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Explore the impacts of Medicaid expansion, essential benefits, and health insurance exchanges on the Texas healthcare system. Understand how the Affordable Care Act is reshaping healthcare delivery.
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Health Care ReformThe Road Ahead August 19, 2010 Ardas Khalsa, Medicaid Coordinator Texas Department of State Health Services
“The future ain’t what it used to be.” ---Yogi Berra
Reforms Medicaid Expansion Benchmark Benefits Plan Essential Benefits Health Insurance Exchange Demonstrations/Grants Health Workforce Impacts to Texas Healthcare Delivery Systems
The Affordable Care Act The Patient Protection and Affordable Care Act (PPACA), was enacted on March 23, 2010. The Health Care and Education Reconciliation Act of 2010 (HCERA) was enacted on March 30, 2010. Together, these two pieces of legislation are called the Affordable Care Act (ACA). The Affordable Care Act will make significant changes to the health care reform market.
Medicaid Expansion Mandatory eligibility group for low income Expands Texas Medicaid (Mandated in January, 2014) as follows: Children 6 – 19 from 100% to 133% FPL Aged, blind and disabled persons from the SSI standard (74% FPL) to 133% FPL Parents of TANF children from 14% to 133% FPL Non-disabled, childless adults from non-covered to 133% FPL Expands foster care Medicaid to age 26
Adult Eligibility Impact 400% FPL Subsidy Subsidy Subsidy Subsidy Subsidy 250 225 200 250% FPL 220% FPL 175 Pregnant 185% FPL 150 125 Expansion 133% FPL Expansion 133% FPL Expansion 133% FPL 100 75 SSI 74% FPL 50 25 14% FPL Parents Aged & Disabled Adults MBI NF, ICF, HCBS waiver
Children’s Eligibility Impact 400% FPL Subsidy Subsidy Subsidy 250 Subsidy 225 200 220% FPL CHIP CHIP CHIP 175 185% FPL 150 125 Expansion 133% FPL* 133% FPL 100 Current 100% FPL 75 50 25 6 – 19 *& former foster kids <26 NF, ICF, IMD HCBS Waiver Newborns<1 1- 5
Eligibility Changes financial eligibility requirements for Medicaid- Must use modified adjusted gross income - MAGI Prohibits assets test and income disregards (except for some groups, such as people on SSI; elderly and disabled, etc.) Includes a 5% income deduction allowance, making the effective ceiling 138% (133% +5%) Requires States to maintain at least existing level of Medicaid eligibility (no stricter rules) until January 2014 (adults) and October, 2019 (children)
Enrolling in Medicaid By 2014 must include – Enrollment via website Enrollment via insurance exchange Coordinate Medicaid / CHIP with exchange Outreach to special populations including people with MHSA disorders, victims of abuse or trauma, homeless youth, individuals with HIV/AIDS, etc.
Benchmark Coverage Foster care expansion and other expansion children receive full Medicaid benefits Some other expansion populations may receive “benchmark or benchmark-equivalent” coverage Benchmark could resemble: Federal employees Blue Cross preferred provider plan, Plans offered or available to state employees, Health maintenance organization (HMO) plan in the state with the largest non-Medicaid enrollment, OR Any other plan approved by the U.S. Secretary of Health and Human Services Benchmark packages must include “essential benefits”
Essential Benefits Ambulatory care Hospitalization Laboratory services Emergency services Maternity and newborn care Pediatric services, including oral and vision care Mental health and substance use disorder services Prescription drugs Rehabilitative and habilitative services and devices Chronic disease management Preventive and wellness services
Prevention in Medicaid State plan option to include clinical preventive services graded A or B by US Preventative Services Task Force. 1% federal match increase if states don’t require co-payment. (January, 2013) States must provide tobacco cessation services for pregnant women. States are not allowed to require cost sharing. (October, 2010)
Federal Medicaid Share For the “newly eligible” (over age 19, not Medicaid eligible before reform law passed)
CHIP Extends federal CHIP funding through 2015 From October 2015 to September 2019: federal CHIP match rate increased by 23% Requires states to maintain existing CHIP eligibility through September 2019 Requires use of modified gross income beginning January 2014
Health Insurance Exchange Must be operational by January 2014. Failure to establish Exchange will result in HHS establishing an Exchange within any non-participating state. State must demonstrate by January 1, 2013, that it will have Exchange operational by January 1, 2014. Must be administered by a governmental agency or non-profit organization.
Health Insurance Exchange Provides one stop insurance shopping for individuals and small businesses. All plans sold in the Exchange must be certified by TDI as meeting minimum federal benefit standards. Exchange must provide a seamless application and enrollment process for individuals who qualify for subsidies, requiring coordination with HHSC for Medicaid and CHIP inclusion. Federal funding: HHS will distribute implementation grants to states within one year after date of enactment of legislation.
Expansion of Insurance Coverage Individual Mandate effective January 2014. Individuals (US citizens and legal residents) required to obtain qualifying coverage that meets federal standards. Can be an individual or group health plan. Exemptions for individuals meeting any of the following: earnings fall below tax filing threshold (currently $12,050 for individual and $18,700 for couple), religious objections, members of Indian tribes, or not covered by insurance for less than three months. Subsidies for families/individuals up to 400% FPL (approximately $43,000 individual, $88,000 family of 4) to apply towards premium costs.
Health Workforce Demand for primary care providers and specialists will increase as more Texans are insured. State will need to examine this increased demand as it relates to the supply of healthcare providers. Strategies for meeting increased demand will need to be explored, i.e. telemedicine, additional use of ancillary service providers.
