ppaca presentation
TRANSCRIPT
Overview of the Patient Protection and Affordable Care Act (PPACA)
Adapted from a presentation given Saturday, November 6, 2010to the Illinois Psychological Association
Doug Walter, J.D., Counsel for Legislative and Regulatory Affairs, Government Relations, Practice
Organization, American Psychological Association
National Health Reform Landmarks and Developments—2000s
• 2003—The Medicare Modernization Act adds a prescription drug benefit to Medicare.
• 2006—The Health Insurance Marketplace Modernization Act (HIMMA) to exempt small business coverage from most state insurance laws defeated.
• 2009—The Health Insurance Technology for Economic and Clinical Health Act (HITECH) enacted to encourage a national electronic health records system.
• 2010—The Patient Protection and Affordable Care Act (PPACA) enacted to reform the national healthcare system.
Patient Protection and Affordable Care Act (PPACA)—The 20,000 Foot View
Among other things, PPACA provides for:
New delivery systems
Market reforms
New insurer requirements
Tax law changes
Medicare and Medicaid reforms
Children’s and special populations’ reforms
New patient care models
Rural protections
Hospital and nursing home reforms
Prevention initiatives
Health care workforce initiatives
Quality reporting
Health research initiatives
Revenue provisions
And more
Many requirements do not fundamentally alter the health care system
• Rather than providing coverage to all through a single system, PPACA expands coverage through various targeted initiatives.
• Instead of requiring integrated care throughout the system, PPACA tests the concept through demonstration programs.
• Medicare and Medicaid are not transformed; rather, the programs are expanded with technical issues addressed.
For example:
PPACA—From Pledge to Enactment
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Feb. 24, 2009: Pres. Obama pledges reform in his 1st address to Congress.
March 5, 2009: The White House holds its first health care summit.
April 21, 2009: Senate Finance Committee begins roundtable discussions to formulate a reform bill.
July 15, 2009: Senate Health, Education, Labor & Pensions Committee approves its version of the health bill.
July 31, 2009: House Energy & Commerce is the third House committee, after Education & Labor and Ways & Means,to approve its version of health bill.
Oct. 13, 2009: Senate Finance Committee approves its version.
Nov. 7, 2009: House passes the Affordable Health Care for America Act (H.R. 3962).
PPACA—From Pledge to Enactment continued
Dec. 24, 2009: Senate passes the Patient Protection and Affordable Care Act (H.R. 3590).
March 21, 2010: House passes PPACA and the Health Care and Education Reconciliation Act.
March 23, 2010: President Obama signs PPACA.
March 25, 2010: The Reconciliation Act passes Senate with PPACA amendments. The House agrees.
March 30, 2010: President Obama signs The Reconciliation Act.
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APAPO’s Health Care Reform Priorities
1. Integrate mental/behavioral health with other health services.
2. Ensure access to mental/behavioral health prevention and wellness services.
3. Develop and maintain a diverse psychology workforce.
4. Ensure access to psychologists’ services in benefit plans.
5. Eliminate disparities in mental health status and care.
6. Increase funding for basic and translational psychological and behavioral research and training.
7. Include strong privacy protections in the development of health information technology.
8. Enhance involvement of psychologists with consumers, families and caregivers.
Details of PPACA
Three main parts/accomplishments:
• Expands Coverage Builds on employer based system through individual mandate and employer
mandate Health benefits exchanges Expansion of CHIP and Medicaid Targeted initiatives
• Provides Market Reforms and Patient Protections
• Transforms the Underlying Delivery System
Details of PPACA: Expands Coverage
Individual mandate: Beginning 2014, most U.S. citizens and legal residents are required to have “minimum essential coverage” or pay a tax penalty.
Employer mandate: Effective 2014, employers with 50 or more employees that do not offer essential minimum coverage must pay a fee of $2,000 per employee, excluding the first 30 employees.
Details of PPACA: Expands CoverageHealth Benefits Exchanges
Effective 2014, individuals without employer coverage, those opting out of their employer coverage, and small employers (with under 100 employees)
may purchase coverage through a Health Benefits Exchange.
Essential benefits:
• preventive services rated A or B by the U.S. Preventive Services Task Force• recommended immunizations• preventive care for infants, children and adolescents• additional preventive care and screenings for women.
Wellstone-Domenici Mental Health Parity and Addiction Equality Act (MHPAEA):
• MHPAEA means that financial requirements and treatment limitations for mental health and substance use disorder benefits in qualified plans can be no more restrictive than the requirements and limitations placed on medical/surgical benefits.
Details of PPACA: Expansion of CHIP and Medicaid
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Medicaid:
• Expanded to eligible individuals at or below 133% of the federal poverty level.
• Mental health services must now be included as basic services, rather than optional services in benchmark equivalent plans.
CHIP:
• Extended through 2015.
• Beginning in 2015, states will receive an increase in the federal match rate up to 100%.
• States must maintain current income eligibility levels for children in Medicaid and CHIP until 2019.
• CHIP-eligible children who are unable to enroll in the program due to enrollment caps will be eligible for tax credits in state Exchanges.
Targeted Initiatives to Expand Coverage
Details of PPACA: Expands Coverage
• Coverage of dependent children expanded- Age limit for unmarried children raised to 26 years for all individual and group health plans (including grandfathered plans).
• Reinsurance program beginning January 1, 2014 will provide health coverage to retirees over age 55 who are not eligible for Medicare. The program will reimburse employers for 80% of retiree claims between $15,000 and $90,000.
• Funding for community health center National Health Service Corps will be increased over five years beginning in 2011.
• Additional support provided for school-based health centers and nurse-managed health clinics.
Details of PPACA: Market Reforms and Patient Protections
Coverage
• Requires group and individual health plans to accept all employers and individuals that apply for coverage and to renew coverage.
• Health plans may not establish eligibility rules based on health status factors, including medical condition, claims experience, medical history, and evidence of insurability.
• Health plans may not rescind coverage except in cases of fraud.
• Preexisting condition exclusions applied to children are prohibited beginning September 23, 2010, and those applied to adults are prohibited beginning January 1, 2014.
• Coverage waiting periods are limited to 90 days.
Premiums• Premium rating may vary only by age (limited to a 3 to 1 ratio), rating
area, family composition, and tobacco use (1.5 to 1 ratio) in the individual and group market and in the Exchange.
• Health plans must report to HHS the proportion of premium dollars spent on clinical services and quality improvement, and provide a rebate to enrollees if the amount of the enrollees’ premium spent on clinical services and quality is less than 85% (large group) 80% (small group and individual).
• Health plans must justify unusual premium increases. A state may recommend to HHS that a health plan be excluded from its Exchange based on unjustifiable premium increases.
Patient Cost-Sharing
• Deductibles for small group market health plans are limited to $2,000 individual/$4,000 family unless contributions are offered that offset deductible amounts above these limits.
• Out-of-pocket limitations are imposed for individuals enrolled in qualified health plans whose income is between 100-400% of the FPL.
• Group and individual health plans (including grandfathered plans) may not place annual or lifetime limits on essential benefits coverage. HHS determines what limits are acceptable prior to 2014.
Other Patient Protections
• Health plans must implement an effective process for coverage claims and appeals.
• Health provider nondiscrimination—Prohibits health plans from discriminating against health professionals from plan participation.
• Grants are provided to states to expand or establish ombudsman or consumer assistance programs.
Details of PPACA: Transforms the Underlying Delivery System
• Insurance Coverage Changes
• Promoting Primary and Integrated Care
• Prevention and Wellness
• Improving Quality
• Long-term Care
• Workforce
Promoting Primary and Integrated Care –Private Healthcare System
• A new HHS demonstration program will provide grants to eligible entities to establish community-based interdisciplinary health teams to support primary care practices and patient-centered medical homes. Psychologists may participate in these health teams.
• A new community-based Collaborative Care Network Program will support consortia of health providers, including psychologists, to coordinate and integrate health care services for low-income uninsured and underinsured populations.
Details of PPACA: Transforms the Underlying Delivery System
Details of PPACA: Transforms the Underlying Delivery System
Prevention and Wellness—Targeted Initiative
• An HHS Preventive Services Task Force will review scientific evidence related to effectiveness and cost-effectiveness of clinical preventive services for the purpose of developing community healthcare recommendations.
• A prevention and health promotion and education campaign to raise public awareness of health improvement across life-span.
• A grant program to explore the delivery of evidence-based and community-based prevention and wellness services to address chronic disease rates and health disparities, especially in rural/frontier areas.
• An Institute of Medicine conference on pain in order to increase the recognition of pain as a significant public health problem.
• New funding for child obesity demonstration projects.
Details of PPACA: Transforms the Underlying Delivery System
Improving Quality—Medicare Payment Reform
• Medicare value-based incentive payments will be made to hospitals that meet specified performance standards.
• Hospitals will be subject to a Medicare payment adjustment penalty for high rates of hospital acquired conditions.
• Medicare physician incentive payments under the quality reporting system are extended; a penalty is imposed for unsatisfactory reporting (in 2015).
• HHS will establish a value-based payment modifier under the physician fee schedule based on a quality to cost ratio.
• Long-term care hospitals, inpatient rehabilitation hospitals, and hospices, starting 2014, will be required to submit data on specified quality measures.
• HHS will develop a plan to implement value-based purchasing for Medicare payments for skilled nursing facilities, home health agencies and ambulatory surgical centers.
PPACA—Implementation TimelineBy 2010:• Review of Health Plan Premium
Increases• Changes in Medicare Provider
Rates• Medicaid and CHIP Payment
Advisory Commission• Comparative Effectiveness
Research• Prevention and Public Health
Fund• Small Business Tax Credits• Coordinating Care for Dual
Eligibles• Medicaid Coverage for Childless
Adults• Reinsurance Program for
Retiree Coverage• Pre-existing Condition Insurance
Plan
• New Prevention Council• Consumer Website• Adult Dependent Coverage to Age
26• Consumer Protections in
Insurance (prohibits lifetime limits, rescinding coverage, denying children coverage for pre-existing conditions, restricts annual limits)
• Insurance Plan Appeals Process• Coverage of Preventive Benefits• Health Centers and the National
Health Service Corps• Health Care Workforce
Commission• Medicaid Community-based
Services
PPACA—Implementation TimelineBy 2011:• Minimum Medical Loss
Ratio for Insurers• Medicare Payments for
Primary Care• Medicare Prevention
Benefits• Center for Medicare and
Medicaid Innovation• Medicare Premiums for
Higher-Income Beneficiaries
• Medicaid Health Homes• Chronic Disease
Prevention in Medicaid• Long-term Care CLASS Act
• National Quality Strategy• Grants to Establish Wellness
Programs• Teaching Health Centers• Medical Malpractice Grants• Funding for Health Insurance
Exchanges• Graduate Medical Education• Medicare Independent
Payment Advisory Board• Medicaid Long-term Care
Services
PPACA—Implementation TimelineBy 2012:
• Accountable Care Organizations in Medicare
• Medicare Independence at Home Demonstration
• Medicare Provider Payment Changes
• Fraud and Abuse Prevention
• Medicaid Payment Demonstration Projects
• Health Care Disparities Data Collection
PPACA—Implementation TimelineBy 2014:• Expanded Medicaid
Coverage• Individual Requirement to
Have Insurance• Free Choice Vouchers• Health Insurance Exchanges• Health Insurance Premium
and Cost Sharing Subsidies• Guaranteed Availability of
Insurance• No Annual Limits on
Coverage• Essential Health Benefits
• Multi-State Health Plans• Temporary Reinsurance
Program for Health Plans• Basic Health Plan• Employer Requirements• Wellness Programs in
Insurance• Fees on Health Insurance
Sector• Medicare Independent
Payment Advisory Board Report
PPACA—What to Expect in the coming months?Lots of regulations to implement the statute.
PPACA—What to expect in the coming months?
With larger Republican Congressional caucus, there could be calls for repeal or attempts to amend the law.
Additional Resources
• APA Practice Central:
http://www.apapracticecentral.org/advocacy/reform/patient-protection.aspx
• The Henry J. Kaiser Family Foundation:
http://healthreform.kff.org/
• Official Government Site:
http://www.healthcare.gov/
Doug Walter, J.D.Legislative and Regulatory CounselGovernment RelationsPractice OrganizationAmerican Psychological Association750 First St., N.E.Washington, DC 20002-4242
(202) 336-5889
(202) 336-5797 (fax)
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