Affordable Care Act

Janlee Wong, MSWNASW California

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Does the ACA Affect You?

• No, 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, or

• Yes, I’m below 400% of poverty, ineligible for Medicaid (due to income) and don’t have health insurance (15%)

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

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.

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

Government Financial Assistance

Government Financial Assistance

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.

Poor Outreach

• The report also found that about 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)

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

Exchange (Marketplace)Individual Mandate

• Conservative ideas from the Heritage Foundation

• First implemented in the Massachusetts Health Connector exchange

• Provides a “marketplace” where consumers can choose a plan (plans all have the same benefits) based on what services they want and what they can afford

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

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.

Covered CA Plan Costs95816

• Individual, 30 years old, $30,000 a year,– $9-150 per month payment– Choices: Anthem Blue Cross, Kaiser, Blue Shield,

Western Health Avantage

• Family of 4, 30 years old, $60,000 a year:– $171 - $911 per month payment– Choices: Anthem Blue Cross, Kaiser, Blue Shield,

Western Health Avantage

Health Benefits Exchange

Essential Health Benefits: Legislation introduced in January 2012, would select the Kaiser small group HMO plan as the state’s benchmark plan (AB 1453/SB 951)Exchange to offer Insurance Companies’ Bronze, Silver, Gold and Platinum plans13 plans are available in the CA Exchange (varies by region)

Which plans were selectedAlameda Alliance for HealthAnthem Blue Cross of CaliforniaBlue Shield of CaliforniaChinese Community Health PlanContra Costa Health PlanHealth NetKaiser Permanente

L.A. Care Health PlanMolina HealthcareSharp Health PlanValley Health PlanVentura County Health Care PlanWestern Health Advantage

Health Benefits ExchangeBasic Health Program (BHP):

Preventive care visits, immunizations, and screenings (such as mammograms and other cancer screenings)Doctor’s visits, outpatient careMaternity, newborn, and pediatric careEmergency and hospital careLaboratory services, prescriptions, and mental health (including substance abuse)

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.

Vision

• Vision benefits will be available for children. • Covered California is considering adding vision

and dental plans as “supplemental plans” for adults through Covered California in 2014

• As a supplemental benefit, the federal premium assistance would not apply to these benefits.

Health Benefits ExchangeConsumer Assistance and Outreach: Employ Navigators to assist with education and enrollment activities. CA will use two distinct types of Assisters registered and certified by the Exchange.

Certified enrollment Assisters (Navigators) will be compensated by the Exchange and at a minimum will include, non-profit organizations, community clinics, County Social Services offices employing Eligibility Workers, and labor unions.

Direct Benefit Assisters, will not be paid by the Exchange and will include health insurance agents, hospitals, and providers.

See Appendix for more details.

Health Benefits Exchange

Information Technology: Requires the creation of a single statewide application that will be available on paper and electronically for all systems and entities accepting and processing applications and eligibility. It also requires a simplified citizenship and identity verification at application and renewal and increased coordination with other public programs.

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

• See Appendix for more information

Role of Social Worker

• 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

Roles of Social Worker

• 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

Roles 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

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.

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

• Continued political turmoil:– Shutdown and debt ceiling politics– 26 states are not expanding Medicaid– 24 states have set up their own exchanges, 27

have federally administered exchanges

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

ASSISTER ENROLLMENT ENTITIES (AEE)

• Assister Enrollment Entities (AEE)

• Assisters must be affiliated with an Assister Entity to be compensated. Uncompensated assisters include Hospitals. providers, and licensed agents. Covered California has not decided on the exact parameters for enrollment entities, but are currently including a wide variety of entities. Assister entities are eligible to be trained and registered to provide in-person assistance to consumers and help them apply for Covered California programs.

Eligible to be AEEs• American Indian Tribe or Tribal

Organizations• Attorneys (e.g., family law

attorneys who have clients that are experiencing life transitions)

• Chambers of Commerce• City Government Agency• Commercial fishing, industry

organizations• Community Clinics• Community Colleges and

Universities• County Health Department that

provide health care services to consumers

• Faith-Based Organizations• Indian Health Services Facilities• Labor Unions• Non-Profit Community

Organizations• Ranching and farming

organizations• Resource partners of Small

Businesses• School Districts• Tax Preparers• Trade, industry, and

professional organizations

In Person Assisters (IPA)

• Individuals who are employed, trained, certified, and linked to Assister Enrollment Entities to provide in-person assistance to consumers and help them apply for Covered California programs.

• Individuals who provide assistance in culturally and linguistic appropriate manners to consumers.

How to Become Affiliated with an Assister Entity

• Call or email Assister Help Desk for AEE contact information

• Help Desk will contact information for AEEs in your area

• Contact AEE in your area to request application• Complete Assister Application• Submit application to AEE• AEE will reviews application and approves affiliation• Individual affiliates with AEE

Covered California Assister Help Desk888-402-0737

assisterinfo@ccgrantsandassisters.org

Background Checks and Finger Printing• Since individual assisters will be dealing with personal information

including financial data, they will be required to pass a background check and be finger printed prior to certification. The cost is to be paid by the assister entity.

Assister Training• Covered California provides free assister training by:• In-person 2-3 day training in various locations throughout the state.• Online Training CourseAssister Timeline• Assister Enrollment Entity Application Release - Spring 2013• Assister Enrollment Entity Training Begins - Summer 2013• IPA Training and Certification Begins - August 2013

Assister Compensation

• In Person Assisters Compensation: IPAs are paid a flat-fee of $58 per successful application (regardless of number of individuals per application) and $25 per successful annual renewal.

• Navigator Compensation: Navigator entities are paid for performance-based block funding based on meeting Covered California enrollment targets.

Navigator Timeline

• Navigator Grant Application Release - June 2013• Navigator Grant Application Submission Due -

Mid-July 2013• Navigator Grant Award - Early October 2013• Navigator Training and Certification Begins -

Mid-November 2013• Navigator Entities begin Enrollment Assistance -

Early December 2013

Accountable Care Organizations(ACOs)

• The core is effective primary care delivered through a “medical home”

• Primary care organizations can transform• Integrated coordinated care similar to the

HMO model• Not surprising Kaiser picked as essential

benefit plan

ACO Characteristics

• a strong primary care/medical 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”