Affordable Care Act of 2010 and Young Adults
For millions of Americans, the Affordable Care Act is a very timely and long-awaited action by our legislature. The group that is, perhaps, the most greatly affected is young adults between the ages of 19 and 26. Estimates by the U.S. Department of Health and Human Services are that 2.37 million will be impacted by this new reform, nearly two million of which are not currently insured.
Although just 17 percent of our overall population is made up of this segmented age group, they represent 30 percent of the total 46 million citizens under the age of 65 who are currently uninsured. One of the obvious reasons for this lopsided statistic is that the unemployment rate for the age group 20-24 has risen over the past year to approximately 17.2 percent. The other major contributor is that young adults are most frequently in employment situations where they are not afforded access to employer-based insurance, i.e. part-time jobs, entry-level jobs or jobs in small businesses.
Although many insurance plans made provisions to institute the new changes early in order to accommodate graduating students and avoid lapses in coverage between graduation and the Act’s September 23 effective date, if a plan did not offer that option, things are now in full swing.
To clarify, the definition of a “child” covered under this provision is:
“…an individual who is a son, daughter, stepson, or stepdaughter of the employee, and a child include both a legally-adopted individual of the employee and an individual who is lawfully placed with the employee for legal adoption by the employee. The term also includes an “eligible foster child” who has been placed with the employee by an authorized placement agency or by judgment, decree, or other order of any court.”
The Act requires coverage be offered for these adult children even if they no longer live with the parent, are not dependents on the parents’ tax returns or are not students. The adult children can be married or unmarried. If married, the coverage requirements do not extend to the spouses or children of the adult child.
Currently, the Affordable Care Act requires that an adult child take health insurance that is offered on his or her job instead of staying on a parent’s plan. However, effective in 2014, it is the option of the adult child to stay on a parent’s plan until age 26, even if offered health insurance through a job.
A couple of other provisions of the Act are that self-insured health plans must also adhere to these requirements; and if a plan does not currently offer dependent coverage, it is not a stipulation that it do so.
In explanation of how enrollment should be handled, the following is taken from the White House Fact Sheet regarding this Act provision:
All Eligible Young Adults Will Have A Special Enrollment Opportunity
For plan or policy years beginning on or after September 23, 2010, plans and issuers must give children who qualify an opportunity to enroll that continues for at least 30 days regardless of whether the plan or coverage offers an open enrollment period. This enrollment opportunity and a written notice must be provided not later than the first day of the first plan or policy year beginning on or after September 23, 2010. The new policy does not otherwise change the enrollment period or start of the plan or policy year.
Another important point in the Act provision detailed in the fact sheet is:
The value of the employer-provided health coverage is excluded from the employee’s income for the entire taxable year in which the child turns 26. Thus, if a child turns 26 in March but stays on the plan through December 31st (the end of most people’s taxable year), all health benefits provided that year are excluded for income tax purposes.
If you have other questions regarding this new Act and how it applies to adult children up to age 26, there is great information at these links:
United States Department of Labor FAQs
National Conference of State Legislatures Table of State Laws
The Commonwealth Fund’s Brief – Rites of Passage: Young Adults and the Affordable Care Act of 2010
Case Management and the Patient Protection and Affordable Care Act
Patient Protection and Affordable Care Act…the title of the health care reform act that has been passed sounds a lot like the goals towards which case managers work every day. The Case Management Model Act of 2009 makes it clear that part of a case manager’s responsibility is to “promote optimal Consumer [patient] safety”, along with being aware of and enlisting resources or programs that can better help the patient, in turn helping costs stay down.
There is a lot of excitement within the case management arena in regards to the future of case management as an elevated career path for nurses and others looking for health care positions, as well as its future as an integral part of the success of health care reform. In an interview regarding the future of case management and its relation to the Patient Protection and Affordable Care Act, Jo Carter, Chair of the Commission for Case Manager Certification, stated…
“…what we see in the Act is that we’ll be utilizing case managers in more and more settings”.
She also commented,
“…When the programs are expanded under the bill, they’re going to be utilizing case management as a central component of the way they operate.”
When asked about the language within the Patient Protection and Affordable Care Act that was specific to case management, Ms. Carter answered…
“There are various provisions of the Act that refer to care coordination and case management. There are things that are specific parts of the Act, like the establishment of outcomes-based measures, that don’t mention care coordination and case management specifically but how those will get carried out through care coordination and case management”.
An area of care that is a cornerstone of case management is transition of care. The National Transitions of Care Coalition (in which the Case Management Society of America is a major player) helped to bring much needed attention to this function, as did the CMSA and the Case Management Model Act of 2009. Care coordination and transition of care outcomes will undoubtedly play a vital part in health care reform, which is where the skills and expertise of case managers can have a major impact.
Obviously, case management can greatly affect patient care and safety through its role in care coordination and transitions of care; but this new health reform act is also concerned with affordable care, so making sure patient care is also fiscally responsible is also its focus.
Carol A. Gleason, chair of CMSA’s Public Policy Committee, expressed her thoughts on the subject:
“Because case management promotes cost-effectiveness, it is essential to the success of reform. Case managers know how to maximize services for patients and make sure they are getting everything they are entitled to, based on their insurance coverage, and are transitioning successfully to the next level of care. This is key to reform.”
Case Management and the Patient Protection and Affordable Care Act seem to go hand in hand in their focus on what takes priority in health care and the outlook on how each will impact the other looks very positive.
Case Managers impacting patient adherence to medications
It’s a little hard to imagine, but it’s been reported that approximately half of patients don’t adhere to the drug regimen prescribed by their doctors, especially, it seems, if the patient is suffering from a chronic condition. The multiple reasons behind non-adherence run the gamut from lifestyle, health literacy (which we discussed last week), length of time required to take the medication, as well as cost and side effects. One study researched showed even those who don’t have any out-of-pocket costs for their medications had a non-adherence rate of almost 40%.
In a report published in the New England Journal of Medicine from April of this year, adherence to medication requirements was cited as a very important aspect of healthcare reform. Hospital admissions that could be pointed to as having been a result of medicines not being taken properly account for between 33 and 69% of the total, amounting to over $100 billion spent on this segment of healthcare. This is obviously a concern not only for the patients, but for their insurance carriers, as well.
This is where the services of a case manager can be of huge benefit. An important role of the case manager is being the “point person” for patients who need support and guidance that continues after they are released from the hospital and/or are given new, possibly different medications. Case managers have the training and experience that is vital in helping to improve adherence to a drug regimen.
Case managers also have another advantage that physicians and office staff do not have, and that is the fact that they are able to follow through with patients in their homes and work with them on the importance of adherence to their medication schedule, especially when they are suffering from chronic conditions. Once a patient is home, it is much easier for all those extenuating circumstances to take over, contributing to the non-adherence problem.
There are some great “models” out there in the community that are, hopefully, paving the way for improvements in the current “system”. One such example is Community Care of North Carolina, which serves patients on Medicaid, as well as those who are uninsured. Its “Pharmacy Home Project” pays the network doctors a fee each month to coordinate care through the use of case managers and clinical pharmacists who work for them on a rotating basis. With this project, CCNC has been able to increase its adherence numbers by rates of 5 to 7%.
Another excellent example of the use of case managers in helping with the issue of adherence is the Group Health Cooperative. Within its system, case managers help to determine whether or not patients are “managing their medical conditions”, which includes following up on whether they are adhering to their medication regimens. The role of the case managers for Group Health Cooperative follows the traditional routines, as well, including educating patients and assisting them in finding resources for more reasonably priced care options and medications. Savings of approximately $476 annually per patient has been seen by implementing this program.
Obviously, the issue of patient adherence to medications, including how case managers can help, is well worth considering when assessing healthcare costs and how to positively impact them without taking away from the quality of care for patients.
Case Management’s Role in Health Literacy
It won’t be long before health care reform begins to take effect and the ranks of the newly insured swell by tens of millions of people. Although this is potentially very good news for Americans who currently don’t have health insurance, it could spell financial disaster for health care providers, health care insurers, and employers, as well. It could turn into a very costly proposition for not only the state of Missouri, but the nation, as a whole, if the issue of health literacy isn’t addressed in a timely and effective manner. Some estimate that health literacy costs our country over $100 billion a year!
Even the smartest among us often have trouble understanding how to take their latest prescription or interpret insurance forms. In a recent St. Louis Business Journal article, author, Arthur Culbert, noted that
“…more than 90 million people in the United States have difficulty understanding and effectively using health information…”.
Health literacy encompasses not only how well an adult can navigate the healthcare system, but also how well he or she understands a doctor’s instructions and what constitutes better choices for preventive care. This trickles down to young adults (teens), as well, as they often take care of themselves when it comes to taking medicines or healthy lifestyle choices.
Along with organizations, such as Health Literacy Missouri (helping to rewrite patient materials), case managers can be of huge benefit to insurers and insured alike. Case managers can be the bridge to patients with health literacy issues. By helping them to navigate the maze that comprises our national healthcare system, case managers can, figuratively speaking, put a finger in the dike holding back billions of healthcare dollars from being wasted.
According to an example cited in the Business Journal article, a one percent decrease in calls to United Health Group’s service centers would save them approximately $24 million. Case managers can help divert patients from calling on overworked customer service and HR departments by transitioning patients from one level of care to another, advocating for patients to be sure they are taking advantage of the best resources for their disease or health condition and by insuring they take medications correctly.
Case managers not only make a difference for the patients, but also for the bottom lines of the companies insuring, employing and providing care for them. They can be an integral part of minimizing the difficulties and expense posed by health literacy in our country.
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Health Management Connect
(formerly Primary Pediatric Management Inc.)
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