Impact of Health Care Reform on the Senior Living Field

Sequoia Region MeetingMay 9, 2010

Joanne Handy, President & CEOAging Services of California

 

How Will Things be Different?

Members as EmployersMembers as Resident AdvocatesMembers as Providers

 

Members as Employers>50 employees

Must offer health insurance

Offer vouchers to those <400% FPL

Have <30 day waiting period for benefits

Coverage less than 60% of cost of benefits qualifies for Exchange or tax credit

 

Members as Resident Advocates Fills the doughnut holeExpands preventative services with no

cost-sharingMore assistance for low incomeIncrease payments for primary care

providersReduce overpayment to Medicare

Advantage PlansEncourage more care coordinationExtend solvency of the Medicare Trust

Fund

 

Members as Service ProvidersCLASS ActValue-based Medicare paymentsBundling post-acute servicesMore funding for home and community

based servicesFunding for care coordination and

transition managementReduce SNF and HHA market basket

increasesTransparency requirements for SNF

 

Phase-In Timeline•9/10

Cannot drop a sick enrollee

Kids stay on parent’s insurance ‘til 26$250 more in doughnut hole

• 1/11 85% of premiums must be spent on

benefits No cost-sharing for Medicare

preventative care

 

Phase-In Timeline2012

CLASS Act plan established

50% brand name drugs covered in the doughnut hole

2014Individual mandate in effect

End to annual and lifetime limits on benefits

2018 – Tax on “Cadillac” health plans2020 – Donut hole fully closed

 

What if . . .CLASS Act passes (it has!!)?Post-acute care is bundled?All dual-eligibles are in managed care

plans?Medicare pays for transition services?What if we ruled the world?

 

Class Act

CLASS is now a reality!

Will be implemented in 2012 and requires 5 years of contributions to vest. Therefore, 2017 is the first year that benefits could begin.

CLASS

 

ImpactSource of private funds for nursing

home, assisted living, home care, and other HCBS

Benefit expected to be $50-$100 per day for life, as long as ADL impairment of 2-4 ADLs

The form is a cash benefit to the consumer, not reimbursement to the provider

 

PositioningEducate consumers to participate

Provide home care – by affiliation or ownership

Strengthen marketing effort direct to consumers

 

Bundling

Post-acute care is bundled for 30 days and acute care

hospital holds the $$

 

Impact

Hospitals only refers to contracted SNF/HHA

SNF/HHA referrals have higher acute care needs

Incentive to use lowest cost post-acute sites

 

Positioning

SCPs become part of hospital networks

Outcome scores key to obtaining contracts

Must negotiate acuity-based ratesWhat’s the case for SNF/HHA controlling the bundle?

 

Dual Eligibles

All dually eligible patients in California are enrolled in a Managed Care Plan (MCO). This is proposed as part of the new 1115 waiver.

 

Impact

MCP becomes the payer for most long stay skilled nursing residents

MCPs pay less than Medi-calMore payment delays and billing

hasslesMCP incentivized to keep members

out of nursing homes

 

PositioningPACE programs expand to manage

less frail dually eligibles

Offer enhanced assisted living as an alternative to skilled

Develop a rate and contract negotiation strategy

 

Transition Benefit

Medicare pays for transition services from acute care to SNF, AL, independent living, and community. Starts in 2011.

Evidence derived from Naylor, Coleman, and Boult transition models

 

Impact

Payment available for transition services to prevent acute care readmissions. Existing models utilize nurses, social worker, or a team.

 

Positioning

Do you want to be a transition provider?

Develop your intervention strategy in your program now

 

The Cheese is Moving . . .