Indiana State Nurses Association

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 +

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

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. Pneumonia Readmissions • 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

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