affordable care act nurse practitioner association of southwestern pennsylvania may 15, 2013 h ealth...
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Affordable Care ActAffordable Care Act
Nurse Practitioner Association of Nurse Practitioner Association of Southwestern Pennsylvania Southwestern Pennsylvania
May 15, 2013May 15, 2013
HEALTHCARE.GOV
Aryanna Abouzari, Esq.Aryanna Abouzari, Esq.Executive OfficerExecutive Officer
U.S. Department of Health & Human U.S. Department of Health & Human Services, Region III Services, Region III
Pennsylvania, Delaware, District of Columbia, Pennsylvania, Delaware, District of Columbia, Maryland, Virginia, West VirginiaMaryland, Virginia, West Virginia
Critical Need for Health ReformCritical Need for Health Reform
48.6 million uninsured Americans 48.6 million uninsured Americans
$3 trillion spent annually on healthcare$3 trillion spent annually on healthcare
17.9 % of our economic output tied up 17.9 % of our economic output tied up in the health care system in the health care system
Without reform, by 2040, 1/3 of Without reform, by 2040, 1/3 of economic output tied up in health careeconomic output tied up in health care
Affordable Care Act OverviewAffordable Care Act Overview Creates Consumer ProtectionsCreates Consumer Protections
Prevents denials of coverage for pre-existing Prevents denials of coverage for pre-existing conditionsconditions
Make health insurance more affordable for Make health insurance more affordable for middle class families and small businesses middle class families and small businesses with tax creditswith tax credits
Expands access to care through Marketplaces Expands access to care through Marketplaces and Medicaid expansionand Medicaid expansion
Highlights for ProvidersHighlights for Providers Increases the number of Primary Care Increases the number of Primary Care
PractitionersPractitioners – Provides new investments to – Provides new investments to increase the number of primary care increase the number of primary care practitioners, including doctors, nurses, nurse practitioners, including doctors, nurses, nurse practitioners, and physician assistantspractitioners, and physician assistants• • Projected to place more than 16,000 health Projected to place more than 16,000 health
professionals over next 5 yearsprofessionals over next 5 years
Community Health CentersCommunity Health Centers - Increases - Increases funding for Community Health Centers to allow funding for Community Health Centers to allow for nearly a doubling of the number of patients for nearly a doubling of the number of patients seen by the centers over the next 5 yearsseen by the centers over the next 5 years• 231 community health centers in PA eligible for 231 community health centers in PA eligible for
fundingfunding• 671,646 patients treated in 2010 at federally 671,646 patients treated in 2010 at federally
supported health centers in the U.S.supported health centers in the U.S.
Highlights for Nursing Highlights for Nursing WorkforceWorkforce
Nurse Education, Practice, Quality & Nurse Education, Practice, Quality & RetentionRetention
Nursing Workforce DiversityNursing Workforce Diversity Nurse Faculty Loan ProgramNurse Faculty Loan Program Advanced Nursing Education ProgramAdvanced Nursing Education Program Advanced Education Nursing Advanced Education Nursing
TraineeshipsTraineeships Nurse Anesthetist TraineeshipsNurse Anesthetist Traineeships
Center for Medicare and Center for Medicare and Medicaid Innovation Medicaid Innovation
Developing payment and delivery system Developing payment and delivery system reforms, focused on:reforms, focused on:
Expanding team-based care coordinationExpanding team-based care coordination Rewarding providers for care outside of traditional Rewarding providers for care outside of traditional
face-to-face visitsface-to-face visits Focusing on aggressive management of Focusing on aggressive management of
chronically ill patientschronically ill patients Expanding access to home-based careExpanding access to home-based care
$10 billion in funding for FY 2011 - $10 billion in funding for FY 2011 - 2019 2019
Opportunity to scale up: authority to Opportunity to scale up: authority to expand successful models to the national expand successful models to the national level level
Center for Medicare and Center for Medicare and Medicaid InnovationMedicaid Innovation
Partnership for PatientsPartnership for Patients Accountable Care OrganizationsAccountable Care Organizations Bundled Payments for Care ImprovementBundled Payments for Care Improvement Community-based Care Transitions Community-based Care Transitions
Program Program Value Based PurchasingValue Based Purchasing Graduate Nurse Education Demonstration Graduate Nurse Education Demonstration
Health Insurance MarketplaceHealth Insurance Marketplace
Sometimes called “Exchanges,” the Sometimes called “Exchanges,” the Marketplace is required by the ACA to be Marketplace is required by the ACA to be created by January 1, 2014created by January 1, 2014
New “marketplace” where small businesses and New “marketplace” where small businesses and individuals can select and enroll in a private individuals can select and enroll in a private health insurance plan health insurance plan
Consumers will have Consumers will have • the same level of benefits and coverage the same level of benefits and coverage
available to members of Congressavailable to members of Congress• more choice and selection in health plansmore choice and selection in health plans
Three models availableThree models available State-BasedState-Based Federal-State PartnershipFederal-State Partnership Federally-FacilitatedFederally-Facilitated
States can apply for Marketplace States can apply for Marketplace establishment funding at any time and be establishment funding at any time and be awarded grants through 2014 awarded grants through 2014
HHS to operate marketplaces for States HHS to operate marketplaces for States that have not elected to do so that have not elected to do so
Marketplace Implementation Marketplace Implementation
Health Insurance Marketplace Health Insurance Marketplace Regional SnapshotRegional Snapshot
• PAPA – – No enabling legislation; Federally-facilitated No enabling legislation; Federally-facilitated
• DE – No enabling legislation; Federal-State PartnershipDE – No enabling legislation; Federal-State Partnership
• MD – Passed enabling legislation; State-based MD – Passed enabling legislation; State-based
• DC – Passed enabling legislation; State-basedDC – Passed enabling legislation; State-based
• WV – Passed enabling legislation; Federal-State WV – Passed enabling legislation; Federal-State Partnership Partnership
• VA – No enabling legislation; Federally-facilitatedVA – No enabling legislation; Federally-facilitated
Financial AssistanceFinancial Assistance
Premium tax creditsPremium tax credits• Will reduce the premium amount the consumer Will reduce the premium amount the consumer
owes each monthowes each month• Available to eligible consumers with household Available to eligible consumers with household
incomes between 100% and 400% of the FPL incomes between 100% and 400% of the FPL ($44,680 for an individual and $92,200 for a family ($44,680 for an individual and $92,200 for a family of 4 in 2012), and who don’t qualify for other health of 4 in 2012), and who don’t qualify for other health insurance coverageinsurance coverage
• Based on household income and family size for the Based on household income and family size for the taxable yeartaxable year
• Paid each month to the insurerPaid each month to the insurer
Financial AssistanceFinancial Assistance
Cost-sharing reductions:Cost-sharing reductions: Reduce out-of-pocket costs (deductibles, Reduce out-of-pocket costs (deductibles,
coinsurance, copayments)coinsurance, copayments)• Generally available to those with income 250% Generally available to those with income 250%
FPL or below (FPL or below ($27,925 for an individual and $27,925 for an individual and $57,625 for a family of 4 in 2012)$57,625 for a family of 4 in 2012)
• Consumer must enroll in a “silver-level” plan Consumer must enroll in a “silver-level” plan
Quality InsuranceQuality Insurance The ACA requires plans inside the Marketplace The ACA requires plans inside the Marketplace
to meet particular actuarial value (AV) targetsto meet particular actuarial value (AV) targets• Bronze = 60% AVBronze = 60% AV• Silver = 70% AVSilver = 70% AV• Gold = 80% AVGold = 80% AV• Platinum = 90% AVPlatinum = 90% AV
““Metal Levels” will enable consumers to Metal Levels” will enable consumers to compare plans with similar levels of coverage, compare plans with similar levels of coverage, promote competition on premiums, and allow promote competition on premiums, and allow plans flexibility to design cost sharing plans flexibility to design cost sharing structuresstructures
Essential Health BenefitsEssential Health Benefits• Ambulatory patient servicesAmbulatory patient services• Emergency servicesEmergency services• HospitalizationHospitalization• Maternity and newborn careMaternity and newborn care• Mental health and substance use disorder Mental health and substance use disorder
services, including behavioral health treatmentservices, including behavioral health treatment• Prescription drugsPrescription drugs• Rehabilitative and habilitative services/devicesRehabilitative and habilitative services/devices• Laboratory servicesLaboratory services• Preventive and wellness services and chronic Preventive and wellness services and chronic
disease managementdisease management• Pediatric services, including oral and vision Pediatric services, including oral and vision
carecare
Quality InsuranceQuality Insurance
Enrollment ProcessEnrollment Process Consumer submits application to the marketplaceConsumer submits application to the marketplace
• OnlineOnline• PhonePhone• MailMail• In PersonIn Person
The marketplace verifies and determines The marketplace verifies and determines eligibility foreligibility for• enrollment in a Qualified Health Plan (QHP)enrollment in a Qualified Health Plan (QHP)• tax credits and cost-sharing reductionstax credits and cost-sharing reductions• Medicaid or CHIPMedicaid or CHIP
Consumer enrolls in a QHP or Medicaid/CHIPConsumer enrolls in a QHP or Medicaid/CHIP• Online plan comparison tool available to inform health plan Online plan comparison tool available to inform health plan
choicechoice• Tax credit is sent to insurer (if eligible) to reduce consumer Tax credit is sent to insurer (if eligible) to reduce consumer
premium owed premium owed
Enrollment AssistanceEnrollment Assistance
Help available in each MarketplaceHelp available in each Marketplace• Toll-free call centerToll-free call center• WebsiteWebsite• Navigator programNavigator program• Certified Application CounselorsCertified Application Counselors• Community-based organizationsCommunity-based organizations• Agents and brokers Agents and brokers
Initial Open Enrollment PeriodInitial Open Enrollment Period
October 1, 2013 – March 31, 2014October 1, 2013 – March 31, 2014
Enroll during the Initial Open Enrollment Period
Your coverage is effective*
On or before December 15, 2013
January 1, 2014
Between the 1st and 15th day of January – March
First day of the following month
Between the 16th and the last day of December – March
First day of the following month
Resources:
Affordable Care Act website –Affordable Care Act website –www.healthcare.gov
Health Insurance Marketplace –Health Insurance Marketplace –
marketplace.cms.govmarketplace.cms.gov
Center for Consumer Information & Insurance Center for Consumer Information & Insurance Oversight website – Oversight website – http://cciio.cms.gov
Affordable Care Act Spanish Affordable Care Act Spanish website website – – www.cuidadodesalud.gov
Thank you!Contact: