Health Care Reform's Impact on People with Disabili9es:

Transcription

1 Health Care Reform's Impact on People with Disabili9es: The Road Ahead Barbara L. Kornblau, JD, OTR American Associa9on on Health & Disability United Spinal Associa9on Our Sponsors:

2 Our Missions American Associa9on on Health and Disability To advance health promo1on and wellness ini1a1ves for people with disabili1es at the federal, state and community level. United Spinal Associa9on To improve the quality of life of all people living with spinal cord injuries and disorders (SCI/D).

3 If You Have Ques9ons Please type your ques9ons in the ques9ons box on your screen. Ques9ons will be answered at the end of the presenta9on

4 Can Congress Repeal ACA? Several bills were introduced in the House of Representa1ves to repeal ACA (113 th Congress) Repeal can pass the House Repeal can t pass the Senate

5 Supreme Court Ruling ACA is cons1tu1onal Individual mandate is a permissible tax The Feds cannot force the states to expand Medicaid. If they don t expand No coverage for single, non- disabled adults from FPL to 133% of the Federal Poverty Level $14,856 for an individual and $ 30,657 for a family of four in 2012 What Can I Do in My State?

6 Coverage Op9ons for Now PCIPs (un1l 2014) (all 50 states) Must be uninsured for 6 months Denied coverage due to pre- exis1ng condi1on AND Ci1zen or legal resident PCIPs cover Primary and specialty care, (including OT, PT, & SLP) Hospital care, and Prescrip1on drugs. State high- risk pools Medicaid expansion You can locate your PCIP at hcps://

7 MEDICAID EXPANSION: STATUS OF STATES

8 Pre- Exis9ng Condi9ons Prohibi1on on coverage exclusions for pre- exis1ng health condi1ons will become effec1ve for most enrollees beginning on or aeer January 1, Insurers cannot charge you higher premiums because of your disability or medical condi1on. Plans must operate on the basis of standard popula1on risk, which looks at everyone - - i.e., both those with and without exis1ng condi1ons - - to determine reasonable costs. Your premium costs may be influenced by your age & smoking habits. Grandfathered individual (non- employer based) insurance plans are not required to eliminate pre- exis1ng condi1on exclusions for children under 19 years old in individual children only or non- group family plans.

9 Grandfathered Plans Defini1on: an exis1ng group or individual (not through an employer) health insurance plan in which a person was enrolled on the date of enactment of ACA March 23, As long as a person was enrolled in the plan on March 23, 2010, that plan has been grandfathered. If you like your health plan you can keep it If a plan significantly reduces benefits or increases out- of- pocket costs for the insured person, then the plan will lose its grandfathered status and you get addi1onal benefits

10 Wellness Benefits If an employer loses its grandfather status, you will get: Coverage of recommended preven1on services with no cost sharing; and Includes, pap smears & women s health, immuniza1on vaccines, screenings for blood pressure, cholesterol (depending on age & risk), depression, type 2 diabetes (for those with high blood pressure), diet counseling (for those at risk of chronic condi1ons) Screening and counseling for: alcohol misuse; drug abuse; obesity; tobacco use for all adults & counseling for users; and colonoscopies for adults over 50; and HIV screenings for high risk adults. Pa1ent protec1ons such as guaranteed access to OB- GYNs and pediatricians.

11 Wellness Cont d Medicare Free Annual Wellness Visit* Physician & pa1ent develop or update personal preven1on plans taking into account medical and family history, detec1on of any impairment, poten1al risk factors from depression and review of the pa1ent s func1oning ability and level of safety. Preven1on Fund Grants to help prevent tobacco use, obesity, heart disease, stroke and cancer; and improve the health of communi1es for people with and without disabili1es * Ask your Medicare Advantage Plan if you are covered for wellness services

12 Limits on Coverage Life1me Limits or Caps on essen1al health benefits Eliminated from all plans September 23, 2010 Can put limits on non- essen1al health benefits Annual Limits or Caps on essen1al health benefits Phased out & eliminated for all new plans issued between 3/23/10 & 1/1/14 1/1/14 - all plans issued or renewed will be prohibited from including annual limits or caps on EHB

13 Excep9ons Grandfathered individual plans (non- employer based plans) are not required to phase out annual limits or caps on essen1al health benefits. All plans can put annual dollar limits and life1me dollar limits on spending for health care services not considered essen1al health benefits.

14 Essen9al Health Benefits ACA included coverage for rehabilita1on and habilita1on in its essen1al health benefits (EHB) Aeer considering the IOM s report, HHS released a bulle1n in December 2011, sesng forth a plan by which states would choose four benchmark plans based on private plans currently in existence in their state. These newly established plans would theore1cally include rehabilita1on, habilita1on, and the other specified essen1al health benefits. Most private plans exclude habilita1on and this creates a dilemma in the states establishing their plans based on exis1ng plans.

15 Essen9al Health Benefits Nov 2012, HHS released an EHB proposed rule to address the dilemma. HHS proposed that if a state s base- benchmark plan does not cover habilita1on, the state can define the services it will include under habilita1ve services. HHS proposed to give the states the flexibility to lead the development of habilita1on services policy. During this policy development process, disability advocates have an opportunity to encourage their states to include preven1ve therapy services & other service in their defini1on of habilita1ve services. The essen1al benefits apply in 2014 to the individual and small employer group insurance coverage that will be sold through the insurance exchanges, and Medicaid plans.

16 Therapy Caps A therapy cap of $1,900 was scheduled to go into effect January 1, 2013, without any excep1ons process. POTUS signed the American Taxpayer Relief Act of 2012 extends Medicare Part B Outpa1ent Therapy Cap Excep1ons Process through 12/31/13. ( Fiscal Cliff Nego1a1ons) Outpa1ent therapists can submit an explana1on to jus1fy con1nued coverage of medically necessary rehab services through their billing process if you exceed the $1,900 cap. Medicare will determine whether you need the addi1onal services. They make a determina1on in the pa1ents favor 90% of the 1me.

17 Home & Community- Based Services (Also known as HCBS) States are having budget crises United Spinal urges you to monitor what your state is doing, to address budgets, & speak out in support of funding for valuable programs in your state: Money Follows the Person (MFP) Community First Choice Op1on

18 HCBS - Money Follows the Person (MFP) ACA strengthened & expanded MFP demonstra1on grants 9/2016 Grants help states defray the cost giving eligible Medicaid beneficiaries living in nursing homes or other ins1tu1ons for a minimum number of days, new opportuni1es to live in the community with the services and supports they need. The grants provide states with enhanced federal matching funds for twelve months for each Medicaid beneficiary transi1oned from an ins1tu1onal sesng to a community- based sesng. As of late 2011, a total of 43 states & Wash. DC. have received federal grant money under the program to transi1on Medicaid beneficiaries living in ins1tu1ons to the community. Par1cipa1ng states will receive >$621 million through 2016.

19 HCBS - Community First Choice Op9on Created by ACA States no longer have to apply for a Medicaid waiver through the Feds to provide community- based supports and services. Allows state Medicaid plans to choose home- and community- based services and supports as the rule, rather than the excep1on. Applies to individuals with disabili1es who are eligible for Medicaid, would otherwise be nursing- home eligible, and have incomes up to 150% of the federal poverty level (i.e., $16,755 for an individual and $34,575 for a family of four in 2012). To encourage states to opt in to this program, the Federal government will give states an addi1onal 6% payment on top of the Federal matching payment they now receive to cover costs associated with the program.

20 Community Living Assistance & Supports (CLASS) The Community Living Assistance and Supports (CLASS) program was repealed as part of the fiscal cliff nego1a1ons. HHS had announced it had difficulty developing its implementa1on plan.

21 Accessible Medical Equipment ACA charged the Access Board with developing minimum technical criteria for medical diagnos1c equipment used in (or with) physician's offices, clinics, emergency rooms, hospitals, and other medical sesngs. The Access Board appointed a commicee of experts, including disability advocates who are wheelchair users to develop voluntary standards with input from the public. The Access Board will release the voluntary standards for improved accessibility when the commicee is finished. Though voluntary in nature, the standards do establish the standard of prac1ce. Please share the standards with your health care providers.

22 Community Health Center Access ACA provides $ for Federally Qualified Health Centers (FQHCs). Safety net providers to meet the health care needs of underserved popula1ons based on income & other factors such as the absence of health coverage, or the inability to afford tradi1onal primary care. Anyone can use these services. Sliding scale payment & must accept Medicaid & Medicare. Must be accessible under Sec1on 504 of the Rehabilita1on Act or they risk losing their federal funding.

23 Cost- Sharing Limits Effec1ve January 1, 2014, the law limits deduc1bles for health plans to $2,000 for a single person for employer- sponsored plans offered in the small group market and $4,000 for families unless contribu1ons are offered that offset deduc1ble amounts above these limits. Health Insurance Exchanges will offer individuals and small businesses four benefit 1ers, as well as a separate catastrophic plan: Bronze plan represents minimum creditable coverage and provides the essen1al health benefits, covers 60% of the benefit costs of the plan, with an out- of- pocket limit equal to the Health Savings Account (HSA) current law limit ($6,250 for individuals and $12,500 for families in 2013); Silver plan provides the essen1al health benefits, covers 70% of the benefit costs of the plan, with the HSA out- of- pocket limits; Gold plan provides the essen1al health benefits, covers 80% of the benefit costs of the plan, with the HSA out- of- pocket limits; and Pla1num plan provides the essen1al health benefits, covers 90% of the benefit costs of the plan, with the HSA out- of- pocket limits.

24 Cost Sharing Limits 2 A catastrophic coverage- only plan, available for purchase to individuals 30 years of age and under, and to individuals exempt from the mandatory coverage mandate because no affordable health plan is available to them or because of hardship. This plan provides catastrophic coverage except that preven1on benefits and coverage for three primary care visits would be exempt from the deduc1ble. Only available in the individual market. The law also reduces the out- of- pocket limits for those with incomes up to 400% of the federal poverty level (FPL) Premium subsidies will be available through the Exchanges for individual taxpayers with household incomes between 100% and 400% of the Federal Poverty Level (FPL). The FPL as of 2012 is $11,170 for an individual and $23,050 for a family of four.

25 State Health Insurance Exchanges States supposed to elect how they planned to implement health insurance exchange by 12/14/12 18 states + DC opted to implement their own state- run HIEs. 22 states opted to have the federal government operate their HIE. 8 states opted to run their own HIEs in partnership with the federal government. 2 states, Florida & New Hampshire failed to meet the deadline have been given un1l February 15, 2013 to decide. If they do not make a decision, the federal government will step in and operate the HIEs in those two states.

26 Changes to Medicare Part D As of January 1, 2013, Medicare Part D will cover smoking cessa1on agents, barbiturates used in the treatment of epilepsy, cancer, or a chronic mental health disorder and benzodiazepines. ACA gradually closes the donut hole in Medicare Part D Prescrip1on Drug Coverage In 2013, Medicare recipients will pay 47.5% for brand- names and 79% for generics in the donut hole. In 2014, the amount is 45% for brand- name drugs and 65% for generics. The cost of prescrip1ons decreases un1l 2020, when you pay 25% for brand- names and 25% for generics and then the donut hole closes.

27 Medicare Durable Medical Equipment & Supplies Compe99ve Bidding Phase 1 DMEPOS Compe11ve Bidding Program started January, 2011 in 9 regions: Cincinna1 Middletown (Ohio, Kentucky and Indiana); Cleveland Elyria Mentor (Ohio); Charloce Gastonia Concord (North Carolina and South Carolina); Dallas Fort Worth Arlington (Texas); Kansas City (Missouri and Kansas); Miami Fort Lauderdale Pompano Beach (Florida); Orlando (Florida); Picsburgh (Pennsylvania); and Riverside San Bernardino Ontario (California)

28 DMEPOS Compe99ve Bidding Phase 2 starts 7/13 in 91 addi1onal loca1ons including large metropolitan area: Los Angeles, CA (including Long Beach and Santa Ana); Chicago, IL (including Indiana and Wisconsin); and New York (including northern New Jersey and Pennsylvania) Mail- order diabe1c supplies also begins in 7/13

29 Items Covered by Compe99ve Bidding Wheelchairs, walkers, oxygen, diabetes blood monitoring devices, enteral nutrients (tube feeding), con1nuous posi1ve air pressure (CPAP) and respiratory assis1ve devices, and hospital beds. CMS recently Combined standard manual wheelchairs, standard power wheelchairs, and scooters to form a new expanded standard mobility device category, and added nega1ve pressure wound therapy pumps and related supplies and accessories to the bidding program.

30 Exempt from Compe99ve Bidding: Complex rehab wheelchairs Off- the shelf ortho9cs provided by physicians or hospitals to their own pa1ents

31 Problems with Compe99ve Bidding Consumers can no longer choose their DME provider. Consumers can only purchase covered DME from Medicare authorized providers, who may not carry the most effec1ve products and services consumers need or use. Consumers may find limited access or no access to cri9cal equipment & supplies, & equipment repairs. Providers must re- bid every three years, which could leave consumers without needed DME items carried by the previously authorized provider.

32 Current Status of Bidding Program Received many complaints Bill was introduced in 112 th Congress died Will be introduced again by Cong. Tom Price (R- 6 th GA) Market Pricing Program Act will increase # of DME providers with an auc1on process without cos1ng Medicare more than the current bidding program United Spinal Associa1on supported this. To stay informed. hcps://

33 Compara9ve Effec9veness Research Compares the outcomes or effec1veness of different treatments or therapies for the same condi1on. Pa1ent- Centered Outcomes Research is another name for CER. CER is supposed to improve quality of care and lower costs by finding the most effec1ve treatment. ACA established the Pa1ent - Centered Outcomes Research Ins1tute (PCORI). PCORI approved 25 awards, = $40.7 million over three years, to fund pa1ent- centered compara1ve clinical effec1veness research projects. Some disability advocates fear that CER does not adequately take into account individual differences among pa1ents that may affect effec1veness. Ex. Seizure Medica1on

34 Training Health Care Professionals to Treat People With Disabili9es Several groups of health professionals at work to develop curriculum on how to treat people with disabili1es. HHS s Health Resources and Services Administra1on (HRSA) is funding some of these programs. Consider assis1ng with training health professional at your local community colleges and universi1es. Many health professionals lack any experience with people with disabili1es Who becer to assist with training them to treat people with disabili1es than people with disabili1es.

35 Reducing Health Dispari9es of People With Disabili9es Improving public health data collec1on for PWD Where do PWD get their health care Which providers are trained to treat PWD How many providers have accessible facili1es & equipment Coverage of preven1ve services without cost sharing requirements. Developing standards for accessible medical equipment Training health care workers to treat PWDs in a culturally competent manner. Improving care coordina1on for people with chronic condi1ons An1- discrimina1on provisions

36 Upcoming Webinars & Conferences United Spinal Associa9on - Webinars Access to the Medical Equipment You Need - March 28 What you Need to Know about Medicaid - May 23 American Associa9on on Health & Disabili9es Health Dispari1es Research at the Intersec1on of Race, Ethnicity, & Disability A Nat l Conference - April Disability and Public Health in the Media - Disability and Health Journal hcp:// and- health- journal This presenta9on is archived at: hcp:// archive/ hcp://

37 Roll on Capitol Hill June 16-19, 2013 United Spinal Associa1ons Annual Policy Conference United Spinal s Public Policy department NSCIA United Spinal s Membership and Chapter division Users First United Spinal s grassroots advocates division You can find more informa1on at: hcp:// on- capitol- hill/

38 Ques1ons Aeer The Webinar? Barbara L. Kornblau Alexandra Bennewith

39 References hcp://cciio.cms.gov/resources/files/factsheet.html hcp:// pre- exis1ng- condi1ons/index.html hcp:// hcp:// endinglimits.html hcp:// older/medicare- preven1ve- services/index.html hcp:// %28541pbh45lvkqjp45eavio445%29%29/naviga1on/manage- your- health/preven1ve- services/preven1ve- service- overview.aspx hcp:// older/medicare- preven1ve- services/index.html

40 References 2 hcp:// %28541pbh45lvkqjp45eavio445%29%29/naviga1on/manage- your- health/preven1ve- services/preven1ve- service- overview.aspx hcp://insurance.about.com/od/healthins/a/irs- Sets Hsa- Contribu1on- Limits.htm ACA 2502 hcps:// medicare- program- changes- to- the- medicare- advantage- and- the- medicare- prescrip1on- drug- benefit hcp:// older/drug- discounts/ index.html