The Affordable Care Act And Tuberculosis Control: August 23, 2013 .
The Affordable Care Act and Tuberculosis Control:Navigating New TerritoryWebinarAugust 23, 2013The Impact of Patient Protection and AffordableCare Act on Tuberculosis ControlChristine S. Ho, M.D., M.P.H.Medical OfficerAffordable Care Act and Tuberculosis Control WebinarAugust 23, 2013National Center for HIV/AIDS, Viral Hepatitis, STD, and TB PreventionDivision of Tuberculosis EliminationObjectivesDescribe: The Affordable Care Act in simple terms The impact of the law on TB control TB programs’ continued role How programs could strategically leverageopportunities presented by the law to ensure TBservicesUnderstanding the Affordable Care ActWHO is covered(and how)WHAT serviceswill be coveredWHEREservices will bedeliveredHOWevaluation willtake place,inform processCurry International Tuberculosis Center1
The Affordable Care Act and Tuberculosis Control:Navigating New TerritoryWebinarAugust 23, 2013How Does the Law Affect TB Control?Covered ServicesUnderAffordable CareActEssentialComponentsof aTB Preventionand ControlProgramOpportunity To Maximize PopulationHealthLeverage the Far Larger Personal Health System toAchieve Population Health GoalsP. Wortley(not to scale!)6The Affordable Care ActAdult children 26 and under can be covered by parents’ plansnow 3.1 million newly covered Expands CoverageUninsured elderly will drop by 20 million in 2015Medicaid expansion to 133% of FPL ( 12 million)Exchanges ( 13 million)Employer and nongroup coverage (-5 files/attachments/44190 EffectsAffordableCareActHealthInsuranceCoverage 2.pdf Offers New Consumer Protections and Choice Generally prohibits denial of coverage based on pre-existing conditions –children now, adults for plan years starting in 2014 Prohibits “rescission” (dropping coverage retroactively) Bans lifetime and annual coverage limits, restrictions on out-of-network ERusage Expands consumers’ rights to appeal denialsCurry International Tuberculosis Center2
The Affordable Care Act and Tuberculosis Control:Navigating New TerritoryWebinarAugust 23, 2013Medicaid Expansion States have the opportunity to expand Medicaideligibility to adults ages 19 – 64 with incomes up to133% of the Federal Poverty Level (FPL) ( 15,282/yearfor an individual, 31,322/year for a family of 4) 100% federal funding through 2016, 90% thereafter States have no deadline for implementing theexpansionOne streamlined application for Medicaid and privatehealth plans in the MarketplaceShifts to simplified way of calculating income todetermine Medicaid/CHIP eligibility Known as Modified Adjusted Gross Income (MAGI)8/13/2013The Health Insurance Marketplace 10178201444 MillionWho Won’t Be Covered?Populations The Size of:ORNYCT201631 MillionGAPACA201537 MillionFLBottom line: Significant continuingneed for safety net servicesPrior to healthcare reform, States could add Medicaideligibility for TB patients States have the option to extend Medicaid eligibility to lowincome persons infected with TBCovered TB-related services include: Prescribed drugsPhysicians’ services (includes outpatient hospital services, rural healthclinic services, and Federally Qualified Health Center (FQHC) services)Laboratory and X-ray servicesClinic and FQHC servicesCase management servicesServices (other than room and board) designed to encourage completionof outpatient regimens, including services to directly observe the intake ofprescribed drugs.9 States have elected to provide this benefit: (AZ, CA, CT, LA,MN,NY, OK, UT, and WY)Receipt of matching Federal dollars for treating eligible TBpatients could alleviate budget difficulties for some statesCurry International Tuberculosis Center3
The Affordable Care Act and Tuberculosis Control:Navigating New TerritoryWebinarAugust 23, 2013Introduction to the Marketplace The Marketplace (or Exchange) Place for qualified individuals and qualifiedemployers to directly compare private healthinsurance options Known as Qualified Health Plans (QHPs) Can directly compare on the basis of price,benefits, quality, and other factors8/13/2013The Health Insurance Marketplace 10110Advantages of the Marketplace Helps enhance competition in the healthinsurance marketIncreases Affordability through premium taxcredits, cost sharing reductionsEnsures Quality through QHPs that must meetbasic standards, including quality standards,consumer protections, and access to an adequaterange of cliniciansMakes Costs Clear by providing information aboutprices and benefits in simple terms consumers canunderstand, so they don’t have to guess about costs8/13/2013The Health Insurance Marketplace 10111What preventive servicesmust be covered under the law? The law requires the following services to be coveredwithout cost-sharing in— United States Preventive Services Task Force (USPSTF) Nongrandfathered individual and small group plansMedicaid expansion plansAll preventive services with an ‘A’ or ‘B’ grade recommendationLTBI screening of high risk persons had an ‘A’ grade in 19962002 recommendations deferred to CDC, ungradedUngraded, LTBI screening not covered without cost-sharingAdvisory Council on Immunization Practices (ACIP) andHealth Resources and Services Administration (HRSA)supported recommendations TB testing for “children at high-risk for TB”Curry International Tuberculosis Center4
The Affordable Care Act and Tuberculosis Control:Navigating New TerritoryWebinarAugust 23, 2013All Qualified Health Plans Will CoverEssential Health Benefits in These Categories1. Ambulatory patientservices2. Emergency services6. Prescription drugs7. Rehabilitative services anddevices8. Laboratory services3. Hospitalization4. Maternity and newborncare5. Mental health andsubstance use disorderservices, includingbehavioral healthtreatment9. Preventive and wellnessservices and chronicdisease management10. Pediatric services, includingoral and vision careThe Health Insurance Marketplace 101Essential Community Providers (ECPs) The law requires that QHPs offered through Marketplacesinclude in their networks “those essential communityproviders, where available, that serve predominately lowincome, medically-underserved individuals.”CMS’ implementing regulations provide that “A QHP issuermust have a sufficient number and geographic distributionof ECPs, where available, to ensure reasonable and timelyaccess to a broad range of such providers ”HRSA identifies ECPs; these include providers eligible for the340B programTB programs can — Be a member of an accountable care organizationIdentify additional hospitals, clinics, practices that evaluate anddiagnose TB suspects and casesEnsure these facilities are designated as ECPExample – Urban County A TB Cases Foreign-born cases US-born cases Mix of newly arrived and settled immigrants or refugeesMedical services through the refugee clinic, federally qualifiedhealth center (FQHC), or other community providersConcentrated in an area with shelters and treatment facilitiesOne FQHC and several non-profit clinics serve this areaOptions to optimize TB screening and evaluation: Non-profit clinic affiliates with an accountable care organization(academic medical center, consortium) and bill for servicesTB program partners with FQHC and refugee clinics to do TBscreening and evaluation, those clinics bill for servicesTB clinic gets 340B or FQHC status and bills for servicesCurry International Tuberculosis Center5
The Affordable Care Act and Tuberculosis Control:Navigating New TerritoryWebinarAugust 23, 2013Meaningful Use RequirementsExamples include: Use of structured fields Use of clinical decision support tools Report clinical quality measures Communicate relevant health information topatients Provide patients ability to view their healthinformation Provide summary of care record fortransitions/referralsP. WortleyClinical Quality Measures—Examples from HIV/AIDSProviders will be required to select qualitymeasures to report onNew/updated HIV measures in endorsementprocess: % of patients seen at least once during 12 monthperiod with suppressed VL% of patients seen at least once during 12 monthperiod on ART% of patients with a visit every 6 months over 24months% of patients with gap in care over 12 month periodP. WortleyClinical Decision Support “A process for enhancing health-related decisions andactions with pertinent, organized clinical knowledgeand patient information to improve health andhealthcare delivery*”CDS can support Retention/re-engagement in carePatient self-care and treatment adherenceData collection and bi-directional reporting and communicatingPerformance measurement and improvement*Osheroff, Teich, Levick, et. al. Improving outcomes with clinical decisionsupport: an implementer’s guide. Second Edition. HIMSS 2012.P. WortleyCurry International Tuberculosis Center6
The Affordable Care Act and Tuberculosis Control:Navigating New TerritoryWebinarAugust 23, 2013Before the Affordable Care Act: Most HD Do Not Billfor Services Health departments provide services to clients Client care regardless of ability to payNo second or third party billingHD might be paying for some insured patientsResults in financial loss for HD, gain for insurance plansFederal, state,or local fundingHealthDepartmentHealthInsurancePlansSubhead for Section – Myriad Pro, 20ptOption 1: Health departments bill for services forexisting insured patients Option 1: Health departments (HD) continue toprovide clinical services to clients Some clients are insured HD bills those health plans for servicesFederal, state,or local fundingHealthDepartmentHealthInsurancePlansSubhead for Section – Myriad Pro, 20ptAdditional patients insured through theAffordable Care ActOption 1: HD cares for clients The Law: HD provides client care regardless ofability to paySecond or third party billing to recoup costs, asan ECP or part of an ACOHealthDepartmentFederal, state,or local fundingExisting HealthInsurancePlans and QHPSubhead for Section – Myriad Pro, 20ptCurry International Tuberculosis Center7
The Affordable Care Act and Tuberculosis Control:Navigating New TerritoryWebinarAugust 23, 2013Option 2: Insured patients receive servicesfrom non-HD providers HD cares for uninsured clients onlyHow does the HD assure quality of servicesfor outside providers?Federal, state,or local fundingHealthDepartmentHealthInsurancePlansSubhead for Section – Myriad Pro, 20ptAdditional patients insuredOption 2: HD partners with QHP providers Additional patients now insured HD does not care of insured patients HD partners with QHP to ensure services delivered There are always uninsured patients that still need careHealthDepartmentFederal, state,or local fundingNetwork Providersfor ExistingHealth InsurancePlans and QHPBilling National Center for Immunization and RespiratoryDiseases (NCIRD) American Recovery and ReinvestmentAct-funded billing project2012 NTCA Billing roundtable sessionCDC and billing activitiesAmerican Health Insurance Plan (AHIP) has 3-part billableproject to support sites (not known whether this will needMOU or workaround) ContractingCodingCredentialingNational Association of City and County Officials(NACCHO) developed a billing toolkitCurry International Tuberculosis Center8
The Affordable Care Act and Tuberculosis Control:Navigating New TerritoryWebinarAugust 23, 2013Continued Role for Public Health Populations most at risk for TB—non US-born, racial orethnic minorities, homeless, and persons affected byalcohol or substance abuse, have limited access tohealth careOngoing transmission, outbreaks, and drug resistancecan result — If contacts of infectious patients are not located andprovided preventive therapy If persons with TB disease are not treated completelyGuarantees for inherently governmental public healthservices were not the goal of the lawAffordable Care Act expansion will not substantiallydecrease the need for these services by CDC and healthdepartment partnersSteps to Leverage TB Services in the Community Study “Alternative Plan” –what is and isn’t coveredIdentify health plans that serve populations at highrisk for TBWork with those plans directly to cover TB-relatedpatient services (such as LTBI treatment)Identify providers that serve individuals at high-risk forTBExplore partnership with these providers Capacity, turnover, realistic activities for partnership Explore future education and quality assuranceopportunities in these settingsAcknowledgementsCDC Ann Cronin Victor Balaban Haley Stolp Stuart Berman Pascale Wortley Rozina Kassam Connie Henderson Suzanne Marks Awal Khan Dolly Katz Lydia OgdenGeorge Washington University Naomi SeilerNational Center for HIV/AIDS, Viral Hepatitis, STD, and TB PreventionCurry International Tuberculosis Center9
The Affordable Care Act and Tuberculosis Control: Navigating New Territory Webinar August 23, 2013 Curry International Tuberculosis Center 7 Before the Affordable Care Act: Most HD Do Not Bill for Services Subhead for Section -Myriad Pro, 20pt Health departments provide services to clients Client care regardless of ability to pay
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The Affordable Care Act enables millions of people to secure access to more affordable health coverage and care through two mechanisms: the Health Insurance Marketplaces, where individuals and small businesses can shop for affordable plans, and the expansion of many state Medicaid programs. The Affordable Care Act also specifically benefits LGBT
The Affordable Care Act The Patient Protection and Affordable Care Act (Affordable Care Act) was signed into law on March 23, 2010. The Affordable Care Act added certain market reform provisions to ERISA, making those provisions applicable to employment-based group health plans. These provisions provide additional protections for benefits under
