonhealthstatus

• Creationof80/20ruleforinsurancecompanies:atleast80centsofeveryinsurancepremiumdollarmustgotowardshealthcareorimprovementstocare;otherwiseinsurancecompaniesmustproviderefundtoconsumers

• Increasedscrutinyforunreasonablepremiumincreasesà nowlegallyrequiredtopubliclyjustifyrateincreaseof10%ormore

• Standardizedbenefits(essentialhealthbenefits)

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EssentialHealthBenefitsCoreservicesrequiredofmostplans

1. Ambulatorypatientservices

2. Emergencyservices

3. Hospitalization

4. Maternityandnewborncare

5. Mentalhealthandsubstanceusedisorder,includingbehavioralhealthtreatment

6. Prescriptiondrugs

7. Rehabilitativeandhabilitativeservicesanddevices

8. Laboratoryservices

9. Preventiveandwellnessservicesandchronicdiseasemanagement

10. Pediatricservices,includingdentalandvisioncare

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*Intendedresult:startingin2014,mosthealthinsuranceplanswillsharecommoncharacteristics.Thosethatcomplyare“QualifiedHealthPlans”.

Additional Changes by the ACA Mandatory insurance enrollment for everyone by March 2014, otherwise

subject to penalty. Effects 6% of population (Urban Institute).

Pay the greater of... Year Percent of

family income Set Dollar Amount

2014 1% $95 per adult and $47.50 per child

(up to $285 for a family)

2015 2% $325 per adult and $162.50 per

child (up to $975 for a family)

2016 and

beyond

2.5% $695 per adult and $347.50 per

child (up to $2085 for a family)

·On June 28, 2012, the Supreme Court confirmed the constitutionality

of the individual mandate for insurance, but that states can opt out of

Medicaid expansion.

Additional Changes by the ACA ·Introduction of premium assistance and cost-sharing

reduction programs for those eligible (up to 400% of federal

poverty level, FPL)

·Optional expansion of Medicaid eligibility to 138% of federal

poverty level (previously 133%)

– States can decline this

·Creation of federal or state-run health care exchanges (health

insurance marketplaces) to make things easier for consumers

(“one stop shop”)

- Feds do this where states decline

- Persons with existing insurance do not need to change

Covered California

• California’s program to implement ACA in the state

• Created to help individuals and small businesses:

• to buy health insurance

• to find out if eligible for financial help, including Medi-Cal

• Covered California – 3 paths to health coverage:

• Medi-Cal (< 138% of FPL)

• Covered Cal plan with premium assistance (138 – 400% of FPL)

• Covered Cal plan without premium assistance (> 400% of FPL)

Covered California: What is it?

California’s Health Care Exchange (first state in the US to

enact legislation)

·Created to serve as easy-to-use marketplace (online portal)

where most Californians can compare and purchase health

insurance coverage

·Actively negotiates price with insurance companies to

optimize premiums for consumers

·Initially funded by grants from the federal government but will

be self-sustainable (not tax-payer funded) by Jan 2015

Covered California

·Estimated that 5.3 million Californians who did not have

health insurance in 2012 (equaling 16% of the population

under age 65) will benefit

·1.4 million Californians will be newly eligible for Medi-Cal

·Any eligible Californian from age 18-64 can shop through

Covered California for health insurance coverage and receive

premium assistance/cost reduction as applicable

·First open enrollment period: Oct. 1, 2013 to March 31, 2014

Who is Eligible?

Individual marketplace:Who is:

• Legal California residents

Who is not:

·Undocumented immigrants

·Currently incarcerated individual

Small Business Health Options Program (SHOP):• Covers businesses with 1-50 eligible employees

• Not eligible are seasonal, 1099, < 20 hours/week, and

temp workers

Howareplansorganized?

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Metaltiersdeterminehowmuchplanpays,comparedtowhatpatientpays

Metaltiersarenamesofthe4majortypesofcoverage.Eachplanmustcoveressentialhealthbenefits,butdifferinsharingofcosts.Bronze>Platinum–ratesgoupbutco-paysgodown.

CoveredCalwebsite(coveredca.com)hasShop&CompareTool toevaluateindividual/familyincomeinrelationtoFPL

Summary of Subsidy Eligibility

If Income is... Then...

• <138% FPL

• 139 - 250% FPL

• Eligible for MediCal

• Eligible for both premium

assistance and cost-share

reductions

• 251 - 400% FPL

• >400% FPL

• Eligible for premium

assistance

• Not eligible for subsidy

19 Regions in CAà Region 17: San Bernardino and Riverside Counties29

Enrollment Statistics: Inland Empire Region 17

Source: Covered California www.coveredca.com

Enrollment by CarrierSubsidy eligible Non-subsidized

Enrollment by Metal TierNon-subsidizedSubsidy eligible

Silver69%

Bronze21%

Platinum 4%

Gold 5%

MinimumCoverage <1%

Silver32%

Bronze30%

Platinum17%

Gold13%

MinimumCoverage 8%

MolinaHealthcare 6%

Blue Shield31%

KaiserPermanente

15%

Anthem17%

MolinaHealthcare 6%

Blue Shield30%

Anthem24%

KaiserPermanente

20%

Health Net31% Health Net

20%

Figures may not total 100 percent due to rounding.

Enrollment Statistics Inland Empire Region 17Oct. 1, 2013, through March 31, 2014

Oct.1,2013throughMarch31,2014

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Enrollment Statistics: Demographics (CA) •Oct. 1, 2013 through Feb. 28, 2014

•Age Breakdown of Covered CA Enrollees •30.00%

•25.00%

•20.00%

•15.00%

•10.00%

•5.00%

•0. 00%

• Subsidy-Eligible• Non-Subsidized

• <18 18 to 25 26 to 34 35 to 44 45 to 54 55 to 64 >65

•Source: Covered California www.coveredca.com

EthnicandLanguageMixofSubsidyEligible

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Enrollment Statistics: Demographics (CA)Medi-Cal Enrollment

Source: Covered California www.coveredca.com

Oct.1,2013throughMarch31,2014

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Implications for Healthcare ProvidersBe prepared for a potentially huge increase in demand

Remember:

•5.3 million previously

uninsured in CA

(319,996 for Region 17)

•1.4 million newly

eligible for Medi-Cal

•In Region 17: 259,541

newly eligible for Medi-

Cal

Source: Inland Empire Children’s Health Initiative

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Concerns and Implications of the ACA…

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Implications for Healthcare Providers • Plan ahead for increases in certain types of patients:

• Those with Medi-Cal (newly eligible)

• Age group (especially 55-64)

• Primary language other than English

• Multiple medical conditions (previously denied coverage

and now eligible through guaranteed issue)

• Know that primary care will be emphasized (e.g. 10% bonus

to Medicare providers (MD, NP, PA) with > 60% primary

care codes)

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•Implications for Healthcare Providers

·Be aware that Medicare reimbursement is shifting from fee-

for-service to bundled payment models

·May voluntarily join an Accountable Care Organization (ACO)

·PrimeCare is pioneer ACO in Inland area, 1 of 6 in California

·Be mindful of the 3-month grace period à the federal law

allows Covered CA enrollees who receive financial subsidies

to keep their health insurance for 3 months after they have

stopped paying their premiums. The health plans must pay first

30 days of the grace period but will not reimburse during months

2 and 3.

•Implications for Healthcare Providers ·Provide current patients information on which insurance

plan(s) your office accepts so that they know when they sign

up through Covered CA

·Covered CA is supposed to provide searchable online

directory but has not been very reliable

·So it’s better to inform patients directly

·For LLU: BlueCross PPO and Health Net PPO/HMO*

·Call California Medical Association (CMA) physician

hotline at 1-800-786-4262 for participation status

Implications for Healthcare Providers • How to tell if a patient is on a Covered CA plan:

• All Covered California insurance cards will have the

Covered California logo on the front or back of the card

• BlueCross Covered CA: ID # begins with “VXB”

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Implications for Healthcare Providers • Health Net Covered CA: Group number begins with 97601

followed by an alfa letter

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Implications for Healthcare Providers • How to tell if a patient is on a Covered CA plan cont’d:

• BlueShield Covered CA: ID # begins with “XED” and

Group number is X0001004 • Molina Covered CA: No identifying info available at this

time

• Kaiser Permanente Covered CA: Covered CA logo is on the back of the card

• Note that these three plans are NOT contracted with LLUMC at this time.

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For Further Information… • For physicians:

• Call California Medical Association (CMA) Physician Hotline at 1-800-786-4262

• Visit http://www.cmanet.org/exchange • Visit http://www.hhs.gov/healthcare/index.html

• For patients:

• Call 1-800-300-1506 for Covered CA Customer Service • Call 888-402-0737 for Certified Enrollment Counselor • Visit https://www.coveredca.com

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•

•Insurance coverage in US over time: •Filling the gaps

•1941

•Employer sponsored insurance (ESI) ·Tax incentive added ·Adults, some •dependents working for large employers

•1965

•Medicare and Medicaid ·Seniors ·Disabled ·Poor kids (0-133% FPL) ·Some parents

•1997 •Children’s Health Insurance Program ·Children of working poor •(133-300% FPL)

•2010

•ACA

·Poor single adults (0-133% FPL* (Medicaid)

·Pre-exist conditions

·Individual and small group insurance

Q & A

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