2. Does the ACA Affect You?
• No, I already have health insurance through my
employer, family member or programs such as
Medicare and Medicaid. (85%)
• Yes, my employer doesn’t provide health
insurance, or
• Yes, I’m below 400% of poverty, ineligible for
Medicaid (due to income) and don’t have health
insurance (15%)
• Yes, I was previously ineligible for Medicaid but
now I am eligible
3. California has the eighth
largest proportion of
uninsured in the nation
and the largest total
number of uninsured. Only
three states (Massachusetts,
Hawaii, and Minnesota) have
uninsured rates under 10%.
*All numbers reflect the non-
elderly population, under age
65.
Source: Employee Benefit
Research Institute estimates of
the 2009 – 2011 Current
Population Survey, March
Supplements.
4.
5. Getting California Covered
• 2.6 million Californians qualify for federal
financial assistance
• Another 2.7 million Californians will benefit
from guaranteed covered coverage
• Estimated 2.3 million California residents will
enroll in a health plan through the Exchange
(Covered California) by 2017
6. Getting California Covered
• 2014, employers with 25 or fewer employees
– possible eligibility for tax credits
• 2014, employers with 50 or fewer employees
can buy plans in the Exchange
• 2015, employers with 100 or fewer employees
can buy plans in the Exchange
9. The Uninsured Unauthorized (5)
A recent report by the UC-Berkeley Center for Labor
Research and Education and the UCLA Center for
Health Policy Research on California residents who
will remain uninsured after the ACA takes effect
found that:
• 66% of the remaining uninsured will be Latino;
• 60% of the remaining uninsured will have limited
English proficiency; and
• 62% of the remaining uninsured will live in
Southern California.
10. Poor Outreach
• The report also found that about 50% of those
still uninsured five years after the ACA takes
effect will qualify for coverage under the
Medi-Cal expansion or for health benefit
exchange subsidies, but they will not be aware
that they qualify because of poor outreach.
Medi-Cal is California's Medicaid program (5)
11. MediCal (Medicaid)
• Another almost 1.5 million Californians are
eligible for expanded Medi-Cal, which will be
open to all individuals under 65 with incomes of
up to $16,000 for an individual and about
$32,500 for a family of four
• End of categorical rules, eligibility based on
income,
• Bye bye asset test (except for foster care children,
SSI/SSDI, elderly)
• Spend down continues
12.
13.
14.
15. Exchange (Marketplace)
Individual Mandate
• Conservative ideas from the Heritage
Foundation
• First implemented in the Massachusetts
Health Connector exchange
• Provides a “marketplace” where consumers
can choose a plan (plans all have the same
benefits) based on what services they want
and what they can afford
16. Health Benefits Exchange
“Covered California”
• Quasi-governmental organization, specifically
an "independent public entity not affiliated
with an agency or department.“
• Contracting with Plans: Contract with carriers
so as to provide health care coverage choices
that offer the optimal combination of choice,
value, quality, and service.”
• For individuals and families ineligible for
Medicaid but below 400% of poverty
17. Subsidies and the Exchange
• 5 million Californians qualify to get insurance on the
Exchange.
• Half of them are eligible for government
subsidies, which are federal tax credits that will offset
the cost of their monthly premium
• The subsidies are available to those who earn $15,850
to about $46,000 a year. A family of four is eligible if
they earn between $32,500 to $94,200 a year
• The more you make, the smaller the subsidy. The less
you make the more assistance you’ll get
• Based on your adjusted gross income plus any tax-
exempt income you might have.
18. Covered CA Plan Costs
95816
• Individual, 30 years old, $30,000 a year,
– $9-150 per month payment
– Choices: Anthem Blue Cross, Kaiser, Blue
Shield, Western Health Avantage
• Family of 4, 30 years old, $60,000 a year:
– $171 - $911 per month payment
– Choices: Anthem Blue Cross, Kaiser, Blue
Shield, Western Health Avantage
19.
20. Health Benefits Exchange
Essential Health Benefits: Legislation introduced
in January 2012, would select the Kaiser small
group HMO plan as the state’s benchmark plan
(AB 1453/SB 951)
Exchange to offer Insurance Companies’ Bronze,
Silver, Gold and Platinum plans
13 plans are available in the CA Exchange (varies
by region)
21. Which plans were selected
Alameda Alliance for
Health
Anthem Blue Cross of
California
Blue Shield of California
Chinese Community
Health Plan
Contra Costa Health Plan
Health Net
Kaiser Permanente
L.A. Care Health Plan
Molina Healthcare
Sharp Health Plan
Valley Health Plan
Ventura County Health
Care Plan
Western Health
Advantage
22. Health Benefits Exchange
Basic Health Program (BHP):
Preventive care visits, immunizations, and
screenings (such as mammograms and other
cancer screenings)
Doctor’s visits, outpatient care
Maternity, newborn, and pediatric care
Emergency and hospital care
Laboratory services, prescriptions, and mental
health (including substance abuse)
23. Pediatric Dental
• Covered California, the state's health
insurance exchange, has said it will offer five
stand-alone pediatric dental plans for 2014 as
well as what's called a "bundled" plan in
which insurers pair a stand-alone dental plan
with a medical plan.
24. Vision
• Vision benefits will be available for children.
• Covered California is considering adding vision
and dental plans as “supplemental plans” for
adults through Covered California in 2014
• As a supplemental benefit, the federal
premium assistance would not apply to these
benefits.
25. Health Benefits Exchange
Consumer Assistance and Outreach: Employ Navigators to assist with
education and enrollment activities. CA will use two distinct types of
Assisters registered and certified by the Exchange.
Certified enrollment Assisters (Navigators) will be compensated by the
Exchange and at a minimum will include, non-profit
organizations, community clinics, County Social Services offices
employing Eligibility Workers, and labor unions.
Direct Benefit Assisters, will not be paid by the Exchange and will
include health insurance agents, hospitals, and providers.
See Appendix for more details.
26. Health Benefits Exchange
Information Technology: Requires the creation
of a single statewide application that will be
available on paper and electronically for all
systems and entities accepting and processing
applications and eligibility. It also requires a
simplified citizenship and identity verification at
application and renewal and increased
coordination with other public programs.
27. Accountable Care Organizations
(ACOs)
• ACO is a network of hospitals, clinics, physician
practices and other providers who work together
to provide coordinated, integrated care for an
assigned population of individuals and who
receive financial compensation for meeting
specific patient outcomes.
• Goal: Reduce or control the growth of healthcare
costs while maintaining or improving the quality
of care
• See Appendix for more information
28. Role of Social Worker
• Social workers should be included in the
interdisciplinary care teams across a broad
array of health care settings
• Social workers are likely the only professionals
devoted to meeting the psychosocial needs of
patients and families
• Social workers extend the team to allow
members to participate at the top of their
licenses
29. Roles of Social Worker
• Clinical social workers – mental and behavioral
health services
• Medical social workers – care coordination
and case management, medically related
social services, patient and family education,
discharge planning, advance care planning,
community outreach and engagement
30. Roles of Social Worker
• Be a voice for social work in the health care
plan’s development of ACOs
• Advocate for comprehensive benefits
including psychosocial services
• Advocate for horizontal integration of health
and human services benefits
• Serve as a resource for identifying hard to
reach populations
31. Social Work Advocacy
NASW and California Deans and Directors got a social worker included
on the California Workforce Investment Board, Health Workforce
Development Council (8)
• Standardize, strengthen and expand curricula and training programs
to increase access and consistent competencies for Community
Health Workers/Promotores, Medical Assistants, Social
Workers, Nurses, Direct Care Workers and other workers.
• Change regulations to allow the services of Community Health
Workers/Promotores to be reimbursable with government and
private payers.
• Develop supportive payment structure and policies targeted at
increasing the attractiveness of primary care as a career path and
retention of primary care providers.
• Ensure adequate payment for primary care and preventive services
with appropriate adjustments in payment incentives.
32. ACA Is Changing
• Check various websites for up to date changes
http://www.healthcare.gov/
http://www.chcf.org/publications/2010/05/the-
affordable-care-act-in-california
• Continued political turmoil:
– Shutdown and debt ceiling politics
– 26 states are not expanding Medicaid
– 24 states have set up their own exchanges, 27
have federally administered exchanges
35. ASSISTER ENROLLMENT ENTITIES (AEE)
• Assister Enrollment Entities (AEE)
• Assisters must be affiliated with an Assister Entity to be
compensated. Uncompensated assisters include
Hospitals. providers, and licensed agents. Covered
California has not decided on the exact parameters for
enrollment entities, but are currently including a wide
variety of entities. Assister entities are eligible to be
trained and registered to provide in-person assistance
to consumers and help them apply for Covered
California programs.
36. Eligible to be AEEs
• American Indian Tribe or Tribal
Organizations
• Attorneys (e.g., family law
attorneys who have clients that
are experiencing life transitions)
• Chambers of Commerce
• City Government Agency
• Commercial fishing, industry
organizations
• Community Clinics
• Community Colleges and
Universities
• County Health Department that
provide health care services to
consumers
• Faith-Based Organizations
• Indian Health Services
Facilities
• Labor Unions
• Non-Profit Community
Organizations
• Ranching and farming
organizations
• Resource partners of Small
Businesses
• School Districts
• Tax Preparers
• Trade, industry, and
professional organizations
37. In Person Assisters (IPA)
• Individuals who are employed, trained,
certified, and linked to Assister Enrollment
Entities to provide in-person assistance to
consumers and help them apply for Covered
California programs.
• Individuals who provide assistance in
culturally and linguistic appropriate manners
to consumers.
38. How to Become Affiliated with an
Assister Entity
• Call or email Assister Help Desk for AEE contact
information
• Help Desk will contact information for AEEs in
your area
• Contact AEE in your area to request application
• Complete Assister Application
• Submit application to AEE
• AEE will reviews application and approves
affiliation
• Individual affiliates with AEE
39. Covered California Assister Help Desk
888-402-0737
assisterinfo@ccgrantsandassisters.org
Background Checks and Finger Printing
• Since individual assisters will be dealing with personal information
including financial data, they will be required to pass a background
check and be finger printed prior to certification. The cost is to be
paid by the assister entity.
Assister Training
• Covered California provides free assister training by:
• In-person 2-3 day training in various locations throughout the state.
• Online Training Course
Assister Timeline
• Assister Enrollment Entity Application Release - Spring 2013
• Assister Enrollment Entity Training Begins - Summer 2013
• IPA Training and Certification Begins - August 2013
40. Assister Compensation
• In Person Assisters Compensation: IPAs are
paid a flat-fee of $58 per successful
application (regardless of number of
individuals per application) and $25 per
successful annual renewal.
• Navigator Compensation: Navigator entities
are paid for performance-based block funding
based on meeting Covered California
enrollment targets.
41. Navigator Timeline
• Navigator Grant Application Release - June
2013
• Navigator Grant Application Submission Due -
Mid-July 2013
• Navigator Grant Award - Early October 2013
• Navigator Training and Certification Begins -
Mid-November 2013
• Navigator Entities begin Enrollment Assistance
- Early December 2013
42. Accountable Care Organizations
(ACOs)
• The core is effective primary care delivered
through a “medical home”
• Primary care organizations can transform
• Integrated coordinated care similar to the
HMO model
• Not surprising Kaiser picked as essential
benefit plan
43. ACO Characteristics
• a strong primary care/medical home foundation
• multidisciplinary health care teams
• targeted care coordination interventions (focused
especially on individuals with multiple chronic
conditions)
• integration with behavioral health and substance
use treatment
• sophisticated information systems that include
electronic medical records
• formal partnerships with “medical neighbors”
