The Affordable Care Act and Covered California A Guide for Health Care Providers
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Spotlight on Reform: The Affordable Care Act and Covered California Wonha Kim, MD, MPH, CPH, FAAP Senior Research Scholar, LLU Institute for Health Policy and Leadership Assistant Professor, Pediatrics, Preventive Medicine, and LLUSPH February 11, 2014
Outline Brief overview of the Affordable Care Act (ACA) Background information on Covered CA What is it? Who is eligible? How are insurance plans organized? How are rates determined? Data on Covered CA enrollment Implications for healthcare providers
Overview of Affordable Care Act In March 2010, President Obama signed into law the Patient Protection and Affordable Care Act (PPACA) Increase health care coverage Reduce health care costs and improve affordability Improve quality of healthcare and population health
Key Changes Mandated by the ACA Young adult coverage: up to age 26 can be covered under parents plan Preventive care coverage: no out-of-pocket costs for preventive services rated A or B by USPSTF Guaranteed coverage: no denials for pre-existing conditions No lifetime or annual limit No rates based on health status Standardized benefits (essential health benefits)
Additional Changes by the ACA Changes to Medicare reimbursement (e.g. bundled payment) Mandatory insurance enrollment by everyone by Jan 2014 Introduction of premium assistance and cost-sharing reduction programs for those eligible Optional expansion of Medicaid eligibility to 138% of federal poverty level (previously 133%) Creation of federal or state-run health care exchanges (health insurance marketplaces) to make things easier for consumers ( one stop shop )
Covered California California s Health Care Exchange (first state in the US to enact legislation) Created to serve as easy-to-use marketplace where most Californians can compare and purchase health insurance coverage Actively negotiates price with insurance companies to optimize premiums for consumers Initially funded by grants from the federal government but will be selfsustainable (not tax-payer funded) by Jan 2015
Covered California Estimated that 5.3 million Californians who did not have health insurance in 2012 (equaling 16% of the population under age 65) will benefit 1.4 million Californians will be newly eligible for Medi-Cal Any eligible Californian from age 18-64 can shop through Covered California for health insurance coverage and receive premium assistance/cost reduction as applicable First open enrollment period: Oct. 1, 2013 to March 31, 2014
19 Regions in CA Region 17: San Bernardino and Riverside Counties
Enrollment Statistics: Inland Empire Region 17 Oct. 1 through Dec. 31, 2013 Non- Subsidized Subsidy Eligible California 75,172 424,936 Total 500,108 Platinum 23% Region 17 Non-subsidized: 4,606 Gold 15% Bronze 28% Minumum Coverage 5% Silver 29% Minumum Coverage Silver Bronze Platinum Gold Region 17 Subsidy Eligible: 34,868 Platinum 7% Bronze 17% Gold 7% Minumum Coverage 1% Minumum Coverage Silver Bronze Silver 68% Platinum Gold State-wide enrollment: 500,108 Region 17 = 8% of statewide enrollment Source: Covered California www.coveredca.com
Enrollment Statistics: Demographics (CA) 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Hispanic Latino, Spanish Origin 86.5% 78.9% 21.1% 13.5% Subsidy-Eligible Non-subsidized Yes No Majority who answered the question were not Hispanic in origin Higher proportion in subsidy-eligible group Ethnicity Subcategory Subsidy-Eligible Non-Subsidized Among those who reported being Hispanic in origin, majority were Mexicans 1.0% 1.5% Cuban 70.9% 62.9% Mexican/ Mexican American 8.6% 1.6% 2.5% 4.5% Puerto Rican Mixed Ethnicity 22% 24.5% Other Source: Covered California www.coveredca.com
Enrollment Statistics: Demographics (CA) 70.0% 60.0% 63.7% Subsidy-Eligible Non-subsidized 52.9% 50.0% 40.0% 30.0% 27.4% 20.0% 15.6% 10.0% 0.0% 3.0% 3.4% White Asian Black or African American 8.2% 11.6% Mixed Race 0.4% American Indian/ Alaskan Native 0.2% 0.2% 0.2% Native Hawaiian/ Pacific Islander 7.8% 5.3% Other Source: Covered California www.coveredca.com
Enrollment Statistics: Demographics (CA) Subsidy-Eligible Non-Subsidized 1.20% 1.60% 0.10% 97.20% Source: Covered California www.coveredca.com
Enrollment Statistics: Demographics (CA) 35.0% Age Breakdown of Covered CA Enrollees (Oct 1 Dec 31) 30.0% 25.0% 20.0% 15.0% Subsidy Eligible Non-subsidized 10.0% 5.0% 0.0% < 18 18 to 25 26 to 34 35 to 44 45 to 54 55 to 64 > 65 Source: Covered California www.coveredca.com
Enrollment Statistics: Insurance Carriers Subsidy Eligible Kaiser Permanente 17% Anthem 16% Health Net 28% Molina Health Care 5% Blue Shield 34% Blue Shield Health Net Kaiser Permanente Anthem Molina Health Care Molina Health Care 5% Enrollment Statistics Inland Empire Region 17 Source: Covered California www.coveredca.com Anthem 25% Blue Shield 33% Non-subsidized Oct. 1 through Dec. 31, 2013 Kaiser Permanente 17% Health Net 20% Enrollment Statistics Inland Empire Region 17 Source: Covered California www.coveredca.com Source: Covered California www.coveredca.com
Implications for Healthcare Providers Be prepared for potentially huge increase in demand Remember: 5.3 million previously uninsured in CA (319,996 for Region 17) 1.4 million newly eligible for Medi-Cal Source: Inland Empire Children s Health Initiative In Region 17: 259,541 newly eligible for Medi-Cal
Implications for Healthcare Providers Plan ahead for increases in certain types of patients: Those with Medi-Cal (newly eligible) Age group (especially 55-64) Primary language other than English Multiple medical conditions (previously denied coverage and now eligible through guaranteed issue) Know that primary care will be emphasized (e.g. 10% bonus)
Implications for Healthcare Providers Be aware that Medicare reimbursement is shifting from feefor-service to bundled payment models May voluntarily join an Accountable Care Organization (ACO) Provide current patients information on which insurance plan(s) your office accepts so that they know when they sign up through Covered CA Call California Medical Association (CMA) Physician Hotline at 1-800-786-4262 if further questions
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