The Affordable Care Act and the Future of Title X Susan Moskosky, MS, RNC Acting Director Tasmeen Weik, DrPH, MPH Health Scientist November 19, 2013 Office of Population Affairs
2 Impact of the ACA on Title X Regardless of whether your individual States/organizations are supportive of the ACA, the health care environment is rapidly changing. Title X service delivery network faces major challenges and must make significant changes in order to remain viable. Together we can ensure that Title X thrives in the new healthcare environment.
3 What We Will Cover Today What Title X Providers Need to Know About the ACA Relevant sections of the ACA that affect Title X Major issues for Title X service delivery sites What we know or anticipate in terms of impact What we know from the Massachusetts experience Where grantees are now Data from a health reform readiness assessment We will stop intermittently for questions so type away in the chat box. Expectations for grantees What it will take to survive in the new environment What you should be doing now Where can you go for more information Grantee resources
Major Provisions for Title X What do I need to know about the ACA? President Lyndon Johnson signs Medicare and Medicaid into law 1965 President Obama signs ACA into law. 2010
5 The Overall Picture Source: American Public Health Association (APHA) Available at http://www.apha.org/nr/rdonlyres/26831f24-882a-4ff7-a0a9-6f49dfbf6d3f/0/acaoverview_aug2012.pdf
6 Insurance Reform What it means for Title X Health insurance marketplace Greater number of insured clients Potential for increased revenue Clients want to see providers in their network Title X service sites need to contract with QHPs Medicaid Expansions Potential for increased Medicaid Revenue Clients need to be enrolled Service sites need to help enroll clients Essential Health Benefits No Cost Sharing Preventive Services Clients will have better access to preventive services Clients want a usual source of care Service sites need to consider expanding services or partnering with primary care
I The Health Insurance Marketplace 7 Marketplace in each State where individuals can shop for coverage. Health insurance marketplace Greater number of insured clients Potential for increased revenue Clients want to see providers in their network Title X service sites need to contract with QHPs 17 State Based Marketplaces 27 Federally Facilitated Marketplaces 7 Partnership Marketplaces Healthcare.gov is a portal to all marketplaces One streamlined application for Medicaid, CHIP, QHPs QHP=Qualified Health Plan
For more information and regular updates, visit the Health IT blog at http://www.hhs.gov/digitalstrategy/tags/health-it 8
9 Essential Health Benefits Preventive Care Most health plans must cover preventive care services without costsharing, including: Evidence-based items or services with a rating of A or B by the United States Preventive Services Task Force Immunizations for routine use in children, adolescents, and adults recommended from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention Evidence-informed preventive care and screenings provided for in comprehensive guidelines supported by HRSA http://www.hrsa.gov/womensguidelines/
10 Preventive Care Family Planning Well-woman visits Counseling and screening for HIV Sexually Transmitted Infection prevention counseling HPV testing Cervical cancer screening Contraception Breastfeeding support, supplies, counseling Screening and counseling for interpersonal and domestic violence
11 What Types of Contraceptives Must be Covered? The no-copay rule applies to the full range of FDA-approved contraceptive methods including, but not limited to: barrier methods, hormonal methods, implanted devices, emergency contraceptives such as ella and Plan B patient education and counseling. Contraceptive methods are covered only if the method is both: FDA-approved and prescribed for a woman by her health care provider. The bottom line for providers? Verify benefits with individual plans; and Understand prescribing rules in your community
12 Types of Contraceptives That Are Not Required The ACA states that there is no coverage requirement for "abortifacient drugs such as RU-486. OTC products such as condoms and spermicides are generally not covered. Neither contraception nor sterilization for men is covered. (These services are not included in the HRSA guidelines.)
13 Grandfathered Plans and Accommodation for Religious organizations Health plans that existed before 2010 are grandfathered and do not need to meet preventive services requirements until they make major changes and lose grandfathered status. Religious organizations Houses of worship are exempt from the requirement. Other non-profit religious organizations e.g., hospitals, universities, charities are not exempt. However, they will not be required to contract, arrange or pay for contraceptive coverage. The bottom line for providers? Verify benefits with individual plans http://www.ofr.gov/ofrupload/ofrdata/2013-15866_pi.pdf
14 Contracting with QHPs and Other Insurance Essential Community Providers Health insurance marketplace Greater number of insured clients Potential for increased revenue Clients want to see providers in their network Title X service sites need to contract with QHPs The final law requires that QHPs have a sufficient number and geographic distribution of essential community providers, where available, to ensure reasonable and timely access to a broad range of such providers for low-income, medically underserved individuals. CMS provides guidance for Federally Facilitated and State Partnership marketplaces on specifics State marketplaces follow guidance from State.
15 Contracting with QHPs Essential Community Providers For Federally Facilitated and State Partnership marketplaces insurers must demonstrate that they meet one of the following standards: Safe harbor standard QHPs must include at least one ECP in each ECP category in each county in the service area, where an ECP in that category is available. Contract with at least 20% of ECPs in service area Minimum Expectation Standard 10% of available ECPs in the plan s service area participate in the issuer s provider network(s) Described in narrative Title X and Title X look-alike health centers are a specific ECP category Standards have to be met in the first year that coverage begins http://www.cms.gov/cciio/resources/regulations-and- Guidance/Downloads/2014_letter_to_issuers_04052013.pdf
Contracting with QHPs Essential Community Providers ECP Provider Categories: 16 FQHC and look alike Ryan White provider Family planning provider Title X Family Planning Clinics and Title X look alike family planning clinics Indian providers Hospitals Other ECP providers STD clinic, TB clinics, Hemophilia treatment centers, black lung clinics, and other entities that serve predominantly low incomemedically underserved individuals. http://www.cms.gov/cciio/resources/regulations-and- Guidance/Downloads/2014_letter_to_issuers_04052013.pdf
17 Contracting with QHPs Essential Community Providers List of ECPs: Non-exhaustive list of available ECPs based on data maintained by CMS and other federal agencies, which issuers may use to calculate the safe harbor and/or minimum expectation thresholds. You don t need to be on the list to be a ECP All Title X providers are considered ECP s If you are not on the list, you may need to INFORM providers that you are a ECP OPA does provide updates to CMS using data submitted in the OPA database. Make sure that EVERY service site is in the OPA database: https://opa-fpclinicsdb.icfwebservices.com/
18 Contracting with QHPs Essential Community Providers Bottom Line: Issuers have to contract with ECP s. Title X providers are automatically ECP s. Issuers have leeway in how they meet the ECP criteria. Find out what the network adequacy standards in your State are. You can still contract with QHPs! Most marketplaces are allowing network adequacy standards to be met during the first year of coverage (2014). Marketplaces are still certifying health plans. Family planning providers should contact the insurance carriers association in their state for help in identifying potential QHPs. Identify health insurance issuers with the greatest market share in the individual and small group market and reach out to those issuers directly.
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20 Contracting with QHP s Issues Title X has faced in contracting with QHP s and the need for systems improvements! Data challenges Quality reporting Need EHR s! Getting set up with claims administration Credentialed provider Payment terms Contracting is complex! FPNTC webinar on Revenue Cycle Management (Contracting): Resources for EHR s Search for these on: www.fpntc.org
21 Questions and Answers Please enter your questions in the comment box. Health insurance marketplace Greater number of insured clients Potential for increased revenue Clients want to see providers in their network Title X service sites need to contract with QHPs. Medicaid Expansions Potential for increased Medicaid Revenue Clients need to be enrolled Service sites need to help enroll clients Essential Health Benefits No Cost Sharing Preventive Services Clients will have better access to preventive services Clients want a usual source of care Service sites need to consider expanding services or partnering with primary care
Medicaid Expansions To expand or not to expand that is the question.
23 Medicaid Expansions States may expand Medicaid to non-elderly adults with incomes up to 133% of the Federal Poverty Level ($15,282/year for an individual, $31,322/year for a family of 4) Current Expansion Status: 26 expanding (including DC) 25 not expanding
24 Medicaid Expansion Traditional Medicaid Medicaid expansion Population Various (mandatory and Non-pregnant adults ages 19-64 with optional) income at or below 133% FPL Benefits Outlined in statute. Alternative Benefit Plan (ABP) which is Mandatory benefits generally based on a commercial plan, include: and must include: FQHC/RHC services Essential Health Benefits (including EPSDT services for preventive health service w/o costchildren under age 21 sharing) Family planning Family planning services and services and supplies supplies (States have discretion FQHC/RHC services to define) EPSDT services for children under 21 There are also optional benefits that States can These plans must also comply with choose to offer. Mental Health Parity Act
25 Who Qualifies for What? Eligible : For insurance To purchase Income level purchased through the insurance % FPL Marketplace: For Medicaid? through Reduced Market- Premium costplaces? Tax Credits sharing Currently eligible people will generally No 0 to 100% remain eligible. Individuals with Yes (Exception: incomes up to 138% FPL will be able to enroll in Medicaid in states that 100% - 138% implement Medicaid expansion Yes Generally not (although some States 138% - 250% Yes cover some individuals) legal immigrants) 250% - 400% No Yes Yes* No Above 400% No Yes No No Not lawfully present No (except emergency Medicaid) No No No Yes*
26 Gaps in Coverage and Subsidies 400% FPL 241% FPL Exchange Subsidies Varies by State 133% FPL 100% FPL 63% FPL 37% FPL Medicaid/CHIP Children 0 Other Adults Jobless Parents Working Parents Pregnant Women Children
27 Medicaid Not Expanding What if a State does not expand Medicaid: People who are currently eligible for Medicaid will likely remain eligible. Individuals should still apply for Medicaid because they may qualify via existing coverage pathways Individuals not eligible for Medicaid can buy a plan in the Marketplace, but those with incomes under 100% FPL ($11,490) are not eligible for financial assistance. Title X sites should pay attention to developments in their state.
28 Contraception: Will insured clients get it for free? In order to receive contraception without cost sharing: You must have private insurance, or an Alternative Benefit Plan under Medicaid. Your insurance cannot be grandfathered. The birth control must be on the list of FDA-approved contraceptives Must be prescribed. Insurer management eg. If your insurer charges for name brand Rx, you must be getting a generic Rx. You can t work for a house of worship that has chosen not to provide it. Bottom line: verify benefits and learn what your local plans are covering.
30 Increasing Revenue Medicaid Expansions Potential for increased Medicaid Revenue Clients need to be enrolled Service sites need to help enroll clients Help clients enroll into health insurance. The time is NOW!
31 Outreach and Enrollment Direct clients to health insurance options Conduct onsite enrollment in reach to existing uninsured clients Outreach to clients in the community You can use title X funding to conduct outreach and enrollment!!!
Assisters Navigators Enrollment Assisters (FFM only) In-person Assisters (SPM only) Certified Application Counselors (hospitals, doctors offices, libraries, existing trusted business partners) Agents/Brokers Call Center Representatives Consumer Assistance Framework Assistance Framework Help consumers through the application, plan comparison, and enrolling in coverage and may be able to provide additional education about health insurance & program options In Find Local Help & Customer Service Referrals Find Local Help shows all organizations that have been trained & are available to help with application & enrollment. Trained state/local government employees will not be displayed. Application & Plan Compare Assistance See individuals personal information & data (PII) Help consumers fill out the application Help consumers compare plans & make an enrollment selection Provide education about the application and plan compare process Some may offer additional education about health insurance basics, program options, and plan offerings May conduct local outreach to bring consumers in the door for assistance Educators Provide basic awareness and education about the Marketplace and serve to refer people to customer service channels for assistance Partners & Stakeholders Local government branches & employees School administration & staff Are not displayed in Find Local Help & are not consumer referral points educators refer consumers Then Direct to Customer Service Website Call Center Assister Outreach about the Marketplace Create awareness of the Marketplace Drive consumers to Customer Service channels (website & assisters) Conduct outreach events & activities Provide basic information about the Marketplace and where to get help
33 Outreach and Enrollment Become a certified application counselor http://marketplace.cms.gov/help-us/partner-with-us.html Partner with local navigators and other assisters https://localhelp.healthcare.gov/
34 Outreach and Enrollment Resources Print ready poster Front desk enrollment job aid Available at: www.fpntc.org Click ACA.
35 Outreach and Enrollment Provider Resources 5 Things You should Tell your Family planning patients about ACA Audio-casts Why providers should enroll Sample patient script (role play) Profile of Title X Agency Doing On-Site Enrollment Setting up enrollment program Sample patient flow (enrollment and financial counseling) Sample job description of enrollment worker Available at: www. fpntc.org Click ACA
36 Keeping the patients you have Plans required to cover essential health benefits. Preventive services (including contraception) covered without cost sharing Clients will have better access to preventive services Clients want a usual source of care Service sites need to consider expanding services or partnering with primary care Retaining clients will be a challenge! Partner with primary care services. Improve patient experience.
37 Keeping your doors open: Increasing Revenue Contracting Conducting regular cost analysis Understanding coding and effectively billing for services Archived Trainings on FPTNC website: Cost analysis (3 webinars) Coding (3-unit online training) Revenue cycle management (3 webinars) Primary care partnerships www.fpntc.org
38 Summary Insurance Reform Implications for Title X Medicaid Expansions More eligible clients Potential for increased revenue Marketplaces More clients have health insurance Clients will go to innetwork providers Help enroll clients in health insurance Contract with QHPs Patient Experience Expand services (primary care) EHRs Claims admini QI Essential Health Benefits Preventive services without cost sharing Clients want more services and a usual source of care Systems improvements Need to contract and bill third party payors Issuers want quality data
39 Questions and Answers Please enter your questions in the comment box. Next up: What will happen to Title X What will it take to thrive Where are grantees. now? What should you be doing now?
What will happen to Title X?
41 What will happen to Title X? Title X is a safety net provider and will continue to serve: Individuals who don t qualify for health insurance Insured and uninsured individuals where confidentiality can not be ensured Individuals who want to continue receiving care at a family planning site (usual source of care)
User Insurance Status: MA (2005-2012) Title X - FPAR Data MA-Insured MA-Uninsured 100% 80% MA General insurance rate 60% 53% 59% 60% 53% 59% 60% 61% 62% 45% 39% 40% 46% 38% 39% 38% 35% 38% 20% 0% 2005 2006 2007 2008 2009 2010 2011 2012 4 2 Source: FPAR 2011
43 Lessons from MA: Revenue Increase in funding from Medicaid and private third party payers. Decrease of 11.74% in revenue from Medicare and other public health insurance programs Total revenue in MA in 2007 increased 11.58%. In the same year, revenue in all other Title X clinics nationwide increased 12.02%. Therefore, despite large increases in Medicaid and private party payments, overall, when compared to the rest of the country, MA saw a 0.44% revenue decrease.
44 So what does this mean for Title X? Sustainability will depend on: Improving Revenue! Effectively contracting and billing third-party payers Implementing EHR s and using them for quality reporting Setting up claims administration Getting clients enrolled into health insurance Retaining current patients Providing quality care Improving patient experience
Surviving in the new environment WHAT WILL IT TAKE?
46 Sustainability Indicators for Family Planning
Where are Title X providers now?
Health Reform Readiness Assessment Focus Areas 48
49 Enrollment 27% reported no outside resources to support enrollment 56% have no plans to include enrollment staff 51% offering enrollment expect an increase in clients Image from: www.kaiserhealthnews.org
Better Health: Primary Care 50
51 Better Health: Electronic Health Records
52 Lower Cost: Revenue Diversification 96% Bill Medicaid 68% Bill Other Third Party Payers 27% reported contracts with Accountable Care Organizations 51% reported contracts with Qualified Health Plans (on the Health Insurance Marketplace) Most grantees expect their networks to see an increase in revenue and client volume due to Medicaid Expansion and/or the Health Insurance Marketplace.
What you should be doing now!
54 Grantee Expectations Conduct an analysis of your service sites Create a long term sustainability plans Consider service sites that may need to be replaced in the next few years Grantees are responsible for assuring geographic service availability
55 Grantee Expectations We will be looking to the grantees to make decisions on: - What level of investment is required to sustain an individual service site? - How much should you invest in making a struggling service site viable versus looking for alternative providers - Depend on availability of alternative provider Provide technical assistance to sites who need a little help!
What are we (OPA) doing?
57 Demonstrating the value of Title X Outreach and enrollment data collection The number of individuals trained as outreach and enrollment workers that have successfully completed all required Federal and/or State training. The number of individuals assisted by a trained outreach and enrollment assistance worker. The number of individuals who receive an eligibility determination for the marketplace, Medicaid, or CHIP with the assistance of a trained outreach and enrollment assistance worker. The number of individuals who enroll with the assistance of a trained outreach and enrollment assistance worker. Working with CMS and other stakeholders Improving FPAR data collection (FPAR 2.0) to better demonstrate Title X performance Monitoring trends
58 Providing Technical Assistance NTC Trainings (for all grantees, subrecipients and service sites) Intensive technical assistance One-on-one for grantees who we have identified as having significant challenges (including environmental challenges in the State) Group technical assistance for grantees we have identified facing similar issues (eg. EHR implementation)
59 Resources Currently Available ACA website www.fpntc.org/aca Email Box for questions familyplanningaca@jsi.com Available national training: Cost Analysis Revenue cycle management (including contracting) 3-unit Coding e-learning Outreach and enrollment resources 5 things providers should know Onsite enrollment resources Podcasts Print ready flyer Front desk enrollment job aid Federal materials www.marketplace.cms.gov
60 Summary ACA will have a positive impact on the health care system and Title X Title X providers need to make system improvements NOW to ensure they thrive in the new healthcare environment.
61 Summary Vision: Title X family planning providers continue to be leading providers of family planning and reproductive health care services. Expectations: In order to realize this vision, Title X grantees will need to: Help clients enroll in health insurance Contract and bill with third party payers Expand primary care services Improve data systems Improve quality and patient experience Vision image from: michaelnichols.org
62 Title X will thrive as a result of the ACA. But we need to make some changes. And we need to do it together.
63 EVALUATION Please provide us with feedback for future ACA related webinars. Suggestions for future topics What you need from OPA
64 Questions and Answers Please enter your questions in the comment box..
THANK YOU!! For all you do, and all you serve!
EXTRA SLIDES For answering questions..
67 Contracting with QHPs Essential Community Providers For Federally Facilitate and State Partnership marketplaces insurers must demonstrate that they meet one of the following standards: Examples: Issuer A proposes a service area in which 80 ECPs are available. Issuer A s network includes 16 ECPs, and Issuer A attests in its narrative justification that it has offered contracts to available Indian providers and one ECP in each major ECP category per county, where an ECP in that category is available. Issuer A meets the safe harbor standard. Issuer B also proposes a service area in which 80 ECPs are available. Issuer B s network includes 8 ECPs. Issuer B meets the minimum expectation by providing a narrative justification explaining why its network includes only 8 ECPs and how it will ensure service for low-income and medically underserved enrollees. If an issuer does not meet either standard, they can provide a narrative justification describing how the issuer s provider network will provide access for low-income and medically underserved enrollees and how the issuer plans to increase ECP participation in future years. Reference: http://www.cms.gov/cciio/resources/regulations-and- Guidance/Downloads/2014_letter_to_issuers_04052013.pdf
68 Marketplace Plans: Who is Not Eligible The following people are not eligible for financial assistance in the Marketplace: Those with other affordable insurance options such as Medicare, Medicaid, or employer-sponsored insurance Persons below 100% FPL (except legal immigrants.) Persons whose income is above 400% FPL for premium tax credits and 250% for cost-sharing reductions. Individuals not lawfully present
69 Marketplace Plans Each QHP must fall into one of four levels of coverage based on actuarial value (AV): bronze, silver, gold, and platinum Bronze: 60% AV Silver: 70% AV Gold: 80% AV Platinum: 90% AV In the Marketplaces, participating QHPs must offer at least one silver level and one gold level plan Silver level plan is the basis for determining premium tax credit amounts and cost-sharing QHP s may vary based on: Premiums, copays, coinsurance Some cover additional benefits Many will only cover providers in their network!
70 Variations in Coverage for the Same Contraceptive Even for the same contraceptive, there can be variations in coverage. For example: If there is a generic version of a contraceptive available, insurers can charge for the name brand as long as the generic is available for free. Both deductibles and cost-sharing can apply. Medicaid beneficiaries who have the traditional benefit package may find that their state s formulary only covers certain contraceptives. Bottom line: Providers should verify benefits with individual plans.
71 Changes in Total Family Planning Users -5.10% -3.87% in Title X 2011 MA US -1.73% 2010 0.78% 2009 0.09% 2.70% 2008 1.13% 1.29% -8.74% -0.01% 2007-10.00% -8.00% -6.00% -4.00% -2.00% 0.00% 2.00% 4.00% Source: FPAR 2011