The Affordable Care Act (ACA) makes improvements to both Medicaid and the State Children’s Health Insurance Program (CHIP). These include expanding Medicaid coverage, controlling costs and improving Medicaid service delivery for beneficiaries, including patients with liver disease. These changes are in the process of being implemented and are outlined below: Medicaid •
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Eligibility Expansion. Eligibility is expanded and all individuals with incomes at or below 133 percent of the federal poverty level will be eligible for coverage as of January 1, 2014. The mandatory Medicaid-‐eligibility level for children ages 6-‐19 increases from 100 to 133 percent of the federal poverty level. This expansion means that non-‐elderly, non-‐pregnant adults without children will be eligible for Medicaid based on their incomes for the first time, and this is the primary mechanism of the ACA to expand access to insurance. Medicaid Benefits. Those newly eligible for Medicaid will be eligible for “benchmark” or “benchmark-‐equivalent” plans, which was defined by the Deficit Reduction Act of 2005. Benchmark plans can either be full Medicaid benefits or a more limited package of benefits. However, all states will be required to provide at least the same essential health benefits required of coverage purchased through an exchange. A complete explanation can be found here. Maintenance of Eligibility. Prior to the Medicaid expansion on January 1, 2014, states are required to maintain the eligibility standards in effect on the date ACA was enacted into law. All individuals who met the state’s eligibility rules as of that date will remain eligible for full Medicaid coverage, not a benchmark plan. However, states providing coverage to beyond those who are pregnant or disabled with incomes above 133 percent of poverty can scale back eligibility for those beneficiaries during that time. Medical Homes. As of January 1, 2011, states have had the option of enrolling Medicaid beneficiaries with at least two chronic conditions, like liver disease, into a health home composed of a team of health providers that would provide comprehensive, care coordination services.
American Liver Foundation 39 Broadway, Suite 2700, New York, NY 10006-3003 Tel: 212-668-1000 Fax: 212-483-8179 HelpLine: 800-GO-LIVER (800-465-4837) www.liverfoundation.org
Prescription Drug Coverage. The ACA reduces the Medicaid programs prescription drug costs. Programs will be eligible for increased drug rebates between 2 and 8 percent depending on the drug. This was effective upon enactment. • Streamlined Enrollment. To simply the complicated enrollment process, the ACA requires states to establish a website or a health insurance exchange through which individuals may apply for Medicaid and CHIP. • Dual Eligibles. There are low-‐income seniors and people with disabilities are eligible for both Medicare and Medicaid and rely on Medicaid to fill the gaps in Medicare coverage. To improve access to services for these individuals, the ACA created an Office of Coordination for Dual Eligible Beneficiaries to align the policies of the two programs, integrate the programs; benefits, improve continuity of care and enhance coordination between the federal and state governments. More information can be found here. • Federal Share Increased. The federal government funds a large part of the Medicaid expansion. It will provide 100 percent of the matching costs for the newly eligible in 2014-‐16, 95 percent in 2017, 94 percent in 2018, 93 percent in 2019 and 90 percent in 2020 and thereafter. • Payments for Primary Care. To address concerns about the ability of Medicaid-‐eligible individuals to find primary care physicians who accept Medicaid, the ACA raises Medicaid reimbursement for primary care services to equal Medicare reimbursement for the same services. This increase is authorized for only 2013 and 2014. IMPORTANT NOTE: The recent Supreme Court decision on the ACA maintained the Medicaid expansion, but limited the Secretary’s authority to enforce it. This means that a state can choose not to implement the expansion, but the Secretary cannot without existing federal program funds. State Children’s Health Insurance Program (CHIP) The ACA extends the existing CHIP program for two years through September 30, 2015 and makes the changes outlined below. • Increases the federal share. Beginning on October 1, 2013 and ending September 30, 2015, the federal matching percentage for CHIP by 23 percent (not to exceed 100 percent). • Ensures maintenance-‐of-‐eligibility standards. The standards in effect on the date of ACA enactment must be maintained. •
American Liver Foundation 39 Broadway, Suite 2700, New York, NY 10006-3003 Tel: 212-668-1000 Fax: 212-483-8179 HelpLine: 800-GO-LIVER (800-465-4837) www.liverfoundation.org
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Screens children for other eligibility. In the event the CHIP allotments prove insufficient to cover all eligible children, the state must also have procedures to screen children for Medicaid eligibility and ensure those ineligible for Medicaid receive coverage through the Exchange. State option for CHIP coverage to children of state employees. Children of state employees who are eligible for health benefits are no longer precluded from participation in the CHIP program.
American Liver Foundation 39 Broadway, Suite 2700, New York, NY 10006-3003 Tel: 212-668-1000 Fax: 212-483-8179 HelpLine: 800-GO-LIVER (800-465-4837) www.liverfoundation.org