The Affordable Care Act www.dpw.state.pa.us

What is the Affordable Care Act?
Patient Protection and Affordable Care Act
(PPACA), a.k.a. ACA
– Federal health care reform law
– March 23, 2010 signed into law by President
Obama
– Goals:
• Expand coverage
• Control health care costs
• Improve health care delivery system
The Affordable Care Act www.dpw.state.pa.us
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What does it do?
• Requires coverage regardless of pre-existing conditions or gender
• Intended to increase rate of individuals covered by insurance through:
– Creation of insurance exchanges and expansion of Medicaid eligibility
– Mandates on employers and individuals
– Premium subsidies
– Tax credits
• Intended to decrease number of uninsured individuals
The Affordable Care Act www.dpw.state.pa.us
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What does it establish?
• Facilitates provision of qualified health coverage
• Mandates health benefit exchanges (also known as Marketplaces) by January 2014 in every state
• Regulatory overhaul of the U.S. healthcare system
The Affordable Care Act www.dpw.state.pa.us
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State Requirements – Insurance Exchanges
• Choose an Insurance Exchange Option by December 14, 2012
• 3 options:
State Based State Partnership Federally Based
State Based Exchange (SBE)
Built and maintained by each state
State Example: Washington
Partnership Exchange
Hybrid Model; state assumes certain responsibilities
State Example: Delaware
Federally Facilitated
Marketplace (FFM)
Built by Federal government, each state establishes an interface with the FFE
State Example: Pennsylvania
35% of states 14% of states 51% of states
The Affordable Care Act www.dpw.state.pa.us
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What role will be played by the FFM?
• The federally facilitated exchange is also referred to as the FFE or federally facilitated marketplace (FFM).
• Individuals may apply for insurance through the
Exchange.
• The Exchange will determine eligibility for:
– Advanced Premium Tax Credit (APTC)
– Cost Sharing Reductions (CSR)
The Affordable Care Act www.dpw.state.pa.us
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What are APTC and CSR?
Advance Premium Tax Credit (APTC): A new tax credit to help individuals and families afford health coverage purchased through the
Exchange.
Cost Sharing Reduction (CSR): A discount that lowers the amount paid out-of-pocket for deductibles, coinsurance, and copayments.
The Affordable Care Act www.dpw.state.pa.us
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How does ACA affect DPW?
What Has DPW Already Done Related to ACA?
• Extended Medicaid Drug Rebates to drugs paid by Medicaid
Managed Care Organizations.
• Implemented several new program integrity and provider enrollment screening processes.
• Began paying increased payments to Medicaid primary care providers.
• Implemented a recovery audit contract to identify payment issues and recoup overpayments.
• Implemented payment policies for hospitals that prohibited payment for a Health-Care Acquired Condition, such as infections acquired at the hospital.
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How does ACA affect DPW?
One goal of ACA is to provide a seamless and simplified enrollment process for all Insurance Affordability programs. Pennsylvania will accomplish this requirement for simplified enrollment by providing multiple ways to apply, including:
• Exchange
– Electronic Application
– Paper Application
• New Pennsylvania paper application form called the PA 600HC
• COMPASS – Updated to comply with ACA
• Phone Applications
There is ‘no wrong door’ when applying for Medical Assistance and other Health Care Plans!
The Affordable Care Act www.dpw.state.pa.us
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How does ACA affect DPW?
• The Modified Adjusted Gross Income (MAGI) standard will now be used for Medicaid eligibility.
– MAGI will apply to adults, children, pregnant women, parents, caretaker relatives, and individuals eligible for family planning services.
– MAGI does NOT apply to SSI recipients; children in foster care; individuals eligible based on being aged, blind, or disabled; working disabled; or individuals in a facility/eligible for home and community based care.
The Affordable Care Act www.dpw.state.pa.us
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What is Early MAGI?
• PA applied for an Early MAGI waiver to start
MAGI October 1, 2013 rather than January 1,
2014.
• Early MAGI will increase efficiency and reduce duplicative processes in the County Assistance
Offices.
The Affordable Care Act www.dpw.state.pa.us
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How does ACA affect DPW?
• Medicaid Eligibility Changes:
– Children ages 6-18 - Income up to 133% of
Federal Poverty Level (FPL)
– Former foster care children up to age 26
• ACA will NOT change eligibility or benefits for our waiver programs for individuals with physical and intellectual disabilities.
The Affordable Care Act www.dpw.state.pa.us
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System Updates and Enhancements
• COMPASS
– System design, screening, eligibility questions and routing
– Ability to link to Federal Exchange
– Ability to obtain information from data matches in
“real time”
• CIS/eCIS/PROMISe
– Medicaid eligibility rules under ACA
– System design and screen changes
The Affordable Care Act www.dpw.state.pa.us
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Consumer Service Center (CSC)
• The Commonwealth has taken steps to ensure that the needs of its citizens are met under the new Federal ACA mandate.
• CMS mandates the availability of a call center to take applications on the phone for
ACA.
• The CSC opened on October 1, 2013 to answer questions about ACA and take
COMPASS applications for health care only.
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Critical Milestones
• October 2013
• Enrollment applications under the new Modified
Adjusted Gross Income (MAGI) eligibility rules begin to be accepted
• January 2014
• Exchange coverage begins for Pennsylvania
The Affordable Care Act www.dpw.state.pa.us
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Questions and Comments
More information on Pennsylvania’s implementation of the Affordable Care Act is available at www.dpw.state.pa.us.
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