by Robert David Zehring, MD
HUERFANO — The Patient Protection and Affordable Care Act (PPACA), more commonly referred to as ObamaCare, moves closer to full implementation this year. Six months ago, I was asked to write an article for the World Journal outlining the basic features of the legislation, with some attention paid to the specifics as they pertain to the citizens of Colorado and Huerfano County. With the re-election of President Obama, it appears unlikely the legislation will be overturned, and it is therefore time to outline what specifics of the PPACA will be implemented in 2013, and what will follow in 2014 as the full impact of the legislation is felt.
The focus for 2013 will be on preventive care and primary care services. For those citizens who currently have health insurance through their employer or have individual coverage, a comprehensive list of preventive care services must be provided. Those services include, in part, screening for breast, colon, rectal and cervical cancer, high blood pressure, high cholesterol, and type 2 diabetes, immunizations for hepatitis, HPV, the flu and pneumococcal pneumonia. Tobacco and alcohol cessation and obesity counseling will be available, and for children, developmental and behavioral assessment is provided. All of these services and more must be provided by all insurance plans in effect as of August 1, 2012. Some services may require small co-pays or small deductibles. If the plan uses a network of providers, only those providers in the network are required to offer these services at little or no additional cost. Most of these services are available to Medicaid recipients at no cost.
The Children’s Health Insurance Plan (CHIP) will be extended through 2014, to include all children from birth through age 18. Eligibility is provided to families earning up to $45,000 annually. It provides care for pregnant mothers through 60 days after delivery, includes well-child visits at no cost, immunizations, dental and vision care, as well as hospital, laboratory and x-ray services, and may require a small premium that cannot exceed 5% of family income.
Acknowledging that by most estimates, there will likely be a shortage of primary care providers of 21,000 by 2015, the PPACA requires that in 2013 and 2014, primary care services for all Medicaid recipients must be reimbursed at 100 percent of comparable services provided to Medicare recipients. This increase will hopefully sustain many primary care provider offices and clinics that otherwise might close due to insufficient operating funds. In addition, PPACA and TARP funds have been provided to underwrite the training of physicians, nurse-practitioners and physician assistants in primary care.
Medicaid eligibility will be at $14,000 annual income for intervals and $29,000 for a family of four. The federal government will fund 100 percent of Medicaid costs for the first three years, and 90 percent thereafter.
The health insurance exchanges that are part of the so-called Individual Mandate provision of the PPACA will begin open enrollment in October of this year, for coverage beginning on January 1, 2014. There will be no pre-existing condition exclusion and no gender-based pricing. Sliding scale premium subsidies will be available for families of four below $92,000 of annual income and individuals below $43,000 of annual income. Small business tax credits for up to 50 percent of premium costs for employees will be available as well.
Regarding the long term disabled, it does not appear that any benefits will be curtailed or adversely modified. Medicare supplement policies are not part of the PPACA program, and premiums will continue to increase. Pre-existing condition exclusion will be prohibited, however.
For Spanish Peaks Regional Healthcare Center (SPRHC), the increase in Medicaid reimbursement for primary care services will be welcome, since at present, providing that care incurs costs significantly greater than current payment received. On the disadvantage side, the Medicare and Medicaid Disproportionate Share Payment for hospital services will be substantially reduced for facilities like SPRHC that provide a significant amount of indigent care.
This year appears to be a year of transition, with expansion of services and enhancement of Medicaid reimbursement being the significant changes. The Individual Mandate, beginning the enrollment process in October and becoming operational next January, will be by far the biggest test of the feasibly and operation of the PPACA. At present, we don’t know the details of the insurance products to be offered to the citizens of Colorado, or how expensive the premiums will be. Once that information is available, employers, employees and individuals will have to make choices as to the scope and cost of their coverage. More on that at a later date.
It is important to note that there will probably be efforts by Congress to modify some of the features of the PPACA coming due in 2014. The insurance industry wants the penalties for failure to purchase coverage through the exchanges to be much heavier than the current legislation calls for. Some existing benefits could be modified or even curtailed, in the name of deficit reduction. For these reasons, it will be necessary to revisit the Individual Mandate and the insurance exchange program in the fall of this year, when the final program details seem cleared.