The document provides an overview of the Affordable Care Act and its impact on hospitals in Kansas. It discusses the expansion of Medicaid, health insurance marketplaces, and insurance reforms taking effect in 2014. These include prohibiting denial of coverage for pre-existing conditions, limiting premium variation based on health status and gender, and guaranteeing availability and renewability of plans. It also outlines the essential health benefits that must be covered and different metal tiers of coverage based on actuarial value. Kansas will utilize a federally-facilitated marketplace while some insurers have committed to offering plans within it. The exchanges aim to increase access, choice, and affordability of insurance plans.

1. September 12, 2013
THE AFFORDABLE CARE ACT:
IMPACT ON HOSPITALS IN KANSAS

2. Agenda and Introductions
Discussion Topic Presenter
Ascension Health’s Role
in this Work
Overview of ACA Coverage
Options
Mary Ella Payne
Senior Vice President
Policy & Legislative Leadership
Ascension Health
Health Insurance Marketplaces,
Insurance Reforms and More
Beth C. Fuchs, Ph.D.
Principal
Health Policy Alternatives, Inc.

3. Our Mission
Rooted in the loving ministry of Jesus as healer, we
commit ourselves to serving all persons with special
attention to those who are poor and vulnerable.
Our Catholic health ministry is dedicated to spiritually
centered, holistic care which sustains and improves the
health of individuals and communities.
We are advocates for a compassionate and just society
through our actions and our words.

4. Health
Ministry
Ascension
Participating Entities
appoint members of
Ascension Health Ministries
“Ascension Health Ministries”
(PJP composed of up to 12 individuals)
Founding Participating Entities
Participating
Entities
Sponsor
System
Parent
Health
Ministries
Approved by Rome
June 30, 2011
Oak Hill
Capital Partners
Ascension
Health
Ventures
Ascension Health
Care Network
Management
Agreement
Leadership
Academy
Ascension
Health
Solutions
Ascension
Health
Services
Ascension
Health
(Delivery)
Health
Ministry
Health
Ministry
Affiliate
Organizations
Appoint
Participating Entities
Infrastructure
Support
Congregation
of St. Joseph
Sisters of St. Joseph
of Carondelet
Daughters of Charity
Province of St. Louise
Alexian
Brothers
Sisters of the
Sorrowful
Mother

5. Ascension Health, part of Ascension, is the largest Catholic and nonprofit
health system, and the third largest system (based on revenues) in the
United States, operating in 23 states and the District of Columbia.
Our Delivery System
Daughters of
Charity Health
System is
an affiliate of
Ascension Health

6. Ascension Health’s Major Healthcare Delivery Platforms
Ambulatory Care and Diagnostics
Ambulatory Surgery Centers 70
Employer/Occ Health 44
Free-standing Imaging 83
Retail Lab Collection Sites 256
Primary Care Clinics 491
Specialty Clinics 260
Retail Pharmacies 35
Sleep Centers 28
Telemedicine Programs 59
Inpatient Facilities
General Acute Care 100
Long-term Acute
Care
3
Rehabilitation 3
Psychiatric 7
Total 113
Prevention & Wellness Programs
Alternative Care 13
Community/Social Services 120
Wellness/Fitness 20
Post Acute Service Sites
Behavioral Health – Acute units 31
Behavioral Health – Outpatient 76
Cancer Centers 20
Durable Medical Equipment 23
Home Health Agencies 26
Hospice/Palliative Programs 35
Infusion Therapy Programs 23
Private Duty Services 4
Rehabilitation – Outpatient 226
Rehabilitation – Inpatient units 35
Updated May 2013
Long-term Care & Senior Living Sites –
38 communities comprised of the
following:
Adult Day Care 11
Assisted Living (AL) 7
Independent Living (IL) 3
Skilled Nursing (SNF) 21
CCRC (combined SNF/AL/IL) 9
PACE 3

7. FY12 Systemwide Statistics*
Discharges 693,544
Available beds 18,450
Number of births 72,121
Total surgical visits 529,341
Home health visits 534,232
Clinic visits 1,877,970
Emergency visits 2,454,455
Physician office visits 6,974,451
Total outpatient visits 20,155,034
Associates 122,000
* FY12 Statistics do not include Ministry Health Care, St. John Health System, or Via Christi Health

8. Strategic Direction:
‘Architecture’ for Realizing our Vision
Vital Presence
Healthcare That Leaves No
One Behind
Inspired People
Trusted Partnerships
Empowering Knowledge
Healthcare That Is Safe
Healthcare That Works
Our outward
promise to those
we serve
Enabled by focused
inner strengths

9. Provider-Centered:
transactional model
Person-Centered:
relationship model
Focus  Providers’ delivery of medical
services to patients to address a
healthcare episode
 Trust-based relationship that promotes a
spiritually centered, holistic approach to
supporting a person’s health and well-being
Locus of
Control
 Primarily providers  Primarily the person and family supported by a
trusted ecology of resources
Nature of
Choices
 Healthcare choices are mostly
reactive
 Health choices are well-understood and frequently
proactive
Primary
Locations
 Hospitals and clinics  More care and support in the community, in the
home and by virtual means
Health
Information
 Provider-based, episodic,
transactional
 Coordinated, transparent data managed by well-
informed individuals
Duration  Episode of care  Lifetime relationships
Transformational Path to Realizing our Vision
Person-
Centered
Approach
Fostering
Continuous,
Dynamic
Relationships
With Those
We Serve
Moving from Provider-Centered
to Person-Centered

10. Our Guiding Features of a Reformed Healthcare Policy
Ensure 100% Access
to Healthcare Services
Achieve Destination of 100% Coverage
Reform Insurance Rules; Shared Obligation
and Responsibility for Coverage
Make Health Insurance
Affordable and Equitable
Eliminate Coverage and Service Gaps,
Particularly for the Vulnerable
Ensure Economic Viability Through Shared
Financial Responsibility
Improved Health for Our Community
We are committed to redesigning the healthcare
delivery system and partnering with policymakers
to achieve 100% access and 100% coverage.

11. An Overview of the
Coverage Continuum
in the Affordable Care Act

12. Healthcare Reform: What Is It?
Healthcare Reform
Quality &
Delivery
System
Reforms
Insurance
Coverage
Expansion
Health
Insurance
Reforms
Patient Protection and
Affordable Care Act (ACA)
signed on March 23, 2010
Constitutionality Affirmed by
Supreme Court on June 28, 2012.
The healthcare reform law makes
sweeping changes to our nation’s
healthcare system with a vision to
provide health coverage to all
Americans and promote more
efficient care delivery.
12

13. 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019
Coverage: Medicaid expansion, major insurance reforms (e.g., guaranteed
issue, rating rules, no pre-ex for adults) insurance exchanges, premium /
cost sharing subsidies, individual / employer responsibility requirements
Medicare Savings: MA payment reductions, productivity offset to FFS updates
Medicare/Medicaid Savings: DSH reductions, IPAB Medicare proposal
Coverage: Small business premium tax credit
Immediate Insurance reforms: high risk pool, dependent coverage to age 26, no pre-ex for kids, loss ratios/ rate review
Delivery System Reform: Center for Medicare and Medicaid Innovation
Delivery System Reform: ACOs, hospital value-based purchasing
Delivery System Reform: Hospital readmissions, payment bundling
Delivery System Reform: Physician quality reporting penalties
New Revenue: Tax on prescription drug manufacturers
New Revenue: Excise tax on medical device makers, Medicare tax on high earners
New Revenue: Tax on health insurers
New Revenue: Tax on
high-cost health plans
Medicare/Medicaid Savings: Medicare provider updates, Medicaid prescription drug rebates
Timeline of Key Health Reform Provisions
Passed March 23, 2010

14. 14
Current Sources of Coverage for
Non-Elderly in U.S. and Kansas (2011-2012)
Kansas U.S.
Employer-Sponsored 60% 56%
Individual Insurance 6% 6%
Medicaid 14% 18%
Other public 4% 3%
Uninsured 15% 18%
Total 100% 100%
Close to 365,000 Kansans are currently uninsured
Sources: Kaiser Family Foundation, http://kff.org/other/state-indicator/nonelderly-0-64/; Kansas Health Institute,
Insurance Exchange Will Provide Many Kansas Consumer With New Options, January 2013,
http://media.khi.org/news/documents/2013/01/07/HR_Exchange.pdf

15. 15
Health Coverage Options for Individuals in 2014
Source: CCIIO, Insuring America, Presentation, NIHCM Webinar, May 7, 2013
133% FPL for family of 3 -- $25,975
400% FPL for family of 3 -- $78,120
Sliding
Scale

16. Supreme Court Decision and Medicaid Expansion
Coverage Expansion Becomes
Voluntary for States
 States can choose not to expand
Medicaid to cover all state
residents under 133% FPL, without
risking federal funding for their
entire Medicaid program.
 HOWEVER, the balance of
Medicaid provisions still stand,
including cuts in funding that
support hospitals that provide
higher levels of care to uninsured
individuals and uncompensated
care.
June 2012 U.S. Supreme Court Decision

17. 17
Kaiser Family Foundation, Status of State Action on the Medicaid Expansion Decision, as of September 3, 2013,
www.statehealthfacts.org
Medicaid Expansion Decision as of
September 3, 2013

18. Source: Kaiser State Health Facts, January 2013
Kansas Medicaid Eligibility and
Eligibility for Tax Subsidies for Private Insurance
Currently Eligible for Medicaid in KS
Eligible for Subsides in the Insurance
Marketplaces (100% – 400% FPL)
31%
25%
No coverage
options for
88,000.
100% FPL
400% FPL
Children Pregnant
Women
Working
Parents
Jobless
Parents
Childless
Adults
150%
133% FPL
100%
150% FPLBy age
0-1 150%
1-5 133%
6-9 100%

19. Income Level
Upper Income
Limit for Family
of Three
Premium as
Percent of
Income
Cost/Month
at High End
Up to 133% FPL $25,975 2% $43
133-150% FPL $29,295 3-4% $98
150-200% FPL $39,060 4-6.3% $158
200-250% FPL $48,825 6.3-8.05% $327
250-300% FPL $55,590 8.05-9.5% $440
300-400% FPL $78,120 9.5% $618
Premium Tax Credits
Individual Premium Tax Credits/
Cost Sharing Reductions
Source: Kaiser Family Foundation, July 2012
Cost-sharing reductions also are available
for individuals <250% FPL.

20. Insurance Reforms
and
Health Insurance
Marketplaces

21. 21
ACA Insurance Reforms Now in Place
 No lifetime limits; limits on use of annual dollar
limits on benefits
 Insurance companies cannot renege on promised
coverage
 No pre-existing conditions exclusions for children
under 19
 Children up to age 26 can be covered a parent’s
plan
 Patient cost sharing eliminated for recommended
preventive services

22. 22
More ACA Insurance Reforms Now In Place
• Medical Loss Ratio
o 80% of insurance premiums must be spent on healthcare
delivery 85% for large insured group plans)
o Insurers must rebate excess premiums
• Enhanced rate (premium) review by state
regulators
• Uniform explanation of coverage documents;
standardized definitions

23. Regulatory Environment for Exchanges in 2014
23
Fair Health Insurance
Premiums
Health status and gender not
used to set premiums; limit on
age rating
Single Risk Pool
Issuers cannot use separate
risk pools to charge certain
customers higher rates
Guaranteed Availability
Coverage must be offered to
all comers, with limited
exceptions, during enrollment
or special enrollment periods
Guaranteed Renewability
Coverage must be renewed for
all policyholders, with limited
exceptions
Adapted from CMS, Health Insurance Market Rules, Rate Review, 2012
These rules apply to insurance sold in and outside of Exchange

24. Under Current Rules, Small Group Rating Rules:
Premiums Vary Significantly
24Source: National Association of Insurance Commissioners and the Center for Insurance Policy and Research
http://www.naic.org/documents/topics_health_insurance_rate_regulation_brief.pdf

25. 25
Insurance Reforms as of 2014
• Insurers have to charge small firms in same area for
identical coverage more similar premiums regardless
of health status of their employees.
• Within area premiums can only vary for family size, age,
tobacco use
• No one can be turned down or cancelled because of
health status, pre-existing condition or use of
healthcare.
• No pre-existing condition exclusions
• Apply at annual and special enrollment periods

26. Insurance Reforms in Kansas as of 2014
For Kansas small businesses--
• Age adjusted community rating (3:1 limits on age
variation)
• No 90-day, pre-existing condition waiting periods for
timely enrollment
• Insurers must offer Essential Health Benefits
Comparable to largest small business policy in the state
May be more comprehensive than current policy
26

27. 27
Essential Health Benefits (EHB)
• States selected among certain existing option(s) for
their EHB benchmark plan. Default is largest small
group policy in the state
• Kansas: BCBS Comprehensive Major Medical-Blue Choice
Blue Shield of Kansas Comprehensive Plan
• EHBs must cover 10 categories of required services:
Ambulatory care, emergency services, hospitalization,
maternity/newborn care, mental health and substance use disorder
services, including behavioral health treatment, prescription drugs,
rehabilitative and habilitative services and devices, laboratory services,
preventive and wellness services and chronic disease management

28. 28
Actuarial Value (AV) and Cost Sharing
• Plans offering EHBs have to meet certain
cost-sharing standards:
Limits on maximum out-of-pocket (MOOP) costs for EHBs:
$6,350 for an individual, $12,700 for a family for 2014
• Plans have to meet certain AV levels (the so-
called “metals” levels)
– Bronze: 60% AV
– Silver: 70% AV
– Gold: 80% AV
– Platinum: 90% AV
• The cost-sharing is reduced on sliding scale
basis under affordability programs

29. Marketplaces will:
Provide one-stop-shopping for individuals and small businesses seeking
healthcare insurance coverage in transparent, competitive marketplaces.
Provide consumer friendly online tools comparing premium rates
and benefit packages for health insurance coverage options that
meet minimum standards.
Allow individuals to apply for insurance subsidies online, in person,
by mail or by telephone.
Bottom line, make it easier to shop for and enroll in health
insurance
Administered by states, the federal government, or a partnership between the two.
What is a Health Insurance Marketplace?

30. 30
Why Marketplaces (Exchanges)?
• Premiums are reduced by pooling small-business
buying power, structure of competition, and
economies of scale
• More choice of insurance options for small
employers and their employees
• Comparing and making choices among insurance
options is easier
• Ultimate goal: drive innovation and improvements
in affordability, quality and customer service

31. 31
Status of the States’ Exchange Decisions for 2014
State-based Exchange:
16 states + DC have
declared
Partnership Exchange:
Seven states are planning
for a Partnership Exchange
Federally-Facilitated
Exchange:
26 states currently default
to the Federally-Facilitated
Exchange
Kaiser Family Foundation, Statehealthfacts.org;
http://kff.org/health-reform/state-indicator/health-insurance-exchanges/#

32. Which Insurers in Kansas will be Selling through the
Individual Exchange?
As of late August
• Blue Cross and Blue Shield of Kansas
• Blue Cross of Kansas City
Also Multistate Plan Program option in same 103 counties
• Coventry Life and Health, and Coventry Health Care of
Kansas
PPO and an HMO
Source: Wichita Eagle, How will the Affordable Care Act Work? August 28, 2013,
www.kansas.com/2013/08/28/2969649/how-will-the-affordable-care-act.html
32

33. Healthcare.gov Revamped
text

34. Federally Facilitated SHOP– www.Healthcare.gov
34

35. InsureKS.org
35
Sponsored by Kansas Department of Insurance

36. 36
• Many key design decisions left to states; therefore what
exchanges do and how well they do it will vary by state
• Exchanges must compete with insurance offered in the
outside market, so will need to offer plans that are cost
competitive and high quality
• Exchanges need to maximize participation to gain scale,
avoid adverse selection
Will Exchanges Succeed?

37. Exchanges Projected to Start at Seven Million
and Reach About 25 Million
Exchange enrollment
estimated to be about
seven million in 2014,
increasing to about
22 million by 2016 and 25
million in 2018.
More than 80 percent of
enrollees estimated to be
eligible for sliding-scale
tax-credits.
About three million
estimated to be in small
business (SHOP)
Exchange.
37
Source: Congressional Budget Office. May 2013 Baseline

38. Exchanges: Overall Timeline
38
2013
October 1 Open-enrollment begins
December 15 Deadline for QHP selection in order to qualify for
January 1, 2014 coverage effective date
2014
January 1 Coverage begins
January 15,
February 15,
March 15
Deadlines for plan selection for enrollment in
following month
March 31 Open-enrollment ends

39. Exchanges:
Reinforcing the New Provider/Purchaser Environment
Incentive for low premium plans in Exchanges, especially to attract
those with tax credits (~ 85% of likely enrollees)
• Premium tax credit tied to second lowest price silver (70% AV) plans
• ACA takes away selected underwriting, pricing, cost control and design
tools that plans have used in small group and individual market
• Result: Plans in Exchanges turning to other cost control devices:
networks, provider pricing, utilization controls
Reinforces comparable pressures on providers from larger employers,
Medicare and Medicaid
• Standardized FFS approaches and payments will be increasingly
unattractive
• Incentives for new arrangements among providers and with payers to
lower total cost growth
39

40. Charity Care and Bad-Debt Exposure Continues
• While number with coverage are likely to increase by about
25 million, providers face financial constraints
About 30 million remaining uninsured
Medicaid an increasing source of coverage with limited payment
rates
• Cost-sharing in Exchanges and in employer policies remains
Cost-sharing continues to increase under traditional employer
policies
Cost-sharing can be substantial even with “minimum essential
coverage” (e.g. larger employer plans)
While maximum out-of-pocket cost limits in place, cost-sharing
remains in the plans in the Exchange
• State law loopholes in insurance regulation
For example, possibility of limited duration plans
40

41. Implications for Hospitals
• Patients covered under Exchange plans may result in better
coverage with lower out of pocket maximums
• There will be more insured patients, but many uninsured likely to be
unaware of the Exchanges and subsidies in 2014; effects of ACA
may be limited at first
• Plans have to meet network adequacy requirements, but Exchange
plans may have narrower networks than non-Exchange plans
• To keep premiums competitive, insurers may try to negotiate deeper
discounts from hospitals
41

42. Eligibility, Outreach
and Enrollment
• Navigators
• Certified Application Counselors (CACs)
• Presumptive Eligibility

43. Eligibility and Enrollment Pathways
and Consumer Assistance
Navigators
Agents / Brokers /
Producers
In-Person
Assisters
Certified
Application
Counselors
Assistance Entities
State Agency
(e.g., Depts. Of Health /
Social Services)
Online PhoneIn-person
Enrollment Complete
Mail

44. Outreach Efforts for 2014 for Kansas Marketplace
• Navigators
Kansas Association for the Medically Underserved, $524,846
• (Consortium of Kansas Hospital Association, the Kansas Association of
Local Health Departments, the Association of Community Mental Health
Centers of Kansas, the Kansas Area Agencies on Aging Association, and
the Kansas Insurance Department). Aim to assist about 48,000 people
Advanced Patient Advocacy, $195,556
Via Christi Health, Ascension Health, $165,683
• Certified application counselors (e.g., community health
centers, hospitals, social service agencies)
• Agents and brokers
• HHS Call Center; www.healthcare.gov
44

45. Navigator Duties
45
Marketplaces must establish a Navigator
program to provide in-person education, and
eligibility/enrollment assistance.
Navigators must:
• Maintain expertise in eligibility, enrollment and
program specifications, and conduct public
education activities to raise awareness about
the Marketplace.
• Provide information and services in a fair,
accurate and impartial manner, and help enrollees
with grievances and complaints.
• Help enrollees select a Qualified Health Plan.
• Provide information in a manner that is culturally and linguistically appropriate,
including individuals with limited English proficiency.

46. What does a CAC organization do?
As a CAC organization, staff will help people understand, apply and
enroll for health coverage through the Marketplace. Hospitals must
agree to make sure that designated individuals complete required
training, and that they comply with privacy and security laws, and other
program standards.
Your organization must:
• Have processes in place to screen your staff to make sure that
they protect consumer information
• Engage in services that position you to help those you serve with
health coverage issues
• Have experience providing social services to the community
September 18, 201346
Certified Application Counselors (CACs)

47. What Is Presumptive Eligibility (PE)?
• Ability for “qualified entities” to make immediate, temporary
Medicaid/CHIP determinations
• Providers are paid for all services provided during temporary
eligibility period
• Individual must complete full Medicaid/CHIP application by
end of the month after the PE determination was made in
order to retain ongoing coverage
• Previously, states could opt to use PE only for children
and/or pregnant women in Medicaid/CHIP
47

48. Two New Ways to Use PE
Two new PE options, available starting January 1, 2014:
1. States can use PE to connect adults to Medicaid (not
just children and pregnant women)
2. Hospitals can use PE for any income-based population
regardless of whether the state uses PE
48

49. Why Is PE An Important Enrollment Tool?
49
Allows people
to connect to
coverage in
trusted
settings when
already
naturally
thinking about
healthcare
Immediate
access to
needed
services, and
providers get
paid
Bridge to
coverage
when real-time
eligibility
determination
not possible
(verification
issues, system
issues, natural
disasters, etc.)
Follow-up,
referrals
essential to
ensure
individuals are
fully enrolled

50. Overview of PE Toolkit
50
www.PresumptiveforHospitals.org

51. What Happens Next?
• Individual must complete full Medicaid application
by the end of the month after the PE determination
was made to keep Medicaid coverage.
• Hospitals are paid for all services provided during
PE period, regardless of a patient’s ultimate
Medicaid eligibility determination.
51

52. Discussion and Q&A