Title: Health Care Reform: Implications for Children with Special Health Care Needs
1Health Care Reform Implications for Children
with Special Health Care Needs
2Presentation Outline
- Background on Family Voices
- Mission
- Public Policy
- Health Care Reform
- In general
- For CYSHCN
- How and why to be involved in public policy
- Discussion and QA
www.familyvoices.org ? 2340 Alamo SE, Suite 102 ?
Albuquerque, NM 87106 ? (p) 888.835.5669 ? (f)
505.872.4780 ?
3Family Voices
- Mission Family Voices aims to achieve
family-centered care for all children and youth
with special health care needs and/or
disabilities.
4Family-Centered Care
- Family-Centered Care
- Because families are at the center of a child's
life, they must be equal partners in
decision-making and all aspects of the child's
care. Family-centered care is community-based,
coordinated, culturally and linguistically
competent, and guided by what is best for each
child and family.
5Family Voices
- Structure
- Based in Albuquerque, NM
- National network membership
- State-Affiliated Organizations
- Provides information and tools to families to
help them make informed decisions - Works to build partnerships between professionals
and families - Advocates for improved public and private policies
6Family Voices and Public Policy
- Public Policy Team in Washington, DC
- Work in coalition with other national groups
(formal and informal) - Families serve as public policy advocates (more
on this later)
7The Health Care Reform Laws
- The Patient Protection and Affordable Care Act
(PPACA) enacted March 23, 2010 - Health Care and Education Affordability
Reconciliation Act enacted March 30, 2010 - Now referred to collectively as the
Affordable Care Act or ACA
www.familyvoices.org ? ?2340 Alamo SE, Suite 102
? Albuquerque, NM 87106 ? (p) 888.835.5669 ? (f)
505.872.4780 ?
8Kaiser Family Foundation Video
9Basic Structure of Law
- Continuation of employer-based health insurance,
with certain standards - State-based Exchanges through which uninsured
individuals can purchase insurance that meets
certain standards (2014) - Subsidized premiums limits on cost-sharing
limits on premiums not based on health status,
gender (2014) - (cont.)
10Basic Structure of Law (cont.)
- Continuation of State Children's Health Insurance
Program (CHIP) until 2015 - Expansion of Medicaid to 133 of the Federal
Poverty Level (2014) optional now - Patients Bill of Rights (insurance reforms)
- Most provisions effective 2014 some now
112010 Provisions
- Maintenance of Effort (MOE) in Medicaid and CHIP
- Option to Expand Medicaid to New Expansion
Populations (up to 133 of FPL) - Creation of a High-Risk Health Insurance Pools
(PCIPs) as of July 1, 2010 - Prohibition on Lifetime Caps and Rescinding
Coverage Restrictions on Annual Caps
122010 Provisions Continued
- Eliminating Pre-Existing Condition Exclusions for
Children under age 19 - Coverage of Adult Children until age 26
- Coverage of Preventive Health Services at no
Charge (Bright Futures) - Strengthening Community Health Centers
www.familyvoices.org ? ?2340 Alamo SE, Suite 102
? Albuquerque, NM 87106 ? (p) 888.835.5669 ? (f)
505.872.4780 ?
132010 Provisions Continued
- Re-Establishing Funding for F2Fs!!!
- Prevention and Public Health Fund
- Maternal, Infant and Early Childhood Home
Visiting Programs - Federal portal (website) for information about
coverage options (www.healthcare.gov)
www.familyvoices.org ? ?2340 Alamo SE, Suite 102
? Albuquerque, NM 87106 ? (p) 888.835.5669 ? (f)
505.872.4780 ?
14Later Important Provisions to Note
- Medicaid Expansion- 133 by 2014
- State Health Insurance Exchanges/Benefits
- Health Homes in Medicaid
- Home and Community-Based Services
- Grants for Navigators
- Medicaid for former foster children up to age 26
- Insurance reforms
www.familyvoices.org ? ?2340 Alamo SE, Suite 102
? Albuquerque, NM 87106 ? (p) 888.835.5669 ? (f)
505.872.4780 ?
15Provisions of special importance to Children and
Youth with Special Health Care Needs (CYSHCN)
16Elimination of Pre-existing Condition Exclusions
for Children Under Age 19
- Effective for plan/policy years beginning on or
after September 23, 2010 - Applies to both issuance of insurance and
coverage of services related to pre-existing
conditions - Does not apply to individual grandfathered plans
(in existence 3/23/10) - Premiums can be higher
17Implications of Ban on Pre-existing Condition
Exclusions
- Some insurers are no longer issuing new
child-only plans - Should not affect current child-only plans
- HHS has told insurers they can limit enrollment
to certain open enrollment seasons, as permitted
under state law - Insurers may take other measure to counter
potential adverse selection
18Prohibition on Rescissions
- For plans/policies effective on or after 9/23/10,
insurers may not rescind policies based on minor
errors in the application - Policies may be rescinded if there was
intentional fraud or misrepresentation of
material facts
19Restrictions on Lifetime and Annual Dollar
Limits
- For plans/policies effective on or after 9/23/10,
insurers may not impose lifetime dollar limits on
the amount they will cover - From 9/23/10 until 1/1/14, annual dollar limits
must not be set below certain thresholds - 750,000 until 9/23/11
- 1.25 million until 9/23/12
- 2 million until 1/1/14
- Annual dollar limits prohibited as of 1/1/14
20High-Risk Pools (PCIPs)
- As of July 1, 2010, state or federal high-risk
pool (Pre-existing Condition Insurance Plans,
PCIPs) available to individuals who are - U.S. Citizens
- Have been uninsured for at least 6 months
- Have a pre-existing condition
- No longer necessary after 1/1/14, when no
pre-existing condition exclusions are permitted
21Illinois PCIP
- Illinois has created its own PCIP
- Features (see handout)
- Premium 111-526
- Deductible 2,000
- Out-of-Pocket Limit 4,350 for medical
(including 2,000 deductible), 1,600 for
pharmacy maximum OOP limit of 5,590 sic - For more information http//insurance.illinois.g
ov/IPXP or 877-210-9167
22Coverage for Dependents until Age 26
- Parents can keep their children on their
insurance plans until the child reaches age 26
(just child not grandchild) - Child need not be a dependent for tax purposes
- Applies even if adult child is married and/or
does not live with parents - Does not apply to grandfathered group plans if
child has offer of insurance coverage from an
employer
23No-Charge Preventive Services
- For new health insurance policies as of 9/23/10,
a full range of preventive services will be
covered pursuant to the Bright Futures
recommendations for children - There may be no copayments, coinsurance or
deductibles applied to preventive services
24Appeals and Reviews
- Families can appeal denials of coverage, followed
by an external review - Pursuant to interim final regulation, coverage
would continue pending review - Decision required within 24 hours for urgent care
- Need to specify that pediatric experts should be
involved in appeals and reviews
25Essential Benefits Package
- Law requires insurance plans sold in exchanges
(2014) to cover essential benefits, which will
include, among other benefits - Habilitation and rehabilation and devices
- Mental health and substance abuse disorder
services (including behavioral health treatment) - Pediatric services, including oral and vision
care - Preventive and wellness services and chronic
disease management
26Family-to-Family Health Information Centers
- F2F HICs are statewide, family-led information
and referral centers that provide information on
health care and insurance to families of
children/youth with special health care needs,
such as disabilities or chronic medical
conditions. - Many are state affiliates of Family Voices
- Illinois F2F HIC is based at The Arc of Illinois
(Faye Manaster)
27Family-to-Family Health Information Centers
- ACA reauthorized and funded the program at the
previous level of 5 million per year for federal
fiscal years 2010, 2011 and 2012 - Provides about 97,500 per center (one in each
state and DC) - Advocacy will be needed to get an extension and
additional funding
28Reform at the State Level the what and how
- Examples of state based options
- Expanding Medicaid
- High-Risk Pools (PCIPs)
- Community First Choice Option
- Creation of State Ombudsman's Office
- Creation of Exchanges
www.familyvoices.org ? ?2340 Alamo SE, Suite 102
? Albuquerque, NM 87106 ? (p) 888.835.5669 ? (f)
505.872.4780 ?
29Families and Professionals as Public Policy
Advocates
- You are already advocates for your children and
patients - Public Policy Advocacy Who, what, when, where,
why, how? (see handout) - Don't forget you are the constituents, the
public!
30 How You Can Get Involved
- Know your state government officials, e.g.,
Insurance Commissioner, legislators - Join relevant coalitions
- Sign up for action alerts (federal and state)
- Submit comments on proposed regulations (federal
and state) - Educate your network
- Be there and be heard!
www.familyvoices.org ? ?2340 Alamo SE, Suite 102
? Albuquerque, NM 87106 ? (p) 888.835.5669 ? (f)
505.872.4780 ?
31Future of Health Care Reform
- Some states are suing federal government to
prevent implementation - Republicans are talking about repeal legislation,
blocking appropriations - Probably okay for next two years, then ???
32Handouts Q A and Discussion