Assuring Health Reform Meets the Needs of Children and Youth with Special Health Care Needs

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Implementing Health Reform: Big PicturePatient Protection and Affordable Care Act

• Approximately 9 million children and 12 million women of reproductive age gain coverage in 2014

• Insurance reforms (potentially) provide new protections, particularly for CYSHCN.

• Expands and strengthens coverage of clinical preventive services.

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Coverage

BenefitsSystems

• Expands Medicaid to all under 133% of poverty. (2014)

• Preserves Medicaid & CHIP coverage for children above 133% of the Federal Poverty Level (FPL). (through 2019)

• Creates state-based Health Insurance Exchanges to provide coverage and provides tax credits to help people with income up to 400% of FPL. (2014)

Coverage Basics

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Preserves and Enhances Medicaid and CHIP

• Eligibility Simplification

• Coordination between Medicaid, CHIP and the Exchanges in determining eligibility

• Maintenance of Effort

• Primary Care Rate Increases

• Hospice Care

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Health Insurance Exchanges

Health Insurance Exchanges Specifics

• Exchange Governing Board

• Stakeholder Consultation

• Enrollment

• Navigator

• Treatment of Direct Primary Care Medical Home

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Grandfathered vs New Health Plans: What Does this Mean?

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New Plans Grandfathered Plans

Lifetime Limits: Prohibits lifetime maximum caps

Group Individual Group Individual

X X X X

Annual Limits: Restricts annual maximum benefits for certain services

X X X

Children Pre Existing Condition: Prohibits pre-existing condition waiting periods for children under 19

X X X

Dependent Age: Requires allowing dependent coverage up to age 26

X X X X

Preventative Care: Provides coverage for defined preventative care services

X X

Health Insurance Reforms

Essential Health Benefits Package Plans in the Exchange (Sec. 1302)

•ambulatory services, •emergency services, •hospitalization, •maternity & newborn care,•mental health & substance use disorder services, including behavioral health treatment,•prescription drugs,

• rehabilitative & habilitative services and devices,.

• laboratory services,• preventive & wellness services

and chronic disease management, and

• pediatric services, including oral and vision care.*

* Details TBD in regulation.

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• Health Homes In Medicaid (Sec. 2703)• CMS Center for Medicare and Medicaid Innovation• Pediatric Accountable Care Demonstration Project

Promoting Medical Homes and Integrated Systems

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Family to Family Health Information Centers

• Calls for a national quality improvement strategy.

• Requires development of voluntary adult Medicaid quality measures.

• Requires enhanced collection and reporting of data on race, ethnicity, sex, primary language, disability status, and for underserved rural and frontier populations.

• Requires collection of access and treatment data for people with disabilities. (Effective two years following enactment).

Quality

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• Will health reform address underinsurance?

• Will the benefits offered through the Health Insurance Exchanges be comprehensive enough to meet the unique needs of CYSCHN?

• Keep families and family-centered care at core of decisions.

• Help families navigate evolving system and new exchanges.

• Demonstrate value to Medicaid and Insurance partners.

Key Challenges

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Implications for State MCH Leaders

• Partner with Medicaid and other stakeholders to assure that health system reforms address the unique needs of CYSCHN.

• Assure that State Plan Amendments for the State Medicaid Health Home Option (Section 2703 of ACA) consider and include CYSHCN and that efforts to advance medical home are coordinated with state Title V MCH Program efforts.

• Use the flexibility of the Title V MCH Services Block Grant to support shared resources (e.g., care coordination, statewide toll-free hotlines, technical assistance, family engagement) in primary care settings and as part of overall systems development for CYSHCN.

• Engage family leaders in developing and improving comprehensive systems of care.

• Partner with Medicaid and other stakeholders in the use of state data sources (e.g., Medicaid claims data, state Title V program performance measures, public health data) for quality assurance and improvement efforts.

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Future of Health Reform?

Is the Medicaid expansion

constitutional?Is the individual mandate

constitutional?

WWW.AMCHP.ORG

Resources

www.amchp.org

Public Law 111-148, Patient Protection and Affordable Care Act: http://www.gpo.gov/fdsys/pkg/BILLS-111hr3590ENR/pdf/BILLS-111hr3590ENR.pdf

AMCHP Health Reform Hub: http://www.amchp.org/Advocacy/health-reform/Pages/default.aspx

Georgetown Center for Children and Families: Summary of Medicaid, CHIP, and Low-Income Provisions in Health Care Reform at http://ccf.georgetown.edu/

Kaiser Family Foundation: Summary of the Patient Protection and Affordable Care Act at http://healthreform.kff.org/

The Commonwealth Fund: Health Reform Resources at: http://www.commonwealthfund.org/Health-Reform.aspx

Sources and Additional Resources

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