Patient Protection and Affordable Care Act

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1 2012 Fall Conference Gregory L. Pemberton (317) Kevin C. Woodhouse (317) *This outline is intended for general information purposes and does not and is not intended to constitute legal advice. Ice Miller LLP PPACA Overview Patient Protection and Affordable Care Act Signed March 23, 2010 and amended by the Health Care and Education Affordability Reconciliation Act on March 30, 2010 Once fully implemented, PPACA is intended to provide all Americans with access to affordable health care coverage. Individual Mandate Health Care Exchanges and Expansion of Medicaid Expansion of Employer Coverage 1

2 Court Challenges Within minutes of President Obama signing ACA, 20 states, two private citizens and the National Federation of Independent Business filed a complaint seeking declaratory judgment and injunctive relief challenging the constitutionality of the law Six states later joined the lawsuit and other lawsuits followed Lower courts were split on the issues. Supreme Court Review Four issues before the Supreme Court: Issue #1: As an initial inquiry, does the litigation with respect to the Act violate the Anti-Injunction Act? Issue #2: Is the individual mandate constitutional? Issue #3: Is the individual mandate severable from the Act? Issue #4: Is the Medicaid expansion constitutional? Oral arguments were held March 26-28, 2012 The Court issued its decision on June 28,

3 Supreme Court Outcome Issue #1: As an initial inquiry, does the litigation with respect to the Act violate the Anti-Injunction Act? No violation the Court could proceed to the merits. Issue #2: Is the individual mandate constitutional? Yes. The Court held that the individual mandate was not constitutional under the Commerce Clause, but nonetheless upheld the mandate as a legitimate exercise of Congress' taxing power under the U.S. Constitution. Supreme Court Outcome (cont'd.) Issue #3: Is the individual mandate severable from the Act? The Court did not need to rule on this issue because it held the individual mandate to be constitutional. Issue #4: Is the Medicaid expansion constitutional? The Court held that Congress overreached its spending powers with the Medicaid expansion by threatening States with the loss of existing Medicaid funding if they decline to comply with the expansion. The Medicaid provision was interpreted narrowly to preclude the Secretary from withdrawing existing funds for failure to comply with the expansion. 3

4 Outcome for Employers The Act continues to be valid law. Employers sponsoring group health plans continue to be subject to all applicable coverage mandates and reporting requirements. The Court's ruling on the Medicaid expansion means some states may decline to expand their Medicaid programs. A state's decision not to expand Medicaid will impact low income employees who would have been covered by Medicaid under the expansion, but are instead eligible for federal tax subsidies on the exchanges, thus possibly triggering penalties for employers. 4

5 Exchanges PPACA creates state-based health benefit Exchanges through which individuals and small employers (up to 100 employees) can purchase coverage. Premium and cost-sharing credits available to individuals with household income between % of federal poverty level (FPL). If state does not establish, federal government will do so, either directly or under an agreement with a non-profit entity. Health plans on Exchange must be issued by licensed health insurance issuer and provide an "essential health benefits package." Must satisfy certain cost sharing limits. Must have four benefit categories (bronze, silver, gold and platinum) plus "young invincible" category. Exchanges 2014 (Cont'd) Small Employers (100 or fewer employees) can purchase health insurance on a Small Business Health Option Program (SHOP) Exchange at varying coverage and cost levels. In the case of plan years beginning before January 1, 2016, a State may elect to define small employer by substituting 50 employees for 100 employees. Beginning in 2017, States may allow businesses with more than 100 employees to purchase health insurance through the Exchange in that State. 5

6 Exchanges 2014 (Cont'd) SHOP Exchanges Plans will cover essential health benefits typical in employer health plans. Four tiers of coverage depending on amount of coverage provided. Underwriting is based only on age and smoking status not medical history. No pre-existing condition exclusions in plans. Depending on the exchange structure, employer chooses the health plans from which employees may choose. Exchange will provide one-stop shopping with "apples-to-apples" comparisons and a single place to enroll employees and remit premiums. Exchanges 2014 (Cont'd) States are taking different approaches with implementation of the Exchanges. Some states have committed to create Exchanges. Some states have refused to create Exchanges, which will require the federal government to create the Exchange. Indiana: Address in a few minutes. 6

7 What Will The Exchanges Do? Certify Health plans as qualified health plans Exemption from the individual coverage mandate and whether "affordable" coverage is available to an individual Administer Operate a toll-free information line Maintain an Internet website that allows consumers to compare available plans Rate qualified health plans based on the HHS-developed rating system Make eligibility determinations for Medicaid, CHIP, etc. Provide to each employer the name of each employee who ceases coverage under a qualified health plan during a plan year Educate Establish the Navigator program to award grants for education and outreach regarding the qualified health plans available through the Exchange and facilitation of enrollment Exchange Benefit Levels Bronze: benefits actuarially equivalent to 60% of the full actuarial value of the benefits provided under the plan Silver: 70% of the full actuarial value Gold: 80% of the full actuarial value Platinum: 90% of the full actuarial value Young Invincible (under 30) Employer Selects Level Employers that opt to provide coverage for their employees through the Exchange select a level of coverage (e.g. "Silver"). The employee may then choose from any qualified health plan available through the Exchange that offers coverage at that level. 7

8 Exchange Subsidies and Medicaid Expansion Premium Assistance Tax Credit Subsidies to individuals between 100% and 400% of FPL Subsidies on a sliding scale based on income Premium assistance tax credit Cost sharing assistance Expansion of Medicaid to 133% of the Federal Poverty Level (FPL) Following Supreme Court ruling, states that do not expand their Medicaid program as provided under PPACA cannot be denied current funding to maintain current Medicaid program. For states that agree to expansion, they will receive more Federal funding to offset much of the additional cost. Federal Poverty Level The 2012 Poverty Guidelines for the 48 Contiguous States and the District of Columbia Persons in family Poverty Guideline 133% 400% 1 $11, $14, $44, $15, $20, $60, $19, $25, $76, $23, $30, $92, $27, $35, $108, $30, $41, $123, $34, $46, $139, $38, $51, $155,

9 Exchange Subsidies The premium assistance tax credit is calculated based on: Premium cost of the second-lowest-cost "Silver" plan offered through a state health benefit exchange; and Income level of the applicant Income Level (% above FPL) Maximum Premium as Percentage of Income Up to 133% 2.0% % 3-4% % 4-6.3% % % % % % 9.5% Individual Penalties General rule that individuals must either secure "qualifying health coverage" or pay tax penalty. Tax penalty Taxpayer pays for him/herself and for tax dependents. Amount of tax penalty is the greater of $695 or 2.5% of modified gross income for the household, up to a maximum of three x $695 ($2,085) per family or 2.5% of household income. No penalty if gap in coverage is less than 3 months. 9

10 Individual Penalties 2014 (Cont d) Exemptions from individual penalties: Financial Hardship (determined by Secretary of HHS) Religious Objections American Indians Undocumented immigrants Incarcerated individuals Those for whom the lowest cost plan option exceeds 8% of an individual s household income Those with incomes below the tax filing threshold (in 2009 the threshold for taxpayers under age 65 was $9,350 for singles and $18,700 for couples) 10

11 Employer Responsibilities Employers are not required to provide coverage, but they face a tax penalty beginning January 1, 2014 if they: fail to provide "minimum essential coverage," or fail to provide "affordable" coverage. Applies to employers with 50 or more full-time employees (including FTEs). Employer Responsibilities 2014 (Cont d) Calculating Size of Employer s Workforce to Determine if Employer is Subject to Penalties Determined based on average in previous calendar year. If not in existence during previous year, reasonable expectations. Full-time employee = works 30 hours per week. Preliminary guidance states count hours for hourly employees. For salaried employees either: (1) count hours; (2) use a days-worked equivalency of 8 hours; or (3) use a weeks worked equivalency of 40 hours. Part-time employee monthly hours totaled and divided by 120 add to number of full-time employees to determine FTEs. Seasonal employees: if an employer's workforce exceeds 50 FTEs for 120 days or fewer in a calendar year and the employees in excess of 50 during those 120 days were seasonal employees, then the employer is not subject to the penalty structure. 11

12 Employer Responsibilities 2014 (Cont d) Situation #1: Employer does not provide "minimum essential coverage" to all full-time employees (and their dependents). "Minimum essential coverage" includes major medical group health plan coverage offered by an employer, whether grandfathered or non-grandfathered. When coverage is not offered, penalty assessed if: One or more full-time employees purchase coverage from an Exchange, AND Any such employee qualifies for a Federal subsidy. Penalty amount: $ per month (or $2,000 per year) for each full-time employee (subject to inflation). First 30 full-time employees exempted. Employer Responsibilities 2014 (Cont d) Example of Situation #1 Employer A has 100 full-time employees and does not provide minimum essential coverage. One of Employer A's employees purchases coverage through an Exchange and qualifies for a Federal subsidy. Employer A is subject to a penalty of $11, per month (or $140,000 per year). Calculation of penalty: 70 employees (first 30 excluded) x $ per month or $2,000 per year. 12

13 Employer Responsibilities 2014 (Cont d) Situation #2: Employer does provide minimum essential coverage to all fulltime employees (and their dependents), but coverage is not "affordable" with respect to at least one full-time employee. Coverage is not "affordable" with respect to an employee if: The employee's contribution under the employer plan exceeds 9.5% of household income (or, under IRS safe harbor rule, 9.5% of employee's W-2 wages), OR The employer plan pays less than 60% of the total cost of benefits provided under the plan. When coverage offered is not affordable, penalty assessed if: One or more full-time employees opt-out of employer coverage and purchase coverage from an Exchange, AND Any such employee qualifies for a Federal subsidy. Penalty amount: $250 per month (or $3,000 per year) for each opting-out employee receiving a subsidy (subject to inflation). Penalty capped at $2,000 per year times total number of full-time employees (subject to inflation), with first 30 full-time employees exempted. Employer Responsibilities 2014 (Cont d) Example of Situation #2 Employer B has 100 full-time employees and provides minimum essential coverage to all full-time employees and their dependents. Employee C's household income is $15,000, and he is charged $1,500 for coverage under Employer B's plan, or 10% of his household income. Thus, the coverage is not "affordable" with respect to Employee C. Employee C opts out of Employer B's health plan, purchases coverage through an Exchange, and qualifies for a Federal subsidy. Employer B is subject to a penalty of $250 per month (or $3,000 per year) for Employee C. If other employees of Employer B are similarly situated, Employer B will pay the same penalty with respect to each such employee, capped at $140,000. Calculation of maximum: 70 employees (first 30 excluded) x $2,

14 Employer Responsibilities 2014 (Cont d) An employee qualifies for a Federal tax subsidy if: the employee purchases coverage on an Exchange; and the employee's household income is between % of the FPL; and EITHER: the employer does not offer coverage; OR the employer offers coverage that is not affordable for the employee, i.e.: The employee's contribution under the employer plan exceeds 9.5% of household income (or, under IRS safe harbor rule, 9.5% of employee's W-2 wages), OR The employer plan pays less than 60% of the total cost of benefits provided under the plan. Currently, 400% of FPL is $92,200/year for a family of four and $44,680/year for individuals. Employer Responsibilities 2014 (Cont d) Impact of Supreme Court ruling on Medicaid expansion States cannot be required to expand their Medicaid programs to cover most individuals whose household income is less than 133% of FPL in order to continue receiving Medicaid funds for their current programs. A state's decision on whether to expand its Medicaid program affects employers because it determines the pool of employees who could be eligible for a Federal subsidy on the Exchange (i.e., Medicaid-eligible employees are not eligible for Federal subsidies on the Exchanges), which in turn impacts employer penalties. 14

15 Employer Responsibilities 2014 (Cont d) Example: Opting-out of Medicaid Expansion Employee D lives alone, has an annual household income of $13,000, and has to pay $1,300 for employer coverage, or 10% of his household income. In a state that agrees to expand Medicaid, Employee D is covered by the expansion because his household income is within 133% of FPL ($14,856.10). Because Employee D will not receive subsidized coverage through an Exchange, Employee D's employer is not subjected to a penalty. In a state that declines to expand Medicaid, Employee D is not eligible for Medicaid, but he is eligible for a Federal tax subsidy if he purchases coverage on the Exchange because his household income is at least 100% of FPL ($11,170). Therefore, Employee D's employer is subject to a penalty for failing to provide Employee D with affordable coverage. Potential Impact of State Decisions on Employers If state declines to expand Medicaid: Employees between % of FPL will not be covered by Medicaid, but will be eligible for federal tax subsidies, triggering employer penalties if employer does not offer affordable coverage to this group (see example on previous slide). Employees under 100% of FPL but not Medicaideligible will be left without Medicaid or subsidized coverage options through an Exchange if employer does not offer affordable coverage to this group. 15

16 HIX Indiana's Approach Governor Daniels has been opposed to the Act from the beginning. Indiana is one of the states that filed the original court action. Lead contributor in 2/7/11 Wall Street Journal Op-Ed piece "If there's to be a train wreck, we governors would rather be spectators than conductors. But if the federal government is willing to re-route the train to a different, more productive track, we are here to help." HIX Indiana's Approach (Cont.) Still, Indiana has done some work to prepare Issued Executive Order on January 3, 2011 Did not commit the state to establish an exchange Allowed the state to plan and study the implications Order points out that stringent timelines make it prudent to conditionally analyze, plan and prepare for a state-based exchange Exchange structured as a non-profit corporation would be best able to coordinate and leverage resources of existing state agencies and protect interests of stakeholders Indiana applied for and was granted initial planning grant (October 2010) and Exchange Level One grant (May 2011). 16

17 HIX Indiana's Approach (Cont.) Indiana's efforts Robust effort to obtain stakeholder input Actuarial analysis of market impact IT Gap Analysis IT Plan to Support Exchange Business Requirements Analysis Budget Financing Plan Legal analysis of various issues Reviewing and commenting on proposed regulations Consideration of potential Indiana statutory changes HIX Indiana's Approach (Cont.) Ultimately "wait and see" Reaction to Supreme Court's Decision Governor Daniels sent a letter on July 30 asking the 3 candidates for their input Pence Indiana will not establish or operate a state-based HIX Gregg Leaning toward a hybrid exchange Boneham Hybrid exchange 17

18 HIX Indiana's Approach (Cont.) Candidate Pence's Reasoning Oppose the Act "Because ObamaCare erodes the freedom of every Hoosier, will increase the cost of health insurance, and will cripple job creation in our state, I believe the State of Indiana should take no part in this deeply flawed healthcare bureaucracy." Understand that some people believe that state would be better off if it established its own Exchange too much uncertainty National debate over ACA is far from over Too much regulatory uncertainty over operation of exchange Fiscal uncertainty cost up to $50 million and higher for Indiana Legal uncertainty as to subsidies and state-based exchanges Decision due to federal government by November 16, 2012 States Developing State-Based Exchanges 18

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21 Organization Service Area 1. Allina Hospitals & Clinics Minnesota and Western Wisconsin 2 Atrius Health Eastern and Central Massachusetts 3. Banner Health Network Phoenix, Arizona Metropolitan Area (Maricopa and Pinal Counties) 4. Bellin-Thedacare Health Partners Northeast Wisconsin 5. Beth Israel Deaconess Physician Organization Eastern Massachusetts 6. Bronx Accountable Healthcare Network (BAHN) New York City (the Bronx) and lower Westchester County, NY 7. Brown & Toland Physicians San Francisco Bay Area, CA 8. Dartmouth-Hitchcock ACO New Hampshire and Eastern Vermont 9. Eastern Maine Healthcare System Central, Eastern and Northern Maine 10. Fairview Health System Minneapolis, MN Metropolitan Area 11. Franciscan Alliance Indianapolis and Central Indiana 12. Genesys PHO Southeastern Michigan 13. Healthcare Partners Medical Group Los Angeles and Orange Counties, CA 14. Healthcare Partners of Nevada Clark and Nye Counties, NV 15. Heritage California ACO Southern, Central, and Coastal California 16. JSA Medical Group, a division of HealthCare Partners Orlando, Tampa Bay, and surrounding South Florida Organization Service Area 17. Michigan Pioneer ACO Southeastern Michigan 18. Monarch Healthcare Orange County, CA 19. Mount Auburn Cambridge Independent Practice Association (MACIPA) Eastern Massachusetts 20. North Texas ACO Tarrant, Johnson and Parker Counties in North Texas 21. OSF Healthcare System Central Illinois 22. Park Nicollet Health Services Minneapolis, MN Metropolitan Area 23. Partners Healthcare Eastern Massachusetts 24. Physician Health Partners Denver, CO Metropolitan Area 25. Presbyterian Healthcare Services Central New Mexico Pioneer Accountable Care Organization Central New Mexico 26. Primecare Medical Network Southern California (San Bernardino and Riverside Counties) 27. Renaissance Medical Management Company Southeastern Pennsylvania 28. Seton Health Alliance Central Texas (11 county area including Austin) 29. Sharp Healthcare System San Diego County 30. Steward Health Care System Eastern Massachusetts 31. TriHealth, Inc. Northwest Central Iowa 32. University of Michigan Southeastern Michigan 21

22 ACO Name Service Area 1. Accountable Care Coalition of Caldwell County, LLC North Carolina 2. Accountable Care Coalition of Coastal Georgia, LLC Georgia, South Carolina 3. Accountable Care Coalition of Eastern North Carolina, LLC North Carolina 4. Accountable Care Coalition of Greater Athens Georgia, LLC Georgia 5. Accountable Care Coalition of Mount Kisco, LLC New York, Connecticut 6. Accountable Care Coalition of Southeast Wisconsin, LLC Wisconsin 7. Accountable Care Coalition of Texas, Inc. Texas 8. Accountable Care Coalition of the Mississippi Gulf Coast, LLC Mississippi 9. Accountable Care Coalition of the North Country, LLC New York 10. AHS ACO, LLC New Jersey, Pennsylvania 11. AppleCare Medical ACO, LLC California 12. Arizona Connected Care, LLC Arizona 13. Chinese Community Accountable Care Organization New York 22

23 ACO Name Service Area 14. Catholic Medical Partners New York 15. Coastal Carolina Quality Care, Inc. North Carolina 16. Crystal Run Healthcare ACO, LLC New York, Pennsylvania 17. Florida Physicians Trust, LLC Florida 18. Hackensack Physician-Hospital Alliance ACO, LLC New Jersey, New York 19. Jackson Purchase Medical Associates, PSC Kentucky, Illinois 20. Jordan Community ACO Massachusetts 21. North Country ACO New Hampshire, Vermont 22. Optimus Healthcare Partners, LLC New Jersey 23. Physicians of Cape Cod ACO, Inc. Massachusetts 24. Premier ACO Physician Network California 25. Primary Partners, LLC Florida 26. RGV ACO Health Providers, LLC Texas 23

24 ACO Name Service Area 1. AzPCP ACO Chandler, Arizona 2. John C. Lincoln Accountable Care Organization, LLC Phoenix, Arizona 3. Fort Smith Physicians Alliance ACO, LLC Fort Smith, Arkansas 4. AppolloMed Accountable Care Organization Inc. Glendale, California 5. Golden Life Healthcare LLC Sacramento, California 6. John Muir Physician Network Walnut Creek, California 7. Meridian Holdings, Inc. Hawthorne, California 8. North Coast Medical ACO, Inc. Oceanside, California 9. Torrance Memorial Integrated Physicians, LLC Torrance, California 10. MPS ACO Physicians, LLC Middletown, Connecticut 11. PriMed, LLC Shelton, Connecticut 12. Accountable Care Coalition of Northwest Florida, LLC Pensacola, Florida 13. Accountable Care Partners, LLC Jacksonville, Florida 24

25 ACO Name Service Area 14. Allcare Options, LLC Parrish, Florida 15. Florida Medical Clinic ACO, LLC Zephryhills, Florida 16. FPG Healthcare, LLC Orlando, Florida 17. HealthNet, LLC Boynton Beach, Florida 18. Integrated Care Alliance, LLC Gainesville, Florida 19. Medical Practitioners for Affordable Care, LLC Melbourne, Florida 20. Palm Beach Accountable Care Organization, LLC West Palm Beach, Florida 21. Reliance Healthcare Management Solutions, LLC Tampa, Florida 22. WellStar Health Network, LLC Marietta, Georgia 23. Advocate Health Partners Rolling Meadows, Illinois 24. Chicago Health System ACO, LLC Westmont, Illinois 25. Deaconess Care Integration, LLC Evansville, Indiana 26. Franciscan AHN ACO, LLC Mishawaka, Indiana ACO Name Service Area 27. Indiana University Health ACO, Inc. Indianapolis, Indiana 28. Genesis Accountable Care Organization, LLC Davenport, Iowa 29. Iowa Health Accountable Care, L.C. Des Moines, Iowa 30. One Care LLC Des Moines, Iowa 31. University of Iowa Affiliated Health Providers, LC Iowa City, Iowa 32. Quality Independent Physicians Louisville, Kentucky 33. Southern Kentucky Health Care Alliance Smiths Grove, Kentucky 34. TP-ACO LLC Baton Rouge, Louisiana 35. Central Maine ACO Lewiston, Maine 36. Maine Community Accountable Care Organization, LLC Augusta, Maine 37. MaineHealth Accountable Care Organization Portland, Maine 38. Accountable Care Coalition of Maryland, LLC Hollywood, Maryland 39. Greater Baltimore Health Alliance Physicians, LLC Baltimore, Maryland 25

26 ACO Name Service Area 40. Maryland Accountable Care Organization of Eastern Shore, LLC National Harbor, Maryland 41. Maryland Accountable Care Organization of Western MD, LLC National Harbor, Maryland 42. Circle Health Alliance, LLC Lowell, Massachusetts 43. Harbor Medical Associates, PC South Weymouth, Massachusetts 44. Accountable Healthcare Alliance, PC East Lansing, Michigan 45. Oakwood Accountable Care Organization, LLC Dearborn, Michigan 46. Southeast Michigan Accountable Care, Inc. Dearborn, Michigan 47. Essentia Health Duluth, Minnesota 48. Medical Mall Services of Mississippi Jackson, Mississippi 49. BJC HealthCare ACO, LLC St. Louis, Missouri 50. Heartland Regional Medical Center St. Louis, Missouri 51. Nevada Primary Care Network ACO, LLC Las Vegas, Nevada 52. Concord Elliot ACO, LLC Manchester, New Hampshire ACO Name Service Area 53. Barnabas Health ACO-North, LLC West Orange, New Jersey 54. Accountable Care Coalition of Syracuse, LLC Syracuse, New York 55. Asian American Accountable Care Organization New York, New York 56. Balance Accountable Care Network New York, New York 57. Beacon Health Partners, LLP Manhasset, New York 58. Chautauqua Region Associated Medical Partners, LLC Jamestown, New York 59. Healthcare Provider ACO, Inc. Garden City, New York 60. Mount Sinai Care, LLC New York, New York 61. ProHEALTH Accountable Care Medical Group, PLLC Lake Success, New York 62. WESTMED Medical Group, PC Purchase, New York 63. Cornerstone Health Care, PA High Point, North Carolina 64. Triad Healthcare Network, LLC Greensboro, North Carolina 65. Mercy Health Select, LLC Cincinnati, Ohio 26

27 ACO Name Service Area 66. ProMedica Physician Group, Inc. Toledo, Ohio 67. Summa Accountable Care Organization Akron, Ohio 68. University Hospitals Coordinated Care Shaker Heights, Ohio 69. North Bend Medical Center, Inc. Coos Bay, Oregon 70. Coastal Medical, Inc. Providence, Rhode Island 71. Accountable Care Coalition of The Tri-Counties, LLC Charleston, South Carolina 72. AnewCare LLC Johnson City, Tennessee 73. Cumberland Center for Healthcare Innovation, LLC Nashville, Tennessee 74. MissionPoint Health Partners Nashville, Tennessee 75. St. Thomas Medical Group PLLC Nashville, Tennessee 76. Summit Health Solutions Knoxville, Tennessee 77. BHS Accountable Care, LLC San Antonio, Texas 78. Memorial Hermann Accountable Care Organization Houston, Texas ACO Name Service Area 79. Methodist Patient Centered ACO Dallas, Texas 80. Essentia Care Partners, LLC Austin, Texas 81. Physicians ACO, LLC Houston, Texas 82. Texoma ACO, LLC Wichita Falls, Texas 83. Central Utah Clinic, P.C. Provo, Utah 84. Accountable Care Coalition of Green Mountains, LLC South Burlington, Vermont 85. Polyclinic Management Services Company Seattle, Washington 86. Aurora Accountable Care Organization, LLC Milwaukee, Wisconsin 87. Dean Clinic and St. Mary's Hospital Accountable Care Organization, LLC Madison, Wisconsin 89. ProHealth Solutions, LLC Waukesha, Wisconsin 27

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29 ACOs and Post-Acute Care ACOs will want to avoid re-admissions and other problems that can arise upon discharge from the Hospital ACOs need to coordinate with post-acute care providers (LTACHs, Rehabilitation, SNFs and Home Health) to effectively manage care How will this be accomplished? What are the challenges to effective coordination? 29

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