1. The Affordable Care Act: Impact and Opportunities for Case Managers Lisa Kraus, RN,BSN, CCM Vice President Care Management CareFirst

2. The Affordable Care Act What’s in a name? When passed on March 23, 2010, the primary goals of the Patient Protection and Affordable Care Act (PPACA) – also referred to as the Affordable Care Act (ACA) or sometimes referred to as “Obamacare” were to: 1)Extend access to affordable health insurance coverage to the uninsured and underinsured 2)Reduce health care costs 3)Establish nationwide consumer protections that apply to all insurance policies Through ACA, the Federal Government: Determined benefit coverage requirements Standardized and simplified product offerings Changed rating rules-no medical underwriting Established online multi-carrier competitive marketplaces (Exchanges) for purchasing “affordable” insurance – either at the federal level or giving states the option to establish their own – to which participating carriers build connections Subsidized costs of coverage for low to moderate income individuals and smaller companies Established implementation timelines 2

3. Insurance Coverage Rules Under the Affordable Care Act The primary intent of the Affordable Care Act (ACA) is to provide health insurance coverage to currently uninsured and underinsured individuals. It seeks to do so through: 1.Expansion of Medicaid eligibility: Up to 133% of the Federal Poverty Limit (FPL) for parents Coverage for childless adults Supreme Court decision allowed states to opt out of this expansion 2.Allowing adult children under age 26 to stay on parent policies 3.Individual mandate to require insurance purchase or pay a penalty 4.Premium and cost sharing subsidies for incomes between 133% and 400% of FPL to enable affordability. Subsidies begin at 100% FPL for states that did not expand Medicaid (e.g., Virginia) 3

4. Industry Reforms Early reforms went into effect in 2010 and 2011. Minimum medical loss ratio (MLR) Benefit enrichments – first dollar coverage for preventive services, guaranteed right to appeal, emergency care outside of health plan network Standardization in how plans are described (Summary of Benefits and Coverage) “Game changing” reforms became effective January 1, 2014. Exchange marketplaces – opened October 1, 2013 Essential health benefits Metal level (actuarial value) standardization Rating rule changes – guaranteed issue; no pre-existing condition exclusions; 3:1 age bands for rating; elimination of benefit caps and limits, etc. 3Rs – risk corridors, risk pools, reinsurance 4

5. What Happens to Today’s Uninsured? National Perspective National Enrollment Projections 1 Exchanges: 24M or 34% Exchanges: 24M or 34% Medicaid: 16 or 23% Medicaid: 16 or 23% Uninsured: 31M or 44% Uninsured: 31M or 44% 2025 Coverage Status (Change due to ACA) 2013 Coverage Status Under 65 Population: 272MUnder 65 Population: 286M Numbers may not add up to totals due to rounding. 1 Individuals reporting multiple sources of coverage were assigned a primary source. 2 “Uninsured” includes unauthorized immigrants and people who are eligible for, but not enrolled in, Medicaid. 3 “Other” includes Medicare. Source: Congressional Budget Office. Effects of the Affordable Care Act on Health Insurance Coverage (May 2013); Congressional Budget Office. Updated Estimates of the Insurance Coverage Provisions of the Affordable Care Act, January 2015. 5

6. Individual Mandate Penalty is the greater of the dollar amount minimum (first two rows of table below) or the applicable percentage of income (third row). The income percentage increases from 1% in 2014 to 2.5% in 2016. Penalty Schedule for Individuals without Health Insurance * Income based on 2014 poverty guidelines Year201420152016 & beyond Adult Penalty Minimum$95.00$325.00$695.00 Child Penalty Minimum (50% of Adult Penalty) $47.50$162.50$347.50 % of Income1.0%2.0%2.5% Example: Penalty at 250% FPL ($29,175/ year*) $292$584$729 Example: Penalty at 400% FPL ($46,680/year*) $467$934$1,167 6

7. Essential Health Benefits 7

8. Impact: What Does This Mean for Case Managers? More people are covered by health insurance plans 8 BUT…

9. Many people who now have health insurance never had health insurance before. 9

10. Impact for Case Managers Patient/ Member Knowledge Lack of understanding of benefits Not familiar with insurance process Pent up demand Many members haven’t seen a provider in a long time Providers may not be able to focus on preventive care as they must address urgent care needs Initially may create higher costs and out of pocket expenses Other factors Various levels of support in the home and ability to manage care Need to consider mental health and substance abuse needs Unique ACA issues Mandated grace periods -If member qualifies for subsidy-must wait 90 days to disenroll for lack of payment -If no subsidy-must wait 60 days to disenroll for lack of payment Fluctuation (ability to move in and out of policies) 10

11. Creates a downstream impact to physician offices, case managers, pharmacies…All health care providers. Difficult to develop and manage treatment plans Challenging to ensure compliance with medications and other treatments Doesn’t fit well with population health measures and metrics 11

12. Opportunities for Case Managers If Opportunity doesn’t knock, build a door 12

13. Where to go for Information Healthcare.gov Marylandhealthconnection.gov 13

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19. Key Opportunities 19

20. We are able to help more people than ever before through: Advocacy Guidance Care Coordination Empowerment What you can do: Learn about the Affordable Care Act Learn about the exchanges and how they work Identify vulnerable members and reach out to them Understand: Patients/members may need more of your time-many don’t understand health care. Some may be frightened or even suspicious- “why do you want to know what meds I am on?” We may need to focus on the immediate or urgent needs first. The system is improving-it is far better today than it was when the exchanges first went live-it will continue to improve over time. 20

21. Do not go where the path may lead, go instead where there is no path and leave a trail. Ralph Waldo Emerson 21

22. Questions 22