Healthcare Reform

1. Healthcare Reform Implications for CDPHE Sara Russell Rodriguez Chronic Disease Director Colorado Department of Public Health and Environment

2. Background • Signed into law on March 23, 2010 • Final bill created through a reconciliation process • Could change items with fiscal impact • No ability to change timelines • Timelines are aggressive • Many of the provisions in the bill have not had funding appropriated

3. Insurance Coverage: Pre-existing Insurance Plan Coverage • Effective July 6, 2010 in Colorado • Colorado runs plan (as opposed to HHS) • Eligibility • Lawfully present in US • Uninsured for the last 6 months • Difficulty getting insurance due to a pre-existing condition

4. Individual Mandate • Tax penalty • $695-$2085 or 2.5% of family income • Penalties are phased in • $95 in 2014 • 2.5% of income in 2016 • Increases yearly with cost of living • Exemptions • Religious • Native American • Those without coverage for less than 3 months • Undocumented • Incarcerated individuals

5. Individual Mandate • Exemptions • Premium exceeds 8% of income • Income less than filing threshold • $9,350 for singles • $18,700 for couples

6. Employer Mandates • Effective January 1, 2014 • 50+ employees with at least one full-time employee • Penalties for those receiving subsidies for purchasing health insurance • Must offer vouchers to those whose employer-based coverage is unaffordable • 200+ employees • Automatically enroll employees in coverage • Employees can opt out

7. Employer Mandates Less than 50 employees are exempt from penalties Employers with less than 25 employees receive tax credit for purchasing health insurance

8. Medicaid Expansion • Effective January 1, 2014 • All individuals under age 65 • Up to 133% of the federal poverty level (FPL) • Financed through • 100% federal funding for 2014-2016 • Decreases incrementally to 90% in 2020 • Increases provider payments for primary care to Medicare rates • 100% federally financed

9. Children’s Health Insurance Plan Maintain current income eligibility 2015 states will receive a 23% increase in federal cost sharing Children ineligible to enroll will receive tax credits in state exchanges

10. Medicaid Initiatives • Funding for innovative payment reform • Accountable care collaboratives • Rural telehealth • Other pilots • Pilots for obesity prevention • Pilots for incentives for chronic disease prevention and management • Medical home incentives

11. Medicaid Initiatives • Requires tobacco cessation counseling and pharmacotherapy for pregnant women • Encourages no cost sharing for preventive benefits • Receive additional federal funding • Waivers • Family planning • Long term care

12. Medicare Initiatives • Payment reform • Accountable care organizations • Preventable admissions; conditions • Reduce Medicare Disproportionate Share Hospital payments • Independent payment advisory board • Independence at home pilot • New office for dual eligibles • Eliminates cost sharing for preventive benefits

13. Health Insurance Exchanges Exchanges need to be effective as of January 1, 2014 Individuals and small businesses (<100 employees) can purchase coverage Offers subsidies for those up to 400% of FPL Allows for catastrophic coverage for those <30 years old or exempt from individual mandate

14. Private Health Insurance • Allows coverage for dependent children up to age 26 (August 2010) • Requires reporting of funding spent on clinical rather than administrative costs • Provides rebate to consumers if exceeds threshold (2011) • Prohibition of lifetime limits on coverage (August 2010) • Prohibition on annual limits (January 2014)

15. Private Health Insurance Prohibit exclusion of pre-existing conditions in children (August 2010) Prohibit exclusion of pre-existing conditions in adults (January 2014) All proposed premium increases must be approved by the state

16. Insurance Coverage • US Preventive Services Task Force A and B Recommendations (Sept 2010) • No cost sharing • Immunizations • Well-child care • Defines essential benefit package (2014) • Limits on deductibles and co-pays • Plans can be “grandfathered” • Exempt from coverage and cost sharing requirements

17. Workforce Development • Workforce development grants • National Health Service Corps • Training programs • EIS, PHPS, laboratory, informatics • Primary care • Dental • Long-term care • Loan Repayment • Allied health professionals, public health, faculty

18. Healthcare Infrastructure • Federally Qualified Health Centers • $11 billion over 5 years • School-based health clinics • Infrastructure • Nurse-managed health clinics • Surveillance and lab capacity • Meaningful Use • Provider payments for Electronic Health Records

19. Prevention and Wellness • Prevention and Wellness fund • Tobacco, physical activity, nutrition, public health infrastructure • Healthy Aging • Chronic Disease Self Management • Pregnancy Assistance • Personal Responsibility • Community Transformation grants

20. Prevention and Wellness • Immunizations • Home Visitation programs • Worksite wellness for small businesses • 5 year grant funding available • Permits employer-based rewards for behavior or outcomes • Menu labeling of chain restaurants and vending machines (2011)

21. Prevention and Wellness Patient navigation services Diabetes Prevention Program Accountable Care Organizations

22. Health Equity Community health teams Workforce diversity Data collection

23. National initiatives • Interagency workgroup on quality measures • National Improvement strategy • Comparative effectiveness research • National Prevention, Health Promotion and Public Health Council • Chaired by Surgeon General • National health promotion and prevention strategy

24. Implications for CDPHE • Coverage of direct services • Some will fall through the cracks • National direction • Clear emphasis on primary prevention • Funding for community-based initiatives

25. Implications for CDPHE • Funding Opportunities • Home Visitation • Pregnancy prevention • Immunizations • Long term care • Primary care • Healthy Aging • Prevention and Wellness Fund • Patient navigation/community health worker • Community transformation grants • Dental sealants

26. Questions?