Transcript 10/31/12 DRAFT POWER POINT WEBINAR - VR-RRTC

Funding Health-Related VR Services:
The Potential Impact of the ACA on
the Use of Private Health Insurance
and Medicaid to Pay for HealthRelated VR Services
WEBINAR
January 8, 2013
WEBINAR SPONSORED BY AND
REPORT PREPARED FOR:
The Rehabilitation Research and
Training Center
on Vocational Rehabilitation
(VR RRTC)
Institute for Community Inclusion
University of Massachusetts Boston
WEBINAR SLIDES AND REPORT
PREPARED BY:
Robert “Bobby” Silverstein
POWERS PYLES SUTTER &
VERVILLE, PC
[email protected]
INTRODUCTION
• FACT: In 2011, $264 million was spent by State VR
agencies for diagnosis and treatment of physical and
mental impairments. [RSA-2, Financial Report]
• ISSUE: Whether the Affordable Care Act (ACA) can be
used to reduce the expenditure of VR funds for healthrelated VR services.
• PURPOSE OF WEBINAR: Review a recent paper:
Funding Health-Related VR Services—The Potential
Impact of the Affordable Care Act on the Use of Private
Health Insurance and Medicaid to Pay for Health-Related
VR Services.
INTRODUCTION
The presentation:
•Describes the VR POLICY FRAMEWORK pertaining
to health-related VR services
•Describes the ACA POLICY FRAMEWORK
potentially applicable to health-related VR services
• Highlights RECOMMENDATIONS for maximizing
the payment of health-related VR services by
private insurers and Medicaid under the ACA
VR POLICY FRAMEWORK
Topics include:
• Health-Related Services and
Supports Considered VR Services,
Definitions
• Comparable Services and Benefits
• Physical and Mental Restoration
• Participation by Clients in the Cost of
Services Based on Financial Need
VR POLICY FRAMEWORK
Health-Related Services and Supports Considered
VR Services, DEFINITIONS
•Physical and Mental Restoration Services
•Orientation and Mobility Services
•Personal Assistance Services
•Rehabilitation Technology Services (Rehabilitation
Engineering, Assistive Technology Devices and
Services)
VR POLICY FRAMEWORK
Health-Related Services and
Supports Considered VR Services,
DEFINITIONS—
•Physical and Mental Restoration
Services [34 CFR 361.5(40)]
VR POLICY FRAMEWORK
Health-Related Services and
Supports Considered VR Services,
DEFINITIONS—
•Orientation and Mobility Services
VR POLICY FRAMEWORK
Health-Related Services and
Supports Considered VR Services,
DEFINITIONS—
•Personal Assistance Services [34
CFR 361.5(39)]
VR POLICY FRAMEWORK
Health-Related Services and Supports
Considered VR Services, Definitions—
•Rehabilitation Technology
•Rehabilitation Engineering
•Assistive Technology Device
•Assistive Technology Service
VR POLICY FRAMEWORK
Comparable Services and Benefits
• Definition
• Determination of availability and exempt services
• Provision of services
• Interagency coordination
• Responsibilities under other laws
VR POLICY FRAMEWORK
Comparable Services and Benefits—DEFINITION [34 CFR
361.5(10)]
•Services and benefits that are –
– Provided or paid for, in whole or in part, by other Federal, State,
or local public agencies, by health insurance, or by employee
benefits;
– Available to the individual at the time needed to ensure the
progress of the individual toward achieving the employment
outcome in the individual's individualized plan for employment;
and
– Commensurate to the services that the individual would
otherwise receive from the designated State vocational
rehabilitation agency.
VR POLICY FRAMEWORK
Comparable Services and Benefits DETERMINATION OF AVAILABILITY AND EXEMPT
SERVICES
•Prior to providing most VR services, the VR agency must
determine the availability of comparable services and
benefits
•A determination that interrupts or delays certain
outcomes not required
•Services exempt from comparable services or benefits
determinations
VR POLICY FRAMEWORK
Comparable Services and Benefits—PROVISION
OF SERVICES [34 CFR 361.53(c)]
•If comparable services and benefits exist and are
available, they must be used by VR agencies to
meet, in whole or in part, the costs of VR services.
•If comparable services and benefits exist but are
not available, the VR agency must provide VR
services until comparable services become available.
VR POLICY FRAMEWORK
Comparable Services and Benefits—INTERAGENCY
COORDINATION [34 CFR 361.53(d); see also 34 CFR
363.50]
•The Governor, in consultation with the VR agency and other
agencies (e.g., Medicaid agency), must ensure that an
interagency agreement or other mechanism takes effect.
•The interagency agreement must delineate:
–
–
–
–
Financial responsibility
Procedures for reimbursing the State VR agency
Dispute resolution procedures
Procedures for identifying coordination and timely delivery
responsibilities
VR POLICY FRAMEWORK
Comparable Services and Benefits—
RESPONSIBILITIES UNDER OTHER LAWS [34
CFR 361.53(e)]
•Obligations of public agencies under ADA and
Section 504 or interagency agreements
•VR agency’s responsibilities if other public
agencies fail to meet their obligations
•Procedures for claiming reimbursement
VR POLICY FRAMEWORK
Physical and Mental Restoration Services [34
CFR 361.48]
•Physical and mental restoration services (see
definition) must be made available by the VR
agency, but only to the extent that financial
support is not readily available from:
– A source other than the State VR agency (such as
through health insurance) or
– A comparable service or benefit (see definition).
VR POLICY FRAMEWORK
Participation by Clients in the Cost of Services
Based on Financial Need
• State VR agency may (but is not required to )
consider financial need
• If the State VR agency chooses to consider
financial need it must maintain written policies
that meet specified conditions.
VR POLICY FRAMEWORK
Participation by Clients in the Cost of
Services Based on Financial Need
A financial needs test may NOT be
used:
•For furnishing personal assistance
services or
•As a condition to furnishing VR services
to SSI and SSDI recipients.
EXAMPLES OF STATE POLICIES
• California
• Florida
• North Carolina
• Massachusetts
ACA POLICY FRAMEWORK
• Overview
• Individual Mandate
• Employer Mandate
• Health Care Exchanges, Including Essential Health
Benefits
• Changes to Private Health Insurance
• Expansion of Public Programs
ACA POLICY FRAMEWORK
Overview
In March 2010, Congress passed
and the President signed into law
the “Affordable Care Act” (ACA).
ACA POLICY FRAMEWORK
Overview
On June 28, 2012, the United States Supreme
Court with the exception of the Medicaid
expansion provision upheld all of the provisions of
the ACA, including:
–
–
–
–
–
Individual mandate,
Employer mandate,
Health care exchanges,
Essential health benefits package, and
Insurance market reforms.
ACA POLICY FRAMEWORK
Overview
•With respect to Medicaid, the Supreme Court
held that if a State chooses not to expand
Medicaid eligibility to cover all non-Medicare
individuals under age 65 with income up to
133% of the Federal Poverty level, the State
may not, as a consequence, lose Federal
funding for its existing Medicaid program. In
other words, the Medicaid expansion is
voluntary, not mandatory.
ACA POLICY FRAMEWORK
Individual Mandate
– Most individuals will be required to have health
insurance beginning in 2014 or pay a financial
penalty.
– Individuals who do not have access to affordable
employer coverage will be able to purchase
coverage through a Health Insurance Exchange.
– For those individuals who cannot afford health
insurance, premium and cost-sharing credits will be
available.
ACA POLICY FRAMEWORK
Employer Mandate
Employers will be required to
provide insurance or pay penalties
for employees who receive tax
credits for health insurance
through the Exchange with
exceptions for small employers.
ACA POLICY FRAMEWORK
Health Care Exchanges—
Establishment
•States are authorized to create State-based
Exchanges where individuals and small businesses
can purchase insurance.
•HHS will establish and operate a Federally-facilitated
Exchange in any State that elects not to do so.
•The Exchanges will provide consumers with information
to enable them to choose among plans.
•Premiums and cost-sharing subsidies will be
available to make coverage more affordable.
ACA POLICY FRAMEWORK
Health Care Exchanges—
Essential Health Benefits
•Effective 2014, qualified health plans in Exchanges will
be required to offer essential health benefits that meet a
minimum set of standards promulgated by the Secretary
of Health and Human Services (HHS).
•All Medicaid “benchmark plans” [see below under
“Expansion of Public Programs (Medicaid)] must cover
these services by 2014.
ACA POLICY FRAMEWORK
Health Care Exchanges—
Defining the Essential Health Benefits Package
In defining the essential health benefits package,
States must start with a typical employer plan
(base-benchmark plan) and then supplement
the base plan to comply with the ACA by
providing an essential health benefits (EHB)benchmark plan.
ACA POLICY FRAMEWORK
Health Care Exchanges—
Essential Health Benefits
The EHB-benchmark plan must include all ten
General categories and the items and services
covered within the categories:
1)
2)
3)
4)
5)
6)
Ambulatory patient services
Emergency services
Hospitalization
Maternity and newborn care
Prescription drugs
Laboratory services
ACA POLICY FRAMEWORK
Health Care Exchanges—
Essential Health Benefits
The EHB-benchmark plan must include all ten general
categories and the items and services covered within the
categories :
7) Mental health and substance use disorder services,
including behavioral health treatment
8) Rehabilitative and habilitative services and devices
9) Preventive and wellness services , including chronic
disease management
10) Pediatric services, including oral and vision care
ACA POLICY FRAMEWORK
Health Care Exchanges—
Defining the Essential Health Benefits
Package
In addition, EHB-benchmark plan must be defined so
that:
– Benefits are not designed to discriminate against individuals
because of age, disability or expected length of life;
– The health care needs of diverse segments of the population
(including disability) are accounted for; and
– The essential benefits are not denied due to an individual’s
present or predicted disability; and
– Benefits are not unduly weighted toward one category of benefits
(there must be an appropriate balance among categories).
ACA POLICY FRAMEWORK
Health Care Exchanges—
•Levels of Coverage
•Limits on deductibles
ACA POLICY FRAMEWORK
Changes to Private Health Insurance—
Overview
Changes to private insurance include
the following:
– Coverage
– Preexisting conditions exclusions
– Premium ratings
ACA POLICY FRAMEWORK
Changes to Private Health Insurance —
Overview
Changes to private insurance include
the following:
– Annual and lifetime limits
– Rescissions
– Coverage of dependents
ACA POLICY FRAMEWORK
Changes to Private Health Insurance—
Overview
Changes to private insurance include
the following:
– Waiting periods
– Preventative services and immunizations
and cost sharing
– Existing plans
ACA POLICY FRAMEWORK
Expansion of Public Programs—
Extension of Medicaid Eligibility (As
Enacted)
•The ACA, as enacted, was designed to extend and simplify
Medicaid eligibility.
•Starting in calendar year 2014, the ACA, as enacted, would
have replaced the complex categorical groupings and
limitations to provide Medicaid eligibility to cover all nonMedicare individuals under age 65 with income up to 133% of
the Federal poverty level ($14,404 for an individual and
$29,327 for a family of four in 2009)
ACA POLICY FRAMEWORK
Expansion of Public Programs—
Extension of Medicaid Eligibility
(Supreme Court)
•On June 28, 2012, the United States Supreme Court upheld all of the
provisions of the ACA, with the exception of the Medicaid expansion
provision.
•The Supreme Court held that if a State chooses not to participate in
this expansion of Medicaid eligibility for low-income adults, the State
may not, as a consequence, lose Federal funding for its existing
Medicaid program.
•In sum, in light of the Supreme Court decision, the Medicaid
expansion envisioned by the ACA is now voluntary, not mandatory.
ACA POLICY FRAMEWORK
Expansion of Public Programs—
Extension of Medicaid Eligibility (Key
Policy Changes)
Under the ACA, for those states electing to participate in
the Medicaid expansion (up to 133% of the FPL), the
following key policy changes apply:
•The Federal government will provide between 100% and
90% of funding for the newly eligible between 2014 and
2020 and beyond.
ACA POLICY FRAMEWORK
Expansion of Public Programs —
Extension of Medicaid Eligibility (Key
Policy Changes)
•There is no deadline by which a State must let the Federal
government know of its intention regarding Medicaid expansion.
•A State which expands eligibility to less than 133% of the FPL
will not be eligible to receive the enhanced match.
ACA POLICY FRAMEWORK
Expansion of Public Programs—
Extension of Medicaid Eligibility
(Benchmark Plans)
•It is important to note that the Medicaid eligibility
expansion group will not be entitled to the full array of
State Medicaid benefits.
•Rather, those individuals will be entitled to “benchmark
coverage” or “benchmark equivalent coverage.”
•All Medicaid “benchmark plans” must cover essential
health benefits by 2014.
ACA POLICY FRAMEWORK
Expansion of Public Programs —
Home and Community-Based Services
State Plan Amendment
•The ACA includes changes to the HCBS State Plan that
enable States to:
– Target HCBS to particular groups of people,
– Make HCBS accessible to more individuals, and
– Ensure the quality of HCBS.
ACA POLICY FRAMEWORK
Expansion of Public Programs —
Community First Choice Option
•Attendant services and supports must be
provided; and
•Additional services and supports must be
made available
RECOMMENDATIONS
INTRODUCTION—
The ACA provides VR agencies with the
opportunity to influence State
policymakers to reduce use of VR funds
to pay for health-related VR services
RECOMMENDATIONS
INTRODUCTION—
Opportunity to Influence
•This opportunity is currently open because states are still in
the process of making key policy decisions regarding:
– State Health Care Exchanges and the scope of the
benchmark package of essential health benefits;
– Medicaid expansion and Medicaid benchmark plans; and
– New options under the Medicaid program, including the
Community First Choice option.
•Opportunity will be ongoing as state participation in programs
evolve.
RECOMMENDATIONS
INTRODUCTION—
Major Recommendations
•Modernizing the Federal and State VR Policy Framework
•Determining the Scope of Essential Benefits Package
Under the ACA
•Determining the Medicaid Benchmark Plans in Medicaid
Expansion States
•Ensuring Funding of Personal Attendants under Medicaid
Buy-in and Community First Choice Options
RECOMMENDATIONS
#1: Modernizing the Federal and State VR Policy
Framework
•The potential of the ACA to reduce payment by VR
agencies for health-related VR services is substantial.
•Examples of health-related VR services include:
– Physical and mental restoration services (e.g., surgery, therapies and
mental health and substance abuse disorder services);
– Rehabilitation technology, assistive technology devices and assistive
technology services; and
– Personal assistance services.
RECOMMENDATIONS
#1: Modernizing the Federal and State VR Policy
Framework
Current legal and policy bases for facilitating payment for
health-related VR services by private health insurance
and
Medicaid include:
• Comparable services and benefits
• Limitations on use of VR funds to pay for physical and mental
restoration services
• Obligation to develop and maintain written policies and
procedures regarding financial responsibility of individuals.
RECOMMENDATIONS
#1: Modernizing the Federal and State VR
Policy Framework
•Recommendation:
– RSA should clarify impact of ACA on payment
for health-related VR services.
– Greater leverage for State VR agencies.
RECOMMENDATIONS
#1: Modernizing the Federal and State VR
Policy Framework
The policy guidance should clarify:
•Use of private insurance and Medicaid prior to use
of VR funds
•Specific policies and procedures in interagency
agreements
•Relationship between VR and EHB-benchmark plan
RECOMMENDATIONS
#2: Determining the Scope of Essential
Benefits Package Under the ACA
State VR agencies have the opportunity to
influence decisions by State policymakers
regarding coverage of health-related VR
services under the EHB-benchmark plan
RECOMMENDATIONS
#2: Determining the Scope of Essential
Benefits Package Under the ACA
• Specifically, VR agencies should be involved
in decisions relating to:
1) Choosing the base-benchmark plan;
RECOMMENDATIONS
#2: Determining the Scope of Essential
Benefits Package Under the ACA
•Specifically, VR agencies should be involved in
decisions relating to determining the scope of
the EHB-benchmark plan by:
2) Supplementing the base-benchmark plan to
include all ten benefit categories (and the items
and services covered within each category)
RECOMMENDATIONS
Specifically, VR agencies should be involved in
decisions relating to determining the scope of
the EHB benchmark plan by:
2)Supplementing the base-benchmark plan by
ensuring compliance with the non-discrimination
provisions of the ACA and ensuring that any
plan enhancements provide for an appropriate
balance between the various benefit categories.
RECOMMENDATIONS
#2: Determining the Scope of Essential
Benefits Package Under the ACA
•Specifically, VR agencies should be involved in
decisions relating to:
3) Defining key terms, including
• Rehabilitative services,
• Habilitative services,
• Rehabilitative and habilitative devices,
RECOMMENDATIONS
#2: Determining the Scope of Essential
Benefits Package Under the ACA
•Specifically, VR agencies should be involved in
decisions relating to:
3) Defining key terms, including
• Durable medical equipment,
• Orthotics,
• Prosthetics,
RECOMMENDATIONS
#2: Determining the Scope of Essential
Benefits Package Under the ACA
•Specifically, VR agencies should be involved in
decisions relating to:
3) Defining key terms, including
• Low vision aids,
• Augmentative and alternative communication
devices, and
• Hearing aids and assistive listening devices.
RECOMMENDATIONS
#2:Determining the Scope of Essential Benefits
Package Under the ACA
• Specifically, VR agencies should be involved
in decisions relating to:
4) Making plan coverage decisions,
reimbursement rates, incentive programs,
and benefit design that are consistent with
private market reforms.
5) Continuing to incorporate existing State
mandates; and
RECOMMENDATIONS
#2: Determining the Scope of Essential
Benefits Package Under the ACA
• Specifically, VR agencies should be involved in
decisions relating to:
6) Defining medical necessity:
– By Incorporating not only improving functioning but also maintaining
and preventing deterioration of physical and cognitive functioning;
– By requiring an individual assessment;
– Based on best available evidence (lack of Level I medical evidence
does not prove the service or device is ineffective or unnecessary);
and
– By prohibiting the use of arbitrary visit limits or other limitations or
exclusions to impede doctor/patient relationship or stop services
prematurely.
RECOMMENDATIONS
#3: Determining the Medicaid Benchmark
Plans in Medicaid Expansion States
• Determining Benchmark coverage and
benchmark equivalent coverage.
RECOMMENDATIONS
#4: Ensuring Funding of Personal Attendants
under Community First Choice Option
• Ensure payment under the Community First
Choice option for personal attendants to
accompany and assist individuals with
disabilities participating in VR programs as
well as in the workplace.
CONCLUSION
The ACA provides a significant
opportunity for State VR agencies to
reduce the amount of VR funds used to
pay for health-related VR services,
thereby increasing the number of
individuals with disabilities served by
the program and/or enhancing the
quality of services provided to current
individuals served by the program.
QUESTIONS?
THANK YOU!
• A big thanks to all the participants
• Stay tuned to http://www.vrrrtc.org for more webinars and
activities
• Hearty thanks to Bobby Silverstein,
and John Halliday
To access these slides and associated documents
please visit – http://www.vr-rrtc.org/node/7
Contact us at – [email protected]