Patricia Gray, J.D., LL.M. Health Law & Policy Institute University of Houston Law Center September 27, 2012

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1 Patricia Gray, J.D., LL.M. Health Law & Policy Institute University of Houston Law Center September 27, 2012

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3 the ACA has put the nation on a path that will transform the nation s sick care system into a true health care system. Jeff Levi, Trust for America s Health

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5 Impacts how vaccines are paid for Private insurance Medicare Medicaid/SCHIP Impacts how vaccine services might be improved New focus on primary care, preventive care New support for community and school based health centers Expanded focus on population health

6 New group and individual health plans Must cover vaccines recommended by the ACIP prior to September, 2009, with no cost-sharing requirements when provided by an in-network provider Must add new ACIP recommendations made after September, 2009, in the next plan year that occurs one year after the recommendation Grandfathered plans May retain cost-sharing requirements until conditions of coverage are modified

7 Medicaid expansion is to provide coverage for adults and children with incomes below 133% of FPL. States are required to extend benchmark coverage to newly eligible enrollees. Benchmark defined in statute as equivalent to standard BC/BS PPO plans, state employee coverage, coverage through HMOs or other equivalent plans approved by the Secretary of HHS.

8 Increased funding to support immunizations States that elect to provide ACIP recommended adult coverage with no cost sharing can get 1% increase in FMAP to help cover costs. States not required to change cost-sharing requirements for currently eligible Medicaid populations. Authorizes increasing minimum reimbursement rates for primary care physicians in family medicine, general internal medicine, and pediatrics.

9 States required to establish health insurance exchanges Exchanges will certify qualified health plans that must cover defined essential health benefits Essential health benefits include ACIPrecommended immunizations without costsharing. States may opt out and allow a federally administered system to come in instead.

10 CHIPRA Reauthorized the SCHIP in 2009 Covers uninsured children ineligible for Medicaid in families with incomes up to 235% above FPL Added pregnant women ineligible for Medicaid to coverage Eliminated the five year waiting period for lawfully present immigrant children and pregnant women ACA Maintains SCHIP until 2019 Requires maintenance of effort from states in order to receive maximum benefits in the future

11 Adoption of Medicare Part D changed how vaccines are paid for under Medicare. Physicians can no longer bill Part B for Part D covered vaccines administered in their offices. Medigap policies only cover co-pays or deductibles for Part A and Part B coverage not Part D prescription drug coverage.

12 ACA added certain preventive care coverage. Non-Medicare plans include specified vaccines Children: DTP, Haemophilus influenzae type b, Hepatitis A, Hepatitis B, Quadrivalent HPV for females, Inactivated Poliovirus, Influenza, MMR, Meningococcal, Rotavirus, and Varicella Adults: Hepatitis A, Hepatitis B, Herpes Zoster, Quadrivalent HPV for females, Influenza, MMR, Meningococcal, Pneumococcal, Tdap, and Varicella Medicare Part B continues to cover Hepatitis B for certain high risk patients and influenza and pneumococcal vaccines for all Medicare enrollees.

13 Cost-sharing not allowed when provided by an in-network provider but only in new group or individual plans. Grandfathered plans can still require cost-sharing. Dual eligibles may be eligible for special assistance to cover vaccine costs under Medicare Part D, but application required. Medicare does not include shingles vaccine under Part B preventive services; may be covered under Part D but Medigap policies don t cover cost-sharing for Part D.

14 If funding authorized, creates opportunity for qualified providers to reach more children and adolescents. Caveats- Clinics required to offer comprehensive primary care but definition does not include preventive care or vaccinations. Definition focuses on health assessment, treatment of minor acute and chronic conditions, and referrals for specialty care and oral health services

15 Enhanced funding will expand number of CHCs Population served by CHC s expected to double by 2019 Population served likely to still be under insured CHCs will continue to be source of lower cost access to vaccines.

16 Several new initiatives proposed Not all up and functioning Funding streams not in place for all Two have focus that includes vaccine policy Community Preventive Services Task Force: goal is to improve coordination between USPSTF and ACIP Outreach proposal: creation of a public/private partnership to support prevention and health promotion campaigns, including defining the preventive measures supported by the ACIP.

17 Meaningful Use Stage 2 Final Rule released New effective date is 2014 Eligible professionals (EPs) eligible hospitals and critical access hospitals (CAHs) must report on the following core objective: Submission of electronic data to immunization registries.

18 Adult coverage in states that decline the Medicaid expansion option Coverage support gap for those with incomes below 100% FPL who purchase through the exchange SCHIP reauthorization expires in 2019 because children should be covered under Medicaid expansion. What happens if Medicaid expansion not adopted?

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20 Election in November, 2012, will impact funding for implementation of the ACA. Unlikely that many changes will occur quickly. Train has left the station, but could be diverted to a track to nowhere if momentum lost.

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