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Health Care Reform: Implications for Children with Special Health Care Needs

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Title: Health Care Reform: Implications for Children with Special Health Care Needs


1

Health Care Reform Implications for Children
with Special Health Care Needs
2
Presentation 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 ?
3
Family Voices
  • Mission Family Voices aims to achieve
    family-centered care for all children and youth
    with special health care needs and/or
    disabilities.

4
Family-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.

5
Family 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

6
Family 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)

7
The 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 ?
8
Kaiser Family Foundation Video
9
Basic 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.)

10
Basic 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

11
2010 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

12
2010 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 ?
13
2010 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 ?
14
Later 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 ?
15
Provisions of special importance to Children and
Youth with Special Health Care Needs (CYSHCN)
16
Elimination 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

17
Implications 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

18
Prohibition 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

19
Restrictions 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

20
High-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

21
Illinois 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

22
Coverage 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

23
No-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

24
Appeals 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

25
Essential 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

26
Family-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)

27
Family-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

28
Reform 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 ?
29
Families 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 ?
31
Future 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 ???

32
Handouts Q A and Discussion
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