Transcript The Affordable Care Act: A Victory for Women Women’s Policy Conference Victoria Veltri, JD, LLM State Healthcare Advocate November 27, 2012

The Affordable Care Act:
A Victory for Women
Women’s Policy Conference
Victoria Veltri, JD, LLM
State Healthcare Advocate
November 27, 2012
Discussion Areas
• What is OHA’s role?
• CT snapshot of healthcare
• The ACA and women’s health
Focus on assisting and educating consumers to
make informed decisions when selecting a
health plan
Assist consumers to resolve problems with their
health insurance plans
Identify issues, trends and problems that may
require executive, regulatory or legislative
intervention – Systemic Advocacy
 Educating consumers about their rights and how to
advocate on their own behalf when they have a
problem or concern about their health plan.
Answer questions and assist consumers in
understanding and exercising their right to appeal a
health plan’s denial of a benefit or service.
OHA provides assistance to any CT resident who
requests our help with a health related issue (includes
private health insurers, group health plans, federal
employee plans, public programs, High Risk Pool,
Medicare, etc.)
Case Management (assess, coordinate, monitor and
evaluate options and services required to meet an
individual’s health or advocacy needs)
Our Work is Guided by Principles
• Principles for Policy Action
– http://www.ct.gov/oha/lib/oha/documents/final_draft__oha_principles_for_determining_policy_action.pdf
– Access to quality healthcare; for our State to be
competitive, our people must be healthy
– Reduction in healthcare system waste; innovation is
essential to maximize value
– Healthcare industry watchdog; cost shifting practices
burden the State’s economy, providers, payors, and
consumers
– Social Justice; OHA has a duty to represent the collective
voice of 3.5 million healthcare consumers
Healthcare is Critical to CT’s Economy
• 12 cents of every dollar spent in CT goes to
healthcare
• 1 out of 8 Ct workers is employed in healthcare
services
• CT employment dropped 4.3% from 2008 to 2009
• Ten major drug 22 biomedical companies as well
as six major HMOs have large facilities in CT
• Every dollar spent on healthcare creates business
activity in CT
A Snapshot of the Medicaid Program: Participation
• Overall, Medicaid currently serves over 575,000
beneficiaries
– 275,000 children (one out of every four kids in Connecticut and
Medicaid covers one out of every four births)
– 148,000 parents
– 65,000 older adults and people with disabilities who are eligible
for both Medicare and Medicaid
– 45,000 older adults and people with disabilities who are eligible
only for Medicaid
– 83,827 low-income adults
– 55% of Medicaid population is female
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Snapshot of the Insured/Insurance in
CT
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59% of CT population covered by employer plan
5% covered by individual insurance
13% Medicare
Only one plan offers maternity coverage in individual
insurance
Pre-existing conditions still in force for adults
Infertility coverage is mandated in CT
Gender Rating Allowed
No mandates for dental and vision for kids
Over 50% are in self-funded plans—CT law N/A
[Kaiser State Health Facts, 2009 data]
Snapshot of Uninsured in CT
• 344, 581
• 41% female
• Concentrated in New Haven, Hartford and
Fairfield counties
• 66K adults estimated to be eligible for Medicaid
under the ACA
• 205K adults eligible for the Exchange
– 32% within 191-300% FPL
– 28% above 400% FPL
– Predominantly between 18-34 years old
Coverage and Public Health
• Health coverage is linked to health
– CT’s uninsured (approx 344,000 people) are 10x less
likely to get care for an injury and 7x less likely to get
care for a medical emergency
– Uninsured go without important screenings and
preventive
• 12% of hospital stays for CT’s uninsured could have been
avoided with early treatment
• Less likely to access ongoing care to mange chronic disease
• Receive fewer medical services and are 25% more likely to
die prematurely
Office of the Healthcare Advocate
Connecticut’s Federally
Recognized Health Insurance
Consumer Assistance Program
COBRA
PPACA
OHA’s PPACA consumer assistance
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Required by CT law and as part of PPACA – and as core area 10 within the Exchange
– Independent office
– Receive and respond to complaints concerning health insurance coverage under state and federal laws
– Toll free line and review of eligibility for programs and referral to other agencies when appropriate
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Assist with the filing of complaints and appeals, including filing appeals with the internal appeal or grievance process of the
group health plan or health insurance issuer involved and providing information about the external appeal process-OHA
provides direct consumer assistance through participation in the grievance process
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Collect, track, and quantify problems and inquiries encountered by consumers
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Educate consumers on their rights and responsibilities with respect to group health plans and health insurance coverage
through extensive outreach activities to reach underserved areas and including media campaigns
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Assist consumers with enrollment in a group health plan or other health insurance coverage by providing information,
referral, and assistance
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Resolve problems with obtaining premium tax credits under section 36B of the Internal Revenue Code of 1986
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Assistance to small businesses
– Health Insurance Exchanges
• Uninsured and self-employed able to purchase insurance through
state-based exchanges
– Funding available to states to establish exchanges until 01/01/15
– Separate exchanges created for small businesses to purchase coverage
(effective 2014)
– Must provide essential health benefits
– No wrong door approach
– Subsidies to purchase health insurance
• Individual ‘s and family’s income 133% to 400% federal poverty
level (FDL, $29,327 for family of 4) to purchase on exchange
– Cannot be eligible for Medicare, Medicaid, and if covered by employer
– Receive premium credits with a cap on how much they have to contribute
to their premiums on a sliding scale
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– Health Insurance Exchanges
• Choice Among Multiple Plans at Varying Levels of Cost
Sharing
• Actuarial Value – % of expenditures paid by the plan—
the remainder is the consumer’s responsibility
– Bronze – 60% (Most current individual and small employer
plans are under 60%--raises some affordability issues)
– Silver – 70%
– Gold – 80%
– Platinum – 90%
• Subsidies will offset some of the cost sharing. Subsidies
will be equal to 95% second lowest silver plan premium and cost
sharing. This will affect affordability, esp. for lower-income people.
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– Individual Mandate
• In 2014, everyone must purchase health insurance or face a $695
annual fine. There are some exceptions for low-income people.
– Employer Mandate
• Technically, there is no employer mandate. Employers with more than
50 employees must provide health insurance or pay a fine of $2000
per worker each year if any worker receives federal subsidies to
purchase health insurance. Fines applied to entire number of
employees minus some allowances
• Small business tax credits are available for purchase of insurance now
and in the Exchange.
– Immigration
• Undocumented immigrants will not be allowed to buy health
insurance in the exchanges - even if they pay completely with their
own money
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Essential Health Benefits
• Required to be offered to plans in the Exchange—individual and
small employer
• Ten areas of benefits– 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; and
pediatric services, including oral and vision care
• EHBs based on a benchmark plan for the first two years of operation
• Individual and small employer plans inside an outside the Exchange must
match design and price
• Mental Health Parity And Addiction Equity Act applies to Individual plans
– Medicaid
• Expanded to include 133% FPL level
• Requires states to include childless adults, starting in 2014
• Feds pays 100% of costs for newly eligible through 2016, 90%
therefafter
• Illegal immigrants not eligible
– Medicare
• $500 billion in Medicare cuts over the next decade
• Closes the Rx donut hole by 2020
– $250 rebate if gap reached by 2010
– 50 % discount on brand name drugs, if in gap beginning 2011
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– Insurance Reforms-apply to individual, large group and small
group (<50 employees) inside and outside the Exchange
• Rescissions Prohibited except for fraud
• Pre-Existing Conditions (PEC)
– Cannot deny children coverage based on PEC, 6 mos. after
enactment
– Cannot deny coverage to anyone with PEC, starting in 2014
– Insurers MUST cover women who get breast cancer, have Csections, receive medical treatment for domestic violence,
chronic conditions like high blood pressure or diabetes or
other conditions
• Gender rating prohibited
• Medical loss ratio – Insurers must spend 80-85% of
premium on medial expenses
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Affordable Care Act Reforms
– Insurance Reforms Continued
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Dependents under 26 can stay on parent’s policy
Age rating limited to 3:1 (now up to 6:1 in CT)
Lifetime limits lifted
Annual limits phased out in 2014
External appeal rights
Preventive Services with no co-pay or deductible*
– Birth control, mammograms, cervical cancer screenings, pelvic
exams, well women exams, osteoperosis and colon cancer
screeings, FDA approved contraceptive methods, breast feeding
support, screenings related to interpersonal violence
– Children’s screenings and vaccinations
– Medicare coverage for screenings and annual wellness exam
*N/A to grandfathered plans. Certain exemptions to contraceptive coverage. See
http://cciio.cms.gov/resources/files/prev-services-guidance-08152012.pdf
– Abortion
• The bill segregates private insurance premium funds from taxpayer
funds. Individuals have to pay for abortion coverage by making two
separate payments, private funds would have to be kept in a
separate account from federal and taxpayer funds.
• No health care plan can be required to offer abortion coverage.
States could pass legislation choosing to opt out of offering
abortion coverage through the exchange. CT has not done so.
• No federal funds can be used to pay for abortions except in the
case of rape, incest or health of the mother
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• PPACA
– Nursing moms at work must be allowed access to a space to
pump.
– Direct Access to OB/GYN
– Medicaid home visitation program for new mothers
– Exchanges must contract with Essential Community Providers
– Personal Responsibility Education Program on Sexuality
– Geriatric Education Centers for family caregivers
– Investment in community health centers, National Health
Service Corps, scholarships and loan repayment, and incentives
for PCPs and other providers, to increase healthcare providers
in underserved areas
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ACA in CT
• Exchange is moving ahead
• EHB package chosen – includes all state insurance mandates,
coverage for elective terminations and contraception*
• For kids – autism mandate in insurance statutes will have to
be covered by individual policies in the Exchange, other
habilitative coverage is less clear
• Pediatric dental benefit will be based on current HUSKY B
benefit
• Pediatric vision coverage will be based on the federal
employee plan
• There will be a standalone dental benefit offered to adults
* For small group plans in the Exchange, state law and federal regulation and guidance exempts certain
qualified religious employers from this coverage. Individual coverage is not impacted by the exemption.
See http://cciio.cms.gov/resources/files/prev-services-guidance-08152012.pdf
The ACA in CT
• Market reforms codified into CT law
– Dependent coverage, rescissions, lifetime limits
– CT law already included direct access to OBGYN
• For self-funded plans50% Ct residents will get new protections,
including external review
• Consumer assistance program running
• MLR provisions-nearly $13 million in rebates this year for 77K families
• Removal of lifetime limit cap has affected 525K women, 370K kids – 1.4
million overall
• 637,900 women will have access to preventive services without cost
sharing
• $63M for discounts in Medicare Part D donut hole
• $24 Million from prevention and public health fund
• $56 million for community centers
http://www.healthcare.gov/law/resources/ct.html
ACA in CT (cont’d)
• Related grants/savings
– $832K for Personal Responsibility Education Program
– $10.5M in Maternal, Infant and Early Childhood Home
Visiting Programs
– $4M pregnancy assistance fund
– $500K Aging and Disability Resource Centers
– $300K Family to Family Health Information Centers
– $3M for SBHCs
– $5M for early retiree reimbursement to the state
http://www.healthcare.gov/law/resources/ct.html
ACA in CT (cont’d)
• Medicaid Low Income Adult Program
– initial expansion paid at 50% by feds
– will be 100% in 2014
• CT Medicaid program ahead of the curve on most coverage
• Medicaid will expand to 133% of FPL in 2014-no asset test
• Medicaid is using care coordination and delivery system
reforms in ACA – PCMH, ICO
Outstanding Issues in CT
• Reaching people in our diverse communities
• Integration of Medicaid and the Exchange
• What will we do to ensure people in 138-200% FPL income
bracket s can afford coverage?
• Ensuring robust provider networks of ECPs, LGBT, reproductive
and other related providers?
• Assuring reporting on health disparities and outcome data
• Accountability for all players
• Sustainability—related to ongoing affordability and innovation
• Healthcare Reform – The Issues
– Method of financing – federal, state, employer, self-pay
– Method of insurance reimbursement – employer mandate,
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individual mandate, single-payer (universal healthcare)
Method for delivering services – doctor, specialist, auxiliary and
allied health, hospital, (e.g., coordinated, integrated: Kaiser Permanente,
Veterans Administration)
Comprehensiveness of health insurance
Cost and cost containment – competition, cost-sharing
Degree of patient choice
Administrative costs
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Moving Away from Sick System
Achieving social justice depends on moving away from our
fractured system
• Data is critical
• Intervention/prevention
• Educating consumers re rights to preventive care
coverage/screenings
• Social determinants/lifestyle choices
• Addresses issues of disparities in access and outcomes
• Addresses work force and IT issues
• Requires broad stakeholder involvement and commitment
of state leadership
• Reform requires transformation beyond the Exchange