The Affordable Care Act:A Victory for Women

Women’s Policy Conference

Victoria Veltri, JD, LLMState Healthcare Advocate

November 27, 2012

Discussion Areas

• What is OHA’s role?• CT snapshot of healthcare• The ACA and women’s health

Focus on assisting and educating consumers to make informed decisions when selecting a health plan

Assist consumers to resolve problems with their health insurance plans

Identify issues, trends and problems that may require executive, regulatory or legislative intervention – Systemic Advocacy

Educating consumers about their rights and how to advocate on their own behalf when they have a problem or concern about their health plan.

Answer questions and assist consumers in understanding and exercising their right to appeal a health plan’s denial of a benefit or service.

OHA provides assistance to any CT resident who requests our help with a health related issue (includes private health insurers, group health plans, federal employee plans, public programs, High Risk Pool, Medicare, etc.)

Case Management (assess, coordinate, monitor and evaluate options and services required to meet an individual’s health or advocacy needs)

Our Work is Guided by Principles

• Principles for Policy Action– http://www.ct.gov/oha/lib/oha/documents/final_draft_

-_oha_principles_for_determining_policy_action.pdf– Access to quality healthcare; for our State to be

competitive, our people must be healthy– Reduction in healthcare system waste; innovation is

essential to maximize value– Healthcare industry watchdog; cost shifting practices

burden the State’s economy, providers, payors, and consumers

– Social Justice; OHA has a duty to represent the collective voice of 3.5 million healthcare consumers

Healthcare is Critical to CT’s Economy

• 12 cents of every dollar spent in CT goes to healthcare

• 1 out of 8 Ct workers is employed in healthcare services

• CT employment dropped 4.3% from 2008 to 2009• Ten major drug 22 biomedical companies as well

as six major HMOs have large facilities in CT• Every dollar spent on healthcare creates business

activity in CT

A Snapshot of the Medicaid Program: Participation

• Overall, Medicaid currently serves over 575,000 beneficiaries

– 275,000 children (one out of every four kids in Connecticut and Medicaid covers one out of every four births)

– 148,000 parents– 65,000 older adults and people with disabilities who are eligible

for both Medicare and Medicaid– 45,000 older adults and people with disabilities who are eligible

only for Medicaid– 83,827 low-income adults– 55% of Medicaid population is female

88

Snapshot of the Insured/Insurance in CT

• 59% of CT population covered by employer plan• 5% covered by individual insurance• 13% Medicare• Only one plan offers maternity coverage in individual

insurance• Pre-existing conditions still in force for adults• Infertility coverage is mandated in CT• Gender Rating Allowed• No mandates for dental and vision for kids• Over 50% are in self-funded plans—CT law N/A

[Kaiser State Health Facts, 2009 data]

Snapshot of Uninsured in CT

• 344, 581• 41% female• Concentrated in New Haven, Hartford and Fairfield

counties• 66K adults estimated to be eligible for Medicaid

under the ACA• 205K adults eligible for the Exchange – 32% within 191-300% FPL – 28% above 400% FPL– Predominantly between 18-34 years old

Coverage and Public Health

• Health coverage is linked to health– CT’s uninsured (approx 344,000 people) are 10x less

likely to get care for an injury and 7x less likely to get care for a medical emergency

– Uninsured go without important screenings and preventive• 12% of hospital stays for CT’s uninsured could have been

avoided with early treatment• Less likely to access ongoing care to mange chronic disease• Receive fewer medical services and are 25% more likely to

die prematurely

Office of the Healthcare Advocate

Connecticut’s Federally Recognized Health Insurance

Consumer Assistance Program

MHPAEA

State Ins.

LawsPPACA

ERISA

COBRAManaged Care

Medicaid

Medicare

HITECH

OHA’s PPACA consumer assistance

• Required by CT law and as part of PPACA – and as core area 10 within the Exchange– Independent office– Receive and respond to complaints concerning health insurance coverage under state and federal laws– Toll free line and review of eligibility for programs and referral to other agencies when appropriate

• Assist with the filing of complaints and appeals, including filing appeals with the internal appeal or grievance process of the group health plan or health insurance issuer involved and providing information about the external appeal process-OHA provides direct consumer assistance through participation in the grievance process

• Collect, track, and quantify problems and inquiries encountered by consumers

• Educate consumers on their rights and responsibilities with respect to group health plans and health insurance coverage through extensive outreach activities to reach underserved areas and including media campaigns

• Assist consumers with enrollment in a group health plan or other health insurance coverage by providing information, referral, and assistance

• Resolve problems with obtaining premium tax credits under section 36B of the Internal Revenue Code of 1986

• Assistance to small businesses

AFFORDABLE CARE ACT

• PPACA– Health Insurance Exchanges

• Uninsured and self-employed able to purchase insurance through state-based exchanges – Funding available to states to establish exchanges until 01/01/15– Separate exchanges created for small businesses to purchase coverage

(effective 2014)– Must provide essential health benefits

– No wrong door approach

– Subsidies to purchase health insurance• Individual ‘s and family’s income 133% to 400% federal poverty

level (FDL, $29,327 for family of 4) to purchase on exchange – Cannot be eligible for Medicare, Medicaid, and if covered by employer– Receive premium credits with a cap on how much they have to contribute

to their premiums on a sliding scale 14

AFFORDABLE CARE ACT

• PPACA– Health Insurance Exchanges• Choice Among Multiple Plans at Varying Levels of Cost

Sharing • Actuarial Value – % of expenditures paid by the plan—

the remainder is the consumer’s responsibility– Bronze – 60% (Most current individual and small employer

plans are under 60%--raises some affordability issues)– Silver – 70%– Gold – 80%– Platinum – 90%

• Subsidies will offset some of the cost sharing. Subsidies will be equal to 95% second lowest silver plan premium and cost sharing. This will affect affordability, esp. for lower-income people.15

U.S. HEALTHCARE QUALITY, COSTS, AND ACCESS TO CARE

• PPACA– Individual Mandate

• In 2014, everyone must purchase health insurance or face a $695 annual fine. There are some exceptions for low-income people.

– Employer Mandate• Technically, there is no employer mandate. Employers with more than

50 employees must provide health insurance or pay a fine of $2000 per worker each year if any worker receives federal subsidies to purchase health insurance. Fines applied to entire number of employees minus some allowances

• Small business tax credits are available for purchase of insurance now and in the Exchange.

– Immigration• Undocumented immigrants will not be allowed to buy health insurance

in the exchanges - even if they pay completely with their own money16

Essential Health Benefits• Required to be offered to plans in the Exchange—individual and

small employer• Ten areas of benefits-

– ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care

• EHBs based on a benchmark plan for the first two years of operation• Individual and small employer plans inside an outside the Exchange must

match design and price• Mental Health Parity And Addiction Equity Act applies to Individual plans

AFFORDABLE CARE ACT REFORMS

• PPACA– Medicaid

• Expanded to include 133% FPL level • Requires states to include childless adults, starting in 2014• Feds pays 100% of costs for newly eligible through 2016, 90%

therefafter• Illegal immigrants not eligible

– Medicare• $500 billion in Medicare cuts over the next decade• Closes the Rx donut hole by 2020

– $250 rebate if gap reached by 2010 – 50 % discount on brand name drugs, if in gap beginning 2011

18

AFFORDABLE CARE ACT REFORMS

• PPACA– Insurance Reforms-apply to individual, large group and small

group (<50 employees) inside and outside the Exchange• Rescissions Prohibited except for fraud • Pre-Existing Conditions (PEC)

– Cannot deny children coverage based on PEC, 6 mos. after enactment

– Cannot deny coverage to anyone with PEC, starting in 2014– Insurers MUST cover women who get breast cancer, have C-

sections, receive medical treatment for domestic violence, chronic conditions like high blood pressure or diabetes or other conditions

• Gender rating prohibited• Medical loss ratio – Insurers must spend 80-85% of premium on

medial expenses

19

Affordable Care Act Reforms

– Insurance Reforms Continued• Dependents under 26 can stay on parent’s policy• Age rating limited to 3:1 (now up to 6:1 in CT)• Lifetime limits lifted• Annual limits phased out in 2014• External appeal rights• Preventive Services with no co-pay or deductible*

– Birth control, mammograms, cervical cancer screenings, pelvic exams, well women exams, osteoperosis and colon cancer screeings, FDA approved contraceptive methods, breast feeding support, screenings related to interpersonal violence

– Children’s screenings and vaccinations– Medicare coverage for screenings and annual wellness exam

*N/A to grandfathered plans. Certain exemptions to contraceptive coverage. See http://cciio.cms.gov/resources/files/prev-services-guidance-08152012.pdf

U.S. HEALTHCARE QUALITY, COSTS, AND ACCESS TO CARE

• PPACA– Abortion

• The bill segregates private insurance premium funds from taxpayer funds. Individuals have to pay for abortion coverage by making two separate payments, private funds would have to be kept in a separate account from federal and taxpayer funds.

• No health care plan can be required to offer abortion coverage. States could pass legislation choosing to opt out of offering abortion coverage through the exchange. CT has not done so.

• No federal funds can be used to pay for abortions except in the case of rape, incest or health of the mother

21

U.S. HEALTHCARE QUALITY, COSTS, AND ACCESS TO CARE

• PPACA– Nursing moms at work must be allowed access to a space to

pump.– Direct Access to OB/GYN– Medicaid home visitation program for new mothers– Exchanges must contract with Essential Community Providers– Personal Responsibility Education Program on Sexuality– Geriatric Education Centers for family caregivers– Investment in community health centers, National Health

Service Corps, scholarships and loan repayment, and incentives for PCPs and other providers, to increase healthcare providers in underserved areas

22

ACA in CT

• Exchange is moving ahead• EHB package chosen – includes all state insurance mandates,

coverage for elective terminations and contraception*• For kids – autism mandate in insurance statutes will have to be

covered by individual policies in the Exchange, other habilitative coverage is less clear

• Pediatric dental benefit will be based on current HUSKY B benefit• Pediatric vision coverage will be based on the federal employee

plan• There will be a standalone dental benefit offered to adults

* For small group plans in the Exchange, state law and federal regulation and guidance exempts certain qualified religious employers from this coverage. Individual coverage is not impacted by the exemption. See http://cciio.cms.gov/resources/files/prev-services-guidance-08152012.pdf

The ACA in CT• Market reforms codified into CT law

– Dependent coverage, rescissions, lifetime limits– CT law already included direct access to OBGYN

• For self-funded plans50% Ct residents will get new protections, including external review

• Consumer assistance program running• MLR provisions-nearly $13 million in rebates this year for 77K families• Removal of lifetime limit cap has affected 525K women, 370K kids – 1.4

million overall• 637,900 women will have access to preventive services without cost sharing• $63M for discounts in Medicare Part D donut hole• $24 Million from prevention and public health fund• $56 million for community centers

http://www.healthcare.gov/law/resources/ct.html

ACA in CT (cont’d)

• Related grants/savings– $832K for Personal Responsibility Education Program– $10.5M in Maternal, Infant and Early Childhood

Home Visiting Programs– $4M pregnancy assistance fund– $500K Aging and Disability Resource Centers– $300K Family to Family Health Information Centers – $3M for SBHCs– $5M for early retiree reimbursement to the state

http://www.healthcare.gov/law/resources/ct.html

ACA in CT (cont’d)

• Medicaid Low Income Adult Program– initial expansion paid at 50% by feds– will be 100% in 2014

• CT Medicaid program ahead of the curve on most coverage• Medicaid will expand to 133% of FPL in 2014-no asset test• Medicaid is using care coordination and delivery system

reforms in ACA – PCMH, ICO

Outstanding Issues in CT

• Reaching people in our diverse communities• Integration of Medicaid and the Exchange• What will we do to ensure people in 138-200% FPL income

bracket s can afford coverage?• Ensuring robust provider networks of ECPs, LGBT, reproductive

and other related providers?• Assuring reporting on health disparities and outcome data• Accountability for all players• Sustainability—related to ongoing affordability and innovation

OVERALL ISSUES TO ADDRESS IN CT

• Healthcare Reform – The Issues– Method of financing – federal, state, employer, self-pay

– Method of insurance reimbursement – employer mandate, individual mandate, single-payer (universal healthcare)

– Method for delivering services – doctor, specialist, auxiliary and allied health, hospital, (e.g., coordinated, integrated: Kaiser Permanente, Veterans Administration)

– Comprehensiveness of health insurance– Cost and cost containment – competition, cost-sharing

– Degree of patient choice– Administrative costs

28

Moving Away from Sick System

Achieving social justice depends on moving away from our fractured system

• Data is critical• Intervention/prevention• Educating consumers re rights to preventive care

coverage/screenings• Social determinants/lifestyle choices• Addresses issues of disparities in access and outcomes• Addresses work force and IT issues• Requires broad stakeholder involvement and commitment of state

leadership• Reform requires transformation beyond the Exchange