The Affordable Care Act: Medicaid Expansion and Care Coordination

Opportunities For Permanent Supportive Housing Providers

Stephanie Altman, Health & Disability Advocates

Major Provisions of the ACA Affecting Low Income Populations

• Medicaid Expansion to 133% FPL for Childless Adults.• Establishment of State Health Care Exchanges and Premium Tax

Subsidies up to 400% FPL.• Individual Mandate Requires taxpayers to pay a penalty if they do not

purchase insurance.• Ban on lifetime limits, pre-existing conditions, gender and health

rating, and rescissions.• Coverage for dependent children up to age 26.• Medicare Part D Donut Hole Closing.

Medicaid Expansion

• New Adult Group for Childless Adults• No need to meet disability criteria or be eligible for SSI• New income methodology under MAGI.• No Asset Test• Real Time Enrollment and Data Matching• Streamlined Citizenship/Identification Documentation• Proposed regulations set forth guidance to the states on how to

integrate new Medicaid with traditional Medicaid.• Our goal is to ensure that no one loses coverage or is “worse off”

after 2014.

Essential Benefits Package

The minimum contents of the essential health benefits package, which will be detailed in regulations to be issued in 2012, comprise the following categories mandated in the Affordable Care Act (all health plans sold through the health care exchange must cover the essential benefits package at a minimum):

Ambulatory patient services; Emergency services; Hospitalization; Maternity and newborn care; Mental health and substance use

disorder services; Prescription drugs; Rehabilative and habilitative services

and devices; Laboratory services; Preventive and wellness services

including chronic disease management;

Pediatric services including oral and vision care.

Providers and the Navigation Role

• Navigators assist people seeking Medicaid or insurance coverage after 2014 enroll in and choose a health plan.

• This is an unfamiliar process for low income vulnerable populations who have had no access to insurance.

• ACA requires that Navigators must be coordinated with community based providers but could be insurance brokers.

• Advocates and providers are supporting systems which use community based providers who have relationships with the populations they serve and are paid to enroll and counsel clients.

Managed Care and Coordinated Care

• States have a wide range of delivery systems for Medicaid including fee for service, managed care, capitated HMOs and coordinated care such as primary care case management and disease management.

• These are all different types of systems to pay providers and to coordinate care for recipients.

• Depending upon the arrangement, Medicaid recipients may or may not be able to choose their providers or switch providers easily.

Illinois Models of Care Coordination

• CSH, HDA and Heartland Health Outreach (and other PSH, behavioral health and medical providers) have collaborated on a report to the state on options for Medicaid reimbursement and service delivery for PSH clients.

• Policy recommendations include: maximizing Medicaid reimbursement for case management and care coordination.

• Case management = care coordination in a managed care setting.• PSH providers can link with FQHCs and behavioral health providers to

coordinate Medicaid enrollment and access to care for their clients.• Everything case managers do for their clients can improve health outcomes.

How Case Managers Can Improve Client Health Outcomes

• Maintaining stable housing.• Providing medication management.• Arranging for medical appointments.• Providing transportation to medical appointments.• Linking clients to income supports and food security.• Linking clients to behavioral health care on site or off site.• Relationships with community health centers to provide primary

care.