Health Care Reform: Implications for Children with Special Health Care Needs

Health Care Reform: Implications for Children with Special Health Care

Needs

To discuss today:

• General overview of the health care reform law

• Provisions of special interest to CYSHCN and their families

• Future of health care reform

• Involvement of advocates at state level

• Resources

www.familyvoices.org ♥ 2340 Alamo SE, Suite 102 ♥ Albuquerque, NM 87106♥ (p) 888.835.5669 ♥ (f) 505.872.4780 ♥

The Health Care Reform Laws

• The Patient Protection and Affordable Care Act (PPACA) – enacted March 23, 2010

• Health Care and Education Affordability Reconciliation Act – enacted March 30, 2010

• Now referred to collectively as the Affordable Care Act or “ACA”


Basic Structure of Law

Continuation of employer-based health insurance, with certain standards

Continuation of State Children's Health Insurance Program (CHIP) until 2019 (funded through 2015)

Expansion of Medicaid to 133% of the Federal Poverty Level (2014); optional now

(cont.)

Basic Structure of Law (cont.)

“Patients Bill of Rights” (insurance reforms) State-based “Exchanges” through which

uninsured individuals can purchase insurance that meets certain standards (2014)

Basic Structure of Law (cont.)

• Subsidies: “Affordability credits” will be provided for coverage purchased in the Exchange for families earning up to 400% FPL (~$73K for family of 3).

• The Exchange will make it easier to compare different insurance plans.

• The Exchange can use its bargaining power to obtain the best price for individuals and small businesses purchasing insurance through the Exchange.

2010 Provisions• Many provisions effective in 2014 – some now

• Option to Expand Medicaid to New Expansion Populations (up to 133% of FPL)

• Creation of a High-Risk Health Insurance Pools (PCIPs) as of July 1, 2010

• Prohibition on Lifetime Caps and Rescinding Coverage; Restrictions on Annual Caps

2010 Provisions Continued…

• Eliminating Pre-Existing Condition Exclusions for Children under age 19

• Coverage of Adult Children until age 26

• Coverage of Preventive Health Services at no Charge (“Bright Futures”)

• Strengthening Community Health Centers


2010 Provisions Continued…

• Re-Establishing Funding for F2Fs!!!

• Prevention and Public Health Fund

• Maternal, Infant and Early Childhood Home Visiting Programs

• Federal “portal” (website) for information about coverage options

• Maintenance of Effort (MOE) in Medicaid and CHIP – opposed by Governors


Medicaid Maintenance of Effort (MOE) in Medicaid and CHIP

• Requires states to maintain their current eligibility standards, methodologies and procedures until 2014 (2019 for CHIP)

• Governors from 33 states have signed letter to Congress asking that provision be repealed


Later Important Provisions to Note

• State Health Insurance Exchanges/Benefits

• Health Homes in Medicaid

• More support for home and community-based services

• Grants for “Navigators”

• Medicaid for former foster children up to age 26

• Medicaid Expansion to 133% of FPL in 2014 www.familyvoices.org ♥ 2340 Alamo SE, Suite 102 ♥ Albuquerque, NM 87106

♥ (p) 888.835.5669 ♥ (f) 505.872.4780 ♥

Medicaid Expansion

• 2014 Medicaid Expansion to133% of the FPL ($14K for an individual; $30K for family of 4)

• Will cover childless adults for first time with federal matching funds

• Estimated that 2 million more will be eligible for Medi-Cal (only legal residents)


Provisions of special importance to Children and Youth with Special Health Care Needs

(CYSHCN)

Elimination of Pre-existing Condition Exclusions for Children

Under Age 19 Effective for plan/policy years beginning on

or after September 23, 2010 Applies to both issuance of insurance and

coverage of services related to pre-existing conditions

Does not apply to individual grandfathered plans (in existence 3/23/10)

Premiums can be higher

Implications of Ban on Pre-existing Condition Exclusions Some insurers are no longer issuing new

child-only plans (current plans not affected)

HHS has told insurers they can limit enrollment to certain open enrollment seasons, as permitted under state law

Insurers may take other measures to counter potential adverse selection

Prohibition on Rescissions

For plans/policies effective on or after 9/23/10, insurers may not rescind policies based on minor errors in the application

Policies may be rescinded if there was intentional fraud or misrepresentation of material facts

Restrictions on Lifetime and Annual Dollar Limits

For plans/policies effective on or after 9/23/10, insurers may not impose lifetime dollar limits on the amount they will cover

From 9/23/10 until 1/1/14, annual dollar limits must not be set below certain thresholds:

$750,000 until 9/23/11 $1.25 million until 9/23/12 $2 million until 1/1/14 Annual dollar limits prohibited as of 1/1/14

Restrictions on Lifetime and Annual Dollar Limits (cont.)

Insurers may still place limits on the number of visits per year, impose other limitations on the scope of services, or drop coverage of specific services not required to be covered under the law.

High-Risk Pools (PCIPs)As of July 1, 2010, state or federal high-risk

pool (Pre-existing Condition Insurance Plans, PCIPs) are available to individuals who are:

US citizens or nationals or are lawfully residing in the US

Have been uninsured for at least 6 months Have a pre-existing condition or have been denied

insurance due to one (states vary on how this is determined)

No longer necessary after 1/1/14 when exclusions are not permitted

California Pre-Existing Condition Insurance Plan

Eligible residents of California can apply through the state’s Pre-Existing Condition Insurance Plan program run by the Managed Risk Medical Insurance Board.

To qualify for coverage:

• You must be a citizen or national of the United States or lawfully present in the United States.

• You must have been uninsured for at least the last six months before you apply.

• You must have a pre-existing condition, have been denied individual health insurance coverage within the past 12 months, or have been offered individual health insurance coverage at a premium rates higher than the California Major Risk Medical Insurance Program (MRMIP) preferred provider organization (PPO) within the last 12 months.

California Pre-Existing Condition Insurance Plan (cont.)

The Pre-Existing Condition Insurance Plan will cover a broad range of health benefits, including primary and specialty care, hospital care, and prescription drugs. All covered benefits are available, even if it’s to treat a pre-existing condition. Premiums are based on subscriber age and region of residence in California.

Monthly Premium: $499 for a 50 year old subscriber in San Francisco

Annual Deductible: Medical• $1,500 in-network / $3,000 out-of-network • Brand Name Prescription Drugs• $500 in-network / $500 out-of network

Annual Out of Pocket Maximum: $2,500 in-network / no maximum out-of-network

For more information please call 1-877-428-5060 Monday-Friday, 8 a.m. to 8 p.m. or, on Saturday, 8 a.m. to 5 p.m. or go to www.pcip.ca.gov.

http://www.pcip.ca.gov/

Coverage for Dependents until Age 26

Parents can keep their children on their insurance plans until the child reaches age 26 (just child; not grandchild)

Child need not be a “dependent” for tax purposes

Applies even if adult child is married and/or does not live with parents

Does not apply to “grandfathered” group plans if child has offer of insurance coverage from an employer

No-Charge Preventive Services

For new health insurance policies as of 9/23/10, a full range of preventive services will be covered pursuant to the “Bright Futures” recommendations for children

There may be no copayments, coinsurance or deductibles applied to preventive services

Essential Benefits Package

Law requires insurance plans sold in Exchanges, and some other plans (as of 2014), to cover “essential benefits,” which will include, among other benefits:

Habilitation and rehabilitation services and devices Mental health and substance abuse disorder services

(including behavioral health treatment) Pediatric services, including oral and vision care Preventive and wellness services and chronic disease

management

Appeals and Reviews

Families can appeal denials of coverage, followed by an external review

Pursuant to interim final regulation, coverage would continue pending review

Decision required within 24 hours for urgent care

“No Wrong Door”• Coordination will be required among

Medicaid, CHIP and the Exchanges, so that applicants for one program will be screened for and can apply to other programs for which they might be eligible instead.

• Example: If a family applies for CHIP, but is eligible for Medicaid, then they can be enrolled seamlessly in the Medicaid program instead.

Concurrent Care for Children in Hospice

• Effective September 23, 2010, children receiving hospice care under Medicaid or CHIP need not forego curative care – they can receive both concurrently.

• This will allow families to benefit from counseling and other hospice services without having to give up treatment for their terminally ill child.

Future of Health Care Reform

Some states are suing federal government to prevent implementation; so far there have been mixed outcomes; likely to go to the Supreme Court.

The House voted to repeal, but legislation will not advance through the Senate.

Appropriations (funding) could be blocked for implementation of some components.

In two years???

Future of Health Care Reform (cont.)

Now, you can call your Senators – especially Feinstein – to urge that health care reform not be repealed

Be prepared to contact your Representative when action alerts are issued

Reform at the State Level

• Creation of Exchange

• Community First Choice Option (Oct. 1, 2011) – Medicaid option – attendant services in community if person would otherwise need nursing home care

• Monitor health care reform implementation


How You Can Get Involved

• Join relevant coalitions

• Sign up for action alerts (federal and state)

• Submit comments on proposed regulations (federal and state)

• Get to know your state government officials, e.g., Insurance Commissioner, legislators

• Educate your network

• Be there and be heard!www.familyvoices.org ♥ 2340 Alamo SE, Suite 102 ♥ Albuquerque, NM 87106♥ (p) 888.835.5669 ♥ (f) 505.872.4780 ♥

Resources -- National

www.amchp.org (Association of Maternal and Child Health Programs – focus on CYSHCN)

http://ccf.georgetown.edu (Center for Children and Families, Georgetown University – great source of information)

www.communitycatalyst.org (Community Catalyst – issues regular updates)

www.familyvoices.org (Family Voices – weekly update for members, alerts)

www.familiesusa.org (Families USA – can sign up for alerts)

www.kff.org (Kaiser Family Foundation; provides short video of health care reform basics.)

To hear an archived teleconference about the impact of healthcare reform on children, especially CYSHCN, and read about the resources available on other healthcare reform websites, go to http://www.spannj.org/Family2Family/new_in_healthcare.htm .

http://www.amchp.org/

http://ccf.georgetown.edu/

http://www.communitycatalyst.org/

http://www.familyvoices.org/

http://www.familiesusa.org/

http://www.kff.org/

http://www.spannj.org/Family2Family/new_in_healthcare.htm

Resources -- California

http://www.statereforum.org/ (State Refor(u)m; National Academy for State Health Policy; provides myriad of resources on state implementation of HCR)

http://www.healthcare.ca.gov/ (California state government; status of HCR in CA)

http://www.chcf.org/publications/2010/05/the-affordable-care-act-in-california (California Health Care Foundation; several useful publications)

http://www.health-access.org (Health Access – California consumer organization; includes 9-month status report on health care reform in CA)

http://www.statereforum.org/

http://www.healthcare.ca.gov/

http://www.chcf.org/publications/2010/05/the-affordable-care-act-in-california

http://www.health-access.org/

Q & A and Discussion

Health Care Reform: Implications for Children with Special Health Care Needs

Documents

Transcript of Health Care Reform: Implications for Children with Special Health Care Needs