1. Indiana State Nurses Association www.indiananurses.org –Meeting of the Members – 9/12/14 –Policy 101 – 11/7/14 ISNAbler bmiley@indiananurses.org @IndianaNurses Indiana State Nurses Association

2. Affordable Care Act Goals Expand Health Coverage Eligibility – Employer Mandate (delayed) – Medicaid Expansion (optional) Easier to Obtain Coverage – Marketplaces Improve Coverage – Insurers Must Be Nicer to Sick People – Provider Incentives/Penalties

3. Supreme Court Decision #1 Individual Mandate Constitutional –Walks like a Tax, Quacks like a Tax Mandatory Medicaid Expansion Unconstitutional –Taking Away All Medicaid Funds if State’s Don’t Expand is Unduly Coercive Remedy Makes Expansion Optional

4. Make Insurers Be Nicer to Sick People Insurance Regulations Individual Mandate Provide Subsidies Children can be on parents’ policies up to age 26

5. Insurers Must Cover Essential Health Benefits Can’t Disqualify Based on Pre-existing Conditions Premiums Can’t Vary Based on Gender Premium Variance Based on Age < 300% Minimum Required Medical Loss Ratio – % of Premiums Spent on Claims & Wellness – Small Group = 80%, Large Group = 85% No Lifetime or Annual Limits on Coverage

6. Physicians Health Plan Network Coverage Area

7. EHB Categories Ambulatory Patient Services Emergency Services Hospitalization Maternity & Newborn Care Mental Health & Substance Use Disorder Services Prescription Drugs Rehabilitative and Habilitative Services Laboratory Services Preventive & Wellness Services Pediatric Services, including Dental & Vision

8. Supreme Court Decision #2 Hobby Lobby doesn’t want employer contributions to cover post-fertilization contraceptives (EHB). Supreme Court holds: –Corporations count as “persons” under RFRA –Contraceptive requirement substantially burdens the exercise of their religion, and –The government interest at stake can be furthered in a less restrictive manner Pending lawsuits on the accommodation

9. Medicaid Expansion Up to 138%* of the Federal Poverty Level – Reduces eligibility criteria beyond income Federal Funding of New Enrollees – 100% for 2014-2016; scales down to 90% in 2020 100% Federal Poverty Level – Individual: $11,670 – Family of 4: $23,850

11. Marketplace Healthcare.gov Operated by state, fed, or hybrid Federal Tax Credits if Income is 100-400% FPL and Employer Doesn’t Offer Coverage Prospective then reconciled or just at tax time 2015 Open Enrollment 11/15/14 – 2/15/15

12. Marketplace Plans Metallic Categories By % of Costs Covered – Bronze: 60%, Silver: 70%, Gold: 80%, Platinum: 90% Catastrophic: high deductible, low premium – Eligible if under 30 or hardship (prior plan canceled) Network must include 30%* of essential community providers Total Out-of-Pocket Expenses Capped in 2015 – $6,600 for individual; $13,200 for family (includes copays, deductibles, not premiums) in network only

13. Employer Mandate Businesses Over 50 Employees (FTE) – Offer Affordable, Adequate Health Coverage to 30+ hour Affordable = contribution < 9.5% of household income Adequate = covers 60% of allowed costs 30 hour/week employees over 3, 6, or 12 months Must include dependents, not required to include spouses – Penalty for (A) not offering & (B) offering inadequate A: (# of workers – 30*) x $2,000 B: Lesser of (A) or $3,000 per FTE receiving Marketplace tax credit 50-99 employees: 2016 100+ employees: 70% compliance in 2015, 95% in 2016

14. Individual Mandate Enforcement by IRS through tax return – Limited to future refunds 2014 Penalty = greater of: – $95 per household adult + $47.5 per child – 1% household income (minus filing threshold) Exemptions if coverage gap < 3 months, low income, hardship, etc. Max $2,448 (average cost of bronze plan)

15. Indiana’s Approach Federally Run Marketplace –132,423 Hoosiers selected a plan in initial enrollment Lawsuit by Schools Seeking to Prevent Employer Mandate Penalty Seeking Repeal of 2.3% Medical Device Tax No Medicaid Expansion Healthy Indiana Plan (HIP) –2.0 Proposal

16. Healthy Indiana Plan Status Federal waiver program requiring fed approval Current HIP enrollment capped HIP 2.0 state public comment phase complete –ISNA gets “advanced practice registered nurse practitioner” changed to “advanced practice registered nurse” Federal public comment period open through 9/21 Proposed Start Date: January 1, 2015

17. Healthy Indiana Plan 2.0 Proposal Replace Medicaid for non-disabled age 19-64 Reimburse at Medicare rates through Hospital Assessment Fees No enrollment cap or annual/lifetime benefits cap Income threshold is 138% FPL POWER account annual balance $2,500 for deductibles, contingent & prorated rollover Monthly contributions: $3, $8, $15, or $25 for HIP +

18. HIP BasicHIP PlusHIP Link Under 100% FPL, no monthly contributions Under 138% FPL, monthly contributions required Under 138% FPL, monthly contribution required Co-payments required for all services except preventive & family planning Failure to make contribution: 100-138% locks out for 6 months, < 100% shift to HIP Basic Failure to make monthly contribution = $50 POWER account penalty Baseline coverage Ex: No dental/vision, limited pharmacy Broader benefits Ex: dental & vision coverage Subsidize purchase of employer plans & dependent coverage

19. Hospital Value Based Purchasing Medicare Bonuses or Penalties –Hospital Inpatient Quality Reporting Program (2,728) Process Measures Patient Surveys Mortality Rates –Myocardial Infarction, Heart Failure, Pneumonia PeriodCurrentOct ’14Oct ’15Oct ‘16 Max % Adjustment1.251.51.752.0

20. Readmissions Reduction Program Reduce Medicare Payments for Hospitals in Inpatient Prospective Payment System Readmissions for Myocardial Infarction, Heart Failure, Pneumonia Risk-adjusted based on age, gender, past medical history, and other health conditions No change or penalty up to 2% in FY2014, 3% in FY2015 In 2015 adding COPD, Hip/Knee Replacement

21. FY2014 modifier from July 2009-2012 data Excess Ratio < 1, better than average, no payment change If Excess Ratio > 1, then plugged into formula that reduces Medicare payments FacilityDischargesReadmitsRisk-adjusted per 100 Benchmark per 100 Excess Ratio Franciscan St M. Dyer 2914717.518.70.9349 Franciscan St M. Hammond 2917222.219.61.1318 Pinnacle Hosp.551317.316.21.0645 Franciscan HC Munster 571117.417.11.0190 Pneumonia Readmissions

22. CMS Innovation Center $10 Billion Budget over 10 Years Accountable Care Organizations – Financial accountability for Medicare population – Share in cost savings Bundled Payments for Care – Different Models for Episode of Care

23. Nurse Programs National Health Service Corps – Nurse Practitioner or Certified Nurse Midwife – Service Commitment to Health Professional Shortage Area Nurse Corps Loan Repayment Program – Registered Nurse or Nurse Faculty – Service Commitment to Critical Shortage Area Nurse Managed Health Clinics

24. ACA Info Resources Indiananurses.org – Indiana State Nurses Association –ISNAbler Marketplace: healthcare.gov or 1-800-318-2596 Marketplace.cms.gov – Provider info by CMS hrsa.gov – Grant programs from HRSA rwjf.org - Robert Wood Johnson Foundation kff.org - Kaiser Family Foundation