the affordable care act and covered california ppt... · overview of affordable care act in march...

The Affordable Care Act and Covered California

A Guide for Health Care Providers

Brought to you by

Loma Linda University Institute for Health Policy

and Leadership

GR

W

Newest Institute at LLUH

To provide the highest level of leadership regarding policies

aimed at preventing disease, promoting high-level wellness,

and restoring human wholeness.

Health Policy Education

Leadership Development

Health Policy Analysis/ Research

Development of New Health Policy

Integrating research and health care practice with health policy and leadership:

GR

W

Keep an eye out...

GR

W

Spotlight on Reform:

The Affordable Care Act and Covered California

Wonha Kim, MD, MPH, CPH, FAAP

Senior Research Scholar,

LLU Institute for Health Policy and Leadership

Assistant Professor,

Pediatrics, Preventive Medicine, and LLUSPH

February 11, 2014

Outline

• Brief overview of the Affordable Care Act (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

Overview of Affordable Care Act

In March 2010, President Obama signed into law the

Patient Protection and Affordable Care Act (PPACA)

• Increase health care

coverage

• Reduce health care

costs and improve

affordability

• Improve quality of

healthcare and

population health

WK

Key Changes Mandated by the ACA • Young adult coverage: up to age 26 can be covered under

parents’ plan

• Preventive care coverage: no out-of-pocket costs for

preventive services rated A or B by USPSTF

• Guaranteed coverage: no denials for pre-existing conditions

• No lifetime or annual limit

• No rates based on health status

• Standardized benefits (essential health benefits)

Additional Changes by the ACA • Changes to Medicare reimbursement (e.g. bundled payment)

• Mandatory insurance enrollment by everyone by Jan 2014

• Introduction of premium assistance and cost-sharing

reduction programs for those eligible

• Optional expansion of Medicaid eligibility to 138% of federal

poverty level (previously 133%)

• Creation of federal or state-run health care exchanges

(health insurance marketplaces) to make things easier for

consumers (“one stop shop”)

Covered California

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

enact legislation)

• Created to serve as easy-to-use

marketplace 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

WK

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

19 Regions in CA Region 17: San Bernardino and Riverside Counties

Enrollment Statistics: Inland Empire Region 17

Minumum Coverage

5%

Silver 29%

Bronze 28%

Platinum 23%

Gold 15%

Region 17 Non-subsidized: 4,606

Minumum Coverage

Silver

Bronze

Platinum

Gold

Source: Covered California www.coveredca.com

Region 17 = 8% of statewide enrollment

California

Non-

Subsidized

75,172

Subsidy

Eligible

424,936

Total 500,108

State-wide enrollment: 500,108

Minumum Coverage

1%

Silver 68%

Bronze 17%

Platinum 7%

Gold 7%

Region 17 Subsidy Eligible: 34,868

Minumum Coverage

Silver

Bronze

Platinum

Gold

Oct. 1 through Dec. 31, 2013

WK

Enrollment Statistics: Demographics (CA)


WK

21.1% 13.5%

78.9% 86.5%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Subsidy-Eligible Non-subsidized

Hispanic Latino, Spanish Origin

Yes No

1.0%

70.9%

1.6% 4.5%

22%

1.5%

62.9%

2.5% 8.6%

24.5%

Cuban Mexican/MexicanAmerican

Puerto Rican MixedEthnicity

Other

Ethnicity Subcategory

Subsidy-Eligible Non-Subsidized

• Majority who answered

the question were not

Hispanic in origin

• Higher proportion in

subsidy-eligible group

• Among those who

reported being

Hispanic in origin,

majority were

Mexicans



52.9%

27.4%

3.0%

8.2%

0.4% 0.2%

7.8%

63.7%

15.6%

3.4%

11.6%

0.2% 0.2%

5.3%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

White Asian Black orAfrican

American

Mixed Race AmericanIndian/

AlaskanNative

NativeHawaiian/

PacificIslander

Other

Subsidy-Eligible Non-subsidized

WK



WK

97.20%

1.20%

1.60% 0.10%

Subsidy-Eligible Non-Subsidized



WK

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

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

Age Breakdown of Covered CA Enrollees (Oct 1 – Dec 31)

Subsidy Eligible

Non-subsidized

Enrollment Statistics: Insurance Carriers


WK

Blue Shield 34%

Health Net 28%

Kaiser Permanente 17%

Anthem 16%

Molina Health Care 5%

Subsidy Eligible Blue Shield

Health Net

Kaiser Permanente

Anthem

Molina Health Care

Enrollment Statistics Inland Empire Region 17 Source: Covered California www.coveredca.com

Blue Shield 33%

Health Net 20%

Kaiser Permanente

17%

Anthem 25%

Molina Health Care 5%

Non-subsidized

Enrollment Statistics Inland Empire Region 17


Oct. 1 through Dec. 31, 2013

Implications for Healthcare Providers

• Be prepared for 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


• 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)

• Be aware that Medicare reimbursement is shifting from fee-

for-service to bundled payment models

• May voluntarily join an Accountable Care Organization (ACO)

• Provide current patients information on which insurance

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

up through Covered CA

• Call California Medical Association (CMA) Physician Hotline

at 1-800-786-4262 if further questions


Q&A Session with Panelists

Coming up in April:

WK

the affordable care act and covered california ppt... · overview of affordable care act in march...

Documents