the affordable care act - advancing states · the affordable care act (aca), and it is made up of...
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www.nasuad.org
The Affordable Care Act • Background
• Coverage
• Long-term Care
• Home and Community Based Services
• Payment Delivery
• Care Transitions
• Assuring Quality
• Supreme Court
5/30/2012
BACKGROUND
Health Reform legislation is commonly referred to as
the Affordable Care Act (ACA), and it is made up of
two pieces of legislation:
1. Patient Protection and Affordable Care Act,
P.L. 111-148, enacted March 23, 2010; and
2. Health Care and Education Reconciliation Act
of 2010, P.L. 111-152, enacted March 30, 2010
Affordable Care Act Titles
• Title I: Quality, Affordable Health Care for All
Americans
• Title II: Role of Public Programs
• Title III: Improving the Quality and Efficiency of
Health Care
• Title IV: Prevention of Chronic Disease and
Improving Public Health
• Title V: Health Care Workforce
• Title VI: Transparency and Program Integrity
• Title VII: CLASS Act
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COVERAGE
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COVERAGE: The Medicaid
Expansion
How will it work? In 2014, all individuals with incomes up to
133% of FPL (In 2009, $14,404 for individuals/$29,326 for a
family of 4) will be covered under Medicaid.
Who will be covered? Eligibility will be based on a modified
adjusted gross income (MAGI) with no asset or resource
test, while maintaining existing counting rules for people
who 65 and older, and for individuals with disabilities.
COVERAGE: The Essential
Health Benefits
• Ambulatory Patient Services
• Emergency Services
• Hospitalization
• Maternity and newborn care
• Mental health and substance use disorder services
• Behavioral Health Treatment
• Prescription Drugs
• Rehabilitative and habilitative services and devices
• Laboratory Services
• Preventive and wellness services
• Chronic Disease Management
• Pediatric Services, including oral and vision care
COVERAGE: The Exchanges
How will it work? The Exchanges are designed to serve as
marketplaces that allow participants to band together and
shop for insurance at competitive rates.
Who will be covered? Initially, participants in the Exchange
will be limited to businesses with 100 or fewer employees,
and to individuals looking to purchase insurance for
themselves.
What if coverage is unaffordable? To facilitate participation
in the Exchanges, premium tax credits will be offered on a
sliding scale basis, and will be available to those with
incomes between 133 and 400% FPL.
LONG-TERM CARE
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LONG-TERM CARE
CLASS ACT Creates a new federally administered national, voluntary insurance program to help adults age 18 and over with disabilities pay for LTSS.
Eligibility: voluntarily enrolled for five years and have a qualifying functional limitation expected to last continuously for 90 days or more
Benefits: cash benefit
Premiums: Depend on age at enrollment and year, but no other factors permitted including underwriting
Will work in conjunction with other long-term services and supports programs such as Medicaid
Update on the CLASS ACT
• On January 5, 2011, the Obama Administration announced the formal launch of an office to administer the CLASS Program within AoA under the leadership of Assistant Secretary Greenlee. Ten months later, on November 14, 2011, HHS Secretary Sebelius recommended that the Department halt its implementation of the CLASS Act, explaining that:
"For 19 months, experts inside and outside of government have examined how HHS might implement a financially sustainable, voluntary, and self-financed long-term care insurance program under the law that meets the needs of those seeking protection for the near term and those planning for the future. ... But despite our best analytical efforts, I do not see a viable path forward for CLASS implementation at this time."
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PREVENTION
• Funding for Health Prevention – Incentives for Prevention of Chronic Diseases in Medicaid
– Prevention and Public Health Fund
– Community Transformation Grants
– Healthy Aging Living Well
– Positive Behavior Grants
• Councils and Taskforce – National Prevention & Wellness Strategy
– Preventive Services Task Force
• Research – Health Research
– Pain Management
– Congenital Heart Disease
– Cures Acceleration Network
Other Provisions of Interest
• Early Retiree Reinsurance Program
• Donut Hole Modifications
• Medicare Advantage payments
• End of Preexisting Conditions
• Lifetime and Annual Limits
HOME AND COMMUNITY
BASED SERVICES
• Community First Choice Option
• State Balancing Incentive Payments
Program
• Reforms to the Medicaid HCBS state plan
option §1915(i)
• Money Follows the Person
• Health Homes
• Dual Eligibles
LONG-TERM CARE: Balancing
Medicaid Medicaid LTSS Spending: Institutional and HCBS
Services from 1990 - 2008
SOURCE: Terence Ng et al, (November 2009), Medicaid Home and
Community Based Services Programs, Kaiser Commission on Medicaid and
the Uninsured
LONG-TERM CARE:
Balancing Medicaid
Balancing
Medicaid
Money Follows the Person
HCBS State Plan Option
Community First Choice Option
The CLASS Act
State Balancing Incentives
Health Homes
Spousal Impoverishment
Community First Choice is a new State Plan
Option for Attendant Care
• 6 percent increase in FMAP indefinitely
• Attendant care for ADLs and IADLs plus
backup systems and training for attendants
• Assessments, data collection required
• Maintenance of effort requirement—
spending for first 12 months must be at least
same level as prior year
Should Your State Consider Community First
Choice?
• Can CFC replace existing personal care in state
plan and waivers? Will eligible population
increase?
• Can state comply with self-direction
requirements?
• Does state have a universal assessment tool?
• Can IT system support quality and data
collection requirements?
• Does state need to “re-base” first to contain
personal care costs over the long term?
State Balancing Incentive Payments Offers Additional
FMAP for Reaching Rebalancing Targets
• <25% spending on community LTSS: 5%
increase in FMAP
• 25% to 50% spending on community LTSS:
2% increase in FMAP
• Must reach rebalancing targets of 25% and
50%, respectively, in four years (FFYs 2011-
2015)
Is State Balancing Incentive Payments an Option
for Your State?
• Can the state meet the aggressive
rebalancing targets? Where is the state now
in the rebalancing life cycle?
• Can the state comply with assessment,
single-point-of-entry, and data collection
requirements?
The 1915(i) State Plan Amendment was Amended
and Now Allows Targeting of Special Populations
• States can target populations–e.g.,
individuals with mental health conditions
• New services for chronic mental illness—day
treatment, partial hospitalization,
psychosocial rehabilitation, clinic services
• Must offer statewide; disallows ceilings on
number of enrollees
What Should States Consider in Adopting a 1915(i)
State Plan Amendment?
• What population could most benefit? Are
there individuals on waivers who could be
transferred over?
• Can population be clearly defined so as to
prevent eligibility “creep?”
• What is the benefit package? Are the
services evidence-based? Will amendment
be cost-effective?
Money Follows the Person Provides a Opportunity
to Promote LTSS Systemic Change
• MFP Demonstrations are now operating in
43 states
• Enhanced FMAP for one year for all
qualifying MFP participants
• Funding for IT and infrastructure
development, specialized staff
States Can Leverage Money Follows the Person as
the Centerpiece of Rebalancing Efforts
• How can your state enhance rebalancing
efforts by positioning MFP as a focal point?
• How can your state strategically invest MFP
“savings?”
Health Homes Can Coordinate an Array of Services for
People with At Least Two Chronic Conditions
• Includes asthma, diabetes, heart disease,
mental health conditions, substance abuse
disorders, obesity
• Can target based on number, type, and
severity of chronic conditions
• 90% FMAP for two years for six core health
home services only
• Dual eligibles cannot be excluded
Are Health Homes an Opportunity for Serving People
in Your State with Complex, Expensive Needs?
• Which populations could benefit?
• Does the state have existing health homes to build
on? Are they evidence-based? Are providers
available?
• Can the program be sustained financially?
• Does the state have experience in coordinating
Medicare/Medicaid benefits for dual eligibles?
• Does the state have experience with managed care
payment methods and encounter data?
• Can the state comply with data collection and
evaluation requirements?
• CMS Center for Innovation
• Medicare and Medicaid Demonstration Projects
Payment Delivery
ACA Promotes Integrated Care for Dual Eligibles
• Establishes Federal Coordinated Health
Care Office (FCHCO)
• FCHCO closely aligned with Center for
Medicare and Medicaid Innovation (CMMI)
for demonstrations and technical assistance
• New opportunity to “synch” renewal periods
for concurrent waivers for dual eligibles
• Special Needs Plans (SNPs) reauthorized
CARE TRANSITIONS
CARE TRANSITION –
actions designed to ensure the
coordination and continuity of
health and community care
during the course of a chronic
or acute illness
CARE TRANSITION
Access to Care
Coordination of Care
Continuity & Translation
Information & Education
CARE TRANSITIONS & COORDINATION
• Improving Care Transition and Coordination
– Community-Based Care Transitions Program
– Aging and Disability Resource Centers (ADRC)
– Accountable Care Organizations
– Health Homes for Enrollees with Chronic Conditions
– Community health teams to support the patient-centered medical
home
– Patient Navigator Program
Assuring Quality
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Elder Justice Act
– Establishes an Elder Justice Coordinating Council
– The law authorizes for fiscal years 2011-2014 , BUT DOES NOT
FUND, several grant programs, including, but not limited to:
• Funding to State and local Adult Protective Services offices
• Demonstration grants to detect and prevent elder abuse
• Grants to improve the capacity of the state Long-Term Care
Ombudsman Program
• Grants to improve ombudsman training
• Grants to provide workforce management technical
assistance
• Establishment and Support of Forensic Centers
Nursing Home Reforms
Quality Improvement Measures
– Quality Assurance and Performance Improvement Program
– Effective Compliance and Ethics Program
– Culture Change and Information Technology Demonstrations
– Standardized Complaint Form
– Nursing Home Compare Medicare Website
– Dementia and Abuse Training
– Report on Five-Star Quality Rating System
Protections
– Notification of Facility Closure
– Background Checks on Employees of Long-Term Care Facilities
– Disclosure of Ownership and Parties
– Imposing civil monetary penalties
– Ensuring Staffing Accountability
Supreme Court Challenge
Where are we now?
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Four questions before the court
• Anti-Injunction Act
– Bars lawsuits prior to the payment of a tax
• The individual mandate requirement
– Commerce Clause
– Necessary and Proper Clause
– Taxing Power
• The Medicaid expansion
– Valid exercise of Congress’s spending power
• The severability
– In the case before the Supreme Court, the lower court held the ACA not severable and invalidated the entire ACA
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Further Information
For Up-to-date information visit NASUAD’s Affordable Care Act’s Webpage:
www.nasuad.org
Contact Information
1201 15th Street NW, Ste 350 Washington, DC 20005 Phone: 202.898.2578 Fax: 202.898.2583