Affordable Care ActCalifornia Implementation

Janlee Wong, MSWNASW California Chapter

April 2014

ACA Goals• Universal coverage– By January 2014, 92% of Californians will be

eligible for coverage (1)– 2.6 million unauthorized immigrants will not (2)

• Affordable Health Plans– Expand Medi-Cal (Medicaid) in Low Income Health

Plan (LIHP) (500,000) (2)– Offer plans in Healthcare Exchange (Covered CA)

• Cost Controls

California has the eighthlargest proportion ofuninsured in the nationand the largest totalnumber of uninsured. Onlythree states (Massachusetts,Hawaii, and Minnesota) haveuninsured rates under 10%.

*All numbers reflect the non-elderly population, under age 65.Source: Employee Benefit Research Institute estimates of the 2009 – 2011 Current Population Survey, March Supplements.

The Uninsured Unauthorized (3)

A recent report by the UC-Berkeley Center for Labor Research and Education and the UCLA Center for Health Policy Research on California residents who will remain uninsured after the ACA takes effect found that:• 66% of the remaining uninsured will be Latino;• 60% of the remaining uninsured will have limited

English proficiency; and• 62% of the remaining uninsured will live in

Southern California.

Immigrants

• The ACA does not change the current eligibility standard preventing most documented immigrants from enrolling in Medicaid or the Children's Health Insurance Program if they have resided in the U.S. for fewer than five years. States are permitted to cover such immigrants in the programs at their own expense, and Medicaid will cover emergency care for all immigrants.

Immigrants

• Undocumented immigrants are not eligible for public health insurance programs, and the ACA in most cases will further exclude them from new coverage opportunities, including state health insurance exchanges and Medicaid expansions.

• Lawful immigrants who have lived in the U.S. for less than five years may participate in health insurance exchanges and obtain subsidies if income-qualified, but in most states, they still will not be able to qualify for full Medicaid coverage.

Immigrants• In California under the state's Medicaid program -- "services

for undocumented immigrants, including prenatal care, pregnancy-related services, nursing home care, and limited breast and cervical cancer treatment," are provided through Medi-Cal

• The Deferred Action for Childhood Arrivals program was created by President Obama in 2012 to grant immigrants who came to the country illegally as children — sometimes called Dreamers — legal status and work authorization for two-year periods.

• Laurel Lucia, a policy analyst at the UC Berkeley Labor Center and author of the report released Tuesday, said California is one of the few states that lets youth with deferred action status enroll inMedicaid.

•

ACA Implementation In CAGoals

1. Expand Coverage in Public Programs2. Simplify and Streamline Eligibility

and Enrollment3. Protect Health Insurance Consumers4. Create a New Marketplace for

Private Health Insurance

Goal 1: Expand Coverage in Public Programs

1. Expand Medi-Cal2. Determine Coverage Options for

Low Income Individuals3. Use Financial Incentives to

Improve Access and Quality

Objective 1: Medi-Cal Expansion

• Current Coverage: Infants and pregnant women (200% Federal Poverty Level - FPL)

• Children (ages 1-5 - 133% FPL), ages 6-19 (100% FPL)

• Low-income parents, elderly, people with disabilities

• ACA expansion: parents of dependent children, foster youth to age 26, non-elderly and childless adults (133% FPL)

Summary - Individuals

Summary - Families

3. Use Financial Incentives to Improve Access and Quality (1)

• Primary care rate enhancement (required). 100% federal financing in 2013 and 2014

• Raises Medi-Cal reimbursement rates to parity with Medicare for certain evaluation and management services provided by primary care physicians.

• 120% increase in reimbursement

Preventive Services w/o Copays

• 1% increase in federal matching payments if the state covers certain recommended immunizations and preventive services without charging Medicaid beneficiaries a share of the cost.

• Adults get 15 services covered for preventive care, women get 22 and kids get 26 covered services. These services include some of the most important types of prevention like immunizations, mammograms and wellness visits. Medicare patients also gain some new benefits under the ACA as the 2010 preventive health mandates apply to them as well.

Goal 2: Simplify and Streamline Eligibility and Enrollment (1)

Objectives1. Improve Consumer Experience– Consumer Application/enrollment: in

person, mail or online

2. Promote and support enrollment– Assisters and Navigators provide

consumers with one-on-one assistance in enrollment

1. Improve Consumer Experience

• “No wrong door”– Medi-Cal enrollment, 58 counties with in person,

mail telephone and online, certified assisters• CalHEERS – California Healthcare Eligibility,

Enrollment, & Retention System (Accenture)• Covered CA website: fact sheets, subsidy

calculator and consumer phone number• Simple Income Eligibility Determination:

Single income standard, no assets test

2. Promote and support enrollmentAssisters/Navigators (6)

• Assister Enrollment Entities (AEE)– Organizations approved by the Exchange to provide

one-on-one consumer assistance– AEEs can be registered in either the Navigator

Program or the In-Person Assistance Program but not both.

– American Indian/Tribal Organizations, Attorneys, Tax Preparers, Trade/Prof. Org., Com Clinics, Colleges, Cities, Unions, Chambers of Commerce, Non-Profits, Schools, Ranch or Farm Organizations (partial list)

2. Promote and support enrollmentNavigators/Assisters (6)

• In-Person Assistance Program (IPA) – Operated by AEE– Hires Assisters to provide one-on-one assistance– AEE paid $58 per enrollment

• Navigator Program– Operated by AEE– Hires Navigators– Awarded grants for outreach, education and

enrollment assistance one-on-one to consumers

Goal 3: Protect health Insurance Consumers

• Objectives:1. Enforce new health insurance coverage rules– Today, CA limits use of pre-existing conditions

limits, and requires annual policy renewal– January 2014: All ACA provisions apply2. Ensure health insurance premium value3. Limit impact adverse risk on rate payers

1. Enforce new health insurance coverage rules

• Grandfathered 2010 plans by individuals and small businesses exempt from ACA

• CA established Pre-Existing Condition Plan Managed Risk Medical Insurance Board (MRMIB) in 2010

• Will transition MRMIB into Exchange or Private Market Jan. 1, 2014

• Small group reform enacted 2012 • Individual plan reform pending legislation

2. Ensure health insurance premium value

1. Establish minimum set of “essential health benefits” (EHB) for individual and small employer coverage

2. State Review of proposed premium increases3. Medical Loss Ratio: health plans spend a

minimum percentage of 80-85% of premium on care– Statutory authority enacted 2012

Essential Health Benefits (EHB) (7)

• Benchmark plan established in 2012 (patterned after Kaiser Small Group HMO

• Includes mental health/substance abuse• Includes Pediatric Dental/Vision supplemental• Currently plans covered by Dept. of Managed

Care must cover EHB, but not Dept. of Insurance plans

• Jan 1, 2014: Plans in and outside Exchange must cover EHB

2. State Review of proposed premium increases (8)

• Implemented 2011, CA Depts of Managed Health Care and Insurance

• Department of Managed Health Care posting rate information, including findings of an unreasonable rate increase, on the Department’s public website.

• Department of Insurance posting public access to rate filings.

• Since January 1, 2011, the Department of Insurance rate review process resulted in some rate reductions and adjustments estimated to save policyholders a total of at least $40 million.

3. Medical Loss Ratio

• 2012– “Anthem Blue Cross, Blue Shield of California and

Kaiser Permanente distribute more than $50 million in rebates across some 1 million California customers.”

– June 2, 2012, Los Angeles Times (9)

3. Limit impact adverse risk on rate payers

1. Traditional Reinsurance2. Risk Adjustment3. Risk Corridors

Legislation to establish a state program failed in 2012 and the federal government will administer this program

Goal 4: Create a New Marketplace for Private Health Insurance

1. Operate the Exchange– CA obtained conditional certification for

“Covered CA” Jan. 2013 and full certification by Oct. 2013

2. Offer coverage through qualified health plans– 11/2012 RFPs for platinum, gold, silver, bronze

and catastrophic benefit plans– 6/2013 Contracting with selected insurers– 10/1/2013 enrollment Oct. 2013

Accountable Care Organizations (ACO) (12)

Experiment or Experience?

• ACO goal: improve care and reduce costs• Method: Collaboration among provider groups,

hospitals, and others— in an environment of aligned financial incentives — to improve coordination, care delivery, and efficiency

• Providers and ACOs share in savings resulting from coordinated care

• Serves as “insurer and provider”

ACO Characteristics

• Choice of providers, often the same existing providers

• Can work within existing health plans including Medicare, Aetna, etc.

• Coordinated care from prevention to acute and post acute

• Information Technology System that reports frequently on healthcare utilization

• Shared savings

Accountable Care Organizations (11)

• Medicare Shared Savings Program (MSSP) ACOs are designated to coordinate care for Medicare fee-for-service beneficiaries.

• Medicare Advanced Payment Model* is a special version of the MSSP ACO model to support infrastructure development.

• Medicare Pioneer ACOs* were among the first Medicare-designated ACOs and take on more risk than the MSSP model.

• Look-Alike ACOs contract with commercial health plans to coordinate care in a similar model to those above.

San Diego ACOs (13)

• North Coast Medical ACO (MSSP) Medicare ACO-Shared Savings Program

• San Diego Independent ACO (MSSP) Medicare ACO-Shared Savings Program

• Sharp HealthCare (Aetna) Look-alike ACO-Contract w/Health Plan For Non-State

• Sponsored Program• Sharp Healthcare (Blue Flex) Look-alike ACO-Contract

w/Health Plan For Non-State • Sponsored Program• Sharp HealthCare ACO (Pioneer) Medicare ACO-

Pioneer

San Diego ACOs Summary (13)

• Total ACOs Operating in the County 5• Total Individual ACO Hospital Partners in the

County 9• Number of PCPs Involved in the ACOs 1,284 • Number of Specialists Involved in the ACOs 2,792• Total Individual Medical Groups/Clinics Utilized in

the County by the ACOs 48• Estimated Lives to Be Served within the Specific

ACO Activity 68,000

Care Coordination (14)

What is it? Wrap around?

• Medical– Medication management– Utilization review/data analysis– Emergency room management– Follow up for specialized care

• Social– Consumer empowerment– Psychosocial assessment– Person in Environment approach– Social and behavioral health services– Cultural humility, advocacy

Texas Promotor(a) (17)

• Communication skills• Interpersonal skills • Service Coordination skills • Capacity-building skills • Advocacy skills • Teaching skills • Organizational skills• Knowledge base on specific health issues

Community Health WorkersWorkforce Innovations (17)

Grand-Aides®• CNA/CMA Training• Primary care and chronic

care• Home visits• Telemedicine• Medication Management• Social issues

Texas Promotor(a)• Communication skills• Interpersonal skills • Service Coordination skills • Capacity-building skills • Advocacy skills • Teaching skills • Organizational skills• Knowledge base on specific

health issues

CA Workforce Investment BoardHealth Workforce Development Council (18)

“Standardize, strengthen and expand curricula and training programs to increase access and consistent competencies for Community Health Workers/Promotores, Medical Assistants, Social Workers, Nurses, Direct Care Workers and other workers.”

Enrollment by Plan

Anthem BC

Blue Shield

Chinese

Contra Costa

Healthnet

Kaiser

LA Care

Molin

aSh

arpVall

ey

Weste

rn HA

369332

13 0.976

238210

32 10.6 10.4 1.6 3.2

000s

Total

Medicare Shared Savings Program (MSSP)Accountable Care Clinical Services (Orange)Accountable Care Clinical Services/Preferred ACOAffiliated Physicians Medical Group ACOAkira HealthAPCN-ACOApolloMed ACOApplecare Medical GroupCedars-Sinai Accountable CareJohn Muir Physician NetworkMeridian HoldingsMeritage ACONorth Coast Medical ACOPremier ACO Physicians NetworkSan Diego Independent ACOTorrance Memorial Integrated PhysiciansUCLA ACOMedicare Advanced Payment ModelGolden Life HealthcareNational ACOMedicare PioneerBrown & Toland PhysiciansHealthCare Partners ACOHeritage California ACOMonarch HealthCareSharp HealthCare

Look Alike ACOsAccess Medical Group/St. John's Health Center/NantWorksAllCare IPA/Doctors Medical CenterBrown & Toland PhysiciansBrown & Toland Physicians/California Pacific Medical CenterGreater Newport Physicians/Hoag HospitalHealthCare Partners Associates Medical GroupHill Physicians/Dignity Health - SacramentoHill Physicians/Dignity Health - County EmployeesHill Physicians/Dignity Health - UC EmployeesJohn Muir HealthPalo Alto Medical FoundationPhysicians Medical Group of Santa Cruz/Dominican HospitalPrimecare Medical NetworkSanta Clara County IPASharp HealthCareSt. Joseph Health

Appendix: California ACOs

References1. http://www.chcf.org/tracking-aca/goal-1/objective-12. http://www.slate.com/articles/news_and_politics/map_of_the_week/2013/02/

map_illegal_immigrant_population_by_state.html3. http://www.californiahealthline.org/articles/2012/10/24/california-considers-strategies-for-treating-

uninsured-immigrants.aspx4. http://www.dhcs.ca.gov/provgovpart/Documents/LIHP/LIHP%20Fact%20Sheet.pdf5. http://www.healthexchange.ca.gov/BoardMeetings/Documents/February26_2013/

VI._BRB_Bridge_Plan_(Update).pdf6. http://www.healthexchange.ca.gov/StakeHolders/Documents/Assisters%20Program

%20Stakeholders%20Webinar%20Draft%20Regs-FINALSlide%20Deck05032013.pdf7. http://kff.org/health-reform/state-indicator/ehb-benchmark-plans/8. http://cciio.cms.gov/Archive/Grants/rate-review-grants.html9. http://articles.latimes.com/2012/jun/02/business/la-fi-insure-rebates-2012060210. http://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/C/PDF

%20CINwebinar04242013HeritageACO.pdf11. http://www.chcf.org/publications/2012/08/aco-map12. http://www.chcf.org/events/2013/cin-webinar-04-24-201313. http://www.cattaneostroud.com/med_group_reports/ACO_Reports/ACO_Report2.pdf14. http://www.socialworkreinvestment.org/2011/remarks/Golden%20testimony_02%2016%2011.pdf15. www.cswe.org/File.aspx?id=6271816. http://

www.socialworkers.org/assets/secured/documents/practice/health/ACOs%20Opportunities%20for%20SWers.pdf

17. http://www.dshs.state.tx.us/mch/chw.shtm18. http://www.cwib.ca.gov/res/docs/special_committees/hwdc/meeting_materials/2013/HWDC%20Re

port%20-%20Draft%20012113.pdf

References• http://

www.californiahealthline.org/road-to-reform/2013/immigrant-health-care-many-not-eligible-for-medicaid-expansion

• http://www.americanthinker.com/blog/2014/02/report_125000_illegals_in_california_qualified_to_be_covered_by_medicaid.html

• http://obamacarefacts.com/obamacare-preventive-care.php• http://news.coveredca.com/