Long Tem Care Not Included in ACA Plans

Following up on my coverage of the North Carolina Senate budget:

As noted in the link above, elderly who have Medicaid via the medically needy provision are ineligible for ACA plans due to their age. The blind and disabled who are younger than age 65 who lose Medicaid are eligible for ACA plans, but a large proportion of the costs of the medically needy who are disabled is Long Term Care. And Long Term Care is not covered by benefit package required by ACA plans. The 10 Essential Health Benefits that are mandated to be covered by the ACA are as follows:

What’s covered in the Health Insurance Marketplace

These essential health benefits include at least the following items and services:

  1. Outpatient care—the kind you get without being admitted to a hospital
  2. Trips to the emergency room
  3. Treatment in the hospital for inpatient care
  4. Care before and after your baby is born
  5. Mental health and substance use disorder services: This includes behavioral health treatment, counseling, and psychotherapy
  6. Your prescription drugs
  7. Services and devices to help you recover if you are injured, or have a disability or chronic condition. This includes physical and occupational therapy, speech-language pathology, psychiatric rehabilitation, and more.
  8. Your lab tests
  9. Preventive services including counseling, screenings, and vaccines to keep you healthy and care for managing a chronic disease.
  10. Pediatric services: This includes dental care and vision care for kids

Specific health care benefits may vary by state. Even within the same state, there can be small differences between health insurance plans. When you fill out your application and compare plans, you’ll see the specific health care benefits each plan offers.

As noted above, states are able to add extra benefit requirements/mandates. However, states are explicitly prohibited from making ACA benefit package include Long Term Care. From the CMS guidance (emphasis below is added by me):

Excluded Benefits

Pursuant to 45 CFR 156.115, the following benefits are excluded from EHB even though an EHB-benchmark plan may cover them: routine non-pediatric dental services, routine non-pediatric eye exam services, long-term/custodial nursing home care benefits, and/or non-medically necessary orthodontia. Please also note that although the EHB-benchmark plan may cover abortion services, pursuant to section 1303(b)(1)(A) of the Affordable Care Act, a QHP issuer is not required to cover these services. Section 156.115(c) provides that no health plan is required to cover abortion services as part of the requirement to cover EHB. Nothing in this provision impedes an issuer’s ability to choose to cover abortion services or limits a state’s ability to either prohibit or require these services under state law.

The fact that Long Term Care is not covered by ACA plans (and my and your employer sponsored private insurance BTW) is a big problem because a large portion of the care being financed by those who would lose Medicaid under the proposal is for Long Term Care Services (From KFF).

ScreenHunter_21 May. 31 09.56

This is not N.C. specific, but provides guidance. For persons age 65+ who lose Medicaid under the proposal, they cannot buy a plan in the ACA marketplace. They will still have Medicare, but it does not cover most Long Term Care. The dark blue bars to the right in the figure above (Long Term Care) will not be paid by Medicare since it does not cover most Long Term Care (the dark blue bars to the left are already mostly being paid by Medicare; these costs will shift to the beneficiaries). For younger than age 65, the light blue bars to the left (acute care) would be covered by ACA plans. The light blue bars to the right (Long Term Care) would not be covered under ACA plans because Long Term Care is not included (and explicitly forbidden) to be covered by ACA plans as noted above.

Summing Up:

  • WRAL reports that there are ~15,000 persons who would lose Medicaid coverage as of Jan 1, 2015 (the numbers in my earlier post were based on 2010 numbers; the magnitudes are not the same, by the by group analysis is)
  • Any of these 15,000 who are age 65 and over cannot buy ACA plans (I can’t find a definitive age breakdown; anyone got it?).
  • Those who are younger than age 65 are eligible for ACA plans, but these plans to do not cover Long Term Care–the most expensive type of care for most of these people, and the very thing that pushed them into medically need Medicaid eligibility in the first place. But, the acute care services incurred by these patients would be covered by ACA plans. There will be some idiosyncratic differences by person in terms of what proportion of their total spending is covered by ACA plans. Those with more acute costs will be better covered by ACA plans than will those with more LTC costs, will be in trouble.

Bottom line is that the Senate Medicaid policy is mostly vague, until it gets to their desire to have Medicaid eligibility as low as possible. I think this is a bad policy. Even worse is that bad policy is being supported by faulty policy logic.

About Don Taylor
Professor of Public Policy at Duke University (with appointments in Business, Nursing, Community and Family Medicine, and the Duke Clinical Research Institute). I am one of the founding faculty of the Margolis Center for Health Policy, and currently serve as Chair of Duke's University Priorities Committee (UPC). My research focuses on improving care for persons who are dying, and I am co-PI of a CMMI award in Community Based Palliative Care. I teach both undergrads and grad students at Duke. On twitter @donaldhtaylorjr

2 Responses to Long Tem Care Not Included in ACA Plans

  1. Pingback: Medicaid reform in North Carolina | freeforall

  2. Pingback: Decreasing Medicaid eligibility: reducing or shifting costs? | freeforall

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