5/30/2012

Transcription

1 The Affordable Care Act Background Coverage Long-term Care Home and Community Based Services Payment Delivery Care Transitions Assuring Quality Supreme Court 5/30/2012

2 BACKGROUND Health Reform legislation is commonly referred to as the Affordable Care Act (ACA), and it is made up of two pieces of legislation: 1. Patient Protection and Affordable Care Act, P.L , enacted March 23, 2010; and 2. Health Care and Education Reconciliation Act of 2010, P.L , enacted March 30, 2010

3 Affordable Care Act Titles Title I: Quality, Affordable Health Care for All Americans Title II: Role of Public Programs Title III: Improving the Quality and Efficiency of Health Care Title IV: Prevention of Chronic Disease and Improving Public Health Title V: Health Care Workforce Title VI: Transparency and Program Integrity Title VII: CLASS Act Page 3

4 COVERAGE Page 4

5 COVERAGE: The Medicaid Expansion How will it work? In 2014, all individuals with incomes up to 133% of FPL (In 2009, $14,404 for individuals/$29,326 for a family of 4) will be covered under Medicaid. Who will be covered? Eligibility will be based on a modified adjusted gross income (MAGI) with no asset or resource test, while maintaining existing counting rules for people who 65 and older, and for individuals with disabilities.

6 COVERAGE: The Essential Health Benefits Ambulatory Patient Services Emergency Services Hospitalization Maternity and newborn care Mental health and substance use disorder services Behavioral Health Treatment Prescription Drugs Rehabilitative and habilitative services and devices Laboratory Services Preventive and wellness services Chronic Disease Management Pediatric Services, including oral and vision care

7 COVERAGE: The Exchanges How will it work? The Exchanges are designed to serve as marketplaces that allow participants to band together and shop for insurance at competitive rates. Who will be covered? Initially, participants in the Exchange will be limited to businesses with 100 or fewer employees, and to individuals looking to purchase insurance for themselves. What if coverage is unaffordable? To facilitate participation in the Exchanges, premium tax credits will be offered on a sliding scale basis, and will be available to those with incomes between 133 and 400% FPL.

8 LONG-TERM CARE Page 8

9 LONG-TERM CARE

10 CLASS ACT Creates a new federally administered national, voluntary insurance program to help adults age 18 and over with disabilities pay for LTSS. Eligibility: voluntarily enrolled for five years and have a qualifying functional limitation expected to last continuously for 90 days or more Benefits: cash benefit Premiums: Depend on age at enrollment and year, but no other factors permitted including underwriting Will work in conjunction with other long-term services and supports programs such as Medicaid

11 Update on the CLASS ACT On January 5, 2011, the Obama Administration announced the formal launch of an office to administer the CLASS Program within AoA under the leadership of Assistant Secretary Greenlee. Ten months later, on November 14, 2011, HHS Secretary Sebelius recommended that the Department halt its implementation of the CLASS Act, explaining that: "For 19 months, experts inside and outside of government have examined how HHS might implement a financially sustainable, voluntary, and self-financed long-term care insurance program under the law that meets the needs of those seeking protection for the near term and those planning for the future.... But despite our best analytical efforts, I do not see a viable path forward for CLASS implementation at this time." Page 11

12 PREVENTION Funding for Health Prevention Incentives for Prevention of Chronic Diseases in Medicaid Prevention and Public Health Fund Community Transformation Grants Healthy Aging Living Well Positive Behavior Grants Councils and Taskforce National Prevention & Wellness Strategy Preventive Services Task Force Research Health Research Pain Management Congenital Heart Disease Cures Acceleration Network

13 Other Provisions of Interest Early Retiree Reinsurance Program Donut Hole Modifications Medicare Advantage payments End of Preexisting Conditions Lifetime and Annual Limits

14 HOME AND COMMUNITY BASED SERVICES Community First Choice Option State Balancing Incentive Payments Program Reforms to the Medicaid HCBS state plan option 1915(i) Money Follows the Person Health Homes Dual Eligibles

15 LONG-TERM CARE: Balancing Medicaid Medicaid LTSS Spending: Institutional and HCBS Services from SOURCE: Terence Ng et al, (November 2009), Medicaid Home and Community Based Services Programs, Kaiser Commission on Medicaid and the Uninsured

16 LONG-TERM CARE: Balancing Medicaid Balancing Medicaid Money Follows the Person HCBS State Plan Option Community First Choice Option The CLASS Act State Balancing Incentives Health Homes Spousal Impoverishment

17 Community First Choice is a new State Plan Option for Attendant Care 6 percent increase in FMAP indefinitely Attendant care for ADLs and IADLs plus backup systems and training for attendants Assessments, data collection required Maintenance of effort requirement spending for first 12 months must be at least same level as prior year

18 Should Your State Consider Community First Choice? Can CFC replace existing personal care in state plan and waivers? Will eligible population increase? Can state comply with self-direction requirements? Does state have a universal assessment tool? Can IT system support quality and data collection requirements? Does state need to re-base first to contain personal care costs over the long term?

19 State Balancing Incentive Payments Offers Additional FMAP for Reaching Rebalancing Targets <25% spending on community LTSS: 5% increase in FMAP 25% to 50% spending on community LTSS: 2% increase in FMAP Must reach rebalancing targets of 25% and 50%, respectively, in four years (FFYs )

20 Is State Balancing Incentive Payments an Option for Your State? Can the state meet the aggressive rebalancing targets? Where is the state now in the rebalancing life cycle? Can the state comply with assessment, single-point-of-entry, and data collection requirements?

21 The 1915(i) State Plan Amendment was Amended and Now Allows Targeting of Special Populations States can target populations e.g., individuals with mental health conditions New services for chronic mental illness day treatment, partial hospitalization, psychosocial rehabilitation, clinic services Must offer statewide; disallows ceilings on number of enrollees

22 What Should States Consider in Adopting a 1915(i) State Plan Amendment? What population could most benefit? Are there individuals on waivers who could be transferred over? Can population be clearly defined so as to prevent eligibility creep? What is the benefit package? Are the services evidence-based? Will amendment be cost-effective?

23 Money Follows the Person Provides a Opportunity to Promote LTSS Systemic Change MFP Demonstrations are now operating in 43 states Enhanced FMAP for one year for all qualifying MFP participants Funding for IT and infrastructure development, specialized staff

24 States Can Leverage Money Follows the Person as the Centerpiece of Rebalancing Efforts How can your state enhance rebalancing efforts by positioning MFP as a focal point? How can your state strategically invest MFP savings?

25 Health Homes Can Coordinate an Array of Services for People with At Least Two Chronic Conditions Includes asthma, diabetes, heart disease, mental health conditions, substance abuse disorders, obesity Can target based on number, type, and severity of chronic conditions 90% FMAP for two years for six core health home services only Dual eligibles cannot be excluded

26 Are Health Homes an Opportunity for Serving People in Your State with Complex, Expensive Needs? Which populations could benefit? Does the state have existing health homes to build on? Are they evidence-based? Are providers available? Can the program be sustained financially? Does the state have experience in coordinating Medicare/Medicaid benefits for dual eligibles? Does the state have experience with managed care payment methods and encounter data? Can the state comply with data collection and evaluation requirements?

27 CMS Center for Innovation Payment Delivery Medicare and Medicaid Demonstration Projects

28 ACA Promotes Integrated Care for Dual Eligibles Establishes Federal Coordinated Health Care Office (FCHCO) FCHCO closely aligned with Center for Medicare and Medicaid Innovation (CMMI) for demonstrations and technical assistance New opportunity to synch renewal periods for concurrent waivers for dual eligibles Special Needs Plans (SNPs) reauthorized

29 CARE TRANSITIONS Access to Care CARE TRANSITION Information & Education CARE TRANSITION Coordination of Care actions designed to ensure the coordination and continuity of health and community care during the course of a chronic or acute illness Continuity & Translation

30 CARE TRANSITIONS & COORDINATION Improving Care Transition and Coordination Community-Based Care Transitions Program Aging and Disability Resource Centers (ADRC) Accountable Care Organizations Health Homes for Enrollees with Chronic Conditions Community health teams to support the patient-centered medical home Patient Navigator Program

31 Assuring Quality Page 31

32 Elder Justice Act Establishes an Elder Justice Coordinating Council The law authorizes for fiscal years , BUT DOES NOT FUND, several grant programs, including, but not limited to: Funding to State and local Adult Protective Services offices Demonstration grants to detect and prevent elder abuse Grants to improve the capacity of the state Long-Term Care Ombudsman Program Grants to improve ombudsman training Grants to provide workforce management technical assistance Establishment and Support of Forensic Centers

33 Nursing Home Reforms Quality Improvement Measures Quality Assurance and Performance Improvement Program Effective Compliance and Ethics Program Culture Change and Information Technology Demonstrations Standardized Complaint Form Nursing Home Compare Medicare Website Dementia and Abuse Training Report on Five-Star Quality Rating System Protections Notification of Facility Closure Background Checks on Employees of Long-Term Care Facilities Disclosure of Ownership and Parties Imposing civil monetary penalties Ensuring Staffing Accountability

34 Supreme Court Challenge Where are we now? Page 34

35 Four questions before the court Anti-Injunction Act Bars lawsuits prior to the payment of a tax The individual mandate requirement Commerce Clause Necessary and Proper Clause Taxing Power The Medicaid expansion Valid exercise of Congress s spending power The severability In the case before the Supreme Court, the lower court held the ACA not severable and invalidated the entire ACA Page 35

36 Further Information For Up-to-date information visit NASUAD s Affordable Care Act s Webpage: Contact Information th Street NW, Ste 350 Washington, DC Phone: Fax: