2. The Patient Protection and Affordable Care Act (ACA) was
signed into law in March of 2010
A governmental policy that changes the delivery of health
care services in a given place
Major Changes:
All Americans must have health insurance by 2014
More emphasis on community-based services and less
reliance on institutional care
Disease prevention and wellness are major themes
WHAT IS THE ACA?
3. Broaden the population that receives health care coverage
through employment, or public sector insurance companies
(e.g. DPW)
Increase the number of health care providers people may
choose from
Improve the referral process and the right to be seen by a
specialist
Mandate health insurance by reducing the cost and making it
affordable for everyone
REFORMS IN THE ACA ATTEMPT TO:
4. A NEW VOCABULARY
Accountable care
organization (ACO)
Basic health programs
Carve-out
Centers for Medicare and
Medicaid Services
Community health centers
Federally Qualified Health
Center
Electronic Health Record
(EHR)
Health care homes
Health information
technology (HIT)
Health information privacy
and security
Health Insurance Portability
and Accountability Act
(HIPAA)
Home and Community-
Based Services
Information transparency
Meaningful User
Medicaid
Medical home
Patient Protection and
Affordable Care Act
6. Core feature of the ACA
Includes:
Individual Mandate provision
Expanding Medicaid eligibility
Establishing Health Insurance Exchanges
Establishing the Essential Health Benefits package
Providing tax incentives to purchase insurance
An estimated 32 million individuals will
become insured by 2019
INSURANCE REFORM
7. Most controversial provision of the ACA
Requires individuals to obtain health
insurance or pay a penalty
Penalties increase each year
Exemptions include:
Religious
Incarceration
Undocumented status
INDIVIDUAL MANDATE
8. Individuals and families with incomes up to
133% of the Federal Poverty Level (FPL) will
be eligible
Appx. $14,850 for an individual
Appx. $30,650 for a family of four
Expected to enroll 11.6 million people in 2014
MEDICAID EXPANSION
9. States must establish by January 2014 or default to
the Federal government
Several requirements:
User Friendly
Must screen and enroll public & private coverage
Must establish “navigators”
Transparency
Self-financing by 2015
HEALTH INSURANCE EXCHANGE
10.
11. Ambulatory patient
services
Emergency services
Hospitalization
Maternity and
newborn care
Mental health and
substance use
disorder services,
including behavioral
health treatment
Rehabilitative and
habilitative services
and devices
Laboratory services
Preventive and
wellness services and
chronic disease
management
Pediatric services,
including oral and
vision care
Prescription drugs
ESSENTIAL HEALTH BENEFITS
WHAT IS ESSENTIAL?
12. Many provisions are already in effect:
Pre-Existing Condition Coverage to age 19
Family Coverage to age 26
No Annual or Lifetime Limits
Closing the Medicare Donut Hole
No co-pays/deductibles for prevention/
promotion interventions
Medical loss ratios now at 85 and 80 %
COVERAGE REFORM
13. QUALITY REFORM
Patient Centered Medical
Homes (PCMH) and Health
Homes
Accountable Care
Organizations
Establishment of National
Quality Measures
14. ACCOUNTABLE CARE ORGANIZATIONS
(ACO)
Providers collectively take
responsibility for the quality and
costs of treatment
If providers can reduce costs
while providing high quality care
they receive a share of the cost
savings
Can be operated by health
systems, health plans, hospitals,
large physician practices or
other medical service
organizations
Population health approach = not
just taking care of the sick but
keeping people healthy
15. PAYMENT REFORM
Payment reform involves moving whole
sectors of the health care field from
encounter payment systems to case and
capitation systems
Lead work in this area will be done by
the Center for Medicare & Medicaid
Innovation:
Medicare ACO Pioneer project
CMMI Innovation Challenge
Medicaid Emergency Psychiatric
Demonstration
This is a 10 year undertaking
16. HIT is the use of computers as a means of
exchanging medical information from doctor to
doctor, or provider to provider
Currently, behavioral healthcare is not receiving
financial incentives to implement needed EHRs for
the field
The Behavioral Health Information Technology Act of
2011, S.B.39, is currently in Congress
Would expand Federal incentives to implement HIT in
physical health care to behavioral health care
HEALTH INFORMATION TECHNOLOGY
REFORM
17. §10334: Elevates
Office of Minority
Health (OMH) to HHS
and requires six HHS
agencies to establish
offices of minority
health
§4302: Mandates
federal health care
programs to collect
and report data on
sex, race, ethnicity,
language and
disability status
§5306: Behavioral
health workforce
development grants
§5313: Community
health workforce
grants to promote
culturally and
linguistically
appropriate services
§3509: Establishes an
Office of Women’s
Health
HEALTH EQUITY PROVISIONS
19. ACA BENEFITS TO PENNSYLVANIANS
Insurance Reform
7.7 million residents are without lifetime limits on
coverage
32,100 young adults received coverage through parent’s
plans
657,000 children can not be denied coverage due to pre-
existing conditions
Medicare Provisions
2.3 million Medicare beneficiaries receiving primary care services
with no copay
Currently, Medicare beneficiaries receiving 50% discount on brand
name drugs in donut hole
By 2020 donut hole will be closed
20. ADVOCACY OPPORTUNITIES
Essential Health Benefits inclusion of behavioral health
services
HHS has given States the discretion to craft the EHB Package
While Mental Health/Substance Use is defined as an essential
health benefit, state determines at what level
Health Insurance Exchange Design & Implementation
Transparency & Governance
Use of Navigators
Other State Legislation
S.B. 10: Amending the PA Constitution
Maintenance of Effort (MOE) Waiver Request