Tags Posts tagged with "affordable care act"

affordable care act

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Associated Press

HARRISBURG, Pa. (AP, June 5) — Pennsylvania took a first step Wednesday toward taking over its online health insurance exchange from the federal government in a bid to cut premiums for people who buy policies in the marketplace created by the Affordable Care Act.

Legislation sponsored by the Republican and Democratic floor leaders in Pennsylvania’s House of Representatives won unanimous approval from the chamber’s Insurance Committee.

Democratic Gov. Tom Wolf is pressing for the bill to pass the Republican-controlled Legislature this month in the hope that its savings measures can be in full effect in 2021.

The administration says it can operate the exchange for less money than the federal government does and use the savings to qualify for extra federal funding for a reinsurance program that helps cover certain high-cost claims.

“The products should not change, but the prices will go down, so I think that’s why it’s a win for us here in the commonwealth,” said House Majority Leader Bryan Cutler, R-Lancaster.

In addition to its high-level support in the House, the legislation is backed by the Pennsylvania Chamber of Business and Industry, the Hospital and Healthsystem Association of Pennsylvania and the Pennsylvania Association of Community Health Centers.

Wolf’s administration says the bill would make two important changes to reduce premiums for the 400,000 people who purchase health insurance through the Healthcare.gov online marketplace.

Currently, the federal government takes 3.5% of the premium paid on plans sold through the exchange, or an estimated $94 million this year.

The state can operate the exchange for $30 million to $35 million, Wolf’s administration says.

It could then use the savings to qualify for extra federal reinsurance funds and use the money to reimburse insurers for certain high-cost claims. Those reimbursements would allow insurers to lower premiums across the board within the state’s insurance marketplace, health insurance policy analysts say.

The state’s share would be about 20% or one-quarter of the reinsurance program cost, according to Wolf administration estimates.

“Both the Trump administration and the Wolf administration are interested in it, have been supportive through the process and I was hoping we could lead by example,” Cutler said.

The Wolf administration said its analysis shows that consumers would see premiums that are 5% to 10% lower than what they would otherwise pay.

Twelve states built and operate their own exchanges, while the Washington, D.C.-based nonpartisan Kaiser Family Foundation says seven other states have started a reinsurance program. Evidence from them shows that insurance premiums paid by consumers can drop, analysts say.

States at first struggled with running their own exchanges when they began in 2014 under former President Barack Obama’s signature health care law.

But Sabrina Corlette, a research professor at the Center on Health Insurance Reforms at Georgetown University, said that operating them has become cheaper and simpler as information technology systems have improved and become standardized.

Running its own exchange also gives the state more control over it, Corlette said. As an example, she noted that the Trump administration has suggested that it might end automatic re-enrollment in the exchange’s insurance policies, thus making it more cumbersome for someone to maintain their policy from year-to-year.

But a state that operates its own exchange could simply keep automatic re-enrollment, which is standard in employer-based insurance systems, Corlette said.

Questions, please contact Jack Phillips.

RCPA is hosting a free educational webinar on the Federal ORP (order, refer, or prescribe) Requirements on Wednesday, August 16, 2017, 1:00 pm – 3:00 pm. The webinar will be presented by David C. McAdoo, MBA, Executive Director, Southwest Behavioral Health Management, Inc. and Jamie Buchenauer, Director, Bureau of Fee for Services. Registration is required. Please register here to participate.

The Affordable Care Act requires all physicians including psychiatrists, physician assistants, and certified registered nurse practitioners to directly enroll in PA State Medicaid (PROMISe) to order, refer, or prescribe medications, testing, services, or other items billed to Medicaid. Any MD acting as the Medical Director in a licensed substance abuse or mental health facility must meet this requirement for the facility to bill Medicaid. Specifically, each psychologist, MD, CRNP, or PA touching the PA State Medicaid program must have at least one PROMISE ID under the NPI number on their license.

This webinar will address the requirement, the specific services that are covered, documentation that must be collected, the modifications needed in claims to bill Medicaid moving forward, and strategies for maintaining patient safety and uninterrupted access to medication and services during the transition to full compliance with this new requirement.


  • Introductions
  • Overview of Goals
    1. Understand the purpose of the ORP
    2. Understand which medical licenses are covered under the ORP
    3. Understand which medications, labs, services, and other benefits are covered under the ORP
    4. Understand the impact of the ORP on Medicaid and Medicare access to:
      1. Medications
      2. Lab Testing
  • PH Testing
  1. Behavioral Health Services
    • BHR Services
    • Peer Support and Psych Rehab
    • Family Based
    • BH services with an identified “medical director”
  • Understand the technical requirements for paper and electronic claim submission compliance with the ORP
  • Identify the changes and/or modifications needed in BH services to document ORP compliance
  • Identify the actions that are needed to assure all clients have uninterrupted access to BH and all prescribed medications
  • Review the timelines for ORP implementation in PA

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RCPA has signed on to a multi-association letter being sent to the PA congressional delegation in Washington, DC urging legislators to carefully evaluate any effort to repeal and replace the Affordable Care Act (ACA), given the critical need to maintain funding for the current Pennsylvania Medicaid program and to protect the vulnerable citizens who rely on Medicaid for critical and necessary care.

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Save the Date Tuesday, January 17:
Call Congress to Protect Medicaid Expansion

As Congress continues taking steps to repeal the Affordable Care Act, the National Council for Behavioral Health is joining together with Mental Health America, Addiction Policy Forum, Depression and Bipolar Support Alliance, and National Alliance on Mental Illness to protect the ACA’s Medicaid expansion.

Next Tuesday, January 17, we are asking advocates to join us in a nationwide call-in day to protect patients’ access to mental health and addictions services by preserving the Medicaid expansion. By taking just 10 minutes next Tuesday to call your Representative and two Senators, you will join thousands of dedicated advocates to have your voice heard in Congress. Join us and help save Medicaid expansion in 2017!

Why is Medicaid expansion important? Medicaid expansion is vital to our community—it provides health coverage to millions of Americans with mental health and addiction disorders. Without Medicaid expansion, low-income people across the country will be left as they were before the ACA, with no pathway to affordable health coverage.

Why advocate now? It is urgent that we defend Medicaid expansion now before Congress votes on ACA repeal. The more noise we make now, the better our chances of delaying or stopping future cuts to Medicaid.

Call-In Day Prep: Mark your calendar for January 17! The National Council will send out more information including step-by-step instructions for National Call-In Day to Protect Medicaid Expansion next week. In the meantime, you can prepare for your calls by reviewing these Call-In Day Instructions and Medicaid expansion talking points.

Have questions? Please feel free to reach out to Stephanie Pellitt at StephanieP@thenationalcouncil.org.

Thank you for your continued hard work and advocacy as we work to protect Medicaid in 2017.


Chuck Ingoglia
Senior Vice President, Public Policy and Practice Improvement
National Council for Behavioral Health

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There are currently concerns that those needing substance use disorder (SUD) treatment cannot access treatment because of high deductibles and co-pays. While this may certainly be true, there may be opportunities and considerations available to an individual that can help to address this issue:

  • Open enrollment to purchase insurance in the federal marketplace is from 11/1/16 – 1/31/17. Because of changing plans and current offerings, even those individuals who have previously signed up for a plan should be encouraged to explore the marketplace for insurance options that might better serve their needs; offering better coverage at a better price.
  • Understand that low premiums can be deceiving; generally plans with lower premiums have higher co-pays and deductibles and can result in higher overall costs.
  • The plans on the marketplace are arranged by metals: bronze (60%); silver (70%); gold (80%); and platinum (90%). The percent figures refer to the actuarial value of a plan, which means the percent of costs the insurance company is projected to pay for the care of all of their enrollees after premiums are paid. So, for a bronze plan, an insurance company is expected to pay 60% of costs after the premium, leaving the consumer with 40%. While a bronze plan may seem like the most affordable as far as premium is concerned, the overall cost to a consumer could be significantly higher once they use health care services.
  • The federal government offers premium assistance for those individuals and families who meet financial eligibility requirements (400% federal poverty limit): $60,000 for individuals/$97,200 for a family of four. This results in a premium reduction in correlation with income. Premium assistance is available for any plan on the federal exchange, but the amount of assistance is based on a household’s income and is relative to the cost of the silver plan.
  • Cost sharing assistance is available to help cover the costs of co-pays and deductibles for individuals earning between $15,800 – $47,520 and families of four earning between $32,319 – $60,000. Cost-sharing assistance is only available to consumers who choose a silver plan.

(Note: the federal government does not offer assistance subsidies for employee-based coverage, which may also have high deductibles and co-pays).

  • Unfortunately, while many individuals in need of SUD services would qualify for the federal assistance subsidies applicable to premiums, co-pays, and deductibles, it is believed that when purchasing insurance from the marketplace they choose the least expensive option (a bronze plan). This makes them ineligible for the cost-sharing financial assistance and, in the long run, costs them more and provides them with coverage that they cannot afford to use.
  • For this reason, all stakeholders (SCAs, case managers, treatment providers, recovery organizations, other advocacy groups, etc.) should encourage individuals who obtain insurance from the marketplace to explore their options during open enrollment and engage the free services of a navigator (an individual who can assist in determining the best insurance options for a particular person), and utilize the Total Cost of Care Calculator.

PA Insurance Department Resources:

Informing and assisting individuals in obtaining the right insurance coverage/plan is paramount to helping them access SUD and other services at an affordable cost, and assuring that agencies are engaged in the most effective methods and responsible use of available funds in providing assistance to those who need it.