Health Reform Law Is Expected to Help People Enrolled in Both Medicaid and Medicare

[NRSKarenRN, BSN, RN]

info from kaiser foundation:

explaining health reform: the new rules for determining income under medicaid in 2014

to provide individuals and families access to affordable, high-quality health care, the patient protection and affordable care act (aca) expands medicaid to cover low-income adults and children with incomes up to 133 percent of the poverty line. millions of low-income parents, non-disabled adults who do not have dependent children (and who are generally ineligible for medicaid today except in a small number of states) and, in some instances, children now covered through the children's health insurance program (chip) will become newly eligible for health coverage through medicaid as a result.

in addition, individuals and families who have incomes above the level needed to qualify for medicaid but below 400 percent of the federal poverty line will receive tax credits to help them purchase coverage in the new health insurance exchanges. people with incomes up to 250 percent of the poverty line receiving premium credits will also get additional assistance with their cost-sharing charges. in total, an estimated 33 million more people who would otherwise be uninsured are expected to have coverage through medicaid, chip and the exchanges by 2021.

brief examines how the health reform law is expected to help people enrolled in both medicaid and medicare

the aca presents an array of new and enhanced options to improve care for dual eligibles: through better care integration,improved quality measures, and increased access to home and community-based long term services and supports. thisbrief identifies major provisions in the aca that relate to the care of dual eligibles, highlighted below.

coordination of care

the aca establishes two new federal entities--the federal coordinated health care office (fchco or duals office) andthe center for medicare and medicaid innovation (cmmi or innovation center)--that will be involved in efforts to study and improve care for dual eligibles. the duals office will be responsible for ensuring that dual eligibles have full access to the benefits to which they are entitled under the medicare and medicaid programs. additionally, this office is charged with providing states, medicare advantage special needs plans, physicians, and other relevant entities with tools and education to necessary for developing programs to align benefits for duals under the medicaid and medicare programs. in comparison, the role of the innovation center (cmmi) will be to test innovative payment and delivery models to lower costs and improve quality for dual eligible beneficiaries.

prescription drugs and medicare advantage plans

the aca eliminates cost sharing in medicare part d plans for some dual eligibles. the law states that all medicare

part d cost-sharing will be waived for full benefit duals who would be institutionalized but for the provision of home and community-based services, effective january 1, 2012. the law also strengthens quality requirements for medicare advantage special needs plans that exclusively serve duals.

long-term care and chronic illness

there is also new option within medicaid to provide health homes for beneficiaries with multiple chronic conditions, at a 90 percent federal matching rate. establishing a medical home could be a first step toward more integrated care for duals, a key goal of the aca. furthermore, the law increases federal support for state efforts to expand home and community based services and supports for long-term care. duals, with their complex health care needs often rely on these services to enable them to remain in the community.

new entities

* new federal coordinated health care office to improve coordination of care for dual eligibles (fchco or duals office)

* innovative models involving dual eligibles may be tested by the center for medicare and medicaid innovation (cmmi or innovation center)

coordination of care

* independence at home medicare demonstration project for beneficiaries with chronic illness

* medicaid option to provide health homes for beneficiaries with chronic conditions

* medicaid waivers involving dual eligibles may last 5 years

preventive benefits (provisions not exclusive to dual eligibles)

* new medicare annual wellness benefit

* medicare and medicaid preventive services

medicare part d prescription drug plans

* improved calculation of low-income subsidy (lis) benchmark premium

* voluntary de minimus policy for lis individuals

* continued eligibility for lis surviving spouses

* plan information lis individuals who are reassigned to another plan

* elimination of cost-sharing for certain full benefit dual eligible individuals

* dispensing techniques for medicines prescribed for long-term care facility residents

* inspector general studies of part d plan formularies

* medication therapy management programs (mtmp) for at-risk enrollees

medicare advantage plans

* extends the authority for ma plans for special needs individuals (snp)

* permanently authorized the senior housing facility demonstration

* hold harmless for pace programs

long-term care (provisions not exclusive to dual eligibles)

* medicaid community first choice option

* money follows the person demonstration extended

* temporary spousal impoverishment protection

* community living assistance services and supports (class) program