Health Care Reform

1. Health Care Reform Jan Heckemeyer Mayme E. Young, JD Department of Mental Health

2. Patient Protection & Affordable Care Act (ACA) and the Health Care & Education Reconciliation Act of 2010; Enacted March 2010. Culmination of more than 70 years of attempts by the federal government to expand health care access and coverage. Contains significant expansions of access and coverage for almost all Americans. What is Health Care Reform?

3. Increase number of people with health coverage. Improve quality of health coverage. Increase wellness and disease prevention efforts. Insurance and payment reform. Overarching Goals of Health Care Reform

4. Uninsured Individuals: • 46 million in United States • 800,000 in Missouri The ACA will expand coverage to an estimated 32 million Americans, including 500,000 Missourians. Health Care Reform

5. Must provide dependent coverage up to age 26. Certain preventative services are covered without requiring co-payments or deductibles. Prohibits rescinding insurance coverage except in cases of fraud. Prohibits annual and lifetime limits on coverage. Children cannot be denied coverage because of pre-existing conditions. Insurance Regulations

6. Over 30 lawsuits have been filed in courts across the country to challenge the constitutionality of key provisions – primarily the “individual mandate”. As of May 6, 2011, five federal district courts have ruled on the merits of the individual mandate – three have upheld the constitutionality and two have struck it down. A number of cases have been dismissed on procedural grounds, such as lack of standing. Of the two rulings striking down the individual mandate, only one court has determined that the individual mandate is not severable and thus, the entire ACA is invalid. Appeals are pending in several circuits with hearings starting soon. It is expected that the Supreme Court will ultimately rule on the constitutionality of the law. Pending Legal Challenges

7. Serves as a health plan shopping mall for individuals and small businesses seeking more stable health care rates and coverage. Employers with 50 or less employees and individuals (including those eligible for Medicaid) choose among plans offered through an Exchange. What is Health Insurance Exchange?

8. Each state must establish a Health Insurance Exchange by January 1, 2014. • Must be operated by a governmental entity or non-profit entity. • For states that do not establish an Exchange, or if the state’s Exchange fails to meet Federal requirements, the Federal government will operate the Exchange. • Exchange must make “qualified” health plans available to individuals and employers. • Exchange must provide “no wrong door” portal for all consumers to determine eligibility and enroll in: • Medicaid, • Children’s Health Insurance Program (CHIP), • Premium tax subsidies to purchase private coverage, and • Non-subsidized private coverage. Health Insurance Exchange Requirements

9. Established Health Insurance Exchange Coordinating Council (HIECC). Received $1 million planning grant. HB 609 organizes the Exchange as a quasi-governmental agency called the “Show-Me Health Insurance Exchange”. As of May 6, 2011, HB 609 has passed the House and is awaiting floor debate in the Senate. Missouri Action on Health Insurance Exchange

10. Guiding Principles: • Maintain market stability and viability. • Enhance competition based on value to consumers. • Constrain the rate of growth of Missouri health care costs. • Improve health status of enrolled populations. • Enhance access to quality affordable health insurance coverage. Show-Me Health Insurance Exchange

11. Key Functions: • Certify “qualified” health plans. • Screen Missouri residents for subsidies, including Medicaid. • Conduct outreach, education and assistance for individuals and small businesses seeking coverage. Show-Me Health Insurance Exchange

12. Beginning January 1, 2014, states will be required to provide Medicaid benefits to uninsured individuals with household incomes up to 133% FPL who are: • Under age 65, • Not pregnant, • Not entitled to or enrolled in Medicare Part A or B, and • Not eligible for Medicaid under any other mandatory category. Medicaid Expansion to 133% FPL

13. Missouri currently covers: • Pregnant women and children. • Parents to approximately 20% of the FPL. • Permanently and totally disabled individuals under age 65 to 85% FPL. Medicaid Expansion to 133% FPL

14. % Gross Monthly Income Medicaid Expansion to 133% FPL 2011 FPL Guidelines

15. States will receive increased federal financial participation for newly eligible individuals in the expansion group: 100% - 2014, 2015 and 2016 95% - 2017 94% - 2018 93% - 2019 90% - 2020 and thereafter Medicaid Expansion to 133% FPL

16. ACA improvements to CHIP: • Simplified enrollment process. • Extended program. • Enhanced federal match - • Missouri will receive a 23% increase in the current federal match rate for children covered through CHIP for 4 years, beginning 2015 through September 2019, • DMH will need to identify children seeking DMH services that qualify for CHIP and assist families with the enrollment process, and • DMH will coordinate with DSS regarding identification of children covered through CHIP. Children’s Health Insurance Program (CHIP)

17. MFP is a federally funded program that allows people with disabilities or who have mental illness or who are elderly and in need of long-term supports and services to have a choice of where they live and receive services. If a person on Medicaid has been in a long-term care facility for at least 90 days, the program allows them to return to their community where they can receive supports and services to help them stay independent. Since this program was first implemented in Missouri in 2008, more than $1 million in new federal money has come to Missouri and more than 225 people have been able to move from institutions back to the community. Money Follows the Person (MFP)

18. In 2006, Missouri applied for and received a MPF grant. DSS is lead agency and administers the grant in partnership with DMH & DHSS. Because Missouri is already participating in MFP, we have an open opportunity to amend the operational protocol and budget to add new services and populations and to request additional administrative funding any time through 2016. Money Follows the Person (MFP)

19. What is a “health care home”? A multidisciplinary team of health care providers who work together to ensure that a person has a regular primary care physician and that their care is coordinated so that all other health care providers involved know what each is doing and what a person needs next in order to have the best health care possible. A health home is responsible for making sure the patient gets all the care he/she needs, but does not have to provide all the care themselves. Health Care Homes for Chronic Conditions

20. What is considered a “chronic condition”? For purposes of the health care home, ACA considers the following to be chronic conditions: • Mental Health Conditions • Substance Use Disorders • Asthma • Diabetes • Heart Disease • Overweight (BMI>25) • Other conditions may also be included Health Care Homes for Chronic Conditions

21. Eligible Individuals: • Persons with 2 chronic conditions. • Persons with 1 chronic condition who are at risk for a 2nd chronic condition. • Persons who have 1 serious and persistent mental health condition. Health Care Homes for Chronic Conditions

22. Emphasizes comprehensive care management. Care coordination and health promotion. Comprehensive transitional care including follow-up from inpatient and other settings. Patient and family support (not defined). Referral to community and support services. Use of health information technology (HIT) to link services. Health Care Homes for Chronic Conditions

23. ACA requires: • A process for hospitals to refer eligible individuals seeking ER services to health care home providers. • A method of tracking avoidable hospital admissions and cost savings due to improved care coordination. • Use of health information technology (HIT) to improve care coordination in service delivery. Health Care Homes for Chronic Conditions

24. Medicaid has traditionally paid for long-term care services for low-income Americans in institutions (i.e., nursing homes, state hospitals or habilitation centers). ACA improves the options available under a state’s Medicaid plan to allow for services to be provided in a home or community-based setting. ACA provides more flexibility to states and creates the ability for states to customize the services provided and the population targeted. DMH is considering a state plan amendment that would allow individuals with mental illness and/or substance abuse to receive better home and community-based services. State Medicaid Plan Options

25. Continue participation and support for Cabinet Team. Provide DMH representation on interagency groups. Educate DMH stakeholders about health care reform opportunities. Participate in statewide infrastructure development, such as the Health Information Exchange, changes to eligibility applications and Medicaid billing changes. Department of Mental Health Commitments

26. Since enactment of the ACA on March 23, 2010, the Department of Health and Human Services has made $47.2 million in new grant funding available in Missouri. (as of 3/22/11) ACA Grant Funding