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![Mandates to Medicaid
The Future of Health Care
Medi-Cal
• Created in California during its 1975 Second Extraordinary Session
• (First Extraordinary Session only considered Medi-Cal, while paying the
Assembly and Senate $240,600)
• Cal. Welf. & Inst. Code § 14000:
“The purpose [of Medi-Cal] is to afford to qualifying health care and related remedial
or preventative services, including related social services which are necessary for
those receiving health care under [Medi-Cal].”
• Includes 25% of California’s population
PAGE: 24](https://image.slidesharecdn.com/statebarpresentationfebruary12013-130125002801-phpapp02/75/Health-Care-of-the-Future-24-2048.jpg)
Uploaded byCraig B. Garner
Health Care of the Future
The document provides an overview of mandates related to Medicaid, including statutory authorities, eligibility requirements, essential health benefits, and the implications of the Affordable Care Act. It discusses Medicaid expansion, the structure of health insurance exchanges, and the key features of health coverage, including penalties for non-compliance and the levels of coverage available. Additionally, it highlights the changes in Medicaid eligibility rules and the potential financial support for states that participate in the expansion.
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Health Care of the Future
- 1. Mandates to Medicaid TheFuture of Health Care State Bar of California, Business Law Section Health Care Committee Teleseminar: February 1, 2013 9:00 AM Presented by Craig B. Garner PAGE: 1
- 2. Mandates to Medicaid The Future of Health Care Minimum Essential Coverage (Meeting the Mandate) PAGE: 2
- 3. Mandates to Medicaid The Future of Health Care Statutory Authority • The Patient Protection and Affordable Care Act (Pub. L. 111-148) + • Health Care and Education Reconciliation Act of 2010 (Pub. L. 111-152) + • Tricare Affirmation Act (Pub. L. 111-159) + • Clarification of Health Care Provided by the Secretary of Veterans Affairs (Pub. L. 111-173) = ________________________________ • 26 U.S.C. § 5000A PAGE: 3
- 4. Mandates to Medicaid The Future of Health Care What Satisfies the Mandate? • Government sponsored programs (Medicare, Medicaid, CHIP, Tricare, Veterans, Peace Corps); or • Employer-sponsored plan; or • Plans in the individual market (Exchange, Basic Health Program or CO-OP); or • Grandfathered health plan; or • Other PAGE: 4
- 5. Mandates to Medicaid The Future of Health Care Minimum Essential The Penalty Yes Coverage? 1. Self-funded student coverage 2. Foreign health coverage 3. Refugee medical assistance NEW WAYS TO QUALIFY (1/30/13) 4. Medicare Part C No 5. State high risk pools 6. AmeriCorp volunteers 1. Religious? 2. Not Present? Exception? Yes 3. In Jail? 4. Low Income? 5. Hardship? 6. Indian Tribe? No $695 (or less) PENALTY (in 2016) or not to Bronze Level of the greater of exceed Coverage 2.5% of household income PAGE: 5
- 6. Mandates to Medicaid The Future of Health Care Collecting the Penalty • Waiver of criminal penalties • Limitations on liens and levies PAGE: 6
- 7. Mandates to Medicaid The Future of Health Care Essential Health Benefits PAGE: 7
- 8. Mandates to Medicaid The Future of Health Care What Are Essential Health Benefits? • Ambulatory patient services • Emergency services • Hospitalization • Maternity and newborn care • Mental health and substance use disorder • Prescription drugs • Rehabilitative and habilitative services and devices • Laboratory services • Preventative and wellness services and chronic disease management • Pediatric services, including oral and vision care 42 U.S.C. § 18022 PAGE: 8
- 9. Mandates to Medicaid The Future of Health Care What Could Be Essential Health Benefits? • Emergency room visits • Ambulance services • Diabetes care management • Kidney dialysis • Physical therapy • Durable medical equipment • Prosthetics • Infertility treatment • Organ and tissue transplantation Institute of Medicine, Essential Health Benefits PAGE: 9
- 10. Mandates to Medicaid The Future of Health Care What Are the Levels of Coverage? • Bronze (60% of the full actuarial value of the benefits) • Silver (70% of the full actuarial value of the benefits) • Gold (80% of the full actuarial value of the benefits) • Platinum (90% of the full actuarial value of the benefits) • Catastrophic (29 years old or younger or exempt from Section 5000A) 42 U.S.C. § 18022(d), (e) PAGE: 10
- 11. Mandates to Medicaid The Future of Health Care Precious Metals (January 2013) • Platinum 30-day average = $1,585 • Gold 30-day average = $1,673 • Silver 30-day average = $31 PAGE: 11
- 12. Mandates to Medicaid The Future of Health Care Health Insurance Exchanges PAGE: 12
- 13. Mandates to Medicaid The Future of Health Care The Health Insurance Marketplace is designed to help you find insurance that fits your budget, with less hassle. No matter where you live, you’ll be able to buy insurance. . . . New laws mean plans must treat you fairly and can’t deny you coverage because of pre-existing conditions. Source: CMS Toolkit PAGE: 13
- 14. Mandates to Medicaid The Future of Health Care How Do Exchanges Work? • Make comparison shopping easy • Lower barriers for new competition in the insurance market • Provide savings and choice through transparency • Determine individual tax credits/subsidies • Compete for enrollees • Focus on the uninsured PAGE: 14
- 15. Mandates to Medicaid The Future of Health Care State-Based Exchange Each individual state operates all Exchange activities, but a state may use federal government services for the following activities: • Premium tax credit and cost sharing reduction determination • Exemptions • Risk adjustment program • Reinsurance program PAGE: 15
- 16. Mandates to Medicaid The Future of Health Care State Partnership Exchange State operates activities for: • Plan management (and/or) • Consumer assistance State may elect to perform or can use federal government Services for the following activities: • Reinsurance program • Medicaid and CHIP eligibility assessment or determination PAGE: 16
- 17. Mandates to Medicaid The Future of Health Care Federally-Facilitated Exchange HHS operates, but state may elect to perform or can use federal government services for the following activities: • Reinsurance program • Medicaid and CHIP eligibility assessment or determination PAGE: 17
- 18. Mandates to Medicaid The Future of Health Care Exchange Transparency As part of the application process, each state should post certain sections from its application on the appropriate state website, including: • Exchange board and governance structure • Stakeholder consultation plan • Outreach and education plan • Role of agents and brokers • Coordination strategy • Pre-Existing Condition Insurance Plan (PCIP) transition • Long-term operational cost plan PAGE: 18
- 19. Mandates to Medicaid The Future of Health Care California Health Benefit Exchange The California Health Benefit Exchange posts the following vision, mission and values on its website (www.healthexchange.ca.gov): • Consumer-focused • Affordability • Catalyst • Integrity • Partnership • Results PAGE: 19
- 20. Mandates to Medicaid The Future of Health Care New Regulations To Ensure Fairness • Limit premium variation to age and tobacco use But what is tobacco use? • Accept all applicants and guarantee renewal Are there capacity limits? • Effective Rate Review Who will conduct the reviews? • Medical Loss Ratio Who will monitor? PAGE: 20
- 21. Mandates to Medicaid The Future of Health Care Medicaid Expansion PAGE: 21
- 22. Mandates to Medicaid The Future of Health Care Statutory Authority for Medicaid Pub. L. 103-448 + Pub. L. 110-90 + Pub. L. 104-226 + Pub. L. 111-3 + Pub. L. 105-12 + Pub. L. 111-5 + Pub. L. 105.33 + Pub. L. 111-148 + Pub. L. 106-113 + Pub. L. 111-152 + Pub. L. 106-169 + Pub. L. 111-309 + Pub. L. 108-448 + Pub. L. 112-78 + Pub. L. 109-91 + _____________________________ 42 U.S.C. § 1396d PAGE: 22
- 23. Mandates to Medicaid The Future of Health Care What Is Medicaid? Health insurance for individuals who qualify financially, as well as families with dependent children, the aged, blind or disabled. • Medi-Cal • KanCare • SoonerCare • Hoosier Healthwise • MassHealth • SALUD! • TennCare PAGE: 23
- 24. Mandates to Medicaid The Future of Health Care Medi-Cal • Created in California during its 1975 Second Extraordinary Session • (First Extraordinary Session only considered Medi-Cal, while paying the Assembly and Senate $240,600) • Cal. Welf. & Inst. Code § 14000: “The purpose [of Medi-Cal] is to afford to qualifying health care and related remedial or preventative services, including related social services which are necessary for those receiving health care under [Medi-Cal].” • Includes 25% of California’s population PAGE: 24
- 25. Mandates to Medicaid The Future of Health Care Medicaid Expansion 77 Federal Register 17144 (Mar. 23, 2012) (Final Rule) • Implemented provisions of the Affordable Care Act related to Medicaid eligibility, enrollment and coordination with the Exchanges, CHIP, and other programs • Simplified the eligibility rules in Medicaid and CHIP • Set the minimum Medicaid income eligibility level of 133 percent of the Federal Poverty Level for most non-disabled adults under age 65 Proposed Rule (Jan. 14, 2013) • Reflects new statutory eligibility provisions •Proposes changes to provide states more flexibility to coordinate Medicaid and CHIP eligibility, appeals and other administrative procedures • Modernizes and streamlines existing rules PAGE: 25
- 26. Mandates to Medicaid The Future of Health Care Medicaid Expansion and the Supreme Court • The United States Supreme Court held that Congress has the authority to offer funding for states to expand Medicaid by 2014 without imposing retroactive financial conditions. National Fed. of Indep. Bus. v. Sebelius, 132 S. Ct. 2566, 2606-07 (2012). • Congress never dreamed that any State would refuse to go along with the expansion of Medicaid. Congress well understood that refusal was not a practical option. (Id. at 2665 (Scalia, Kennedy, Thomas and Alito, JJ, dissenting). PAGE: 26
- 27. Mandates to Medicaid The Future of Health Care Medicaid Expansion (Nov. 2012) Not Participating Leaning Toward No Undecided Participating Leaning Toward Yes PAGE: 27
- 28. Mandates to Medicaid The Future of Health Care Medicaid Expansion (Jan. 2013) After Election refers to views as of January 13, 2013. In states with newly elected governors, before election refers to the views of the outgoing governor, and after election refers to the views of the governor-elect. Source: Sommers, U.S. Governors and the Medicaid Expansion, New Engl. J. Med. (Jan. 2013) PAGE: 28
- 29. Mandates to Medicaid The Future of Health Care Medicaid Expansion By the Numbers • The Federal Government will pay 100% of added expense for newly eligible beneficiaries through 2016, 95% in 2017, 94% in 2018, 93% in 2019 and 90% in 2020 and thereafter. • States must pay “qualified” physicians Medicaid fees at least equal to Medicare rates starting in 2013. • Pay increase applies to family physicians, internists and pediatricians (and in some instances specialists) provided (1) they are Board-certified or (2) at least 60% of the Medicaid codes they billed in the previous year were primary care codes identified in the Affordable Care Act. PAGE: 29
- 30. Mandates to Medicaid The Future of Health Care Questions? • www.healthcare.gov (U.S. Government) • www.healthreform.kff.org (The Henry J. Kaiser Foundation) • www.hhs.gov (The U.S. Department of Health and Human Services) • www.cms.gov (Centers for Medicare & Medicaid Services) • www.oshpd.ca.gov/reform (Office of Statewide Health Planning & Development) • www.chhs.ca.gov (California Health & Human Services Agency) • www.ppaca.me PAGE: 30
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