Health Care
Reform
Jan Heckemeyer
Department of Mental Health
What is Health Care Reform?
Patient Protection & Affordable Care Act
(ACA) and the Health Care & Education
Reconciliation Act of 2010; Enacted March
2010.
Contains significant expansions of access
and coverage for almost all Americans.
Overarching Goals of Health Care Reform
Increase number of people with health
coverage
Improve quality of health coverage
Increase wellness and disease prevention
efforts
Insurance and payment reform
Health Care Reform
Uninsured Individuals:
 46 million in United States
 800,000 in Missouri
The ACA will expand coverage to an estimated 32
million Americans, including 500,000 Missourians.
Insurance Regulations
Changes effective for health plan years beginning
on or after September 23, 2010:
 Must provide dependent coverage up to age 26
 Certain preventative services are covered without
requiring co-payments or deductibles.
 Prohibits rescinding insurance coverage except in
cases of fraud
 Prohibits annual and lifetime limits on coverage
 Children cannot be denied coverage because of preexisting conditions.
Pending Legal Challenges
 Over 30 lawsuits have been filed in courts across the
country to challenge the constitutionality of the law –
primarily the “individual mandate”.
 The “individual mandate” requires most people to have
insurance or pay a special tax; Larger businesses will also
pay fines if they do not provide insurance to their
employees.
 Five federal district courts have ruled on the merits of the
individual mandate – three have upheld the constitutionality
and two have struck it down.
 Two federal Court of Appeals have issued rulings – One
upheld the law and the other ruled that the individual
mandate was unconstitutional but the rest of the law was
upheld.
 It is expected that the Supreme Court will ultimately rule on
the constitutionality of the law.
What is Health Insurance Exchange?
 Serves as a health plan shopping mall for
individuals and small businesses seeking more
stable health care rates and coverage.
 Employers with 50 or less employees and
individuals (including those eligible for Medicaid)
choose among plans offered through an
Exchange.
 Provides quick, easy access to a menu of options
for health insurance coverage comparing
premium rates and benefit packages.
Health Insurance Exchange Requirements
 Each state must establish a Health Insurance Exchange by
January 1, 2014.
 Must be operated by a governmental entity or non-profit
entity.
 For states that do not establish an Exchange, or if the
state’s Exchange fails to meet Federal requirements, the
Federal government will operate the Exchange.
 Exchange must make “qualified” health plans available to
individuals and employers.
 Exchange must provide “no wrong door” portal for all
consumers to determine eligibility and enroll in:
 Medicaid
 Children’s Health Insurance Program (CHIP)
 Premium tax subsidies to purchase private coverage
 Non-subsidized private coverage
Missouri Action on Health Insurance Exchange
 Established Health Insurance Exchange
Coordinating Council (HIECC).
 Received $1 million planning grant.
 Received approximately $21 million federal grant
to help implement an Exchange.
 Legislation was introduced in last session to
organize the Exchange as a quasi-governmental
agency called the “Show-Me Health Insurance
Exchange”.
 Legislation passed the House but was not voted
on by the full Senate when the session ended in
May.
Show-Me Health Insurance Exchange
Key Functions:
 Certify “qualified” health plans
 Screen Missouri residents for subsidies,
including Medicaid
 Conduct outreach, education and assistance
for individuals and small businesses seeking
coverage
HIE Navigators
 Navigators are entities that conduct outreach, education
and enrollment into qualified health plans through the state
Exchange.
 A state Exchange must establish a program under which it
awards grants to Navigators.
 To be eligible to receive a Navigator grant, an entity must
demonstrate that it has existing relationships or could
readily establish relationships with employers, employees,
consumers and self-employed individuals likely to enroll in
qualified health plans through the Exchange.
 Potential Navigator entities include:
 Trade, industry, and professional associations
 Community and consumer-focused non-profit groups
 Chambers of commerce
 Unions
HIE Navigators
Duties of Navigators:
 Conduct public education activities to raise awareness of
the availability of qualified health plans
 Distribute information concerning enrollment in qualified
health plans and available tax credits and other costsharing reductions
 Facilitate enrollment in qualified health plans
 Provide referrals to appropriate state agencies or other
health insurance consumer assistance offices
 Provide information in a manner that is culturally and
linguistically appropriate to the needs of the population
being served in the Exchange
HIE Navigators
Recommended State Timelines:
 2011 – Preliminary planning activities including
developing high level milestones and timeframes
for establishing the Navigator program
 2012 – Determine targeted organizations in the
State who would qualify as Navigators
 2013 – Award grants or contracts to Navigator
entities; Train Navigators and begin operations
Medicaid Expansion to 133% FPL
Beginning January 1, 2014, states will be
required to provide Medicaid benefits to
uninsured individuals with household
incomes up to 133% FPL who are:
 Under age 65,
 Not pregnant,
 Not entitled to or enrolled in Medicare Part A
or B, and
 Not eligible for Medicaid under any other
mandatory category.
Medicaid Expansion to 133% FPL
Missouri currently covers:
 Pregnant women and children
 Parents to approximately 20% of the FPL
 Permanently and totally disabled
individuals under age 65 to 85% FPL
Medicaid Expansion to 133% FPL
% Gross Monthly Income
Family Size
85%
100%
133%
1 person
$772
$908
$1,208
2 people
$1042
$1,226
$1,631
3 people
$1,312
$1,544
$2,054
4 people
$1,584
$1,863
$2,478
5 people
$1,854
$2,181
$2,901
2011 FPL Guidelines
Medicaid Expansion to 133% FPL
States will receive increased federal financial
participation for newly eligible individuals in
the expansion group:
100% - 2014, 2015 and 2016
95% - 2017
94% - 2018
93% - 2019
90% - 2020 and thereafter
Health Homes for Persons with Chronic Conditions
 States have the option of enrolling Medicaid
beneficiaries with chronic conditions into a Health
Home.
 A Health Home is a multidisciplinary team of
health care providers who work together to
ensure that a person has a regular primary care
physician and that their care is coordinated so
that all other health care providers involved know
what each is doing and what a person needs next
in order to have the best health care possible.
 A health home is responsible for making sure the
patient gets all the care he/she needs, but does
not have to provide all the care themselves.
Health Homes for Persons with Chronic Conditions
For the purposes of Health Homes, ACA considers the
following to be chronic conditions:
Serious Mental Health Conditions
Substance Use Disorders
Asthma
Diabetes
Cardiovascular Disease – including hypertension
Overweight (BMI>25)
Other conditions may also be included
Health Homes for Persons with Chronic Conditions
Eligible Individuals:
 Persons with 2 chronic conditions
 Persons with 1 chronic condition who
are at risk for a 2nd chronic condition
 Persons who have 1 serious and
persistent mental health condition
Health Homes for Persons with Chronic Conditions
Requirements:
Care coordination and health promotion
Comprehensive transitional care including
follow-up from inpatient and other settings
Patient and family support
Referral to community and support
services
Use of health information technology to
link services
Health Homes for Persons with Chronic Conditions
Missouri is the first state to submit a
Medicaid state plan amendment to
implement Health Homes. There are two
types of Health Homes:
 Primary Health Care
• Federally Qualified Health Centers (FQHCs)
• Rural Health Centers (RHCs)
• Physician Practices
 Behavioral Health Care
• Community Mental Health Centers (CMHCs) and
CMHC Affiliates
Department of Mental Health Commitments
 Continue participation and support for
Cabinet Team.
 Provide DMH representation on interagency
groups.
 Educate DMH stakeholders about health care
reform opportunities.
 Participate in statewide infrastructure
development, such as the Health Insurance
Exchange, changes to eligibility applications
and Medicaid billing changes.