Indiana State Nurses Association• www.indiananurses.org–Meeting of the Members – 9/12/14– Policy 101 – 11/7/14

• ISNAbler• bmiley@indiananurses.org @IndianaNurses

Indiana State Nurses Association

Affordable Care Act Goals• Expand Health Coverage Eligibility– Employer Mandate (delayed)– Medicaid Expansion (optional)

• Easier to Obtain Coverage – Marketplaces

• Improve Coverage– Insurers Must Be Nicer to Sick People– Provider Incentives/Penalties

Supreme Court Decision #1

• Individual Mandate Constitutional–Walks like a Tax, Quacks like a Tax

• Mandatory Medicaid Expansion Unconstitutional– Taking Away All Medicaid Funds if State’s

Don’t Expand is Unduly Coercive• Remedy Makes Expansion Optional

Make Insurers Be Nicer to Sick People

Insurance Regulations

Individual Mandate

Provide SubsidiesChildren can be on parents’ policies up to age 26

Insurers

• Must Cover Essential Health Benefits• Can’t Disqualify Based on Pre-existing Conditions• Premiums Can’t Vary Based on Gender• Premium Variance Based on Age < 300%• Minimum Required Medical Loss Ratio– % of Premiums Spent on Claims & Wellness– Small Group = 80%, Large Group = 85%

• No Lifetime or Annual Limits on Coverage

Physicians Health Plan

Network Coverage

Area

EHB Categories• Ambulatory Patient Services• Emergency Services• Hospitalization• Maternity & Newborn Care• Mental Health & Substance Use Disorder Services• Prescription Drugs• Rehabilitative and Habilitative Services• Laboratory Services• Preventive & Wellness Services• Pediatric Services, including Dental & Vision

Supreme Court Decision #2• Hobby Lobby doesn’t want employer

contributions to cover post-fertilization contraceptives (EHB).

• Supreme Court holds:– Corporations count as “persons” under RFRA – Contraceptive requirement substantially burdens

the exercise of their religion, and – The government interest at stake can be

furthered in a less restrictive manner• Pending lawsuits on the accommodation

Medicaid Expansion

• Up to 138%* of the Federal Poverty Level– Reduces eligibility criteria beyond income

• Federal Funding of New Enrollees– 100% for 2014-2016; scales down to 90% in 2020

• 100% Federal Poverty Level– Individual: $11,670– Family of 4: $23,850

Marketplace

• Healthcare.gov• Operated by state, fed, or hybrid• Federal Tax Credits if Income is 100-400% FPL

and Employer Doesn’t Offer Coverage• Prospective then reconciled or just at tax

time• 2015 Open Enrollment 11/15/14 – 2/15/15

Marketplace Plans• Metallic Categories By % of Costs Covered– Bronze: 60%, Silver: 70%, Gold: 80%, Platinum: 90%

• Catastrophic: high deductible, low premium– Eligible if under 30 or hardship (prior plan canceled)

• Network must include 30%* of essential community providers

• Total Out-of-Pocket Expenses Capped in 2015– $6,600 for individual; $13,200 for family (includes copays,

deductibles, not premiums) in network only

Employer Mandate• Businesses Over 50 Employees (FTE)– Offer Affordable, Adequate Health Coverage to 30+ hour

• Affordable = contribution < 9.5% of household income • Adequate = covers 60% of allowed costs• 30 hour/week employees over 3, 6, or 12 months• Must include dependents, not required to include spouses

– Penalty for (A) not offering & (B) offering inadequate• A: (# of workers – 30*) x $2,000• B: Lesser of (A) or $3,000 per FTE receiving Marketplace tax credit

• 50-99 employees: 2016• 100+ employees: 70% compliance in 2015, 95% in 2016

Individual Mandate• Enforcement by IRS through tax return– Limited to future refunds

• 2014 Penalty = greater of: – $95 per household adult + $47.5 per child– 1% household income (minus filing threshold)

• Exemptions if coverage gap < 3 months, low income, hardship, etc.

• Max $2,448 (average cost of bronze plan)

Indiana’s Approach• Federally Run Marketplace– 132,423 Hoosiers selected a plan in initial

enrollment

• Lawsuit by Schools Seeking to Prevent Employer Mandate Penalty

• Seeking Repeal of 2.3% Medical Device Tax• No Medicaid Expansion• Healthy Indiana Plan (HIP) – 2.0 Proposal

Healthy Indiana Plan Status• Federal waiver program requiring fed

approval• Current HIP enrollment capped• HIP 2.0 state public comment phase

complete– ISNA gets “advanced practice registered nurse

practitioner” changed to “advanced practice registered nurse”

• Federal public comment period open through 9/21

• Proposed Start Date: January 1, 2015

Healthy Indiana Plan 2.0 Proposal• Replace Medicaid for non-disabled age 19-64• Reimburse at Medicare rates through Hospital

Assessment Fees• No enrollment cap or annual/lifetime benefits cap• Income threshold is 138% FPL• POWER account annual balance $2,500 for

deductibles, contingent & prorated rollover • Monthly contributions: $3, $8, $15, or $25 for HIP +

HIP Basic HIP Plus HIP Link

Under 100% FPL, no monthly contributions

Under 138% FPL, monthly contributions required

Under 138% FPL, monthly contribution required

Co-payments required for all services except preventive & family planning

Failure to make contribution: 100-138% locks out for 6 months, < 100% shift to HIP Basic

Failure to make monthly contribution = $50 POWER account penalty

Baseline coverageEx: No dental/vision, limited pharmacy

Broader benefitsEx: dental & vision coverage

Subsidize purchase of employer plans & dependent coverage

Hospital Value Based Purchasing

• Medicare Bonuses or Penalties– Hospital Inpatient Quality Reporting Program

(2,728)

• Process Measures• Patient Surveys• Mortality Rates– Myocardial Infarction, Heart Failure, Pneumonia

Period Current Oct ’14 Oct ’15 Oct ‘16

Max % Adjustment 1.25 1.5 1.75 2.0

Readmissions Reduction Program

• Reduce Medicare Payments for Hospitals in Inpatient Prospective Payment System

• Readmissions for Myocardial Infarction, Heart Failure, Pneumonia• Risk-adjusted based on age, gender, past

medical history, and other health conditions• No change or penalty up to 2% in FY2014, 3% in

FY2015

• In 2015 adding COPD, Hip/Knee Replacement

• FY2014 modifier from July 2009-2012 data• Excess Ratio < 1, better than average, no payment change• If Excess Ratio > 1, then plugged into formula that reduces

Medicare payments

Facility Discharges Readmits Risk-adjusted per 100

Benchmark per 100

Excess Ratio

Franciscan St M. Dyer

291 47 17.5 18.7 0.9349

Franciscan St M. Hammond

291 72 22.2 19.6 1.1318

Pinnacle Hosp. 55 13 17.3 16.2 1.0645Franciscan HC Munster

57 11 17.4 17.1 1.0190

Pneumonia Readmissions

CMS Innovation Center

• $10 Billion Budget over 10 Years• Accountable Care Organizations– Financial accountability for Medicare

population– Share in cost savings

• Bundled Payments for Care– Different Models for Episode of Care

Nurse Programs• National Health Service Corps– Nurse Practitioner or Certified Nurse Midwife– Service Commitment to Health Professional

Shortage Area

• Nurse Corps Loan Repayment Program– Registered Nurse or Nurse Faculty– Service Commitment to Critical Shortage Area

• Nurse Managed Health Clinics

ACA Info Resources

• Indiananurses.org – Indiana State Nurses Association– ISNAbler

• Marketplace: healthcare.gov or 1-800-318-2596

• Marketplace.cms.gov – Provider info by CMS• hrsa.gov – Grant programs from HRSA • rwjf.org - Robert Wood Johnson Foundation• kff.org - Kaiser Family Foundation