The New Economy: Rethink, Realign, Reinvent How will the ACA Impact People with Disabilities?

1. The New Economy: Rethink, Realign, ReinventHow will the ACA Impact People with Disabilities? 2012 National Employment Conference Barbara Otto, CEO, Health & Disability Advocates botto@hdadvocates.org 1

2. Objectives • Impart critical information on how ACA will impact workers with disabilities • Share information on how decisions states will be making about the ACA will impact Vocational Rehabilitation • Update on howThink Beyond the Label is facilitating realignment and creating new opportunities for businesses to find resources and connect to qualified job candidates with disabilities.

3. What the“ACA” is really about… 3

4. Re-Design of Health Delivery System is an Opportunity • Human Services delivery system vs. “health care” or “employment services” delivery system • Employment is a social determinant of health and should be tracked and monitored Socio-Economic Physical Environment Individual Characteristics

5. Specific Provisions of ACA & People with Disabilities: Paths to Coverage • Pre-existing Conditions in Insurance Plans Eliminated • Individuals who previously went bankrupt over health care costs may now find affordable coverage • Extension of dependent care coverage to 26 • Massive change to mental health populations where onset ranges from 16-26 • Early intervention is key to long-term health • Elimination of caps on coverage • Beneficial for individuals with health insurance experiencing traumatic injuries or long-term medical conditions • Closing the doughnut hole for Medicare part D

6. ACA & People with Disabilities: Paths to Coverage 6

7. Post 2014: Insurance Affordability Programs Single State, Streamlined Application for Health Coverage If no disability, households can get a subsidy for the Exchange “Regular” Medicaid or Medicaid Optional Program 7

8. Eligibility Screening for Insurance Affordability Programs: Modified Adjustable Gross Income • Modified Adjusted Gross Income is a tax methodology and will be determined by IRS based on tax returns. • Calculated for the “household” and based on earnings listed in W-2. • Does not consider assets • MAGI may be applied to all applicants at the time of enrollment because of the simplified one entry point system. 8

9. Intersection of Employment & Access to Health Coverage • How will the states and the federal government identify people with disabilities in the single state application process? • Once identified, what will a “deeper dive” on eligibility for Medicaid and Medicaid optional programs like the Medicaid Buy-in look like? • During initial eligibility determinations and redetermination, will low wage earners with disabilities be placed into the Medicaid “Adult” group or the Exchange when the state’s Medicaid Buy-in would be more appropriate? 9

10. How will All of this work for American Indians & Alaska Natives? • ACA makes the Indian Health Care Improvement Act Reauthorization permanent and authorizes new programs within IHS • Expanded IHS services including mental and behavioral health • Increasing clinician recruitment and retention in Tribally Operated Health Programs • Access to Federal Employees Health Benefits program

11. How will this Impact Access to Health Care for Non Citizens & Migrant Workers? • Naturalized citizens will have the same access and requirements as U.S. born citizens • Lawfully Present Immigrants: • Eligibleto Purchase Insurance from the State Health Insurance Exchange • Eligiblefor premium tax credits • Must be (or is reasonably expected) to be lawfully present during entire period of enrollment • Will be subject to individual mandate.

12. How will the ACA Impact Migrant Workers? • Migrant Health Centers will continue to be an important safety net • ACA provides $11 billion in dedicated funding for community health centers – the National Association of Health Centers believes this will allow migrant health centers to almost double their capacity

13. ACA & People with Disabilities: Infrastructure / Delivery System • Essential Health Benefits creates a “foundation” for services packages available to all Americans: • No federal standard and no federal definitions • States can choose between different options – Alternative Benefits Plans on which to base their EHB plans (more detail in next slide) • States must cover all the categories outlined in ACA -- even if not covered in the insurance products they select for the Exchange

14. ACA Infrastructure & Essential Health Benefits • Insurance policies must cover these benefits to be certified and offered in Exchanges, and all Medicaid plans must cover these services by 2014. • Coverage must be equivalent (in actuarial value) to one of alternative benefits plans: Federal Employee Health Benefits Plan, State Employee Plan, Small Business Commercial HMO Product, or Secretary-approved coverage. • Outpatient and lab services; • Emergency services; • Hospitalization; • Maternity and newborn care; • Pediatric services, including oral and vision care; • Mental health and substance abuse, including behavior health treatment, with parity to physical health services; • Prescription drugs; • Rehabilitative and habilitative services and devices; • Preventive and wellness services and chronic disease management. 14

15. Consideration: Essential Health Benefits • Specific EHB services under the Medicaid expansion & Exchange are unknown at this time – CMS is seeking comments, but won’t provide “final” guidance until 2016 • States may include services that are not required, but services may not be more generous than what is already available in the existing state plan.

16. ACA & Intersection with Employment VR & Comparable Benefits: will ACA alleviate fiscal pressure? American Indians & Alaska Natives: Will ACA mean better health care? ? VR Processes: will the ACA change how we counsel customers? 16

17. Important Role for VR In ACA Infrastructure Development & Implementation • Program & services in Medicaid & Exchange: • Is the state creating a new Medicaid Adult Group? • Is the state operating its own Exchange? • How will eligibility for the Insurance Affordability Groups work? • What services are included in the Essential Health Benefits? Will it alleviate pressure on VR? • How will IHS and community health centers be impacted by ACA? • Have you been in any sessions at the state level where they’re talking about HCBS modifications or improvements (State plan options, waiver development, grant programs)? • Even in states that don’t opt for Medicaid expansion, there may be savings for VR in comparable benefits…

18. ACA Incentives Create More Opportunities for Employment Focused Programs • ACA has several avenues to integrate employment related health services and Medicaid funded employment services in the evolving health delivery system • Examples: • Health Home Models for individuals with chronic conditions • Medicaid State Plan Options like 1915 (i) • Money Follows the Person • States are looking at how to integrate expectation of employment – a social determinant of health – into their new systems of coordinated care • Example: Oregon

19. Roles in Health Delivery System: VR Counselors 19

20. How does Think Beyond the Label Help? Rethinking business engagement strategies: online tools, resources & access to job candidates in one place Reinventing employment services marketing: connecting businesses & people with disabilities directly Realigning communication strategies & providing thought leadership: blogs, success stories & earned media 20

21. Targeted Business Tools & Marketing “The folks behind a new online tool called Hire Gauge … help employers calculate the potential cost benefits of hiring someone with a disability.” Rita Pyrillis, Workforce Management 21

22. New Strategies for Businesses to Connect Directly to Job Candidates with Disabilities “Seventy percent of disabled Americans say they want to work full-time, but only about 21 percent do. Think Beyond the Label, … hopes to change that.” Karen E. Klein, BusinessWeek Online 22

23. New Strategies for Businesses to Connect Directly to Local Resources like VR “Think Beyond the Label [helps] employers of all sizes throughout the nation find local resources for recruiting disabled workers.”Sarah E. Needleman, The Wall Street Journal 23

24. Business Communication that Redefines the Pool of Job Candidates with Disabilities TBTL job seekers: • Live in all 50 states • Have experience in more than 26 different industries • 25% have 5+ years experience • 20% have 10+ years experience • 30% have professional certifications, college degrees & beyond 24

25. Health & Disability Advocates works across public, private and social sectors to create smarter systems of health, disability and employment. Barbara A. Otto botto@hdadvocates.org 312.265.9090 Follow: @BarbAOtto, @hdadvocates, Visit: www.thinkbeyondthelabel.com