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The George Washington University Geiger Gibson Program in Community Health Policy 2013 Distinguished Visitor A Tale of T

The George Washington University Geiger Gibson Program in Community Health Policy 2013 Distinguished Visitor A Tale of Two States: New Hampshire & Vermont Tess Kuenning, CSN, MS, RN President and Chief Executive Officer Bi-State Primary Care Association October 2, 2013.

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The George Washington University Geiger Gibson Program in Community Health Policy 2013 Distinguished Visitor A Tale of T

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  1. The George Washington University Geiger Gibson Program in Community Health Policy 2013 Distinguished Visitor A Tale of Two States: New Hampshire & Vermont Tess Kuenning, CSN, MS, RN President and Chief Executive Officer Bi-State Primary Care Association October 2, 2013

  2. A Tale of Two States:Reflection from Charles Dickens “It was the best of times, it was the worst of times, it was the age of wisdom, it was the age of foolishness, it was the epoch of belief, it was the epoch of incredulity, it was the season of Light, it was the season of Darkness, it was the spring of hope, it was the winter of despair, we had everything before us, we had nothing before us, we were all going direct to Heaven, we were all going direct the other way— in short, the period was so far like the present period, that some of its noisiest authorities insisted on its being received, for good or for evil, in the superlative degree of comparison only.” GWU: Geiger Gibson Program in Community Health Policy

  3. Overview • About Bi-State Primary Care Association • NH/VT Demographics and Medicaid Eligibility • NH/VT Safety Net Providers: Vehicle for Services • NH/VT Pre-ACA: Leadership and the Environment • Overview: ACA Purpose, Value Proposition, Timeline and Supreme Court Decision • NH/VT Post-ACA Implications: Leadership and the Environment (Finance and Systems Reform; the Exchange and Market Penetration; O/E Navigators) • Implications to Primary Care Safety Net Providers GWU: Geiger Gibson Program in Community Health Policy

  4. About Bi-State • Private nonprofit 501(c)3 nonpartisan charitable organization • Two- state broad membership of 34 organizations that provide and/or support community-based primary care services • Promote/assure primary health care services for everyone but focus in medically underserved communities • Public policy/health systems reform/workforce • Develop strategies/policies/programs that promote and sustain community-based primary health care services with federal/state/regional policymakers and health policy organizations/foundations/payers GWU: Geiger Gibson Program in Community Health Policy

  5. Population Served:NH/VT/United States Demographics • Bi-State members see: • VT: 1 in 4 total population; 29% of Medicaid enrollees • NH: 1 in 10 total population; 30% of Medicaid enrollees GWU: Geiger Gibson Program in Community Health Policy

  6. Current State Medicaid Eligibility • NH • Children (1-18): • Medicaid: 185% FPL • CHIP: 185%-300% FPL • Pregnant women: 185% FPL • Parents: 40% FPL • Seniors: 76% FPL • Disabled: 76% FPL • Working disabled: 450% FPL • Adults (19-64) without children or disability: Ineligible • Newly eligible: 138% FPL • VT • Children (0-18): 300% FPL • Pregnant women: 200% FPL • Adults (including disabled1): • Singles/couples: $975/month • Asset limits: • Singles: $2,000 • Couples: $3,000 • No resource test for pregnant women GWU: Geiger Gibson Program in Community Health Policy

  7. Vehicle for Services GWU: Geiger Gibson Program in Community Health Policy

  8. Pre-ACA History:Elected Officials/Politics • NH • Historical: NH Governor R controlled since 1857 (exception D for 12 years) • Current: NH Governor D controlled since 1997 (exception R for 2 years) • June 2013, Governor (D) signed law prohibiting state participation in state-based health Exchange • State: House 400 (D controlled); Senate 24 (R controlled); Executive Council 5 (D controlled) • Swing state with sharp swings • VT • Historical: VT Governor R controlled; 1962-present alternating party control • Historical: Governor Dean (D) 1991-2003 • Current: VT Governor D since 2011 • State: House (150) and Senate (30) both D controlled since 1997 with exception of 4-year span with a R controlled House • Liberal/progressive ideology GWU: Geiger Gibson Program in Community Health Policy

  9. Pre-ACA History: Environment (NH) • Pillar Project incentive (2002) • Health promotion/disease prevention • Medical home • NH Citizens Health Initiative (2004) • 10-year plan • Framework for systems and finance reform • Public dialogue GWU: Geiger Gibson Program in Community Health Policy

  10. Pre-ACA History: Environment (VT) • Governor’s Initiative: Blueprint for Health (2003) • Transform health care services • Collaborative community effort; seamless PCMH care • VT Coalition 21 (2004) • 28 organizations: forge consensus to transform health care system • Adopted 6 principles to implement state health care reform; springboard for reform • Legislative Reform • Act 128 (2010): health care financing and universal access bill • Act 48 (2011): 3 primary areas: 1) creation of the Green Mountain Care Board (GMCB); 2) VT Health Connect the VT Exchange; and 3) GMCB universal system to cover all VT residents in 2017 • Act 171 (2012): health care reform implementation GWU: Geiger Gibson Program in Community Health Policy

  11. ACA: Purpose • Signed into law March 23, 2010 • Improve quality and lowering health care costs • New consumer protections; Patient Bill of Rights • Access to health care with Health Insurance Marketplace • Benefits for women • Young adult coverage up to age 26 • Strengthening Medicare • Holding insurance companies accountable GWU: Geiger Gibson Program in Community Health Policy

  12. ACA: Value Proposition • Coverage • Ends pre-existing condition exclusions for children (2010) • For adults 2014 and gender discrimination • Keeps young adults covered (2010) • Ends arbitrary withdrawals of insurance coverage (2010) • Insurance company must justify premium increases • 85% of premiums must go to health services • Guarantees right to appeal • Costs • Ends lifetime limits on coverage • Reviews premium increases • Helps people get the most from their premium dollars • Care • Covers preventive care at no cost to individuals (2010) • Protects choice of doctors • Removes insurance company barriers GWU: Geiger Gibson Program in Community Health Policy

  13. ACA: Timeline Overview • 2011: Patient Bill of Rights and Medicare free preventive services and receive 50% discount on brand name drugs in the Medicare “donut hole” • 2011: New Center for Medicare and Medicaid Innovation to improve health care quality and efficiency • 2012: ACO providers work together in integrated health care systems • 2012: Standardize billing and use of EHR and MU • 2013: Pay Medicaid at parity with Medicare (2 years) • 2013: Expand Medicaid to 138% FPL • 2013: Open enrollment in Health Insurance Marketplace begins October 1; offer tax credits 100-400% FPL and small business tax credit • 2014: Access to affordable health insurance options on Marketplace; individual mandate/shared responsibility or pay penalty • 2015: Pay physicians based on value, not volume; pay for quality GWU: Geiger Gibson Program in Community Health Policy

  14. ACA: Investments in the NHSC and Community Health Centers GWU: Geiger Gibson Program in Community Health Policy

  15. ACA: Supreme Court Decision • On June 28, 2012, the Supreme Court (SC) upheld the constitutionality of the ACA • Four discrete issues the Justices viewed: • If the SC should hear the case at all, as there is no “standing” since SC does not usually hear theoretical cases) [heard the case] • Whether the individual mandate is constitutional [upheld] • What will happen if they strike down the mandate [no longer an issue] • Whether Congress exceeded its Constitutional authority in expanding the eligibility and coverage thresholds that states must adopt to remain eligible for Medicaid [upheld the ability of the states to expand Medicaid but gave states the ability to choose or not choose expansion without losing their existing Medicaid funding; ultimately creating an option versus a mandate] GWU: Geiger Gibson Program in Community Health Policy

  16. Post-ACA ImplicationsLeadership: Elected Officials • NH: Divided Government • Swing state with sharp left and right swings; Elections: • 2012: Democrats 222-178 • 2010: Republicans 298-102 • 2008: Democrats 225-175 • Current environment: • Democrats control the House, Executive Council and Governor’s office while Republicans control the State Senate • Compromise: Medicaid Study Commission with report due October 15 • VT: GMCB Authority • Independent 5 member Board appointed by Governor • Authority: • Oversee all the new health system design • Regulate hospital budgets and capital • Regulate insurance rates and approve plans for health insurance in the Exchange • Build and retain workforce • Build and maintain the electronic health information systems and all payment reform GWU: Geiger Gibson Program in Community Health Policy

  17. Post-ACA ImplicationsEnvironment: Finance & Systems Reform • NH • Awaiting Medicaid Study Commission Report • Medicaid Care Management (MCM) • Mandatory MCM • Delay regarding hospital lawsuit/Medicaid rates • Resolved so first stage start date December 1, 2013 • FQHC MCO • MCM contract negotiation • Workforce capacity building • Clinical/financial investment • VT • CMS State Innovation Model funds: $45 million • Implement systemic health system transformation • Payment reform initiatives • Medicare, Medicaid and commercial ACO pilots • FQHC ACO for Medicare Shared Savings and new designs for Medicaid and commercial payment reform GWU: Geiger Gibson Program in Community Health Policy

  18. Post-ACA ImplicationsEnvironment: Health Information Exchange • NH: Federal/State Exchange • NH Health Insurance Exchange Marketplace • 1 Qualified Health Plan (Anthem) • Contracting with reduced rates • Narrow market promising volume • Market shift: 11 of 26 hospitals have no contract • Confusion and concern prevalent due to limited provider Exchange network • VT: State Exchange • VT Health Connect (VHC) • 2 Qualified Health Plans (BCBS and MVP) • Significant statewide activity, education and technical assistance GWU: Geiger Gibson Program in Community Health Policy

  19. ACA: The Exchange • Affected:Obtain minimal essential health coverage (MEC) or pay a penalty • Uninsured individuals • Individuals on VHAP or Catamount (ends 12/31/13; move to Medicaid or Catamount) • Employees of businesses <50 FT people (FT = 30+ hours/week) • Individuals whose employer decides to drop coverage • Self-employed individuals • Not Affected: No action • Individuals who get their insurance through large employer (>50 FTE; including COBRA) • Individuals on Medicare • Individuals currently on Medicaid/CHIP/Dr. Dynasaur • Individuals through VA/DOD • Exceptions: religious conscience; Indian tribes; no filing requirement (income below threshold); hardship; unaffordable coverage options (costs more than 8% of household income) 2014: Shared Responsibility Provision (SRP)/Individual Mandate GWU: Geiger Gibson Program in Community Health Policy

  20. ACA: The Exchange • Virtual on-line Marketplace • Compare health insurance options (VT 2 Carriers with multiple products/NH 1 Carrier with13 products) • Enroll in health plan (open October 1/coverage January 1) • Secure financial assistance to help pay for care • Enroll: Web/phone/paper application/in-person assistance GWU: Geiger Gibson Program in Community Health Policy

  21. ACA: Marketplace Standard Benefits • Essential Health Benefit (EHB): all plans must have EHB but amount of coverage varies • Benchmark plan: • Ambulatory patient services • Emergency services • Prescription drugs • Rehabilitative and habilitative services and chronic disease management • Hospitalization • Maternity and newborn care • Mental health and substance use disorder services, including services for behavioral health treatment • Laboratory services • Preventive and wellness • Pediatric services, including oral and vision care GWU: Geiger Gibson Program in Community Health Policy

  22. ACA: Common Health Insurance Terms/Meanings Have Changed • Premium: Amount paid for your healthy insurance • PCP: Medical doctor (MD/DO) who provides direct service • Pre-Existing Conditions: A health condition or illness that you had before your first day of coverage (2014 no longer an issue/can’t be turned away/can’t charge different rates on health status or gender) • Co-Payment: A fixed fee that you pay out of pocket for each visit • Deductible: A set amount that you pay before your plan starts paying for covered services • Co-Insurance: The % of the cost of covered services that is shared by you and your insurance company after you’ve met your deductible • Out of Pocket Limit: The most you pay for in-network deductibles, co-insurance and co-payments before your insurance begins to pay 100% GWU: Geiger Gibson Program in Community Health Policy

  23. ACA: What are the “Metal Level” Plans? • Platinum: Provides 90% Coverage with 10% Out of Pocket • Gold Plan: Provides 80% Coverage with 20% Out of Pocket • Silver Plan: Provides 70% Coverage with 30% Out of Pocket* • Bronze Plan: Provides 60% Coverage with 40% Out of Pocket Relationship between Coverage Premium Costs and Out of Pocket: • Higher Coverage/Less Out of Pocket/Less Cost • Lower Coverage/Higher Out of Pocket/More Cost Limits on how much Out of Pocket Expenses: • Total cost sharing per year (deductibles, co-pay and co-insurance) • Individual: $6,350 • Family: $12,700 GWU: Geiger Gibson Program in Community Health Policy

  24. VT Health Connect GWU: Geiger Gibson Program in Community Health Policy

  25. ACA: Consumer Choices: What is Key to Understand? • Am I eligible for coverage through Medicaid or Exchanges? • What if I am eligible for Medicaid but then earn additional income; how to shift to the Exchange? • What do the basic health insurance terms mean? (premium/co-pay/deductible/co-insurance/out of pocket) • Do I qualify for financial help? • How do I get that financial help? • What would be my penalty for not purchasing insurance? • Can I afford additional adult dental or vision? • Are my providers in this network? • What prescription coverage will I have re generic/brand? GWU: Geiger Gibson Program in Community Health Policy

  26. Post-ACA ImplicationsEnvironment: O&E/Navigator • NH • Certified Application Councilors (CAC); 5 hours • O&E at health center; 5 hours • Navigator funds (CMS); 20-24 hours • Bi-State received funds • Bi-State to coordinate 8 FTE Navigators among FQHCs, North Country Health Consortium and Bi-State to coordinate efforts to maximize funding opportunity and support enrollment of individuals • VT • CAC: VT, all same training re 20-24 hours • O&E at health center: VT, all same training • Navigator funds to state: VT, all same training • Bi-State received funds • Bi-State to work with FQHCs to coordinate efforts to maximize funding opportunity and support enrollment of individuals GWU: Geiger Gibson Program in Community Health Policy

  27. VT Health Connect GWU: Geiger Gibson Program in Community Health Policy

  28. VT Health Connect: PREMIUM ASSISTANCE GWU: Geiger Gibson Program in Community Health Policy

  29. VT Health Connect GWU: Geiger Gibson Program in Community Health Policy

  30. ACA: Implications to Primary Care Safety Net Providers • Educate your board, staff, patients, community, elected officials • Know your patient population and community • Federal law/state law: Implications? • State environment: Embrace the changes? • Politics: Strategies to influence direction or strategies to maximize funding • Strategies/funding/support of the changes to finance and systems reform; regulatory and legal interpretation (MACRO) • Strategies/funding/support on operational changes to maximize and strengthen operations and systems (MICRO) • Strengthen existing relationships and build new partnerships GWU: Geiger Gibson Program in Community Health Policy

  31. Contact Tess Stack Kuenning, CNS, MS, RN President and Chief Executive Officer Bi-State Primary Care Association 525 Clinton Street, Bow, NH 03304 (603) 228-2830, extension 112 tkuenning@bistatepca.org www.bistatepca.org GWU: Geiger Gibson Program in Community Health Policy

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