State Activities to Implement the Affordable Care Act

Transcription

1 State Activities t Implement the Affrdable Care Act Fr the Oklahma Jint Cmmittee n the Federal Health Care Law Octber 26, 2011 Laura Tbler and Martha Salazar Natinal Cnference f State Legislatures Laura.tbler@ncsl.rg Martha.salazar@ncsl.rg 1

2 2010 Timeline Putting Infrmatin fr cnsumers nline. Prhibiting denying cverage f children based n pre-exist. cn. Prhibiting insurance cmpanies frm rescinding cverage Eliminating lifetime limits n insurance cverage N lifetime dllar limits n essential benefits fr insurance cverage Appealing insurance cmpany decisins Establishing cnsumer assistance prgrams in the states Prviding small business health insurance tax credits New health plans must prvide n-cst preventive services Preventing disease and illness- Preventin & Public Health Fund Fcusing n reducing/eliminating health care fraud. 2

3 2010 Timetable Establishing high risk pls fr uninsured Americans with preexisting cnditins. Extending cverage fr yung adults. Expanding cverage fr early retirees. Rebuilding the primary care wrkfrce. Hlding insurance cmpanies accuntable fr unreasnable rate hikes. Allwing states t cver mre peple n Medicaid (CT, MN and DC). Increasing payments fr rural health care prviders. Strengthening cmmunity health centers. 3

4 2011 Timetable Offering prescriptin drug discunts t senirs, 1.7 millin as f Sept 2011(27,000 in Oklahma). 1/1/11 Prviding free preventive care fr Medicare senirs. 1/1/11 Center fr Medicare & Medicaid Innvatin t test new ways f delivering care t patients t imprve quality & efficiency and submit natinal plan by 1/1/11. Cmmunity Care Transitins Medicare Demnstratin 1/1/11 Establish the Independent Payment Advisry Bard t recmmend ways t bring dwn csts. 10/1/11 Cmmunity First Chice Optin fr hme and cmmunity-based services and ther incentives t prmte Medicaid HCBS. 10/1/11 Implement medical lss rati prvisins. 1/1/11 Gradually eliminate higher Medicare Advantage payments. 1/1/11 4

5 2012 Timeline Hspital Value-Based Purchasing prgram fr Medicare that links payment t utcmes. 10/1/12 Incentives t frm Accuntable Care Organizatins. 1/1/12 Reducing paperwrk and administrative csts. 10/1/12 Cllect data and reprt n health disparities. 3/1/12 5

6 2013 Timetable New funding t state Medicaid prgrams cvering preventive services fr patients. Effective January 1, Natinal pilt prgram n payment bundling. N later than 1/1/13 Increasing Medicaid payments fr primary care services t at least 100% f Medicare payment rates. 1/1/13 Tw mre years f funding t cntinue cverage fr CHIP. 10/1/13 6

7 2014 Timetable Expand Medicaid t Americans wh earn less than133% f the pverty level (apprximately $14,000 fr an individual and $29,000 fr a family f fur).1/1/14 Individual mandate fr health cverage. 1/1/14 Health insurance exchanges peratinal. 1/1/14 Prhibit insurance cmpanies frm discriminatin due t pre-ex. cnd. r gender (individual and small grup market). 1/1/14 Eliminate annual limits n insurance cverage fr all plans.1/1/14 Cverage fr individuals participating in clinical trials. 1/1/14 Tax credits fr peple with incmes between 100% and 400% f the pverty line wh are nt eligible fr ther affrdable cverage. 1/1/14 Secnd phase f the small business tax credit. 1/1/14 7

8 2015 Timeline Pay physicians based n value nt vlume. A new prvisin will tie physician payments t the quality f care they prvide. 1/1/15 8

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10 Health Refrm Implementatin Entities MA RI CT NJ DE MD DC Legislative Branch Entity Executive Branch Entity Legislative & Executive Entity N Official Existing Entity 10

11 ACA Grant Funding t the States A ttal f nearly $4 billin has been awarded t all 50 states and 8 f the territries fr varius purpses: health insurance exchange; health insurance market; health care wrkfrce; public health investment; public health preventin fund; cmmunity health centers; lng term care; investments in research, data and develpment. 5 states have returned federal ACA grant mney: FL, KS, LA, NH, OK. NCSL's web page n ACA grant funding 11

12 Medical Lss Rati ACA requires that premium dllars cllected by insurance cmpanies be spent n health care services/quality imprvements: 80% fr individual and small emplyer plans and 85% fr large emplyer plans. (self-insured are exempt) 16 states and Guam (as f 9/22/2011) have applied fr waivers r adjustments f this prvisin, 5 apprved t date, 2 rejected. Maine, New Hampshire, Nevada, Iwa and Kentucky had their waivers apprved. Nrth Dakta and Delaware had their waivers rejected. OK: request t adjust the MLR standard t 65 percent, 70 percent, and 75 percent fr 2011, 2012, and 2013, respectively (received by HHS n 09/01/11) fr the individual and small grup market. 6 laws passed (with 4 enacted in CT, GA, ID, ME) defining minimum expenditures n health services. 12

13 Rate Review The ACA requires that health insurers justify unreasnable health insurance rate increases t states and the federal gvernment. Nearly half f states debated whether and hw t revise premium rate review prcess and 11 enacted a variety f laws (5 in 2011) At least 6 states apprved measures t expand authrity f regulatrs t review rates (e.g., institute prir apprval, hld public hearings, repeal deemer clauses) NV and CT Gvernrs veted bills that wuld have impsed rate review requirements beynd ACA. NCSL Reprt n premium rate reviews 13

14 Health Insurance Mandates ACA: States must cver cst f mandated benefits beynd essential benefits package. Every state has a substantial number f state laws (abut 1,800) that "mandate" private market health insurance t cver specific benefits/prvider services. Mre than half f states have mandate review r mandate evaluatin laws and bards. Oct 6, 2011 IOM Reprt HHS rules expected by May 1, 2012 Expect states t address existing state law related t mandates in 2012 and

15 Mre n health insurance and cnsumer prtectins ACA grants t states t establish, expand r prvide supprt fr a state-based ffice f health insurance cnsumer assistance r health insurance mbudsman. At least 35 states received grants. At least 16 states cnfrmed their internal appeals and external review prgrams t ACA. 47 states had already passed laws t create internal/external appeals. At least 7 states amended their laws t permit rescissins nly fr fraud r intentinal misrepresentatin f material fact The ACA permits states t frm health care chice inter-state cmpacts and allw insurers t sell plicies in any state participating in the cmpact. In 2011, Gergia became the first state t enact an ut-f-state purchase ptin pst ACA. WY and RI have a similar law that passed pre-aca.

16 Cverage fr Children and Yung Adults The ACA extends health cverage fr yung adult children under their parent's health plan up t the age f 26 effective 9/23/2010. State actin: 11 mre states allwed adult dependent children t cntinue cverage until age 26 since the ACA was signed. Prir t the ACA enactment, there were 37 states that had sme variatin f a dependent cverage law. Under the ACA, health plans cannt limit r deny benefits r deny cverage fr a child yunger than age 19 because f a "pre-existing cnditin State actin: 8 states prhibited children s pre-existing exclusin perids. Sme states have passed legislatin, created regulatins r enfrced existing state laws t require insurers that participate in the individual market t ffer cverage t children under age 19, including Arkansas, Califrnia, Clrad, Kentucky, New Hampshire and Washingtn. 16

17 Single payer insurance One state passed a law related t establishing a single payer health care system as an alternative t the ACA: VT. One state (IL) adpted a nnbinding reslutin urging Cngress and the President t immediately cnsider enactment f a single payer ptin based n the Medicare mdel fr adptin as an additinal cmpnent f a natinal health refrm plan. 17

18 Health Infrmatin Technlgy Medicaid Electrnic Health Recrds Incentive Prgram: This prgram was created as a part f the ARRA, hwever, many prvisins f the ACA are clsely aligned with creating a mdern, electrnic system t allw cnsumers, prviders and health systems t seamlessly btain and share health infrmatin. Oklahma Medicaid Electrnic Health Recrds Incentive Prgram Established in January 2011 by the Oklahma Health Care Authrity Qualified prviders receive financial assistance t ffset the cst f adpting, implementing and upgrading certified electrnic health recrds technlgy As f Octber 2011, nearly $51 millin in federal funds distributed t 862 eligible prfessinals and 45 eligible hspitals

19 Public health, preventin and wellness The ACA preventin and wellness prvisins apprpriate funding t states t imprve access t cmmunity health services, strengthen public health infrastructure, and prmte healthy eating and living. The law establishes the fllwing: A Natinal Preventin, Health Prmtin and Public Health Cuncil and a Preventin and Health Prmtin Strategy; A Preventin and Public Health Fund; State grants t imprve public health; Requirements t cver clinical preventive services; Nutritinal labeling requirements; and Insurance wellness prgrams. Oklahma has received $5,151,076 in state public health grants authrized under the ACA. 19

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21 Key Cverage Prvisins Maintains an emplyer-based system & private market Requires mst peple t have insurance ("individual mandate") Requires health insurance exchanges Expands Medicaid significantly (t 133% FPL) Enacts health insurance refrms

22 Majr State Rles May create & administer high-risk pls May create & administer health insurance exchanges Must expand Medicaid & pay fr a prtin Must cnduct public utreach & crdinate prgrams Must enfrce health insurance regulatins Must deal with wrkfrce issues

23 What is an Exchange? It is a marketplace fr health insurance. Prvides a set f cverage ptins fr individuals and small businesses with mre transparency than currently exists tday. It is a vehicle fr administering the new federal tax credits fr certain peple that dn t have cverage thrugh their emplyer. It is an enrllment "facilitatr" fr public prgrams such as Medicaid and CHIP.

24 Health Insurance Exchanges Every state must have Exchange(s) fr individuals and small businesses (up t 100 emplyees), effective Jan. 1, 2014; May pen t large emplyers effective January 1, 2017; r "alternative" prgram. Flexibility in determining if the state will create an exchange (feds will run it, if nt), wh will gvern it, and hw it will be structured. Exchange plans must ffer a minimum level f cverage. HHS released guidance and regulatins in the Prpsed Rules and the Natinal Assciatin f Insurance Cmmissiners released mdel legislatin.

25 Federal Funding Awarded 49 states and DC received up t $1 millin in Exchange Planning Grants. Fur territries received similar grants n March 21, states and a multi-state cnsrtium led by the University f Massachusetts Medical Schl received ver $241 millin in Early Innvatr grants t develp mdel Exchange IT systems. 13 states and the District f Clumbia were awarded arund $185 millin dllars in level ne Exchange Establishment grants. Three states, Indiana, Rhde Island and Washingtn, were awarded grants n May 23, 2011.

26 Deciding t Establish a State-Based Exchange If a state decides it wuld like t establish a state-based health insurance exchange, it must ntify the Secretary f the Department f Health and Human Services via a State Plan by January 1, The State must demnstrate it is in the prcess f establishing an exchange that will be peratinal by January 2014.

27 AK* HI Summary f Establishment Legislatin Octber 2011 OR CA** WA NV ID AZ UT MT WY NM CO ND SD NE TX KS OK* MN* IA* MO AR LA WI IL IN MI TN OH KY MS AL GA Legislatin Pending Did Nt Pass in 2011 Enacted Exchange Establishment/Intent N 2011 Legislative Actin t Establish an Exchange * Indicates that it is a carry ver state and the bill can be reintrduced in the 2012 legislative sessin. ** Califrnia is the nly state t pass exchange establishment in WV VT PA SC* FL NY VA NC NH* ME* MA RI* CT NJ DE MD DC

28 State Optins t Create Health Insurance Exchanges If a state decides t establish an exchange, it has the fllwing ptins: A state gvernmental Agency Existing Executive Branch Agency -r Independent public agency A nn-prfit rganizatin Will there be a gverning bdy and wh will serve as the bdy? Cntract with ther eligible entities t carry ut varius functins f the exchange. Hw will the state regulate insurers in the exchange?

29 State Structure Gvernance Carrier Selectin Califrnia Independent State Agency 5 Member Bard Active Purchaser Clrad Nn-Prfit 12 Member Bard Nt an Active Purchaser Cnnecticut Quasi-Public Agency 14 Member Bard Active Purchaser Hawaii Nn-Prfit 15 Member Interim Bard Cmmissiner Will Determine Illinis Intent Maryland Independent State Agency 9 Member Bard Bard f Directrs will decide Massachusetts Independent State Agency 11 Member Bard Active Purchaser

30 State Structure Gverning Carrier Selectin Nevada Nrth Dakta Independent Public Agency Intent 10 Member Bard Nt determined in Legislatin Oregn Quasi-Gvernmental 9 Member Bard Active Purchaser Utah Existing Agency-Office f Cnsumer Health Services Nt a set number, can be up t 9 Vermnt Existing Agency A Deputy Cmmissiner f the Department f Health Access Virginia Intent All plans are allwed t participate Nt an Active Purchaser Washingtn West Virginia Public/Private Partnership separate frm the state New Entity within the Office f Insurance Cmmissiner 11 Member Bard Bard f Directrs will Decide 10 Member Bard Nt an Active Purchaser

31 All State Actins Enacted Exchange Legislatin Pending Legislature Created Study Entity (specifically fr exchanges) Legislative Actin Nt Taken r Did Nt Pass in 2011 Executive Branch Actin

32 Other Legislative Actins Study Panels and Intent Bills Illinis Mississippi Missuri Nrth Dakta Virginia Wyming Included in ther general implementatin entities like NC that included exchanges as part f the wrking sub grups t study exchanges.

33 Executive Branch Actins Alabama-Gvernr Rbert Bentley created the Alabama Health Insurance Exchange Study Cmmissin. Gergia-Gvernr Nathan Deal created the Gergia Health Insurance Exchange Advisry Cmmittee. Indiana-Gvernr Mitchell Daniels, Jr. established the Indiana Health Benefit Exchange as a nn-prfit rganizatin in the state. Rhde Island-Gvernr Lincln Chafee established the Rhde Island Health Benefits Exchange as a divisin within the Executive Department. A 13 member bard will gvern the exchange, the bard is allwed t determine which health plans will be allwed in the exchange.

34 Nn-Legislative Actins Luisiana Gvernr annunced that the federal gvernment will run the exchange in the state. Mississippi The Mississippi Cmprehensive Health Insurance Risk Pl Assciatin will establish the state s health insurance exchange. Mississippi s Insurance Cmmissiner Mike Chaney determined that the assciatin had the statutry authrity t establish an exchange. Once the assciatin presents a plan, it will need apprval frm the insurance cmmissiner and HHS but will nt need further legislative actin t mve frward due t statutry authrity it was given in 2009 as the state high risk health pl prgram.

35 Massachusetts What we knw frm thers In 2006, Massachusetts passed health refrm legislatin that develping the Cmmnwealth Health Insurance Cnnectr Authrity. The bard was initially charged with implementing the exchange. It established prcedures fr selecting and apprving private plans t be ffered in the Cnnectr. The bard als develped enrllment prcedures.

36 Massachusetts Cnnectr What we knw s far: Massachusetts has the highest rate f insured residents in the natin, 98.1%. Massachusetts already has in place many f the laws nw required by ACA. Lessns Learned frm Jn Kingsdale, frmer Directr f the Cnnectr: 1. It s a campaign 2. Research & experiment 3. Cmmunicate, cmmunicate, cmmunicate 4. Huge technlgy challenge/pprtunity 5. Outsurce, partner & cllabrate

37 What we knw frm thers. Utah Utah passed legislatin in 2008 and 2009 that led t the creatin f the Utah Health Exchange. Administered and facilitated by the Office f Cnsumer Health Services (existing state agency). Since the fall f 2009, the Utah Health Exchange has allwed emplyees f small emplyers, n a pilt basis, t cmpare, select, and enrll in cmmercial health insurance thrugh an entirely nline, internet-based prcess. In the fall f 2010, the Exchange was pened t all small emplyers and t large emplyers, n a pilt basis.

38 Utah Exchange Develping a blueprint fr implementatin Mdifying system and expanding internet prtal t meet federal requirements fr premium tax subsidies and credits and Medicaid and CHIP eligibility. Lessns Learned frm Frmer Speaker David Clark 1. Supprt and Cperatin Within and Acrss State Gvernment is Key 2. Begin with the End in Mind 3. Develp a General Timeline 4. Identify Specific Prblems t be Addressed 5. Demgraphy is Destiny

39 States are mving alng Vermnt HB 202--Establishes a strategic plan fr creating a single-payer and unified health system in the State f Vermnt and includes the exchange in their state based health refrm legislatin. Luisiana has decided t let the federal gvernment run the exchange in the state Virginia intends t establish an exchange

40 Cncerns with Setting Up State Exchanges Timeline Guidance First regulatins published in July Medicaid crdinatin, subsidies, essential benefits, quality, and ther regulatins still t cme IT Systems 40

41 NCSL Resurces n the ACA Federal Health Refrm Main Page Health Refrm: State Actins Newsletter State Actins t Implement Health Benefit Exchanges States Challenging Health Refrm