6/7/2014 UCSF Antepartum and Intrapartum Management June 7, 2014 The Affordable Care Act is Here: Now What? Michael S. Policar, MD, MPH Clinical Professor of Ob,Gyn, & RS UCSF School of Medicine policarm@obgyn.ucsf.edu No commercial disclosures for this lecture ACA: What’s Been Done So Far? 2010-2013 � Young adults covered on parents plan until 26 years old � No restrictions on pre-existing conditions for children <19 � Medicare: rebates and discounts on brand-name prescription drugs in Part D “doughnut hole” � Ban on lifetime benefit caps and rescissions � Phased-in ban on annual policy limits � Insurance rate increase restrictions – Plans must spend > 80% of premiums on health care � First dollar coverage of many preventive services (no-cost sharing…i.e., no deductible or co-payments) 1
6/7/2014 The Individual Mandate ACA: What Started on 1/1/2014? � All citizens, legal immigrants 18 and older must have coverage � Individual requirement to have insurance � Tax penalty if no coverage (by 2016)… higher of – $695/person; up to 3 times for a family, or � State Medicaid expansion – 2.5% of household income � Go-live for health insurance benefits through state health � Exemptions granted for insurance exchanges (enrollment started 10/1/13) – Undocumented persons � Essential health benefit (EHB) standards – No coverage for less than 3 months – Lowest cost plan > 8% personal income (net of subsidies) � Insurance market reforms; no rating on health, gender – Religious objection – No restrictions for adults with pre-existing conditions – Individuals who are incarcerated � Employer shared responsibility penalties – Members of Native American tribes – People who have incomes below the tax-filing threshold ‒ Delayed until 2015 ($9,750 for single and $27,100 for a family of four) Women and the Health Care Law in CA Little or no change National Women’s Law Center and State Partners - April 2013 Military Insured through Undocumented Veterans Admin employer individuals • In CA, 2.8 million women (24%) women are uninsured – 25% of black women Minor changes – 35.3% of Hispanic women Medicare Medicaid – Compared to 14% of white women • Up to 856,000 women in CA will be newly insured once this coverage is fully implemented Major changes • This coverage expansion will reduce uninsurance in Uninsured Self employed Small California by 39% business 2
6/7/2014 Major Changes (19-49) 2 yr. extension (2016) • Uninsured • Self employed • Small business • SB <50 workers (50-99 workers) ? ? <50: business 5 5 1 pay can purchase 0 0 0 fine % % 0 <25: business % tax credits Employer Medi-Cal based HI State Health Insurance Exchanges CA Health Benefit Exchange Small Business Health “Covered California” Options Program (SHOP) October 1, 2014 October 2015 Insurance Status of Non‐elderly Women in CA Modified Adjusted Gross Income (MAGI) Determines Program Eligibility Household Size If income is less If income between AIM than… 1 $ 15,867 $ 15, 857-45,960 2 $ 21,404 $ 21,404-62,040 3 $ 26,952 $ 26,952-78,120 4 $ 32,500 $ 32,500-94,200 5 $ 38,407 $ 38,047-110,280 You may Medi-Cal Premium assistance qualify for through Covered CA 3
6/7/2014 Medicaid and Women’s Health Services • Payer for 40-50% of U.S. births • Expansion in Medicaid eligibility to cover adults with incomes below 138% of the federal poverty level – Previously: “Broke plus something else” – With expansion: men and women with incomes below $15,867 individual; $32,500 for a family of 4 • Federal government will cover 100% of expansion costs until 2017, then drops to 90% by 2020 – Reason for rejection of expansion by many states… • Creates a “coverage gap” for the poor in 25 states Health Insurance Exchanges Medi-Cal Expansion • To be eligible for Medi-Cal Expansion you must be ALL of… � Subsidies for families 138-400% federal poverty level – A U.S. citizen, U.S. national or lawfully present in the U.S. − Premium tax credit (toward purchase of insurance), and – A resident of California − Cost-sharing tax credit (rebate on OOP costs) – Less than 65 years old − 399% FPL: $44,680 individual; $92,200 family of four – Have a family income at, or below, 138% of the Federal � Tax credit applied at enrollment; no wait till taxes filed Poverty Level – Children of families whose income is at, or below, 250% of the Federal Poverty Level • All “new” Medi-Cal enrollments via M’cal managed care 4
6/7/2014 Health Insurance Exchanges • Premiums are higher at Level Plan covers each level Platinum 90% • Subsidy based on average Gold 80% Silver plan cost • Out of pocket max= Health Silver 70% Savings Account limit Bronze 60% • $5,950 individual Catastrophic < 30 years old • $11,900 family • Lower out-of-pocket limits if subsidized Coveredca.com Which Plans Were Selected for Covered CA? Alameda Alliance for Health L.A. Care Health Plan Anthem Blue Cross of California Molina Healthcare Blue Shield of California Sharp Health Plan Valley Health Plan Chinese Community HP Ventura County Health Care Plan Contra Costa Health Plan Western Health Advantage Health Net Kaiser Per manente 5
6/7/2014 Features of Covered California Features of Covered California � Open enrollment is October 1, 2013 thru March 31, 2014 • Rates vary by region, by metal level, and age – Next open enrollment is in Oct 2014 for 2015 • The following are not factored into rates – Preexisting conditions – Earlier if “life-changing event”: loss of job, death of spouse, birth of child – Gender – Smoker vs. non-smoker � On-line premium calculator available • Compared to the small employer market, rates range from � Available in 10 languages 2 percent above the 2013 average premium to 29 percent below the rates in California’s most populous markets Access For Infants And Mothers Program • Low cost affordable health coverage for middle-income pregnant women • Cost is 1.5% of net annual income; billed over 12 months • Coverage for pregnant women who… – Do not have health insurance OR have private insurance with a maternity-only deductible > $500; and, – Are not eligible for no-cost Medi-Cal or Medicare and, – Have family income above no-cost Medi-Cal; and, – Are less than 30 weeks pregnant http://www.aim.ca.gov 6
6/7/2014 Access For Infants And Mothers Program Cost of the AIM Program • Available plans Adjusted Annual Household Income $39,840.00 – SF county: Anthem Blue Cross HMO Multiply the Adjusted Annual – Alameda: Anthem Blue Cross HMO Household Income by 1.5% to calculate – Contra Costa: CC Health Plan; Kaiser Permanente x 1.5% the cost to participate in the AIM – San Mateo: Kaiser Permanente program • What are the benefits of having AIM as opposed to Total Annual AIM Contribution $597.60 pregnancy-related restrictive Medi-Cal only? – AIM offers comprehensive benefits, including pregnancy • No deductibles or copayments and non-pregnancy related service Reproductive Cancer Healthy Pregnancy Immunizations Chronic Health Behaviors related conditions STI and HIV Breast Cancer Alcohol S&C • Alcohol • TdaP, Td CV: HTN, counseling ; all • Mammography S&C booster, lipids sexually active F) • MMR, varicella Ct, GC, Syphilis • Genetic S&C Tobacco C&I • Tobacco Influenza T2DM screening C&I screen � Specified preventive services must be covered with no HIV screening • Preventive Diet • Folic acid • Hepatitis A, B Depression cost-sharing (no out-of-pocket costs) (adults at HR; all medication counseling if supplement • Meningococcal screen sexually active F) counseling CVD risk � Applies to private and public programs Contraception Cervix: Interpersonal • GDM • HPV Osteo- – (New) Private insurance policies 2010 (women w/repro • Cytology and DV S&C screen (women 19 ‐ 26) porosis capacity • HPV + cytology • Rh screen screen – Medicare, Medicaid 2011 • Anemia screen – State insurance exchanges 2014 Colorectal: Well ‐ woman • STI screen • Pneumococcal Obesity FOBT, visits • Bacteruria • Zoster screen; C&I • Colonoscopy, screen if obese • � Improves coverage for preventive services in many Sigmoid • • Lactation individual and small group plans Supports S&C: screening and counseling C&I: counseling and interventions 7
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