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)
12. What is covered
Essential Health Benefits
1. Ambulatory patient services
2. Emergency services
3. Hospitalization
4. Maternity and newborn care
5. Mental health and substance use disorder services,
including behavioral health treatment
6. Prescription drugs
7. Rehabilitative and habilitative services and devices
8. Laboratory services
9. Preventive and wellness services and chronic disease
management
10. Pediatric services, including oral and vision care
13. Plans
• Standardized plans ‐ Bronze, Silver, Gold,
Platinum (from 60‐40 to 90‐10 Premium‐
Copay)
• No Rescissions, No Lifetime Limits & Restricted
Annual Limits
• Medical Loss Ratio, Consumers rebates, 80‐
85% on healthcare and quality
• Elimination of the Medicare Part D doughnut
hole ($2,700 to $6,154)
14. Who Pays?
• Insurance model: the high cost of the sick
offset by low cost of the healthy
• Young adults (up to age 26) covered by
parents
• Emphasizes and pays for prevention
• Sets minimum benefit levels so health plans
compete with each other on cost and quality
• Creates a state run health benefit exchange
market structure for individuals and business
15. Reducing Healthcare Costs
While Expanding Coverage
• Cover the healthy as well as the sick
• Wellness and prevention, early diagnosis
• Reductions in unnecessary testing and referrals
• Reductions in preventable emergency room visits
and hospitalizations
• Reductions in infections and adverse events in
hospitals
• Reductions in preventable readmissions,
• Use of lower‐cost treatments, settings, and
providers
16. Plans are Income Tested
• Households earning less than 250 percent of the
federal poverty level can receive financial help if
they enroll in a Silver plan; the less income they
earn, the more financial assistance they can
receive.
• For example, individuals earning between 150 to
250 percent of the federal poverty level can
expect to pay $20 to see their primary care
physician, while those earning 100 to 150 percent
would pay $4.
17. How to Get Coverage
• Many employers will simply continue plans for
employees
• Employers with 50 or more FTE workers
required to provide health insurance or pay a
penalty
• Expands Medicaid (Medi‐Cal) up to 133% of
poverty ($14,404 indiv to $29, 327 family of 4)
• Health Benefits Exchange (Covered California)
• Accountable Care Organizations (ACOs)
18. Employers
• For employers without employee plans:
– For businesses with 50 or fewer full time
employees, qualified plans available in Exchange
– No penalties for 50 or less employers if health
coverage not offered
• Reactions
20. Business Incentives
• Small Business Tax Credits: 2 million workers
get their insurance from an estimated 360,000
small employers
• Early Retiree Reinsurance Program (ERRP)
partially reimburses employment‐based plans
for health benefits for early retirees and their
spouses, surviving spouses and dependents
• Health Care Exchanges Available to Small
Business
21. Sole Proprietors
• Health care reform ends discrimination by
insurance companies based on pre‐existing
conditions and gender. The new law also
eliminates lifetime caps, restricts annual caps
and ends the practices by which health
insurance companies retroactively end a
policy when someone becomes sick. (1)
22. Sole Proprietors
• Premium Subsidies and Cost Sharing
Credits (Starting in 2014) – Subsidies and
credits to lower premiums and cost‐sharing
requirements are available to individuals and
families with incomes below 400 percent of
the federal poverty line (below $88,000 a year
for a family of four) who purchase coverage in
the newly established exchanges. (1)
23. 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.”
28. 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
29. 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
31. 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
32. 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
33. 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
35. 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:
– 27 states are expanding Medicaid, 16 are not and 8
are undecided (Feb 2013)
– 17 states have set up exchanges, 27 have not
– Some continue to seek repeal or delay
