Affordable Care ActAffordable Care Act

Nurse Practitioner Association of Nurse Practitioner Association of Southwestern Pennsylvania Southwestern Pennsylvania

May 15, 2013May 15, 2013

HEALTHCARE.GOV

Aryanna Abouzari, Esq.Aryanna Abouzari, Esq.Executive OfficerExecutive Officer

U.S. Department of Health & Human U.S. Department of Health & Human Services, Region III Services, Region III

Pennsylvania, Delaware, District of Columbia, Pennsylvania, Delaware, District of Columbia, Maryland, Virginia, West VirginiaMaryland, Virginia, West Virginia

Critical Need for Health ReformCritical 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 17.9 % of our economic output tied up in the health care system in the health care system

Without reform, by 2040, 1/3 of Without reform, by 2040, 1/3 of economic output tied up in health careeconomic output tied up in health care

Affordable Care Act OverviewAffordable Care Act Overview Creates Consumer ProtectionsCreates Consumer Protections

Prevents denials of coverage for pre-existing Prevents denials of coverage for pre-existing conditionsconditions

Make health insurance more affordable for Make health insurance more affordable for middle class families and small businesses middle class families and small businesses with tax creditswith tax credits

Expands access to care through Marketplaces Expands access to care through Marketplaces and Medicaid expansionand Medicaid expansion

Highlights for ProvidersHighlights for Providers Increases the number of Primary Care Increases the number of Primary Care

PractitionersPractitioners – Provides new investments to – Provides new investments to increase the number of primary care increase the number of primary care practitioners, including doctors, nurses, nurse practitioners, including doctors, nurses, nurse practitioners, and physician assistantspractitioners, and physician assistants• • Projected to place more than 16,000 health Projected to place more than 16,000 health

professionals over next 5 yearsprofessionals over next 5 years

Community Health CentersCommunity Health Centers - Increases - Increases funding for Community Health Centers to allow funding for Community Health Centers to allow for nearly a doubling of the number of patients for nearly a doubling of the number of patients seen by the centers over the next 5 yearsseen by the centers over the next 5 years• 231 community health centers in PA eligible for 231 community health centers in PA eligible for

fundingfunding• 671,646 patients treated in 2010 at federally 671,646 patients treated in 2010 at federally

supported health centers in the U.S.supported health centers in the U.S.

Highlights for Nursing Highlights for Nursing WorkforceWorkforce

Nurse Education, Practice, Quality & Nurse Education, Practice, Quality & RetentionRetention

Nursing Workforce DiversityNursing Workforce Diversity Nurse Faculty Loan ProgramNurse Faculty Loan Program Advanced Nursing Education ProgramAdvanced Nursing Education Program Advanced Education Nursing Advanced Education Nursing

TraineeshipsTraineeships Nurse Anesthetist TraineeshipsNurse Anesthetist Traineeships

Center for Medicare and Center for Medicare and Medicaid Innovation Medicaid Innovation

Developing payment and delivery system Developing payment and delivery system reforms, focused on:reforms, focused on:

Expanding team-based care coordinationExpanding team-based care coordination Rewarding providers for care outside of traditional Rewarding providers for care outside of traditional

face-to-face visitsface-to-face visits Focusing on aggressive management of Focusing on aggressive management of

chronically ill patientschronically ill patients Expanding access to home-based careExpanding access to home-based care

$10 billion in funding for FY 2011 - $10 billion in funding for FY 2011 - 2019 2019

Opportunity to scale up: authority to Opportunity to scale up: authority to expand successful models to the national expand successful models to the national level level

Center for Medicare and Center for Medicare and Medicaid InnovationMedicaid Innovation

Partnership for PatientsPartnership for Patients Accountable Care OrganizationsAccountable Care Organizations Bundled Payments for Care ImprovementBundled Payments for Care Improvement Community-based Care Transitions Community-based Care Transitions

Program Program Value Based PurchasingValue Based Purchasing Graduate Nurse Education Demonstration Graduate Nurse Education Demonstration

Health Insurance MarketplaceHealth Insurance Marketplace

Sometimes called “Exchanges,” the Sometimes called “Exchanges,” the Marketplace is required by the ACA to be Marketplace is required by the ACA to be created by January 1, 2014created by January 1, 2014

New “marketplace” where small businesses and New “marketplace” where small businesses and individuals can select and enroll in a private individuals can select and enroll in a private health insurance plan health insurance plan

Consumers will have Consumers will have • the same level of benefits and coverage the same level of benefits and coverage

available to members of Congressavailable to members of Congress• more choice and selection in health plansmore choice and selection in health plans

Three models availableThree models available State-BasedState-Based Federal-State PartnershipFederal-State Partnership Federally-FacilitatedFederally-Facilitated

States can apply for Marketplace States can apply for Marketplace establishment funding at any time and be establishment funding at any time and be awarded grants through 2014 awarded grants through 2014

HHS to operate marketplaces for States HHS to operate marketplaces for States that have not elected to do so that have not elected to do so

Marketplace Implementation Marketplace Implementation

Health Insurance Marketplace Health Insurance Marketplace Regional SnapshotRegional Snapshot

• PAPA – – No enabling legislation; Federally-facilitated No enabling legislation; Federally-facilitated

• DE – No enabling legislation; Federal-State PartnershipDE – No enabling legislation; Federal-State Partnership

• MD – Passed enabling legislation; State-based MD – Passed enabling legislation; State-based

• DC – Passed enabling legislation; State-basedDC – Passed enabling legislation; State-based

• WV – Passed enabling legislation; Federal-State WV – Passed enabling legislation; Federal-State Partnership Partnership

• VA – No enabling legislation; Federally-facilitatedVA – No enabling legislation; Federally-facilitated

Financial AssistanceFinancial Assistance

Premium tax creditsPremium tax credits• Will reduce the premium amount the consumer Will reduce the premium amount the consumer

owes each monthowes each month• Available to eligible consumers with household Available to eligible consumers with household

incomes between 100% and 400% of the FPL incomes between 100% and 400% of the FPL ($44,680 for an individual and $92,200 for a family ($44,680 for an individual and $92,200 for a family of 4 in 2012), and who don’t qualify for other health of 4 in 2012), and who don’t qualify for other health insurance coverageinsurance coverage

• Based on household income and family size for the Based on household income and family size for the taxable yeartaxable year

• Paid each month to the insurerPaid each month to the insurer

Financial AssistanceFinancial Assistance

Cost-sharing reductions:Cost-sharing reductions: Reduce out-of-pocket costs (deductibles, Reduce out-of-pocket costs (deductibles,

coinsurance, copayments)coinsurance, copayments)• Generally available to those with income 250% Generally available to those with income 250%

FPL or below (FPL or below ($27,925 for an individual and $27,925 for an individual and $57,625 for a family of 4 in 2012)$57,625 for a family of 4 in 2012)

• Consumer must enroll in a “silver-level” plan Consumer must enroll in a “silver-level” plan

Quality InsuranceQuality Insurance The ACA requires plans inside the Marketplace The ACA requires plans inside the Marketplace

to meet particular actuarial value (AV) targetsto 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 Metal Levels” will enable consumers to compare plans with similar levels of coverage, compare plans with similar levels of coverage, promote competition on premiums, and allow promote competition on premiums, and allow plans flexibility to design cost sharing plans flexibility to design cost sharing structuresstructures

Essential Health BenefitsEssential Health Benefits• Ambulatory patient servicesAmbulatory patient services• Emergency servicesEmergency services• HospitalizationHospitalization• Maternity and newborn careMaternity and newborn care• Mental health and substance use disorder Mental health and substance use disorder

services, including behavioral health treatmentservices, 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 Preventive and wellness services and chronic

disease managementdisease management• Pediatric services, including oral and vision Pediatric services, including oral and vision

carecare

Quality InsuranceQuality Insurance

Enrollment ProcessEnrollment Process Consumer submits application to the marketplaceConsumer submits application to the marketplace

• OnlineOnline• PhonePhone• MailMail• In PersonIn Person

The marketplace verifies and determines The marketplace verifies and determines eligibility foreligibility 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/CHIPConsumer enrolls in a QHP or Medicaid/CHIP• Online plan comparison tool available to inform health plan Online plan comparison tool available to inform health plan

choicechoice• Tax credit is sent to insurer (if eligible) to reduce consumer Tax credit is sent to insurer (if eligible) to reduce consumer

premium owed premium owed

Enrollment AssistanceEnrollment Assistance

Help available in each MarketplaceHelp 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 brokers Agents and brokers

Initial Open Enrollment PeriodInitial Open Enrollment Period

October 1, 2013 – March 31, 2014October 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 1st and 15th day of January – March

First day of the following month

Between the 16th and the last day of December – March

First day of the following month

Resources:

Affordable Care Act website –Affordable Care Act website –www.healthcare.gov

Health Insurance Marketplace –Health Insurance Marketplace –

marketplace.cms.govmarketplace.cms.gov

Center for Consumer Information & Insurance Center for Consumer Information & Insurance Oversight website – Oversight website – http://cciio.cms.gov

Affordable Care Act Spanish Affordable Care Act Spanish website website – – www.cuidadodesalud.gov

Thank you!Contact:

aryanna.abouzari@hhs.gov