The Affordable Care Act (ACA) and Children with Special Health Care Needs

Carol Tobias

Boston University School of Public Health

The Catalyst Center: Who are we?

• A National Center dedicated to the MCHB outcome measure: “…all children and youth with special health care needs have access to adequate health insurance coverage and financing for their care”.

• A Cooperative Agreement with the Maternal and Child Health Bureau of HRSA

• Housed at the Health and Disability Working Group at the BUSPH

Who are CSHCN?

CSHCN have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and also require health and related services of a type or amount far greater than required by children generally.*

*McPherson, M, et al. A new definition of children with special health care needs (Elk Grove Village, IL: Pediatrics, 1998),102: 137-140**Health Resources and Services Administration, Maternal and Child Health Bureau. The National Survey of Children with Special Health Care Needs Chartbook 2005–2006. (Rockville, MD: U.S. Department of Health and Human Services, 2007).

10.2 Million •Children in the US have special health care needs**

1 in 7 (13.8%) •Children in the US have special health care needs**

Insurance Coverage of CSHCN

9% of CSHCN were uninsured at some point during the survey year, 3.6% were uninsured when the survey was conducted.

Adequacy of Coverage

• Co-payments• Deductibles• Benefit limits

– Therapies– Medical equipment– Supplies– Mental health

• Annual or Lifetime benefit caps

What do CYSHCN need from health care reform?

Coverage that is:•Universal and continuous•Adequate

•Affordable

The Patient Protection and Affordable Care Act of 2010 (ACA)

Universal and continuous coverage

Ban on coverage denial for pre-existing conditions

Effective 9/23/2010, Applies to most children under age 19 with certain restrictions

20,000 applications for children’s coverage were denied for pre-existing conditions in 2008

Most of the ifs, ands or buts about this provision will be eliminated by 2014

Other provisions

• Dependent coverage for youth up to age 26• No rescission of coverage regardless of the cost

or amount of services used, effective Sept. 2010• Guaranteed issue, effective 2014• Exchanges for small employers, families and

individuals will offer insurance with the provisions above in 2014

• Maintenance of effort for Medicaid and CHIP

Grandparents

But…..• Many privately insured individuals will be in

grandfathered plans• Grandfathered plans only lose this status if there is a

substantial:– Increase in premiums or– Reduction in coverage

• “Substantial” – to be defined

Adequate Coverage

Essential Benefits• Effective Jan, 2014 plans offered through

the Exchanges (and some outside plans) must provide

Essential BenefitsGrandfathered and self-insured plans are exempt*

*Approximately 80% of privately insured individuals receive coverage in plans that would be considered grandfathered or self-insured today.

Typical coverage gaps for CSHCN

• Habilitative therapies: physical, occupational, speech/language****

• Prescription medications****• Durable medical equipment*?*? (devices)• Consumable supplies: diapers, wipes, hearing

aid batteries, disposable dressings, etc.• Eye glasses, hearing aids****• Mental health services****• Dental care****

Eliminating benefit caps

• Effective Now– no more lifetime benefit caps for existing or new plans– no annual benefit cap of less than $750,000

• Effective Jan. 2014 – no annual benefit cap at all

• BENEFITS can still be capped, e.g. 20 physical therapy visits, 15 mental health sessions.

Other improvements to adequacy

• Medicaid benefits, including EPSDT, will be available to children < 133% of FPL

• Health homes for specific chronic conditions

• Increase in Medicaid rates for primary care services to match the Medicare rate.

Affordable Coverage

Components of affordability

• Scope of covered services• Cost of insurance premiums• Cost and number of co-payments• Cost of coinsurance• Amount of the deductible

Subsidies and Tax Credits - 2014

• Premium tax credits, on a sliding scale, for families with incomes up to 400% of the FPL.

• Cost-sharing subsidies for families up to 250% of the FPL

• Available when purchasing silver category of coverage in Exchanges

Figuring it Out

• Exchanges will provide calculators to help families figure out the cost of coverage.

• Will help to compare both the benefits and cost of coverage

• Exchanges also provide a website for comparing plan benefits and costs

Affordable or not?

• Most CSHCN receive coverage in grandfathered or self-insured plans

• Cost-sharing limits not applicable• Lower income families still face high

expenses unless really low income• In spite of all the changes, the more you

use services, the more you will pay

Summary•There are several major improvements in universal and continuous coverage through ACA.

•Still major gaps in coverage adequacy

•Affordability?