1. Affordable Care Act
California Implementation
Janlee Wong, MSW
NASW California Chapter
April 2014

2. ACA Goals
• Universal coverage
– By January 2014, 92% of Californians will be
eligible for coverage (1)
– 2.6 million unauthorized immigrants will not (2)
• Affordable Health Plans
– Expand Medi-Cal (Medicaid) in Low Income Health
Plan (LIHP) (500,000) (2)
– Offer plans in Healthcare Exchange (Covered CA)
• Cost Controls

3. California has the eighth
largest proportion of
uninsured in the nation
and the largest total
number of uninsured. Only
three states (Massachusetts,
Hawaii, and Minnesota) have
uninsured rates under 10%.
*All numbers reflect the non-
elderly population, under age
65.
Source: Employee Benefit
Research Institute estimates of
the 2009 – 2011 Current
Population Survey, March
Supplements.

5. The Uninsured Unauthorized (3)
A recent report by the UC-Berkeley Center for Labor
Research and Education and the UCLA Center for
Health Policy Research on California residents who
will remain uninsured after the ACA takes effect
found that:
• 66% of the remaining uninsured will be Latino;
• 60% of the remaining uninsured will have limited
English proficiency; and
• 62% of the remaining uninsured will live in
Southern California.

6. Immigrants
• The ACA does not change the current
eligibility standard preventing most
documented immigrants from enrolling in
Medicaid or the Children's Health Insurance
Program if they have resided in the U.S. for
fewer than five years. States are permitted to
cover such immigrants in the programs at
their own expense, and Medicaid will cover
emergency care for all immigrants.

7. Immigrants
• Undocumented immigrants are not eligible for
public health insurance programs, and the ACA in
most cases will further exclude them from new
coverage opportunities, including state health
insurance exchanges and Medicaid expansions.
• Lawful immigrants who have lived in the U.S. for
less than five years may participate in health
insurance exchanges and obtain subsidies if
income-qualified, but in most states, they still will
not be able to qualify for full Medicaid coverage.

8. Immigrants
• In California under the state's Medicaid program -- "services
for undocumented immigrants, including prenatal care,
pregnancy-related services, nursing home care, and limited
breast and cervical cancer treatment," are provided through
Medi-Cal
• The Deferred Action for Childhood Arrivals program was
created by President Obama in 2012 to grant immigrants who
came to the country illegally as children — sometimes called
Dreamers — legal status and work authorization for two-year
periods.
• Laurel Lucia, a policy analyst at the UC Berkeley Labor Center
and author of the report released Tuesday, said California is
one of the few states that lets youth with deferred action
status enroll inMedicaid.

9. ACA Implementation In CA
Goals
1. Expand Coverage in Public Programs
2. Simplify and Streamline Eligibility
and Enrollment
3. Protect Health Insurance Consumers
4. Create a New Marketplace for
Private Health Insurance

10. Goal 1:
Expand Coverage in Public Programs
1. Expand Medi-Cal
2. Determine Coverage Options for
Low Income Individuals
3. Use Financial Incentives to
Improve Access and Quality

11. Objective 1: Medi-Cal Expansion
• Current Coverage: Infants and pregnant
women (200% Federal Poverty Level - FPL)
• Children (ages 1-5 - 133% FPL), ages 6-19
(100% FPL)
• Low-income parents, elderly, people with
disabilities
• ACA expansion: parents of dependent
children, foster youth to age 26, non-elderly
and childless adults (133% FPL)

12. Summary - Individuals

13. Summary - Families

14. 3. Use Financial Incentives to Improve
Access and Quality (1)
• Primary care rate enhancement (required).
100% federal financing in 2013 and 2014
• Raises Medi-Cal reimbursement rates to parity
with Medicare for certain evaluation and
management services provided by primary
care physicians.
• 120% increase in reimbursement

15. Preventive Services w/o Copays
• 1% increase in federal matching payments if the state
covers certain recommended immunizations and
preventive services without charging Medicaid
beneficiaries a share of the cost.
• Adults get 15 services covered for preventive
care, women get 22 and kids get 26 covered services.
These services include some of the most important
types of prevention like immunizations, mammograms
and wellness visits. Medicare patients also gain some
new benefits under the ACA as the 2010 preventive
health mandates apply to them as well.

16. Goal 2: Simplify and Streamline
Eligibility and Enrollment (1)
Objectives
1. Improve Consumer Experience
– Consumer Application/enrollment: in
person, mail or online
2. Promote and support enrollment
– Assisters and Navigators provide
consumers with one-on-one assistance in
enrollment

17. 1. Improve Consumer Experience
• “No wrong door”
– Medi-Cal enrollment, 58 counties with in person,
mail telephone and online, certified assisters
• CalHEERS – California Healthcare Eligibility,
Enrollment, & Retention System (Accenture)
• Covered CA website: fact sheets, subsidy
calculator and consumer phone number
• Simple Income Eligibility Determination:
Single income standard, no assets test

18. 2. Promote and support enrollment
Assisters/Navigators (6)
• Assister Enrollment Entities (AEE)
– Organizations approved by the Exchange to provide
one-on-one consumer assistance
– AEEs can be registered in either the Navigator
Program or the In-Person Assistance Program but not
both.
– American Indian/Tribal Organizations, Attorneys, Tax
Preparers, Trade/Prof. Org., Com Clinics, Colleges,
Cities, Unions, Chambers of Commerce, Non-Profits,
Schools, Ranch or Farm Organizations (partial list)

19. 2. Promote and support enrollment
Navigators/Assisters (6)
• In-Person Assistance Program (IPA)
– Operated by AEE
– Hires Assisters to provide one-on-one assistance
– AEE paid $58 per enrollment
• Navigator Program
– Operated by AEE
– Hires Navigators
– Awarded grants for outreach, education and
enrollment assistance one-on-one to consumers

20. Goal 3: Protect health Insurance
Consumers
• Objectives:
1. Enforce new health insurance coverage rules
– Today, CA limits use of pre-existing conditions
limits, and requires annual policy renewal
– January 2014: All ACA provisions apply
2. Ensure health insurance premium value
3. Limit impact adverse risk on rate payers

21. 1. Enforce new health insurance coverage rules
• Grandfathered 2010 plans by individuals and
small businesses exempt from ACA
• CA established Pre-Existing Condition Plan
Managed Risk Medical Insurance Board
(MRMIB) in 2010
• Will transition MRMIB into Exchange or
Private Market Jan. 1, 2014
• Small group reform enacted 2012
• Individual plan reform pending legislation

22. 2. Ensure health insurance premium value
1. Establish minimum set of “essential health
benefits” (EHB) for individual and small
employer coverage
2. State Review of proposed premium increases
3. Medical Loss Ratio: health plans spend a
minimum percentage of 80-85% of premium
on care
– Statutory authority enacted 2012

23. Essential Health Benefits (EHB) (7)
• Benchmark plan established in 2012
(patterned after Kaiser Small Group HMO
• Includes mental health/substance abuse
• Includes Pediatric Dental/Vision supplemental
• Currently plans covered by Dept. of Managed
Care must cover EHB, but not Dept. of
Insurance plans
• Jan 1, 2014: Plans in and outside Exchange
must cover EHB

24. 2. State Review of proposed premium increases (8)
• Implemented 2011, CA Depts of Managed Health Care
and Insurance
• Department of Managed Health Care posting rate
information, including findings of an unreasonable rate
increase, on the Department’s public website.
• Department of Insurance posting public access to rate
filings.
• Since January 1, 2011, the Department of Insurance
rate review process resulted in some rate reductions
and adjustments estimated to save policyholders a
total of at least $40 million.

25. 3. Medical Loss Ratio
• 2012
– “Anthem Blue Cross, Blue Shield of California and
Kaiser Permanente distribute more than $50
million in rebates across some 1 million California
customers.”
– June 2, 2012, Los Angeles Times (9)

26. 3. Limit impact adverse risk on rate
payers
1. Traditional Reinsurance
2. Risk Adjustment
3. Risk Corridors
Legislation to establish a state program failed in
2012 and the federal government will
administer this program

27. Goal 4: Create a New Marketplace for
Private Health Insurance
1. Operate the Exchange
– CA obtained conditional certification for
“Covered CA” Jan. 2013 and full certification by
Oct. 2013
2. Offer coverage through qualified health plans
– 11/2012 RFPs for platinum, gold, silver, bronze
and catastrophic benefit plans
– 6/2013 Contracting with selected insurers
– 10/1/2013 enrollment Oct. 2013

29. Accountable Care Organizations (ACO) (12)
Experiment or Experience?
• ACO goal: improve care and reduce costs
• Method: Collaboration among provider
groups, hospitals, and others— in an
environment of aligned financial incentives —
to improve coordination, care delivery, and
efficiency
• Providers and ACOs share in savings resulting
from coordinated care
• Serves as “insurer and provider”

30. ACO Characteristics
• Choice of providers, often the same existing
providers
• Can work within existing health plans
including Medicare, Aetna, etc.
• Coordinated care from prevention to acute
and post acute
• Information Technology System that reports
frequently on healthcare utilization
• Shared savings

31. Accountable Care Organizations (11)
• Medicare Shared Savings Program (MSSP) ACOs are
designated to coordinate care for Medicare fee-for-
service beneficiaries.
• Medicare Advanced Payment Model* is a special
version of the MSSP ACO model to support
infrastructure development.
• Medicare Pioneer ACOs* were among the first
Medicare-designated ACOs and take on more risk than
the MSSP model.
• Look-Alike ACOs contract with commercial health plans
to coordinate care in a similar model to those above.

32. San Diego ACOs (13)
• North Coast Medical ACO (MSSP) Medicare ACO-
Shared Savings Program
• San Diego Independent ACO (MSSP) Medicare ACO-
Shared Savings Program
• Sharp HealthCare (Aetna) Look-alike ACO-Contract
w/Health Plan For Non-State
• Sponsored Program
• Sharp Healthcare (Blue Flex) Look-alike ACO-Contract
w/Health Plan For Non-State
• Sponsored Program
• Sharp HealthCare ACO (Pioneer) Medicare ACO-
Pioneer

33. San Diego ACOs Summary (13)
• Total ACOs Operating in the County 5
• Total Individual ACO Hospital Partners in the
County 9
• Number of PCPs Involved in the ACOs 1,284
• Number of Specialists Involved in the ACOs 2,792
• Total Individual Medical Groups/Clinics Utilized in
the County by the ACOs 48
• Estimated Lives to Be Served within the Specific
ACO Activity 68,000

34. Care Coordination (14)
What is it? Wrap around?
• Medical
– Medication management
– Utilization review/data analysis
– Emergency room management
– Follow up for specialized care
• Social
– Consumer empowerment
– Psychosocial assessment
– Person in Environment approach
– Social and behavioral health services
– Cultural humility, advocacy

35. Texas Promotor(a) (17)
• Communication skills
• Interpersonal skills
• Service Coordination skills
• Capacity-building skills
• Advocacy skills
• Teaching skills
• Organizational skills
• Knowledge base on specific health issues

36. Community Health Workers
Workforce Innovations (17)
Grand-Aides®
• CNA/CMA Training
• Primary care and chronic
care
• Home visits
• Telemedicine
• Medication Management
• Social issues
Texas Promotor(a)
• Communication skills
• Interpersonal skills
• Service Coordination skills
• Capacity-building skills
• Advocacy skills
• Teaching skills
• Organizational skills
• Knowledge base on specific
health issues

37. CA Workforce Investment Board
Health Workforce Development Council (18)
“Standardize, strengthen and expand curricula
and training programs to increase access and
consistent competencies for Community Health
Workers/Promotores, Medical Assistants, Social
Workers, Nurses, Direct Care Workers and other
workers.”

41. Enrollment by Plan
369
332
13 0.976
238
210
32 10.6 10.4 1.6 3.2
000s
Total

42. Medicare Shared Savings Program (MSSP)
Accountable Care Clinical Services (Orange)
Accountable Care Clinical Services/Preferred ACO
Affiliated Physicians Medical Group ACO
Akira Health
APCN-ACO
ApolloMed ACO
Applecare Medical Group
Cedars-Sinai Accountable Care
John Muir Physician Network
Meridian Holdings
Meritage ACO
North Coast Medical ACO
Premier ACO Physicians Network
San Diego Independent ACO
Torrance Memorial Integrated Physicians
UCLA ACO
Medicare Advanced Payment Model
Golden Life Healthcare
National ACO
Medicare Pioneer
Brown & Toland Physicians
HealthCare Partners ACO
Heritage California ACO
Monarch HealthCare
Sharp HealthCare
Look Alike ACOs
Access Medical Group/St. John's Health
Center/NantWorks
AllCare IPA/Doctors Medical Center
Brown & Toland Physicians
Brown & Toland Physicians/California Pacific Medical
Center
Greater Newport Physicians/Hoag Hospital
HealthCare Partners Associates Medical Group
Hill Physicians/Dignity Health - Sacramento
Hill Physicians/Dignity Health - County Employees
Hill Physicians/Dignity Health - UC Employees
John Muir Health
Palo Alto Medical Foundation
Physicians Medical Group of Santa Cruz/Dominican
Hospital
Primecare Medical Network
Santa Clara County IPA
Sharp HealthCare
St. Joseph Health
Appendix: California ACOs

43. References
1. http://www.chcf.org/tracking-aca/goal-1/objective-1
2. http://www.slate.com/articles/news_and_politics/map_of_the_week/2013/02/map_illegal_imm
igrant_population_by_state.html
3. http://www.californiahealthline.org/articles/2012/10/24/california-considers-strategies-for-
treating-uninsured-immigrants.aspx
4. http://www.dhcs.ca.gov/provgovpart/Documents/LIHP/LIHP%20Fact%20Sheet.pdf
5. http://www.healthexchange.ca.gov/BoardMeetings/Documents/February26_2013/VI._BRB_Brid
ge_Plan_(Update).pdf
6. http://www.healthexchange.ca.gov/StakeHolders/Documents/Assisters%20Program%20Stakehol
ders%20Webinar%20Draft%20Regs-FINALSlide%20Deck05032013.pdf
7. http://kff.org/health-reform/state-indicator/ehb-benchmark-plans/
8. http://cciio.cms.gov/Archive/Grants/rate-review-grants.html
9. http://articles.latimes.com/2012/jun/02/business/la-fi-insure-rebates-20120602
10. http://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/C/PDF%20CINwebinar04242013
HeritageACO.pdf
11. http://www.chcf.org/publications/2012/08/aco-map
12. http://www.chcf.org/events/2013/cin-webinar-04-24-2013
13. http://www.cattaneostroud.com/med_group_reports/ACO_Reports/ACO_Report2.pdf
14. http://www.socialworkreinvestment.org/2011/remarks/Golden%20testimony_02%2016%2011.p
df
15. www.cswe.org/File.aspx?id=62718
16. http://www.socialworkers.org/assets/secured/documents/practice/health/ACOs%20Opportuniti
es%20for%20SWers.pdf
17. http://www.dshs.state.tx.us/mch/chw.shtm
18. http://www.cwib.ca.gov/res/docs/special_committees/hwdc/meeting_materials/2013/HWDC%2
0Report%20-%20Draft%20012113.pdf

44. References
• http://www.californiahealthline.org/road-to-reform/2013/immigrant-
health-care-many-not-eligible-for-medicaid-expansion
• http://www.americanthinker.com/blog/2014/02/report_125000_illegals_i
n_california_qualified_to_be_covered_by_medicaid.html
• http://obamacarefacts.com/obamacare-preventive-care.php
• http://news.coveredca.com/