Affordable Care Act’s Impact on the VA

1. DUANE FLEMMING, PMPVHA OFFICE OF THE ASSISTANT DEPUTY UNDER SECRETARY FOR HEALTH FOR POLICY AND PLANNING Affordable Care Act’s Impact on the VA PRESENTATION TO THE NURSES ORGANIZATION OF VETERANS AFFAIRS 34TH ANNUAL MEETING June 26, 2014

2. Agenda • Review key provisions of the Affordable Care Act (ACA). • Examine the implications of the ACA for Veterans, eligible beneficiaries, and VA health care. • Learn about VA’s successful strategic communication effort. • Measure the impact of the health care law on VA. • Review ongoing efforts and key dates for ACA and VA.

3. Affordable Care Act (ACA) Key Provisions • ACA, also known as the health care law, was created to • Expand access to affordable health care coverage, • Control health care costs, and • Improve the health care delivery system. • Most individuals required to have health coverage that meets the minimum essential standard. • Enrollment in VA health care, CHAMPVA or Spina Bifida programs meet the standard. • Established Health Insurance Marketplaces. Certain individuals, based on their income, may be eligible for assistance to lower the cost of health care coverage premiums. • Under the Medicaid expansion provision of ACA, states have the option to expand Medicaid eligibility to up to 138% of the Federal Poverty Level. • Established demonstration projects known as the Accountable Care Organizations.

4. Premium Tax Credit – Illustrative Example • Paid directly to health plan to offset the total cost of the health insurance premium. • Based on individual/family income, up to 400% of the Federal Poverty Level. • Based on sliding scale with lowest income households paying smallest share.

5. Individual Mandate Requirement • Individuals and families who do not have qualifying health coverage beginning in January 2014 must make a payment when filing their taxes. • The flat rate payment is phased in for the first three years (2014-2016). • Payment increases after 2016 with a cost-of-living adjustment.

6. ACA Implementation Timeline • March • The ACA became Law • June • Medicare beneficiary drug rebate • September • Coverage for young adults • Preventive care coverage • Other insurance changes • Health care workforce commission establishment • January • Prescription drug discounts to close the Medicare drug coverage gap • Medicare bonus payment for primary care • Medicare prevention benefits without cost sharing • CIIO establishment • March • Grants for Health Insurance Marketplaces • December • Pioneer ACOs announced • January • Annual fees on pharmaceutical industry • March • Data collection to reduce health care disparities • October • Medicare value-based purchasing • Reduce Medicare payments for hospital readmission • January • Individual mandate for health insurance • Health insurance marketplaces • Premium subsidies to eligible individuals • Essential health benefits package • Medicaid coverage expansion • Impose fees on health insurance sector • January • State notification regarding marketplaces • Closing the Medicare drug coverage gap • Medicare tax increase for certain individuals/families • Impose tax on Medical devices • October • Open enrollment began • Health Insurance Marketplaces became operational • January 2016 • Employer mandate for companies with 100 or more employees • January 2016 • Employer mandate for companies with 50 to 99 employees • January 2018 • Impose tax on high-cost insurance 2010 2011 2012 2013 2014 2015-2018

7. Affordable Care Act Key Policy Issues • Medicaid Expansion: As of May 2014, 27 states and the District of Columbia are expanding their Medicaid programs to all nonelderly low-income adults. • Implications for Veterans • Implications for Community Health Centers • Implications for Access to Mental Health Services • Marketplace: As of May 2014, 36 states will rely on the federal health insurance marketplace for 2015 enrollment. • Limited Provider Networks: Large and small insurers are limiting the number of doctor and hospital groups in their networks in order to control costs. • Employer-Sponsored Coverage: Employers consider shifting workers into the marketplaces instead of providing coverage for workers with high medical costs.

8. Strategic Implications of ACA to VA • The enactment of the ACA has strategic and policy implications for VA as some Veterans gained new options for health care coverage under the law starting in 2014, potentially impacting VA enrollment and utilization. • Other potential impacts of ACA to VA: • Information technology (IT): Develop an IT system to provide information to IRS. • Data requirements: Develop and maintain a database to track certain VA beneficiaries. • Workforce: Ability to attract and maintain a highly skilled health care workforce in light of increased overall demand for health care services and opportunities in the public and private sectors. • Impact of Accountable Care Organizations (ACOs). • Impact in areas with access and system capacity challenges. • Impact on maintaining affiliations with academic medical centers.

9. ACA Implications for Veterans • ACA will give some Veterans the option to decide whether to use VA for health care, or choose non-VA care options. • Depending on where Veterans live, and their income levels, they may become eligible for Medicaid or assistance to purchase health coverage through the health insurance marketplace. Veterans’ decisions may be based on decisions their families make on their healthcare. • Since VA enrollment meets the standard for coverage under the law, enrolled Veterans are not eligible for assistance in purchasing insurance. • Increased options have implications for VA. • Veterans will expect VA to be able to assist them in understanding their options and deciding what’s best for them and for their families.

10. The Veteran Population: Enrollment and Health Insurance Coverage Data Sources: 2012 American Community Survey, 2012 VHA End of Year Enrollment Reports, and Base Year 2012 VA Enrollee Health Care Projection Model

11. VHA’s ACA Implementation Activities • VHA Policy and Planning is leading and coordinating health reform efforts. • Examining strategic and operational issues impacting VA’s implementation of ACA. • Chartered an Integrated Project Team to provide advice and subject matter expertise to VA leadership. • Made accomplishments in the areas of policy, operations, communications, information technology, solicited VISN interest in affiliations with accountable care organizations, and conducted an educational campaign for Veteransand eligible beneficiaries. • Executing a communications strategy that includes a VA ACA website, print materials, and social media messaging. • Continuing collaboration with other federal agencies / meeting requirements as outlined by Department of Health and Human Services. • Monitoring the national health policy landscape. • Conducting focused outreach campaigns to target non-enrolled Veterans (e.g., uninsured, low-income, enrollment-eligible).

12. VA’s Overarching Communication Strategy • VA’s focus is two fold: • Educate Veterans that VA health care meets ACA health insurance standards and promote VA health care as an option (for those not currently enrolled); and • Communicate to Veterans and their families the value of health insurance and provide information about the Marketplace to those not eligible for care through VA, including Veterans’ families. • To execute a multi-faceted strategy to engage with Veterans, staff and other stakeholders about VA and ACA. • There are approximately 22M Veterans, 8.76M are enrolled in VA health care programs • There are an estimated 1.2M uninsured Veterans, most are eligible for VA health care • To ensure consistent communications with these audiences, VA has developed key messages to share with Veterans and other VA beneficiaries. • VA began communicating information on ACA in July 2013. • Communicate with VA employees through established workforce communication channels and other medium including TMS modules, VA eHealthUniversity.

13. VA’s Overarching Communication Strategy (cont.) • Communications plan and materials were developed through a collaborative team and available for dissemination to Veterans and beneficiaries. • Materials include: • Fact Sheet • Frequently Asked Questions • Poster • Language for VA social media sites • VHA’s Chief Business Office developed a website and an interactive web tool where Veterans and eligible beneficiaries can obtain additional information about VA health care programs, health care benefits and ACA.

14. Key Messages • VA wants all Veterans to receive health care that improves their health and well-being. • VA will assist Veterans and other beneficiaries to determine their eligibility for VA health care and other health coverage options. • If enrolled in VA health care, a Veteran does not need to take additional steps to meet the health care law coverage standards. • The health care law does not change VA health benefits or Veterans’ out-of-pocket costs. • Veterans and other beneficiaries not currently enrolled in VA health care can apply for enrollment at any time. • Applications are accepted online at www.va.gov/healthbenefits/enroll, by phone at 877-222-VETS, by mail, or in person at a VA medical facility. • VA will continue to provide Veterans with high quality, comprehensive health care and benefits they are earned through their service. • Veterans’ family members and Veterans not eligible for VA care may secure coverage through the Marketplace. 

15. ACA Outreach Efforts • Landing Site (interactive website with ACA information, comparison tool, etc.) • Veterans’ family members webpage with link to healthcare.gov • Direct Mail • Print/Online/Media Communications • Social Media (Facebook, Twitter, Blogs) • In-Person Communication Tools • Collaboration with other Federal agencies and partners • HHS, DoD, DOL, SBA • State Governors and State Veterans Agencies • Leverage partnership opportunities • VSOs , NGOs, MSOs • Veteran small business owners

16. ACA Outreach Efforts www.va.gov/aca

17. ACA Outreach Efforts: VA Health Benefits Explorer

18. ACA Outreach Efforts: VA Health Benefits Explorer (cont.)

19. Targeted Outreach • VA has a goal of identifying for outreach a cohort of non-enrolled Veterans having a high probability of being eligible for enrollment and accessing VHA services once enrolled who are also most likely to lack health insurance coverage. • Identified non-enrolled eligible Veterans using the American Community Survey and USVETS data. • Shared workbooks with each VISN and conducted conference calls with nearly all VISNs to orient them to the data. • VISNs are able to select the cohort for outreach and tailor letters to Veterans. • Working with VISNs to complete assessment and mail letters to Veterans promptly.

20. VA ACA Metrics

21. Veteran Enrollment: Monitoring ACA Impact

22. Collaboration Efforts with HHS • HHS hosted monthly Regional ACA meetings to provide standardized information to federal partners about the provisions in the ACA and to facilitate communication with the general public. • HHS interested in those states and counties with the highest percentages of uninsured. • HHS launched a redesigned website www.healthcare.gov. VA has visibility on this site. • HHS is asking other federal agencies to provide information to assist them in communicating at the state and local levels. • HHS is interested in learning more about eligibility for VA health care coverage. • VHA is working with HHS to participate on a Center for Consumer Information and Insurance Oversight (CCIIO) webinar to share VA information with Navigators and Assisters.

23. Affordable Care Act Key Dates in 2014 April 15, 2014 Special enrollment period for the federally-facilitated health insurance marketplace ends April 30, 2014 Special enrollment period for some state-based health insurance marketplaces ends May 27, 2014 Health plans begin submitting applications to certify qualified health plans on the federally-facilitated health insurance marketplace June 27, 2014 End of application period October 14, 2014 CMS begins sending certification notices and health plan agreements to insurers November 15, 2014 2015 OPEN ENROLLMENT BEGINS April 1 – November 14, 2014 Individuals can enroll through special periods if meeting certain qualifying events. • Sources: §155.420 — Special enrollment periods. Exchange establishment standards and other related standards under the Affordable Care Act [45 CFR 155], CCIIO, “2015 Letter to Issuers in the Federally-facilitated Marketplaces,” March 14, 2014; Deloitte Health Care Current April 8, 2014

24. In Summary • Reviewed key provisions of the Affordable Care Act (ACA). • Examined the implications of the ACA for Veterans, eligible beneficiaries, and VA health care. • Learned about VA’s successful strategic communication effort. • Reviewed key metrics to assess the impact of the health care law on VA. • Highlighted ongoing efforts and key dates for ACA and VA.

25. Resources • VA’s Landing Page www.va.gov/aca • ACA Communication Resource Center https://cbomssp.hec.med.va.gov/acacomm • For additional questions / information about VA and ACA vhacohealthreform@va.gov • For information on ACA and the Marketplace, visit: www.healthcare.gov

26. Additional Information

27. 2013 Federal Poverty Levels 27

28. Essential Health Benefits • Essential Health Benefits are items and services in 10 categories that must be included in plans sold through the health insurance marketplaces. • Ambulatory patient services • Emergency services • Hospitalization • Maternity and newborn care • Mental health and substance use disorder services, including behavioral health treatment • Prescription drugs • Rehabilitative and habilitative services and devices • Laboratory services • Preventive and wellness services and chronic disease management, and • Pediatric services, including oral and vision care • Levels of coverage for these benefits will vary from plan to plan.