Health Reform & Immuniza3ons in 2014 Associa(on of Immuniza(on Managers Atlanta, Georgia Alexandra Stewart stewarta@gwu.edu Milken Ins(tute, School of Public Health, Department of Health Policy, GWU July 10, 2014 1
PRESENTATION OVERVIEW 1. What is health reform 2. What are the goals of health reform 3. Private Insurance Coverage of Immunizations 4. Grandfathered Plans 5. Public Insurance Coverage of Immunizations 6. Federal Funding for Vaccine Programs 2
PURPOSE 1. Compare relevant ACA provisions to their implementation 2. Recognize how ACA impacts select states 3. Identify any gaps in coverage or access resulting from the differences 4. Propose solutions 3
HEALTH REFORM IS: The Patient Protection and Affordable Care Act (PPACA) (Signed March 23, 2010) The Health and Education Reconciliation Act (Signed March 30, 2010) Several regulations designed to explain & implement the laws (Preventive Services, Grandfathering) 4
THE GOALS OF HEALTH REFORM ARE TO: Extend health insurance coverage to 94% of Americans Lower the cost of health care Improve quality of health care 5
VACCINES ARE EXPLICITLY & IMPLICITLY ADDRESSED THROUGHOUT THE STATUTE 6
ALL TYPES OF INSURANCE WILL BE REQUIRED TO COVER IMMUNIZATIONS 7
PRIVATE INSURANCE COVERAGE OF IMMUNIZATIONS State Regulated (Non- Grandfathered) State Regulated (Grandfathered) State Exchange Plans 1. Dependent coverage required to age 26 2. Must cover ACIP recommended vaccines 3. No cost-sharing 1. Dependent coverage required to age 26 (1/1/14) 2. Not required to cover immunizations 3. Must continue or improve current coverage policy 4. No rescissions of coverage except for fraud or non-payment 5. No pre-existing condition limitations 1. Must cover ACIP recommended vaccines 2. No cost-sharing 8
GRANDFATHERED PLANS Private plans in effect 3/23/10 may retain current coverage practices ROUTINE CHANGES (Permissible) SIGNIFICANT CHANGES (Not Permissible) Viola&on of even 1 requirement = permanent loss of grandfathered status Cost Adjustments that keep pace with medical inflation Adding new benefits Making modest adjustments to existing benefits Voluntarily adopting consumer protections under new law Changes to comply with state/ federal requirements Reducing or eliminating existing coverage Increasing deductibles or copayments by more than the rate of medical inflation + 15% Requiring consumers to switch to another grandfathered plan in order to avoid new consumer protections Merging with another plan in order to avoid complying with health reform Source: Group Health Plans and Health Insurance Coverage relating to status as a grandfathered health plan under the PPACA; interim final rule and proposed rule, 75 Fed. Reg. 34,538 at 34,543 (June 17, 2010) 9
% OF COVERED WORKERS ENROLLED IN GRANDFATHERED PLANS 10
11
MEDICAID 12
Medicaid Federal/state funded health insurance for the lowest income individuals Every state, DC, 5 Territories participate in Medicaid 2012 adult enrollees (ages 19 through 64): 19 million 11million live in 10 states: California, New York, Florida, Pennsylvania, Michigan, Ohio, Illinois, Texas, Massachusetts, Tennessee 2017 adult enrollees: 31 million 1 Coverage for immunizations for adults is optional. States determine: Which (if any) vaccines to cover Enrollee copayment policy Provider reimbursement policy Settings where vaccines may be administered 1 Congressional Budget Office, Spending and enrollment detail for CBO s February 2013 baseline: Medicaid. 2013 13
ACA Provisions Important to Medicaid & Immunizations PROVISION 1: Programs may expand Medicaid eligibility to include adults with income at or below 133% FPL 2014 FPL + 33% = $15,521 single $31,720 family of 4 14
State Medicaid Expansion Decisions, as of 03/26/14 WA OR NV CA ID AZ UT MT WY CO NM ND SD NE KS OK MN WI IA IL MO AR MS MI OH IN KY TN AL VT NY PA WV VA NC SC GA ME NH MA CT RI NJ DE MD DC AK TX LA HI FL Implementing Expansion in 2014 (27 States including DC) Open Debate (5 States) Not Moving Forward at this Time (19 States) Kaiser Family Founda(on, h`p://kff.org/health- reform/slide/current- status- of- the- medicaid- expansion- decision/ 15
Kaiser Family Foundation, http://kff.org/health-reform/slide/current-status-of-the-medicaid-expansion-decision 16
ACA Provisions Important to Medicaid & Immunizations PROVISION 2: Must provide benchmark coverage to newly eligible enrollees (as of 01/01/14) PROVISION 3: Immunization coverage remains optional for adult enrollees who qualify through traditional eligibility categories (before 01/01/14) 17
States with ACIP coverage 2012 (n=51) AK WA OR NV CA ID UT MT WY CO ND SD NE KS MN IA MO AZ OK AR NM WI IL IN MS MI KY TN AL NY PA OH WV VA GA SC VT NC NH ME NJ MD MA RI CT DE DC TX LA FL HI 18
Source: Milken Ins(tute/SPH Medicaid Benefit Design and Cost- sharing Policy 2013 19
ACA Provisions Important to Medicaid & Immunizations PROVISION 4: Effective January 1, 2014: States covering all recommended adult vaccines while prohibiting cost-sharing will receive a 1% increase in the Federal Medical Assistance Percentage (FMAP) for the service FMAP determines the federal contribution individual states are eligible to receive to support Medicaid 1 Title IV, Subtitle B, Sec. 4106. 2 Assistant Secretary for Planning and Evaluation (ASPE), Department of Health and Human Services. Federal Medical Assistance Percentages or Federal Financial Participation in State Assistance Expenditures (FMAP). November, 10, 2011. http://aspe.hhs.gov/health/fmap.htm. 3 www.socialsecurity.gov. Social Security Online: Compilation of the Social Security Laws. Sec. 1905. [42 U.S.C. 1396d]. http://www.ssa.gov/op_home/ssact/title19/1905.htm. 20
1% FMAP Increase No deadline to submit State Plan Amendment to request increase No end point for the 1% As of July 2014 (11) states have received approval from CMS: 1. California 6. Nevada 2. Colorado 7. New Hampshire 3. Delaware 8. New Jersey 4. Hawaii 9. New York 5. Kentucky 10. Ohio 11. Wisconsin Personal Communication: Mary Beth Hance, Senior Policy Advisor, Division of Quality, Evaluation and Health Outcomes, Children and Adults Health Program Group, Center for Medicaid and CHIP Services, CMS 21
2012: States Covering all ACIP Adult Vaccines & Prohibiting Cost-sharing (n = 15) AK AK WA OR NV CA ID UT MT WY CO ND SD NE KS MN IA MO AZ OK AR NM WI IL IN MS MI KY TN AL PA NY OH WV VA GA VT SC NC ME MA RI NJ DE CT MD DC TX LA FL HI Connecticut, Idaho, Kentucky, Maryland, Massachusetts, Nebraska, Nevada, New Jersey, New Mexico, New York, Oklahoma, Tennessee, Utah, Vermont, Wyoming NON EXPANSION STATES: Idaho, Oklahoma, Tennessee, Wyoming Source: Milken Ins(tute/SPH Medicaid Benefit Design and Cost- sharing Policy 2013 EXPANSION STATES: Connecticut, Kentucky, Maryland, Massachusetts, Nevada, New Jersey, New Mexico, New York, Utah (Under Review) Vermont 22
ACA Provisions Important to Medicaid & Immuniza3ons Provision 5: Effective January 1, 2014: Reimbursement will increase to at least 100% of Medicare payment rates for primary care services & vaccine administration (Family, General, Internal, Pediatric medicine physicians) Effective for 2013 & 2014 only States will receive 100% federal funding for: The difference between current state payment rates & the Medicare payment rate The Health Care and Education Reconciliation Act TITLE I COVERAGE, MEDICARE, MEDICAID AND REVENUES; Subtitle C Medicaid ; Sec. 1202. Payments to primary care physicians. 23
ACA Provisions Important to Medicaid & Immunizations Provision 5: As of July 2014 CMS has approved plans for all states & they are operational 24
MEDICARE 25
MEDICARE Part B: VACCINES Enacted in 1965: Excluded coverage of vaccines as preventive services ELIGIBLE POPULATIONS: Individuals entitled to Part A & others age 65 & older TOTAL COVERED in 2012: 50 million 8 million non elderly + disabilities; 2 million live in LTCs 1981 Pneumococcal (once per lifetime) 1984 Hepatitis B (risk-based) 1993 Influenza (annually) 1993 Administration Fee (Regional differences) MEDICARE PART D - VACCINES Includes Vaccines not covered under part B Source: Medicare at a Glance, November 14, 2012. Kaiser Family Foundation. www.kff.org 26
MEDICARE Part B: REIMBURSEMENT REIMBURSEMENT FOR PREVENTIVE SERVICES: HOSPITAL OUTPATIENT DEPARTMENT PREVENTIVE SERVICES: Any preventive services furnished by an outpatient department of a hospital shall be reimbursed at 100%, rather than under the prospective payment system for outpatient departments. 1. Pneumococcal, influenza and hepatitis B vaccines 2. Initial preventive physical examination 3. Personalized prevention plan services including education regarding immunizations TITLE IV - PREVENTION OF CHRONIC DISEASE AND IMPROVING PUBLIC HEALTH; Subtitle B Increasing Access to Clinical Preventive Services 27
FUNDING FOR VACCINE PROGRAMS 28
FUNDING FOR VACCINE PROGRAMS CDC CONTRACTS States may use State funds to purchase adult vaccines under CDC contracts. GRANTS Provides grants to States to improve immuniza(on coverage of children, adolescents, and adults through the use of evidence- based interven(ons as recommended by the Community Preven(ve Services Task Force: Reminders or recalls for pa(ents or providers Home visits SECTION 317 Reauthorized: FY 2014 alloca(on = $452 million Presiden(al Request FY2015 = $433 million SOURCE: TITLE IV - Preven3on Of Chronic Disease and Improving Public Health; Sub&tle C Crea&ng Healthier Communi&es;Sec. 4204. Immuniza3ons. 29
Section 317 Vaccine Purchase Funding FY2000-FY2013 Source: Centers for Disease Control and Prevention $300 $250 $200 $150 $100 $50 $0 * only an estimate at this time 30