The Affordable Care Act and the I/DD Community

Presented by Ari Ne’eman October 15, 2013

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The Affordable Care Act and the I/DD Community

The Autistic Self Advocacy Network 2013 H St., 7th Floor • Washington, DC 20006 Voice: (202) 596-1056 www.autisticadvocacy.org

The Pre-ACA Status Quo
• Most people with I/DD get access to health care from Medicare, Medicaid • Medicaid has robust benefits but poor provider access • Commercial health insurance charges more to people with disabilities, other pre-existing conditions • Commercial insurance frequently doesn’t cover services PWD need

Prior to 2014, you might be charged more for insurance if…
• …you have a disability • …you have a chronic health condition • …you have needed medical services in the past • …you are a woman • …you are a domestic violence survivor • …you are overweight

Patient Protection and Affordable Care Act of 2010

• Signed into law on March 23rd, 2010 • Created a structure for universal health insurance coverage, consumer protections in commercial insurance & miscellaneous other provisions

Immediate Impact of the Law
• Young adults can stay on their parents insurance till age 26; • Prohibition against imposing lifetime caps on dollar value of care & services; • Prohibition on rescinding coverage except in cases of fraud; • Prohibition on imposing annual limits on coverage below certain amounts (annual limits to be eliminated entirely in 2014); • Prohibition on denying coverage to children based on pre-existing conditions. • Free preventative health care, without co-pays or deductibles

2014 Impact of the Law
• End to Pre-Existing Condition Discrimination – insurers can only vary price on the basis of age, tobacco use, family size and geography; • Establishment of a Marketplace System – a one-stop website where consumers can compare prices and benefits, then buy insurance; • Insurance Subsidies for individuals making between 100% to 400% of the poverty level; • Medicaid expansion to cover all under 133% of the Federal Poverty Level (in states that don’t opt out) • Requiring all Plans in the Marketplace to meet minimum Essential Health Benefit standards;

• Requirement that all Americans have health insurance.

Marketplaces

Provider Search

Essential Health Benefits
Set by states in relation to several options offered by HHS, but must include benefits from each of the following categories: • • • • • • • • • • ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and, pediatric services, including oral and vision care.

Metal Levels

Medicaid Expansion

Traditional Medicaid vs. “Alternative Benefit Plans”
• Households making up to 133% of the Federal Poverty Level eligible for expansion ($15,282 for household of 1); • Much of expansion population will receive “alternative benefit plan” instead of traditional Medicaid – may include less benefits, no LTSS coverage; • Those deemed “medically frail”, including people with I/DD, eligible for traditional Medicaid; • During enrollment, you will be asked, “Do you have a physical, mental, or emotional health condition that causes limitations in activities (like bathing, dressing, daily chores, etc.) or live in a medical facility or nursing home?” • Answering yes will direct you towards eligibility process for traditional, more expansive Medicaid

Advocacy Priorities Regarding the Exchanges & Medicaid Expansion
• What will states determine as the Essential Health Benefits package? What coverage for “habilitative services” will be included? • Will your state expand Medicaid? What will “Alternative Benefit Package” include? • What else can the Marketplace be used as an enrollment tool for? • How will Marketplace coverage and Medicaid interact with each other? – Section 1905(a) – Bridge Plans – Medicaid Buy-In

ACA’s LTSS Provisions
• Community First Choice State Option • State Balancing Incentive Program • Money Follows the Person Demonstration Re-Authorization • Dual Eligible Demonstrations

Community First Choice State Option
• States receive a 6% enhanced match for community services; • Must meet certain requirements, including prohibition on waiting lists for benefits under the option; • Can be a useful tool for advocates working to eliminate waiting lists or to preserve existing waiting list-free services with additional federal funds; • California & Oregon have CFC applications approved; • Arizona & Maryland have submitted CFC applications • Multiple other states planning submissions

State Balancing Incentive Program
• States who have less than 50% of their Medicaid LTSS budget in HCBS receive a 2% enhanced match – states with less than 25% of their Medicaid LTSS budget receive a 6% enhanced match; • Intended to incentive re-balancing towards community services in states that have lagged the farthest behind; • States must commit to meeting specified targets re: expanding HCBS, implementing program reforms (i.e: No Wrong Door policy, independent case management, standardized assessment tool, etc.) • Promising – but I/DD advocates should remain vigilant re: standardized assessment.

Money Follows the Person
• Initially created by Deficit Reduction Act of 2005; • Federal government pays 100% of the costs of community services for first 12 months after someone leaves an institution; • Between 2008 and 2011, MFP has transitions almost 20,000 people from institutions into the community; • Approximately 97% of MFP participants who leave an institution stay in the community; • ACA re-authorized MFP until 2016 and changed eligibility requirements to make it available to those who’ve been in an institution only 3 months, instead of 6.

Questions?

Ari Ne’eman President Autistic Self Advocacy Network aneeman@autisticadvocacy.org http://www.autisticadvocacy.org

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