www.nasuad.org

The Affordable Care Act • Background

• Coverage

• Long-term Care

• Home and Community Based Services

• Payment Delivery

• Care Transitions

• Assuring Quality

• Supreme Court

5/30/2012

BACKGROUND

Health Reform legislation is commonly referred to as

the Affordable Care Act (ACA), and it is made up of

two pieces of legislation:

1. Patient Protection and Affordable Care Act,

P.L. 111-148, enacted March 23, 2010; and

2. Health Care and Education Reconciliation Act

of 2010, P.L. 111-152, enacted March 30, 2010

Affordable Care Act Titles

• Title I: Quality, Affordable Health Care for All

Americans

• Title II: Role of Public Programs

• Title III: Improving the Quality and Efficiency of

Health Care

• Title IV: Prevention of Chronic Disease and

Improving Public Health

• Title V: Health Care Workforce

• Title VI: Transparency and Program Integrity

• Title VII: CLASS Act

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COVERAGE

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COVERAGE: The Medicaid

Expansion

How will it work? In 2014, all individuals with incomes up to

133% of FPL (In 2009, $14,404 for individuals/$29,326 for a

family of 4) will be covered under Medicaid.

Who will be covered? Eligibility will be based on a modified

adjusted gross income (MAGI) with no asset or resource

test, while maintaining existing counting rules for people

who 65 and older, and for individuals with disabilities.

COVERAGE: The Essential

Health Benefits

• Ambulatory Patient Services

• Emergency Services

• Hospitalization

• Maternity and newborn care

• Mental health and substance use disorder services

• Behavioral Health Treatment

• Prescription Drugs

• Rehabilitative and habilitative services and devices

• Laboratory Services

• Preventive and wellness services

• Chronic Disease Management

• Pediatric Services, including oral and vision care

COVERAGE: The Exchanges

How will it work? The Exchanges are designed to serve as

marketplaces that allow participants to band together and

shop for insurance at competitive rates.

Who will be covered? Initially, participants in the Exchange

will be limited to businesses with 100 or fewer employees,

and to individuals looking to purchase insurance for

themselves.

What if coverage is unaffordable? To facilitate participation

in the Exchanges, premium tax credits will be offered on a

sliding scale basis, and will be available to those with

incomes between 133 and 400% FPL.

LONG-TERM CARE

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LONG-TERM CARE

CLASS ACT Creates a new federally administered national, voluntary insurance program to help adults age 18 and over with disabilities pay for LTSS.

Eligibility: voluntarily enrolled for five years and have a qualifying functional limitation expected to last continuously for 90 days or more

Benefits: cash benefit

Premiums: Depend on age at enrollment and year, but no other factors permitted including underwriting

Will work in conjunction with other long-term services and supports programs such as Medicaid

Update on the CLASS ACT

• On January 5, 2011, the Obama Administration announced the formal launch of an office to administer the CLASS Program within AoA under the leadership of Assistant Secretary Greenlee. Ten months later, on November 14, 2011, HHS Secretary Sebelius recommended that the Department halt its implementation of the CLASS Act, explaining that:

"For 19 months, experts inside and outside of government have examined how HHS might implement a financially sustainable, voluntary, and self-financed long-term care insurance program under the law that meets the needs of those seeking protection for the near term and those planning for the future. ... But despite our best analytical efforts, I do not see a viable path forward for CLASS implementation at this time."

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PREVENTION

• Funding for Health Prevention – Incentives for Prevention of Chronic Diseases in Medicaid

– Prevention and Public Health Fund

– Community Transformation Grants

– Healthy Aging Living Well

– Positive Behavior Grants

• Councils and Taskforce – National Prevention & Wellness Strategy

– Preventive Services Task Force

• Research – Health Research

– Pain Management

– Congenital Heart Disease

– Cures Acceleration Network

Other Provisions of Interest

• Early Retiree Reinsurance Program

• Donut Hole Modifications

• Medicare Advantage payments

• End of Preexisting Conditions

• Lifetime and Annual Limits

HOME AND COMMUNITY

BASED SERVICES

• Community First Choice Option

• State Balancing Incentive Payments

Program

• Reforms to the Medicaid HCBS state plan

option §1915(i)

• Money Follows the Person

• Health Homes

• Dual Eligibles

LONG-TERM CARE: Balancing

Medicaid Medicaid LTSS Spending: Institutional and HCBS

Services from 1990 - 2008

SOURCE: Terence Ng et al, (November 2009), Medicaid Home and

Community Based Services Programs, Kaiser Commission on Medicaid and

the Uninsured

LONG-TERM CARE:

Balancing Medicaid

Balancing

Medicaid

Money Follows the Person

HCBS State Plan Option

Community First Choice Option

The CLASS Act

State Balancing Incentives

Health Homes

Spousal Impoverishment

Community First Choice is a new State Plan

Option for Attendant Care

• 6 percent increase in FMAP indefinitely

• Attendant care for ADLs and IADLs plus

backup systems and training for attendants

• Assessments, data collection required

• Maintenance of effort requirement—

spending for first 12 months must be at least

same level as prior year

Should Your State Consider Community First

Choice?

• Can CFC replace existing personal care in state

plan and waivers? Will eligible population

increase?

• Can state comply with self-direction

requirements?

• Does state have a universal assessment tool?

• Can IT system support quality and data

collection requirements?

• Does state need to “re-base” first to contain

personal care costs over the long term?

State Balancing Incentive Payments Offers Additional

FMAP for Reaching Rebalancing Targets

• <25% spending on community LTSS: 5%

increase in FMAP

• 25% to 50% spending on community LTSS:

2% increase in FMAP

• Must reach rebalancing targets of 25% and

50%, respectively, in four years (FFYs 2011-

2015)

Is State Balancing Incentive Payments an Option

for Your State?

• Can the state meet the aggressive

rebalancing targets? Where is the state now

in the rebalancing life cycle?

• Can the state comply with assessment,

single-point-of-entry, and data collection

requirements?

The 1915(i) State Plan Amendment was Amended

and Now Allows Targeting of Special Populations

• States can target populations–e.g.,

individuals with mental health conditions

• New services for chronic mental illness—day

treatment, partial hospitalization,

psychosocial rehabilitation, clinic services

• Must offer statewide; disallows ceilings on

number of enrollees

What Should States Consider in Adopting a 1915(i)

State Plan Amendment?

• What population could most benefit? Are

there individuals on waivers who could be

transferred over?

• Can population be clearly defined so as to

prevent eligibility “creep?”

• What is the benefit package? Are the

services evidence-based? Will amendment

be cost-effective?

Money Follows the Person Provides a Opportunity

to Promote LTSS Systemic Change

• MFP Demonstrations are now operating in

43 states

• Enhanced FMAP for one year for all

qualifying MFP participants

• Funding for IT and infrastructure

development, specialized staff

States Can Leverage Money Follows the Person as

the Centerpiece of Rebalancing Efforts

• How can your state enhance rebalancing

efforts by positioning MFP as a focal point?

• How can your state strategically invest MFP

“savings?”

Health Homes Can Coordinate an Array of Services for

People with At Least Two Chronic Conditions

• Includes asthma, diabetes, heart disease,

mental health conditions, substance abuse

disorders, obesity

• Can target based on number, type, and

severity of chronic conditions

• 90% FMAP for two years for six core health

home services only

• Dual eligibles cannot be excluded

Are Health Homes an Opportunity for Serving People

in Your State with Complex, Expensive Needs?

• Which populations could benefit?

• Does the state have existing health homes to build

on? Are they evidence-based? Are providers

available?

• Can the program be sustained financially?

• Does the state have experience in coordinating

Medicare/Medicaid benefits for dual eligibles?

• Does the state have experience with managed care

payment methods and encounter data?

• Can the state comply with data collection and

evaluation requirements?

• CMS Center for Innovation

• Medicare and Medicaid Demonstration Projects

Payment Delivery

ACA Promotes Integrated Care for Dual Eligibles

• Establishes Federal Coordinated Health

Care Office (FCHCO)

• FCHCO closely aligned with Center for

Medicare and Medicaid Innovation (CMMI)

for demonstrations and technical assistance

• New opportunity to “synch” renewal periods

for concurrent waivers for dual eligibles

• Special Needs Plans (SNPs) reauthorized

CARE TRANSITIONS

CARE TRANSITION –

actions designed to ensure the

coordination and continuity of

health and community care

during the course of a chronic

or acute illness

CARE TRANSITION

Access to Care

Coordination of Care

Continuity & Translation

Information & Education

CARE TRANSITIONS & COORDINATION

• Improving Care Transition and Coordination

– Community-Based Care Transitions Program

– Aging and Disability Resource Centers (ADRC)

– Accountable Care Organizations

– Health Homes for Enrollees with Chronic Conditions

– Community health teams to support the patient-centered medical

home

– Patient Navigator Program

Assuring Quality

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Elder Justice Act

– Establishes an Elder Justice Coordinating Council

– The law authorizes for fiscal years 2011-2014 , BUT DOES NOT

FUND, several grant programs, including, but not limited to:

• Funding to State and local Adult Protective Services offices

• Demonstration grants to detect and prevent elder abuse

• Grants to improve the capacity of the state Long-Term Care

Ombudsman Program

• Grants to improve ombudsman training

• Grants to provide workforce management technical

assistance

• Establishment and Support of Forensic Centers

Nursing Home Reforms

Quality Improvement Measures

– Quality Assurance and Performance Improvement Program

– Effective Compliance and Ethics Program

– Culture Change and Information Technology Demonstrations

– Standardized Complaint Form

– Nursing Home Compare Medicare Website

– Dementia and Abuse Training

– Report on Five-Star Quality Rating System

Protections

– Notification of Facility Closure

– Background Checks on Employees of Long-Term Care Facilities

– Disclosure of Ownership and Parties

– Imposing civil monetary penalties

– Ensuring Staffing Accountability

Supreme Court Challenge

Where are we now?

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Four questions before the court

• Anti-Injunction Act

– Bars lawsuits prior to the payment of a tax

• The individual mandate requirement

– Commerce Clause

– Necessary and Proper Clause

– Taxing Power

• The Medicaid expansion

– Valid exercise of Congress’s spending power

• The severability

– In the case before the Supreme Court, the lower court held the ACA not severable and invalidated the entire ACA

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Further Information

For Up-to-date information visit NASUAD’s Affordable Care Act’s Webpage:

www.nasuad.org

Contact Information

1201 15th Street NW, Ste 350 Washington, DC 20005 Phone: 202.898.2578 Fax: 202.898.2583