THE PATIENT PROTECTION AND AFFORDABLE CARE ACT Susan Horky, LCSW.
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Transcript of THE PATIENT PROTECTION AND AFFORDABLE CARE ACT Susan Horky, LCSW.
Components
Patient-related Ensuring coverage Increasing access Fairness/transparency/getting value Increasing quality
Systems efforts Supporting prevention Decreasing costs Workforce development Additional systemic changes
Ensuring insurance
No annual or lifetime caps
Can’t be kicked off insurance if sick or made mistakes on application
Can’t be denied coverage due to pre-existing condition
Ensuring insurance
Dependents remain on parents’ insurance till 26
Can’t be made to wait more than 90 days for coverage
Ensuring Insurance
People with insurance can keep their current insurance (or choose not to)
If you’re uninsured you can: Obtain insurance through employer Go to an exchange [Obtain Medicaid]
Tax credits available for people < 400% FPL = $94,200 for a family of four
Tax credit
Generally available only for people who buy individual/family policies through an exchange
Available for people who have employer based health insurance IF
The employees’ part of the premium is more than 9.5% of household income or
If the plan covers less than 60% of medical costs
Ensuring insurance
Tax credits will insure that premiums will not exceed the percent indicated below, for various levels above poverty level:
A person who earns 150 percent of the poverty line (about $17,235) would be expected to pay no more than 3 percent of their income on premiums, or $517
Ensuring Insurance: Affordability Sets limits to how much families must
pay out of pocket
2013 limits are $6,250 for an individual and $12,500 for family
These amounts are indexed annually for inflation
Ensuring Insurance: Exchanges Similar to buying car insurance, but
online
Choose from different options, clearly laid out
Users won’t know if exchange is set up by state or federal government
Ensuring Insurance
“Navigators” will assist patients in navigating the insurance and healthcare systems
Navigator grants available to states, agencies, universities
Penalties for no coverage
Some people who choose not to have coverage will be required to pay a penalty
This is NOT the case if: Your share of premiums (after federal subsidies
and employer contributions) would total more than 8 percent of your income
Your income is below the income tax filing threshold, and so you’re not required to file taxes
You were uninsured for less than three months of the year (If over three, the penalty is pro-rated)
You choose not to get insurance for religious reasons
Penalties for no coverage
The Urban Institute estimates that approximately 6% of the population (roughly 18 million Americans) will even have to consider the question of whether to get insurance or pay a penalty
Penalty in 2015 will be $95.00 Proof will be filed with income tax Penalty will be deducted from
income
Ensuring Insurance
Small businesses (<50 employees) are specifically exempted from having to provide insurance
Large employers do have to have to provide insurance or pay a penalty, as then the cost of providing coverage to their employees is covered by tax payers
Small businesses-Incentives
Very small businesses (< 25 employees) can get tax credits to help with insurance if they choose to offer it
Small businesses with up to 100 employees will have access to state-based Small Business Health Options Program (SHOP) Exchanges
SHOP exchanges are estimated to reduce by 4% the costs small businesses pay in premiums
Grandfathered Insurance Policies
Grandfathered plans are those in existence prior to 2014 who apply for grandfathered status (partial ACA exemption)
Grandfathered plans lose their status if they significantly raise premiums, copays etc
Grandfathered plans
Get rid of lifetime insurance caps
Offer dependent coverage for young adults until age 26
Keep people on their insurance even if they made mistakes on application (rescission)
Provide preventive care without cost-sharing
Offer “essential health benefits" for individual and small group plans
Refrain from imposing annual dollar limits (for individual policies only)
Provide coverage to children under 19 if they have a pre-existing conditions (for individual policies only)
Do have to Don’t have to
Essential health benefits (Required for individual and small group plans only) Ambulatory patient
services
Emergency services
Hospitalization
Maternity and newborn care
Mental health and substance use disorder services including behavioral health treatment
Prescription drugs
Rehabilitative and habilitative services and devices
Laboratory services
Preventive and wellness services and chronic disease management
Pediatric services, including oral and vision care..
Increasing access
Making healthcare choices more understandable
Choosing own PCP
No ER prior authorization required
Encouraging cultural competence Workforce diversity grants Health care professionals training for diversity
Increasing access
Significant focus on (and funding for) Federally Qualified Health Centers Community Health Centers which serve a
variety of Federally designated Medically Underserved Area/Populations (MUA or MUP).
Migrant Health Centers which provide culturally-competent and primary preventive medical care to migrant and seasonal agricultural workers,
Health Care for the Homeless Programs which reach out to homeless individuals and families and provide primary and preventive care and substance abuse services, and
Public Housing Primary Care Programs that serve residents of public housing and are located in or adjacent to the communities they serve.
Increasing access
School based health centers
Co-locating primary and specialty care in community-based mental health settings
Extension of family-to-family health information centers
Removing barriers and improving access to wellness for individuals with disabilities
Counting resident time in non provider settings.
Fairness/Value/Transparency Low salaried individuals must have same
insurance options as high salaried individuals
All people must be charged the same premiums for the same coverage except for:
Individual vs. family coverage The insurance rating area in which the person lives The age of the person (but cannot vary more than 3:1) Whether or not the person uses tobacco (but cannot
vary more than 1.5:1)
Fairness/Value/Transparency All approved health insurance plans must
have same components (within Silver, Gold and/or Platinum)
Amount patient pays of own healthcare costs (through deductibles and copays) Bronze plan: 40% Silver plan: 30% Gold plan: 20% Platinum plan: 10%
Fairness/Value/Transparency 80%-85% of premium incomes must be
spent on healthcare
If insurance company spends more than 15%-20% premium incomes on administrative costs or profits, they must send rebates to the insured
Fairness/Value/Transparency Each hospital must
make public a list of the hospital's standard charges for items and services it provides
Each health insurance plan must have a clear plan for appealing their coverage decisions and standardized complaint forms
Nursing home compare Medicare website
Quality
Payments to hospitals will be linked to quality measures, including Readmissions Hospital acquired infections Patient perceptions of care Health outcomes Patient safety/medical errors Implementation of wellness programs
Quality
Technical assistance will be available to hospitals, to help improve quality
Healthcare professionals and hospitals will get bonuses for quality reporting
They will also be penalized for not doing quality reporting
Quality
Significant funding available to create innovative programs that improve quality:
Aging and disability resources centers Medical Home projects Integrated care around hospitalizations MCH Home visiting projects Research into postpartum depression Train health professionals in quality
initiatives and patient safety
Quality
Health care delivery system research
Medication management services in treatment of chronic disease.
Design and implementation of regionalized systems for emergency care
Trauma care centers and service availability
Program to facilitate shared decision-making
Presentation of prescription drug benefit and risk information
Patient navigator program
Improving women’s health
Community Health Teams
Quality
Funding for innovative programs, continued Research into health disparities Childhood Obesity Demonstration Project Demonstration project concerning
individualized wellness plan Community transformation grants Patient-Centered Outcomes Research
Prevention
Rebates on premiums if person uses employer-based fitness plan
No cost-sharing on preventive coverage for individual or group insurance purchased through exchanges
Clinical and community preventive services; Community education and outreach campaign about prevention
Nutrition labeling of standard menu items at chain restaurants.
No co-pays on ACIP recommended Immunizations
Prevention
Incentives for prevention of chronic diseases in patients with Medicaid
Coverage of comprehensive tobacco cessation services for pregnant women with Medicaid
Improving access to preventive services for eligible adults in Medicaid Providers will be paid at Medicare rates for
preventive services for Medicaid patients
Cultural competency, prevention, and public health and individuals with disabilities training
Workforce development National health care workforce commission;
Health care workforce assessment
Public health workforce recruitment and retention programs
State health care workforce development grants
Federally supported student loans
Nursing student loan program; Nurse education, practice, and retention grants; Advanced nursing education grants
Health care workforce loan repayment programs
Workforce Development
Mental and behavioral health education and training grants
Training opportunities for direct care workers
Training in family medicine, general internal medicine, general pediatrics, and physician assistants
Nurse-managed health clinics
National Health Service Corps
Allied health workforce recruitment and retention programs; Grants to promote the community health workforce