Hospitals And The Affordable Care Act (ACA)

Hospitals and theAffordable Care Act (ACA)

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Andrea ThompsonMichael Thompson

Hospitals and the Affordable Care Act (ACA)5

Discussion PointsØ Define the Affordable Care Act (ACA)Ø Describe main changes since the ACAwent into effectØ Describe how the ACA may affecthospitals and your work as a healthcareproviderØ Answer your questions6

“The Signing of ACA”(OBAMACARE)March 20107

Affordable Care Act : The Purpose1. Make health insurance available tomore people2. Make health insurance more affordable3. Make health insurance easier tounderstand8

Key Activities to Date2010201120122013q Individual Mandateq Young Adult Coverageq No Pre-Existing Conditionsq No Lifetime Limitsq Medicaid Expansionq The Healthcare Insurance Marketplace9

Individual Mandate (Shared Responsibility)Starting in 2014, you MUST have health coverage orpay a penalty.Accepted forms of coverage:q Public insuranceq Employer-sponsored insuranceq An individual policyq A policy through the MarketplaceYou may have to pay a fee with your tax return(Starting when you file your 2014 tax return in 2015)10

What is the penalty 14 951%2015 3252%2016 6952.5% You pay the higher amount between flatdollar amount and the percentage. The penalty for minors is half the amountof adults11

Young Adult CoverageA child under age 26, can stay on his or herparent’s health plan.This applies even if the child is: Married Living outside the family home Financially independent Have coverage offered at work12

Pre-Existing ConditionsIf you have a pre-existing condition, youcannot be denied health insuranceq If you under 19 today, you cannot bedeniedq As of Jan 1, 2014, no one can be denied13

No Lifetime LimitsInsurance companies cannot stop paying foressential health benefit services simplybecause your claims are high.Essential health benefits are a set of healthcare service categories that must becovered by plans in the Marketplace(examples: ER and Maternity)14

What if you can’t affordinsurance ?Depending on your income, you may be able toget help in the form of:1. Discounts (credits) against your premium or2. Help with out-of-pocket costs in your plan(cost sharing). Income must fall between 100% and 400% of the federalpoverty level. For example, that’s 11,490 and 45,960 peryear for an Individual15

Medicaid ExpansionAs part of the Supreme Court ruling on the ACA,each state had the option to expand Medicaid.Perceived Benefits of expansion:q Close the coverage gap of people who make too muchto qualify for Medicaid but too little to buy privateinsuranceq Shift 100% of costs from State to Federal government,from 2014 to 2017 – 90% thereafter16

Medicaid Expansion continued. . .Current breakdown of states with and withoutMedicaid expansion.1. Number of states expanding: 262. Number of states not expanding: 2517

Medicaid Expansion continued. . .18 (Kaiser Family Foundation 2013)

Two other changes . . .19

What Happens To Medicare? Medicare coverage is protectedMore preventive servicesSave money on brand-name drugsDonut hole will be closed by 202020

What about COBRA in 2014 ?Under the ACA, individuals will have theoption to avoid COBRA and purchaseprivate insurance through the Marketplace21

The Health Insurance Marketplace22

When can you enroll in the Marketplace ?Marketplace Initial Open Enrollment : Started October 1, 2013 and endsMarch 31, 2014 Annual Open Enrollment periods after thatstart on October 15 and end on December 7 Special Enrollment Periods available onlyunder certain conditions during the year23

Marketplace TypesThe are three types of Marketplaces:1. Federally Facilitated Marketplace (FFM) –run entirely by the federal government(NJ and PA, under www.healthcare.gov)2. Partnership – run primarily by state withassistance from the federal government(DE – called “Choose Health”)3. State – run entirely by the state(MD – called “Maryland Health Connection”)24

Four Main Plan %Silver70%30%Gold80%20%Pla num90%10%CatastrophiccoverageTiers serve two main purposes:q To create standardized levels of insurance forindividuals and small businessesq To serve as benchmarks for premium creditsand cost-sharing subsidies25

Essential Health BenefitsQualified Health Plans cover Essential Health Benefits, whichinclude at least these 10 categories26

Free Preventive ServicesYou won’t be charged for services that aredefined as “Preventive” - examples include:Blood pressure screeningCervical cancer screeningObesity screening and counselingDepression screeningDomestic and interpersonal violencescreeningq Immunizations (vaccines)q q q q q 27

Let’s now discuss HCP’s and Hospitals28

Hospitals and Healthcare ProfessionalsHow MAY hospitals be affected bythe ACA, and how will your workas an HCP change?29

First, HCP’s .30

The ACA and HCP’s Free Preventive CareCracking Down on FraudRebuild the Primary CareWorkforceMore People on MedicaidIncreased Payments forRural HCP’sConstructing morecommunity health centersImproving Healthcare QualityNew Innovations31 Reducing Paperwork andAdministrative CostsFighting Health DisparityIncreasing MedicaidPayments for Primary CareCoverage for IndividualsParticipating in Clinical TrialsPaying Physicians Based onValue not VolumeCulturally and LinguisticallyAppropriate Services

The Details Free Preventive Care: All new plans must cover certainpreventive services such as colonoscopies and mammogramswithout charging a co-pay, deductible or coinsurance Rebuilding the Primary Care Workforce: There are newincentives in the law to expand the number of primary caredoctors, nurses and physician assistants Expansion of Medicaid: Some states will expand and receivefederal funds Rural Health Providers: Increased payments to rural healthcare providers to help them continue to serve theircommunities.32

Continued Strengthening Community Health Centers: The law includesfunding to support new and expand existing health centersacross the country Improving Healthcare Quality and Efficiency: The lawestablishes a new Center for Medicare & Medicaid Innovation.Testing new ways of delivering care to patients. Aim to improvequality and reduce costs. There are also new innovationstargeting waste in the system New Innovations: Projects are being targeted towards wastein the system to reduce costs Reducing Paperwork and Administrative Costs: Move toelectronic health records33

Continued Reduce Health Disparity: The law requires federal healthprograms to collect and report racial, ethnic and language data Increasing Medicaid Payments for Primary Care: The lawrequires states to pay primary care physicians no less than thecurrent Medicare rate Ensuring Coverage for Individuals Participating in ClinicalTrials: insurers cannot drop or limit coverage for an individualbecause they participated in a trial that treats cancer or otherlife threatening disease Paying Physicians Based on Value not Volume: Paymentstied to the quality of care34

And now, Hospitals .35

Surge of Patients, initially The increased number of newly insured and theexpansion of Medicaid in some states could floodhospitals with new, high use patients, taxingunderstaffed teams Hospitals could also receive less money for thesame services in the short term based on thegovernment’s decision to lower Medicarereimbursements.36

More Transparency for Hospitals The ACA aims to increase transparency byrequiring tax exempt hospitals to conduct aCommunity Health Needs Assessment The hospitals will also be required to establisha written financial assistance policy37

Transitional Care for Seniors Transitional Care for Seniors Leaving theHospital: The Community Care Transitionsprogram will help high risk Medicare beneficiarieswhen they leave the hospital avoid unnecessaryreadmissions by coordinating care38

Quality Focused Service Less volume, more quality will be the normamong hospitals – expansion of AccountableCare Organizations (ACOs). The law providesincentives for physicians to join together to formACOs If ACOs provide high quality care and reducecosts they can keep some of the money theyhelped save.39

Quality Focused Service, continued Linking Payment to Outcomes. Hospitalperformance is required to be publicly reported During transition toward this quality direction,hospitals will operate in two different worlds, partvolume, part goal-based performance Financial incentives available to hospitals whoperform well. Government determines goodperformance through a combination of clinicaloutcomes and patient satisfaction surveys40

Quality Focused Service, continued Two payment systems are being establishedwith the goal of tying reimbursement to qualityThey are:1) Value-based purchasing2) Bundled payments Government is penalizing hospitals that performpoorly. Hospitals with “excessive” readmissionrates will receive lower Medicare reimbursements41

Fewer Charity Care CasesShould the act help more people get insurance,hospitals could get paid for charity care that theynow provide for free to uninsured patients42

This law is complex and will be challenging There will be lots of churn in the systemso HCP’s have to be aware of what’schanged already and what changes arecoming. I want to give you an example of someof the situations you may encounter43

Example of “Split” Eligibility“A pregnant mother, her 5 year old child and herhusband have a household income which is 150% FPLor 35,325” Mother qualifies for Medicaid until 60 dayspostpartum, then she transitions to the advancedpremium tax credit program. Father qualifies for the premium tax credit program. Newborn will qualify for Medicaid until age one, thentransition to CHIP The five year old qualifies for CHIP44

Eligibility Challenges The eligibility rules for the ACA are highlycomplex Different family members may qualify fordifferent public programs such as CHIP andMedicaid Family members may be split across differentinsurance issuers and delivery systems45

Split Eligibility Insurance Cards46

Recommendations1. Educate, Educate, Educate Train staff onhealthcare basics as well as overview of theACA. They need to understand healthinsurance basics2. Prepare for the high probability of churn(changes in insurance type based onconditions such as losing or gaining income)3. Develop a “cheat sheet”47

Points to Rememberq The Marketplace is the new way to find andbuy health insuranceq Individuals and families may be eligible forlower costs on their monthly premiums andout-of-pocket costsq Newly insured individuals will require specialattention and different systems48

Points to Remember continued . .q Insurance will continue to be sold outside of theMarketplaceq Purchase from Marketplace not requiredq The Marketplace is the only place to get thepremium tax credits and cost sharingreductionsq HCP’s and Healthcare Organizations canexpect “churn”q Educating Staff is very important49

Points to Remember continued . .q The system is changing to “pay forperformance”q Quality not quantityq Accountability and efficiencyq ACO’s MAY be a viable option for somehospitalsq Cultural Competence and LinguisticallyAppropriate Services are important andexpected50

Questions ?51

Thanks for joining us !How to reach us :(856)222-0861info@marblestoneconsulting.com52

Designated a “National Center of Excellence” by the National Institutes of Health, . Annual Open Enrollment periods after that start on October 15 and end on December 7 . programs to collect and report racial, ethnic and language data