Legal Services and Im plem entation of The Affordable Care Act John Boum an, President Sargent Shriver National Center on Poverty Law Managem ent Inform ation Exchange July 2013
Affordable Care Act • ALL of this impacts Legal Services • Expands affordable coverage and launches initiatives to reduce cost of heatlhcare – Insurance Market Reforms – Health Ins. Marketplace (Exchange) – New Medicaid Eligibility Category – Health System Reforms
Som e of the ACA ’ s Insurance Market Reform s
ACA Insurance Market Reforms • Lifetime dollar limits banned in 2010 • Annual dollar limits begin phase-out in 2010, banned 2014 • Gender price discrimination banned in 2014 • Rescissions banned in 2010 • Pre-existing conditions can no longer be used as a reason to deny insurance • 2010 : insurers required to cover children with pre-existing conditions • 2014: insurers required to cover adults with pre-existing conditions
ACA Insurance Market Reforms (cont.) • Small Business Tax Credit : Tax credits to help qualifying small businesses and nonprofits pay for private health insurance for their employees • Dependent Coverage Provision : – If you are under 26 years old and your parent has a health insurance policy that provides “ dependent ” coverage, then you can purchase the dependent- coverage option • Medical Loss Ratio : Requires insurance companies to spend at least 80%-85% of the premium dollars they collect on medical care and quality improvement activities (or rebate to consumers)
No Cost-Sharing for Preventive Services • Abdominal Aortic • Type 2 Diabetes Aneurysm • Diet • Alcohol Misuse • HIV • Aspirin • Obesity • Blood Pressure • Sexually Transmitted • Cholesterol (over 50) Infection (STI) • Colorectal • Tobacco Use • Depression • Syphilis • Immunizations Details at: www.healthcare.gov
No Cost-Sharing for Preventive Services - Wom en • Anemia • Folic Acid • Bacteriuria • Gestational diabetes • BRCA • Hepatitis B • Breast Cancer • HPV DNA Test Mammography and Breast • HIV screening and Cancer Chemoprevention counseling • Breastfeeding • Osteoporosis • Cervical Cancer • Rh Incompatibility • Chlamydia Infection • Well-woman visits • Contraception • Domestic and interpersonal violence screening
Legal Services: market reforms • Organizational health policies changing • Clients with employer-based or private insurance should get these benefits • Impact in medical debt cases? • Medicare changes to co-pays, donut hole • Advising community groups and social enterprises about their coverage options and the small business tax credit
Health Insurance Marketplace
The Marketplace (Exchange) • Online one-stop-shop for insurance • Consumer friendly format with uniform plain language terms, creates apples to apples comparisons and competition • Sliding scale tax credits from 100% up to 400% of poverty level that make premiums affordable • Sliding scale subsidy helps with out-of-pocket costs • Health plans required to offer comprehensive coverage (“essential health benefits”), have enough doctors, perform well on quality measures 10
ACA: Essential Health Benefits in the Marketplace Plans (at least) • Ambulatory Patient Services • Emergency Services • Hospitalization • Maternity and Newborn Care • Mental Health and Substance Abuse Services (Including Behavioral Health Treatment) • Prescription Drug Coverage • Rehabilitative and Habilitative Services and Devices • Laboratory Services • Preventive and Wellness Services • Chronic Disease Management • Pediatric Services, Including Oral and Vision Care
Outreach and Enrollment: Navigators and In Person Assistors • Duties: – Facilitate enrollment in the Marketplace – Be experts in eligibility, enrollment and program specifications – Conduct public education activities to raise awareness – Give fair, accurate, impartial information – Have cultural and linguistic competence – Refer people with grievances, complaints, appeals • Key to increased coverage and care • Strong conflict of interest provisions, training, and oversight • Primary difference b/w Navigators and IPAs will be sources of funding • ENROLLMENT STARTS OCTOBER 1!
Marketplace Gaps • If no Medicaid expansion: under 100% FPL not covered • Under 100% FPL LPRs in the five year waiting period for Medicaid • Undocumented barred from Marketplace and Medicaid (CIR might change this, probably not) • Employer-based coverage for dependents • Those who still can’t afford it • Those eligible but not enrolled
Individual Mandate/ Responsibility Provision • Requires all U.S. citizens and lawfully residing immigrants to have coverage • Enforcement takes effect January 2014 • Makes healthy people participate • Legal Services: exceptions to the mandate penalty, including low income
Legal Services: Marketplace • Learn how to use it • Wheelhouse issues: eligibility determinations, consumer rights, notices, due process • Maximize community knowledge, outreach • Teach it • Advice to community organizations about the business mandate and tax credits • Advice to entrepreneurs • Non-citizen issues
ACA ’ s New Medicaid Eligibility Category
Medicaid’s gap is filled • For states that adopt it (NFIB v. Sibelius) • In 2014 the Medicaid categories are eliminated • All citizens and LPRs with five years in U.S., ages 19- 64 with incomes up to 133% FPL (138% with 5% income disregard) will be eligible • Enrollment will be via the Exchange • Federal government will pay for 100% of the cost of newly eligible for first 3 years and then at least 90% of the cost thereafter
Who are the uninsured Illinoisans that the new Medicaid Eligibility Category would cover?* 522,000 people newly eligible in Illinois Racial Breakdown • 51.2% White • 15.6% Hispanic • 27.6% African American • 5.6% Other Parental Status • Parents: .05% • Adults without Dependent Children 99.5% * Urban Institute, August 2012, Uninsured Adults newly eligible for Medicaid under the ACA with Incomes below 138% of poverty (133% FPL plus a 5% income disregard) 18
Legal Services: Medicaid, states in • Wheelhouse issues – enrollment, eligibility, budgeting, notices, procedures, due process • Interface with the Marketplace • Benefits package – not necessarily same as “old Medicaid” • Interface with “old Medicaid” (disability) • Outreach • Single application (TANF, SNAP) • Expertise, issue-spotting, “loops” for constant improvement
Legal Services: Medicaid, states still out • Do what you can within restrictions to push for adoption • Collect stories • Under 100% group -- uninsured? • Maximize private insurance options • Strengthen safety net • Track experience in states that do adopt • SSI advocacy
Health Care Delivery Reform s and Cost Controls
ACA Strategies • Coverage controls costs: enables prevention • Care coordination, other experimentation • Community based long term care • Quality initiatives, hospital billing changes • Non-profit co-op insurance • Healthcare workforce development • Medicare (doughnut hole, other reforms) • Maximize information tech for eligibility and health care itself
Legal Services: Delivery and Cost reforms • Be aware these things driving client issues • Community development transactions: need sites for community based long term care • Healthcare workforce: appropriate curricula at community colleges; completion strategies • Social determinants of health: new payers for social services and housing allies? • Medical-legal partnerships: new payers for legal services?
Legal Services in General and Resources
As Alex says: • Convene • Train trainers • Provide technical assistance • Be ready as frontline provider – pay attention to the wheelhouse issues • If sidelined on policy issues, still in the game -- stories, information loop, relationships -- group representation -- transactional representation -- medical-legal opportunities
Resources Federal: www.healthcare.gov National: www.kff.org, www.familiesusa.org Kids: www.ccf.georgetown.edu Legal: www.healthlaw.org Seniors: www.nsclc.org Mental Health: www.bazelon.org Shriver Brief: www.theshriverbrief.org
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