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What health reform means for the people of Illinois

A blog by IllinoisHealthMatters.org

Wednesday, December 19, 2012

Advanced Practice Nurses: Willing to Meet the Needs of the Medicaid Expansion

This guest post was written by Donna Petko, MSN(c), BSN, RN; Clinical Director; 1st Choice Home Health Providers, LLC

If Medicaid Eligibility Expansion (HB 6253) is approved in early January 2013, an estimated 342,000 low-income adults in Illinois will become eligible and enrolled in Medicaid over the next four years.  Once these individuals become insured, they are likely to seek out primary care providers.  However, as designated by the United States Department of Health and Human Services, 100 counties in Illinois have been identified as having State Physician and/or Federal Health Professional Shortage areas (Health & Medicine Policy Research Group [HMPRG], 2012).  Who will provide primary health care services to these newly enrolled Illinois residents?

Advanced practice nurses (APNs) are one solution to the growing shortage of primary care physicians (PEW, 1999).  APNs are registered nurses who have advanced knowledge and clinical training, a graduate degree, and hold national certification.  These professionals serve as health care providers in a broad range of primary care, acute care, and outpatient settings.  In Illinois, there are four categories of APNs: certified nurse-midwife (CNM), clinical nurse specialist (CNS), certified nurse practitioner, (CNP) and certified registered nurse anesthetist (CRNA).  Currently, there are more than 7,500 advanced practice nurses in the state of Illinois (HMPRG, 2012).

What do advanced practice nurses do?  APNs diagnose illnesses, prescribe treatments and medications, and provide primary care services in a variety of settings which include hospitals, clinics, community health centers, nursing facilities, and schools (HMPRG, 2012).  According to the Institute of Medicine (IOM) report The Future of Nursing: Leading Change, Advancing Health (2010), APNs increase patient safety, access, and continuity of care.  Data from studies on APNs show that these professionals deliver safe, high-quality primary care services (ANA, 2012). 

In order to meet the growing need for healthcare services within the state, APNs need to practice to the fullest extent of their education and training. How do we increase access to healthcare services for Illinois residents?  By changing the Nurse Practice Act and removing practice barriers: 

  • Eliminating the requirement for a written collaborative agreement between physicians and APNs 
  • Allowing APNs to participate in the insurance exchange as primary care providers
  • Providing APNs with full plenary authority to provide access to Illinois residents needing primary care services (HMPRG, 2012).

Besides providing safe, high-quality healthcare, APNs provide a considerable cost savings as well.  For example, the average cost of a nurse practitioner (NP) visit is between 20-35% less than the average cost of an office-based physician visit (Medical Expenditure Panel Survey, 2010).  Furthermore, malpractice rates of NPs are no higher in states with independent NP practice when compared to those states where collaboration is required for practice (HMPRG, 2012).

In addition to supporting HB 6253, which will allow Illinois to leverage over $5 billion in federal Medicaid funding to provide comprehensive health care coverage to over 342,000 low-income individuals (Becker, 2012), please support advanced practice nurses in their quest to provide better access to healthcare services for Illinois residents.  Because APNs are more likely to work in underserved areas caring for Medicaid beneficiaries than primary care physicians (Grumbach et al., 2003; Kaiser, 2011), the barriers to practice must be removed.

The Illinois General Assembly needs to pass HB 6253 by January 9, 2013, the end of the current legislative session, to ensure programs and systems are in place just 12 months from now, when one of the largest parts of health care reform begins (IHM, 2012).  Once this bill is passed, the only way to ensure better access to care for Illinois residents is by changing the Nurse Practice Act to allow APNs to practice to the fullest extent of their education and training. 

Please continue to support this common-sense, fiscally sound legislation in Illinois.  To find out who your legislators are, go to the Illinois State Board of Elections Search PagePlease share this message and urge your friends and family members to tell their legislators to support these efforts between now and January 9, 2013. For more info, read this fact sheet from Health & Medicine Policy Research Group. 

Tuesday, December 18, 2012

What Happens to the Pre-Existing Condition Plans on Jan. 1, 2014?

This post is the first in a series on the Illinois State Partnership Exchange Blueprint Application, which is pending approval by the Federal Government. 

For years, health insurance carriers refused to sell coverage to individuals with pre-existing medical conditions. The Affordable Care Act (ACA) created federally funded high risk pools across the country, including the Illinois Pre-Existing Condition Insurance Plan (IPXP) so that people denied for that reason would not have to go without health insurance. Starting on January 1, 2014, the ACA bans insurance companies from denying coverage based on pre-existing conditions. As a result, IPXP will no longer be needed, and coverage under the plan will be terminated.

So what happens to the enrollees of IPXP on January 1, 2014? 

The ACA dictates that anyone currently enrolled in IPXP will be transitioned into a private insurance plan via the state health insurance exchange. This transition process will happen at the end of 2013. According to the Illinois State Partnership Exchange Blueprint Application, the state has mechanisms in place to prevent lapses in health coverage, as follows:
  • Illinois will send at least three letters to IPXP enrollees containing information on the transition process;
  • The state will conduct proactive outreach to IPXP participants and update the IPXP website with relevant information; and
  • The Illinois health insurance exchange will have extra personnel at the call center specifically to assist with the IPXP transition.

IPXP will only extend coverage for health services until December 31, 2013, which means that all current IPXP enrollees will need to find an alternative health plan before January 1, 2014.  Claims dating from before December 31, 2013 will need to be filed in the close-out period, which will run until June 30, 2015. If deferral funding for the IPXP program has run out, however, even claims filed before that date will not be payable.

Open enrollment into the state health insurance exchange will begin on October 1, 2013, with insurance coverage beginning on January 1, 2014. If current IPXP enrollees purchase a plan during open enrollment, there should be no gaps in their health coverage. Since Illinois is still in the process of establishing its health insurance exchange, check back here for details on how and where to enroll in a health insurance exchange plan, as well as future updates on the IPXP transition process. If you have questions now, contact IPXP at (877) 210-9167, or e-mail your question directly to IPXPInquiry@healthalliance.org

Monday, December 17, 2012

Five Myths about the Medicaid Expansion

The Supreme Court's June 2012 Affordable Care Act ruling was decisive about the implications of the individual mandate; however, it was less decisive about the ACA's Medicaid expansion. The court gave flexibility to each state to decide whether to expand Medicaid to its low income uninsured (below 138% FPL) residents. This flexibility has caused some confusion (some legitimate and some purposeful) about the implications of the Supreme Court decision. Below we address some of the myths vs. realities of the Medicaid Expansion and what it means for Illinois residents:

Medicaid Myth #1: Few states will expand their Medicaid programs.
As of 12/12/12, according to health care experts Avalere Health, 18 states have signaled that they will expand, 10 have said that they won't and 23 are undecided. Another health care expert, the Advisory Board Company, shows 14 states in the "not participating" or "leaning toward not participating" group while 18 states are in the participating or leaning toward participating group. Notably, this week, Nevada's Republican Governor and GOP leaders just signaled that they will opt in.

Medicaid Myth #2: Many low-income residents would be eligible for federal subsidies on the exchange if a state does not expand Medicaid. Expanding Medicaid takes away their opportunity to purchase private insurance.
The reality is that people living under 100% FPL WILL NOT qualify for subsidies to buy health insurance on the Exchanges and will be the only ones (besides undocumented immigrants) left out in the cold if Illinois doesn't expand Medicaid. Without the new Medicaid eligibility category, these individuals are in a new “donut hole” and will likely be priced out of affordable health insurance through the Exchange because they won’t qualify for the federal financial help. The Urban Institute estimates that of the newly eligible population, approximately 431,000 Illinoisans with household incomes less than 100% FPL will be left in the cold if Illinois does not implement the new Medicaid eligibility category. They will have to continue to access safety-net providers and emergency rooms for care, driving up costs for these providers and showing up sicker. In addition, we all pay more when others are uninsured: according to a study conducted by Millman, Inc., an independent actuarial consulting firm, every family with health insurance pays an additional $1,000 per year to pay for care for the uninsured.

The only "low-income" residents that are either eligible for subsidies on the Exchange OR can participate in Medicaid if Illinois expands Medicaid are people living between 100% -138% FPL. This is a small number of people. Even among those small numbers who DO qualify for exchange subsidies and take up that coverage, the greater cost-sharing requirements for exchange coverage than in Medicaid means that these adults will experience greater financial burdens associated with meeting their health care needs.
Medicaid Myth #3: The state will pay for the Medicaid expansion but will not pay for federal insurance subsidies.
: Not true. The state will not pay for Medicaid Expansion from 2014 through 2016. The federal government pays 100% of the expansion. From 2017
through 2020, the state will slowly start picking up a very small percentage that will slowly increase from 5% to 10% by 2020. In 2020 and beyond, the state will only be responsible for 10% of the cost of the Expansion population.

Medicaid Myth #4: The federal government is already trying to shift more Medicaid expansion costs to the states as a major part of the fiscal year 2013 budget.
We have no reason to believe that this will happen and the reality is that President Obama is committed to ensur
ing full implementation of the Medicaid Expansion by states. On December 10, the Obama administration backed away from roughly $100 billion in Medicaid savings it had proposed during deficit-reduction talks earlier this year. In its December 10, 2012 FAQ to states, CMS notes: "The Supreme Court decision has made the higher matching rates available in the Affordable Care Act for the new groups covered even more important to incentivize states to expand Medicaid coverage. The Administration is focused on implementing the Affordable Care Act and providing assistance to states in their efforts to expand Medicaid to these new groups." We have no reason to believe that the federal government will change its mind about the 90% match in the year 2020 and beyond for the Expansion population.

Medicaid Myth #5: Overloading a broken Medicaid program hurts the most vulnerable. Adding so many more people to the Medicaid program will only make these problems worse. 
Reality: The poor who are also uninsured right now still get sick and use health care services. They just don't receive care when they need in the appropriate setting because they end up waiting until their conditions worsens or becomes an emergency. The Medicaid Expansion will allow this group for the first time to have health insurance, and therefore greater access to care at the right time, in the right setting. In addition, in a report released by the GAO (Government Accountability Office) last month, the GAO found that "in calendar years 2008 and 2009, less than 4 percent of beneficiaries who had Medicaid coverage for a full year reported difficulty obtaining medical care, which was similar to individuals with full-year private insurance." In fact, IL received a bonus payment of over $15 million last year for meeting quality and other standards in the CHIP program

The current Illinois Medicaid program is not broken; it is efficiently run. Nationally, the per enrollee cost growth in Medicaid (6.1%) is lower than the per enrollee cost growth in comparable coverage under Medicare (6.9%), private health insurance (10.6%), and monthly premiums for employer-sponsored coverage (12.6%). Illinois’ average annual growth in Medicaid spending for FY2007-FY2010 was 6.6%. While it is true that Medicaid in Illinois pays providers less than they typically receive from private insurance (and therefore fewer providers accept patients with Medicaid), to address this issue, beginning January 2013, the Affordable Care Act will be increasing Medicaid payments for primary care doctors.

These aren't the only myths about the Medicaid expansion; the opponents are so bereft of data that they have to result to myth-making. The reality is that the Medicaid expansion makes good fiscal sense and will make a huge difference in the lives of literally hundreds of thousands of Illinois residents. The reality is that the Medicaid expansion is an excellent deal for the state of Illinois.

Health & Disability Advocates
Heartland Alliance for Human Needs and Human Rights
Sargent Shriver National Center on Poverty Law

Friday, December 14, 2012

The Affordable Care Act and You: The New Consumer Benefits

The election is over, and the Affordable Care Act (ACA) is here to stay. The Shriver Center, along with numerous national and local advocacy organizations, has been active in getting the word out about what is in the ACA. Surveys show that many people are unaware of the benefits that are available to them because of the ACA and that most Americansapprove of the consumer benefits offered by the Act. And so, we are launching a biweekly blog series called “The Affordable Care Act and You” because it is time to get to know the ACA.

Let’s start with the basics. What is the Affordable Care Act? Signed on March 23, 2010, the Affordable Care Act sets forth provisions and regulations to reform our health care system in a way that offers more people access to health care. It is important to know that not all insurance plans are subject to the consumer protections rules of the ACA. Employer-sponsored health insurance plans that existed before March 23, 2010, are granted a “grandfather status,” which basically means that they have to abide only by some of the rules of the ACA. However, insurance plans created after that date must abide by all of the ACA’s regulations.

The ACA has decreased the number of uninsured individuals in the U.S., ensured that insurance companies spend at least 80% of your premium dollars on your medical needs, and has made it easier for small businesses to offer health insurance to their employees. These are just some of the existing reforms made by the ACA; in this first blog in the series we will talk about several more consumer benefits provided for in the Act.

1. The ACA makes preventive services free of cost-sharing.

Too many Americans refrain from getting needed preventive care because of the expenses they must pay out-of-pocket.Preventive care is crucial for the simple fact that it helps individuals to avoid costly and deadly illness by detecting health issues early. The ACA requires health plans, excluding grandfathered plans, to offer you preventive services at no additional cost. This means that your immunizations, screenings, and checkups are covered—no out-of-pocket expenses. And for women, well-woman visits, mammograms, contraceptives, and other services are also free of cost-sharing. You can find the full list of preventive services that are now free of cost-sharing here.

2. The ACA bans lifetime dollar limits.

Medical expenses are costly for a healthy individual; for millions of Americans living with a chronic medical condition, health care costs can lead to financial ruin and loss of health insurance. For years, it has been perfectly legal for insurance companies to impose a lifetime dollar limit on your health coverage. And once you reach that amount, they can stop paying for your health expenses. Now, because of the ACA, if you or someone you know has a medical condition, there is no longer a need to worry about losing insurance coverage because of lifetime dollar limit. Because of the ACA, insurance companies are banned from imposing a lifetime dollar limit on your coverage. In addition, the use ofannual dollar limits will be phased out over the next two years and banned entirely in 2014.

3. The ACA provides for dependent coverage for young adults up to the age of 26.

The ACA’s dependent coverage provision allows young adults up to the age of 26, to stay or be added to their parents’ health insurance. The young adult population, or so-called “young invincibles,” often struggle to afford health insurance, and many just go without. Since the dependent coverage provision went into effect in 2010, 13.7 million young adultswere able to remain or rejoin their parents’ health insurance. If you are under the age of 26, or a parent of a young adult under the under this age, check to see if your insurance plan offers dependent coverage up to the age of 26.

4. The ACA will assure that pre-existing conditions will no longer be a barrier to coverage.

Several common health conditions—asthma, high blood pressure, arthritis—can be considered pre-existing conditions. Insurance companies, if they choose to, can refuse to cover you because of a pre-existing condition. Since the passage of the ACA, children can no longer be denied health insurance because of a pre-existing condition. Adults, on the other hand, must wait until 2014 to receive the same benefit. Luckily, the federal government, under the ACA, provided funding to the states for temporary high-risk pools. This funding provides health insurance for adults with pre-existing conditions who are unable to find coverage because of their conditions. In Illinois, this program is called the Illinois Pre-existing Condition Plan (IPXP), and you can enroll by contacting the Department of Insurance.

5. The ACA will end gender rating.

In many states, women can be charged more for health insurance than men—as much $391 more annually! This surprisingly common practice—where insurance company charge more based on gender—is called gender rating. In states that do not already prohibit gender rating, 95% of the best-selling health insurance plans practice it. In Illinois, 100% of the best-selling health insurance plans practice gender rating. Starting in 2014, the ACA will ban gender rating in all states.

These five patient consumer benefits are only the tip of the iceberg. Once the ACA is fully implemented, Americans can expect health insurance to be more accessible, affordable, and comprehensive. Now you know some of the consumer benefits that may benefit you or your family and friends. So spread the word!

This post originally appeared on The Shriver Brief.
Coauthored by Viviane Clement and Andrea Kovach.

Friday, December 7, 2012

The 12 Days of … Medicaid?

On the 1st day of Medicaid the IL House should give us Medicaid for 342K uninsured, 2 of 3 working.
BACKGROUND: HB 6253 will cover an estimated 342,000 uninsured Illinoisans. According to data from the Kaiser Family Foundation (link to http://www.kff.org/uninsured/upload/8350.pdf), over 60% of these newly eligible individuals are employed, but working at low-wage or part-time jobs that offer don’t offer health insurance at all, or offer coverage that is not affordable.

On the 2nd day of Medicaid the Gen Assembly should provide coverage to 342K, feds pay 100% thru 2016.
BACKGROUND: HB 6253 will leverage $5.7 billion in Medicaid funding to cover low-income, uninsured people in Illinois. The best part? It will cost Illinois nothing in 2014-2016 because the federal government will pay 100% of the cost. The state pays no more than 10% through 2020. Support HB 6253! Click here to send a message to your Illinois legislator. http://wfc2.wiredforchange.com/o/8810/p/dia/action3/common/public/?action_KEY=8966

On the 3rd day of Medicaid the Gen Assembly should create new health care jobs.
BACKGROUND: Covering newly eligible people will create jobs and generate revenue. A substantial number of jobs will be generated by the Affordable Care Act’s $5.7 billion in federal funding for Medicaid due to its multiplier effect throughout the economy. State and local revenue increase when Illinois residents pay income, sales, and other taxes generated by the federal funding for covering newly eligible people; this revenue would offset much, perhaps all, of any additional costs. Source: http://www.theshriverbrief.org/2012/07/articles/health-care-justice/expanding-medicaid-the-choice-is-clear/

On the 4th day of Medicaid the Gen Assembly should cut $1K hidden health tax on people w/insurance.
BACKGROUND: Every family with health insurance pays an additional $1,000 per year to pay for care for the uninsured.  Hospitals and doctors raise the rates they charge people with insurance to cover bills for people who can’t pay them, which are then passed along in the form of higher insurance rates.  Covering 342,000 Illinoisans through new Medicaid will reduce uncompensated care and slow the rise in costs of private insurance for all of us. Read the Families USA report, and then take action and tell your Illinois legislator to support HB 6253.

On the 5th day of Medicaid the Gen Assembly should give IL $5.7 b federal $ for 342K newly insured.

BACKGROUND: HB 6253 will leverage $4.6 billion in new federal Medicaid funding for Illinois in 2014-16. This will allow the state to provide comprehensive health care coverage for an estimated 342,000, low-income people who are currently uninsured. Most importantly, the federal government will pay 100% of the cost of care for this new population in 2014-17, dropping to 90% by 2020.

On the 6th day of Medicaid the Gen Assembly should provide 342k Illinoisans access to preventive services.
BACKGROUND: Today, low-income uninsured people have limited access to cost-saving prevention services like mammograms, diabetes or heart disease screens, HIV tests, flu shots, or counseling to stop smoking. These services lead to early detection and treatment of costly and life-threatening medical conditions that can cause disability or death. HB 6253 will leverage federal Medicaid funding and bend the health care cost curve by providing these and other prevention services to 342,000 low-income, uninsured Illinoisans.

On the 7th day of Medicaid the Gen Assembly should provide a healthier workforce by passing HB 6253.
BACKGROUND: Over 60% of people newly eligible for Medicaid as a result of HB 6253 are working. Providing Medicaid to this group would improve their health, as shown by a New England Journal of Medicine study of Oregon (http://www.nejm.org/doi/full/10.1056/NEJMp1108222). The study demonstrated that newly enrolled individuals were 25% more likely to report that they were in good health. Other research shows that Medicaid coverage reduces the death rate (http://www.nytimes.com/2012/07/26/health/policy/medicaid-expansion-may-lower-death-rate-study-says.html?pagewanted=all&_r=0).

On the 8th day of Medicaid, the IL General Assembly should see a local map of new Medicaid eligibles
Health & Disability Advocates has built a great tool that maps where individuals newly eligible for Medicaid live. You can dive down to your community area for details and demographics. Check it out!  http://visualizingreform.illinoishealthmatters.org/uninsured#40,25|-88,5|7|-1|4 Legislative district data will be available online in January 2013!

On the 9th day of Medicaid, the Gen Assembly should replace state funding w/ federal $$ for mental health care.
Illinois now spends millions of dollars in state general funds on mental health services for low-income, uninsured people. The Center on Budget & Policy Priorities estimates that State and local governments provided 44 percent of the funding for state mental health agencies in 2009, amounting to $17 billion. By passing HB 6253 and providing Medicaid coverage to these individuals, Illinois can leverage federal funding to cover half or more of the cost of these services, significantly reducing the cost to the state.

On the 10th day of Medicaid, the IL Gen Assembly should bring health coverage to +12K uninsured #vets in Illinois with HB 6253.
Covering newly eligible people will provide Medicaid coverage for Illinois’ veterans. Not all veterans are able to get care at a Veterans Affairs hospital. And, in fact, according to the Social IMPACT Research’s Center, filling the Medicaid gap would bring health coverage to 1,800 of the new veterans in Illinois (military service members who have been deployed in 2001 or later) and 12,600 of all veterans. Illinois needs to take care of veterans, and filling the Medicaid gap will do just that for many of them. Nationally, in 2014, nearly half of uninsured veterans will likely qualify for the new Medicaid coverage

On the 11th day of Medicaid the Gen Assembly should provide more support for community health centers.
Today, community health centers (also called Federally Qualified Health Centers) are one of the only sources of free health care for hundreds of thousands of low-income, uninsured people in Illinois. HB 6253 will provide many of those individuals with health insurance through Medicaid, helping community health centers to strengthen their finances and provide better, more comprehensive care, including prevention services. More information on community health centers and health reform can be found here.

On the 12th day of Medicaid the Gen Assembly should simply do the right thing & pass HB 6253
BACKGROUND:The Medicaid expansion is simply the right thing to do. We have a chance, through the incredible leveraging of federal funds, to provide health coverage—and the chance for better health and upward mobility—to hundreds of thousands of our state’s most vulnerable, needy residents. We can create a system that expands its circle of moral concern to include the uninsured, recognizing as Justice Ruth Bader Ginsburg wrote in N.F.I.B. v. Sebelius, that “[v]irtually everyone … consumes health care at some point in his or her life.”

Starting today, we’re kicking off a new feature called the “12 Days of Medicaid.” It’s a social media advocacy campaign designed to educate Illinoisans about the importance of passing the Medicaid Eligibility Expansion (HB 6253) in early January 2013.

The bill will allow Illinois to leverage over $5 billion in federal Medicaid funding to provide comprehensive health care coverage to over 342,000 low-income individuals. The new funding was made available through the Affordable Care Act. The Illinois General Assembly needs to pass HB 6253 by January 9, 2013, the end of the current legislative session, to ensure programs and systems are in place just 12 months from now when one of the largest parts of health care reform begins.

For more information on HB 6253, here are several fact sheets: 
Medicaid Financing for the Uninsured Under the Affordable Care Act 
What is the Medicaid Expansion? Fact Sheet and Client Stories 
Medicaid Opportunity Fact Sheet With List of Supporters

So stay tuned for a social media message of the day every weekday from now through December 24. 

Please share the messages on Facebook and Twitter and urge your friends and family members to tell their legislators to support common-sense, fiscally sound legislation in Illinois. 

AIDS Foundation of Chicago
Health & Disability Advocates
Heartland Alliance
Illinois Maternal & Child Health Coalition
Sargent Shriver National Center on Poverty Law

Friday, November 30, 2012

Illinois Takes Three Big Steps Forward in Health Reform Implementation

After the November election confirmed the permanent status of the Affordable Care Act (ACA), Illinois wasted no time getting the law’s reforms under way. In less than a month, three big changes have brought the state closer to ACA implementation:

1. On November 19, 2012, Cook County opened enrollment into “County Care,” the Medicaid expansion program for eligible county residents. Through a Section 1115 Waiver approved by the federal government, Cook County will pilot the ACA’s Medicaid expansion in 2013 – a full year before the rest of the state. The program will provide eligibility and access to care to approximately 250,000 low income adults in the County and will operate on a “medical home” model – which means the county’s patients would have a doctor, a nurse, a social worker, and a medical assistant assigned to manage their health care. Stay tuned for County Care progress reports.

2. Not to be out-done by Cook County, Illinois legislators filed a bill (HB 6253) earlier this week to expand Medicaid to all low income Illinoisans (earning up to 138% FPL or about $16,000/year). The Medicaid expansion is a cornerstone of the ACA’s success: it will provide comprehensive medical benefits to 600,000 individuals and is a fiscal boon to the state - bringing in an estimated $5.7 billion in Medicaid provider payments (through 2016) with no net state costs. It will also reduce hospital, Township and local government costs to cover the uninsured. To learn more, check out these fact sheets – one by Health & Disability Advocates and one by the Department of Health & Family Services.

3. The Illinois Department of Insurance was also busy this month, submitting on November 16, 2012, the state’s application to run a Partnership Health Insurance Exchange. In a partnership model, the state and federal government will share responsibilities for administering the online marketplace that will help over one million individuals and small businesses shop for quality health coverage. The state will need to decide soon how it will roll out its Navigator and in person consumer assistance programs. Once the blueprint becomes public, we will post it on Illinois Health Matters.

Finally, we'd be remiss if we didn't mention major policy activity on the federal level, too: right before Thanksgiving HHS published proposed rules governing the ACA's Essential Health Benefits provision, wellness programs and private insurance market reforms. Health Affairs has a great blog post summarizing these federal notices.

Illinois Health Matters will be following all of these federal and state developments closely. Check back for news and updates! Or feel free to ask us a question directly: email us at info@illinoishealthmatters.org.
Stephani Becker
Project Director, Illinois Health Matters

Friday, November 16, 2012

Update:Illinois’ Care Coordination and Managed Care System

In January 2011, the Illinois legislature passed a bill that requires 50% of the State’s Medicaid population to be covered in a risk-based care coordination program by 2015. Subsequently, in May 2012, the State Legislature passed the SMART Act, cutting Medicaid services and projecting cost savings through various care coordination initiatives.

The care coordination, or managed care, initiatives referenced through this bill are: the Integrated Care Program, the Dual Eligibles Capitation Demonstration and the Innovations Program. All three of these initiatives have a goal to better coordinate primary, acute, behavioral health and long-term supports and services thereby improving the delivery of health services and lowering health costs.

The move to better coordinate care across primary, acute, behavioral health and long-term supports and services is in alignment with the federal Affordable Care Act (ACA), passed in March 2010. In fact, Illinois has made an effort to take advantage of several of the ACA provisions to move towards a better coordinated and integrated health system.

One of the ACA provisions Illinois is interested in is called Medicaid health homes for individuals with chronic conditions. To date, Illinois has filed a draft Medicaid state plan amendment to create health homes. The other federal ACA inititiave relating to care coordination that Illinois interested in is the Medicare-Medicaid Alignment Initiative, or the Dual Eligibles Demonstration Project. Illinois has submitted a proposal for this demonstration project.

For more details about the various care coordination, or managed care, initiatives in Illinois, please reference the document “Illinois Health Reform 2012: Care Coordination, Managed Care and Long-Term Services and Supports” developed by Health & Medicine Policy Research Group.

Kristen Pavle
Associate Director, Center for Long-Term Care Reform
Health & Medicine Policy Research Group

Monday, November 12, 2012

After The Election: A Consumer's Guide To The Health Law

This post originally appeared on Kaiser Health News; bMary Agnes Carey and Jenny Gold

Now that President Barack Obama has won a second term, the Affordable Care Act is back on a fast track.
Some analysts argue that there could be modifications to reduce federal spending as part of a broader deficit deal; for now, this is just speculation. What is clear is that the law will have sweeping ramifications for consumers, state officials, employers and health care providers, including hospitals and doctors.
While some of the key features don't kick in until 2014, the law has already altered the health care industry and established a number of consumer benefits.
Here's a primer on parts of the law already up and running, what's to come and ways that provisions could still be altered.
I don't have health insurance. Under the law, will I have to buy it and what happens if I don’t?
Today, you are not required to have health insurance. But beginning in 2014, most people will have to have it or pay a fine. For individuals, the penalty would start at $95 a year, or up to 1 percent of income, whichever is greater, and rise to $695, or 2.5 percent of income, by 2016.
For families the penalty would be $2,085 or 2.5 percent of household income, whichever is greater. The requirement to have coverage can be waived for several reasons, including financial hardship or religious beliefs.
Millions of additional people will qualify for Medicaid or federal subsidies to buy insurance under the law.
While some states, including most recently Alabama, Wyoming and Montana, have passed laws to block the requirement to carry health insurance, those provisions do not override federal law.
I get my health coverage at work and want to keep my current plan. Will I be able to do that? How will my plan be affected by the health law?
If you get insurance through your job, it is likely to stay that way. But, just as before the law was passed, your employer is not obligated to keep the current plan and may change premiums, deductibles, co-pays and network coverage.
You may have seen some law-related changes already. For example, most plans now ban lifetime coverage limits and include a guarantee that an adult child up to age 26 who can't get health insurance at a job can stay on her parents' health plan.
What other parts of the law are now in place?
You are likely to be eligible for preventive services with no out-of-pocket costs, such as breast cancer screenings and cholesterol tests.
Health plans can't cancel your coverage once you get sick – a practice known as "rescission" – unless you committed fraud when you applied for coverage.
Children with pre-existing conditions cannot be denied coverage. This will apply to adults in 2014.
Insurers will have to provide rebates to consumers if they spend less than 80 to 85 percent of premium dollars on medical care.
Some existing plans, if they haven't changed significantly since passage of the law, do not have to abide by certain parts of the law. For example, these "grandfathered" planscan still charge beneficiaries part of the cost of preventive services.
If you're currently in one of these plans, and your employer makes significant changes, such as raising your out-of-pocket costs, the plan would then have to abide by all aspects of the health law.
I want health insurance but I can’t afford it. What will I do?
Depending on your income, you might be eligible for Medicaid. Currently, in most states nonelderly adults without minor children don't qualify for Medicaid. But beginning in 2014, the federal government is offering to pay the cost of an expansion in the programs so that anyone with an income at or lower than 133 percent of the federal poverty level, (which based on current guidelines would be $14,856 for an individual or $30,656 for a family of four) will be eligible for Medicaid.
The Supreme Court, however, ruled in June that states cannot be forced to make that change. Republican governors in several states have said that they will refuse the expansion, though that may change now that Obama has been re-elected.
What if I make too much money for Medicaid but still can't afford to buy insurance?
You might be eligible for government subsidies to help you pay for private insurance sold in the state-based insurance marketplaces, called exchanges, slated to begin operation in 2014. Exchanges will sell insurance plans to individuals and small businesses.
These premium subsidies will be available for individuals and families with incomes between 133 percent and 400 percent of the poverty level, or $14,856 to $44,680 for individuals and $30,656 to $92,200 for a family of four (based on current guidelines).
Will it be easier for me to get coverage even if I have health problems?
Insurers will be barred from rejecting applicants based on health status once the exchanges are operating in 2014.
I own a small business. Will I have to buy health insurance for my workers?
No employer is required to provide insurance. But starting in 2014, businesses with 50 or more employees that don't provide health care coverage and have at least one full-time worker who receives subsidized coverage in the health insurance exchange will have to pay a fee of $2,000 per full-time employee. The firm's first 30 workers would be excluded from the fee.
However, firms with  50 or fewer people won't face any penalties.
In addition, if you own a small business, the health law offers a tax credit to help cover the cost. Employers with 25 or fewer full-time workers who earn an average yearly salary of $50,000 or less today can get tax credits of up 35 percent of the cost of premiums. The credit increases to 50 percent in 2014.
I'm over 65. How does the legislation affect seniors?
The law is narrowing a gap in the Medicare Part D prescription drug plan known as the "doughnut hole." That's when seniors who have paid a certain initial amount in prescription costs have to pay for all of their drug costs until they spend a total of $4,700 for the year. Then the plan coverage begins again.
That coverage gap will be closed entirely by 2020. Seniors will still be responsible for 25 percent of their prescription drug costs. So far, 5.6 million seniors have saved $4.8 billion on prescription drugs, according to the Department of Health and Human Services.
The law also expanded Medicare's coverage of preventive services, such as screenings for colon, prostate and breast cancer, which are now free to beneficiaries. Medicare will also pay for an annual wellness visit to the doctor. HHS reports that during the first nine months of 2012, more than 20.7 million Medicare beneficiaries have received preventive services at no cost.
The health law reduced the federal government's payments to Medicare Advantage plans, run by private insurers as an alternative to the traditional Medicare. Medicare Advantage costs more per beneficiary than traditional Medicare. Critics of those payment cuts say that could mean the private plans may not offer many extra benefits, such as free eyeglasses, hearing aids and gym memberships, that they now provide.
Will I have to pay more for my health care because of the law?
No one knows for sure. Even supporters of the law acknowledge its steps to control health costs, such as incentives to coordinate care better, may take a while to show significant savings. Opponents say the law’s additional coverage requirements will make health insurance more expensive for individuals and for the government.
That said, there are some new taxes and fees. For example, starting in 2013, individuals with earnings above $200,000 and married couples making more than $250,000 will paya Medicare payroll tax of 2.35 percent, up from the current 1.45 percent, on income over those thresholds. In addition, higher-income people will face a 3.8 percent tax on unearned income, such as dividends and interest.
Starting in 2018, the law also will impose a 40 percent excise tax on the portion of most employer-sponsored health coverage (excluding dental and vision) that exceeds $10,200 a year and $27,500 for families. The tax has been dubbed a "Cadillac" tax because it hits the most generous plans.
In addition, the law also imposes taxes and fees on several major health industries. Beginning in 2013, medical device manufacturers and importers must pay a 2.3 percent tax on the sale of any taxable medical device to raise $29 billion over 10 years. An annual fee for health insurers is expected to raise more than $100 billion over 10 years, while a fee for brand name drugs will bring in another $34 billion.
Those fees will likely be passed onto consumers in the form of higher premiums.
Has the law hit some bumps in the road?
Yes. For example, the law created high-risk insurance pools to help people purchase health insurance. But enrollment in the pools has been less than expected. As of Aug. 31, 86,072 people had signed up for the high-risk pools, but the program, which began in June 2010, was initially expected to enroll between 200,000 and  400,000 people. The cost and the requirements have been difficult for some to meet.
Applicants must be uninsured for six months because of a pre-existing medical condition before they can join a pool. And because participants are sicker than the general population, the premiums are higher.
Enrollment has increased since the summer, after the premiums were lowered in some states by as much as 40 percent and some states stepped up advertising.
A long-term care provision of the law is dead for now. The Community Living Assistance Services and Supports program (CLASS Act) was designed for people to buy federally guaranteed insurance that would have helped consumers eventually cover some long-term-care costs. But last fall, federal officials effectively suspended the program even before it was to begin, saying they could not find a way to make it work financially.
Are there more changes ahead for the law?
Some observers think there could be pressure in Congress to make some changes to the law as a larger package to reduce the deficit. Among those options is scaling back the subsidies that help low-income Americans buy health insurance coverage. The amount of the subsidies, and possibly the Medicaid expansion as well, could be reduced.  
It’s also possible that some of the taxes on the health care industry, which help pay for the new benefits in the health law, could be rolled back. For example, legislation to repeal the tax on medical device manufacturers passed the House with support from 37 Democrats (it is not expected to receive Senate consideration this year). Nine House Democrats are co-sponsoring legislation to repeal the law’s annual fee on health insurers.
Meanwhile, the Independent Payment Advisory Board (IPAB), one of the most contentious provisions of the health law, is also under continued attack by lawmakers. IPAB is a 15-member panel charged with making recommendations to reduce Medicare spending if the amount the government spends grows beyond a target rate. If Congress chooses not to accept the recommendations, lawmakers must pass alternative cuts of the same size.
Some Republicans argue that the board amounts to health care rationing and some Democrats have said that they think the panel would transfer power that belongs on Capitol Hill to the executive branch. In March, the House voted to repeal IPAB.