1. Affordable Care Act
Janlee Wong, MSW
NASW California
October 2014
Google: slideshare Janlee Wong

2. Course Objectives
• Understand what the Affordable Care Act is
and how it is implemented in California
• How it affects you
• How it covers the uninsured
• How it reforms both service delivery and
financing incentives
• What are the roles of social workers and how
to get involved (advocacy)

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.

4. What is the ACA
• Affordable Care Act or “Obamacare”
• First successful major national reform enacted
since Medicare (1935) and Medicaid (1965)
• First step towards “universal” healthcare
• Expands “single payer” Medicaid (MediCal)
• NASW policy goal is universal single payer
healthcare system

5. ACA Market Reforms (31)
• Insurers are prohibited from setting lifetime limits on essential health
benefits, such as hospital stays, beginning with new policies issued.
Approximately 12 million people in California are no longer subject to these
limits as a result of the act, according to federal estimates.
• Insurers are no longer allowed to re-examine a customer’s initial application
to cancel, or “rescind,” their coverage due to unintentional mistakes or
minor omissions.
• Dependent children up to age 26 must be offered coverage under a parent’s
insurance plan. Federal data indicates that more than 435,000 young adults
in California have gained coverage as a result of this provision of the act.
• Insurers may not exclude children under the age of 19 from coverage due to
a pre-existing medical condition.
• Insurers are now required to spend the vast majority of premium dollars
on medical care and quality improvement activities, and a smaller, limited
amount on overhead expenses such as marketing, profits, salaries,
administrative costs and agent commissions.

6. ACA Accomplishments (9)(12)
• More uninsured covered (fell from 20% to 15%
nationwide)
• More Latino uninsured covered (fell from 36%
to 23% - 2013-2014) In CA Latinos make up
60% of the uninsured
• 25% reduction in uncompensated hospital
care ($5.7 billion)

7. ACA Reduces Readmissions (26)
19.5
19
18.5
18
17.5
17
16.5
Medicare Hospital Readmissions
2007 2008 2009 2010 2011 2012 2013
Medicare Hospital
Readmissions

8. Getting California Covered
• 2.6 million Californians qualify for federal
financial assistance
• Another 2.7 million Californians will benefit
from guaranteed covered coverage
• Estimated 2.3 million California residents will
enroll in a health plan through the Exchange
(Covered California) by 2017

9. Getting California Covered
• 2014, employers with 25 or fewer employees
– possible eligibility for tax credits
• 2014, employers with 50 or fewer employees
can buy plans in the Exchange
• 2015, employers with 100 or fewer employees
can buy plans in the Exchange

10. Income & ACA
$9 per hour min. wage =$15,750 annually, $13 per hour = living wage in US
$15 per hour min. wage = $26,250 annually or twice the federal poverty threshhold

11. Income & ACA

12. MediCal (Medicaid)
• Another almost 1.5 million Californians are
eligible for expanded Medi-Cal, which will be
open to all individuals under 65 with incomes of
up to $16,000 for an individual and about
$32,500 for a family of four
• End of categorical rules, eligibility based on
income,
• Bye bye asset test (except for foster care children,
SSI/SSDI, elderly)
• Spend down continues

13. Special Medi-Cal Eligible Populations
• Homeless
• Aged out transitional foster youth
• Parolees, probationers
– Oakland, Alameda county expects to enroll some
18,000 Medicaid-eligible inmates and detainees in
the coming years

14. Dual Eligibles (26)
• Coordination of Care (new “duals” offices)
• Prescription Drugs (elimination of cost sharing, Part
D for home and community based care clients)
• Medicare Advantage Plans (improved quality
measures)
• Long-Term Care and Chronic Illness (Medical Homes)

17. Poor Outreach
• 50% of those still uninsured five years after
the ACA takes effect will qualify for coverage
under the Medi-Cal expansion or for health
benefit exchange subsidies, but they will not
be aware that they qualify because of poor
outreach. Medi-Cal is California's Medicaid
program (5)

18. Enrollment: Social Workers Can Help
Nov. 15 to Feb. 15, 2015
• Champions for Coverage.
Marketplace.cms.gov/technical-assistance-resources/
assisterprograms/champion-apply.
hmtl
• Enroll America: www.enrollamerica.org
• Certified Application Counselor:
marketplace.cms.gov, “About Assister
Programs”
• Local Help Directory: localhelp.healthcare.gov

20. Health Benefits Exchange
“Covered California”
• Quasi-governmental organization, specifically
an "independent public entity not affiliated
with an agency or department.“
• Contracting with Plans: Contract with carriers
so as to provide health care coverage choices
that offer the optimal combination of choice,
value, quality, and service.”
• For individuals and families ineligible for
Medicaid but below 400% of poverty

21. Healthcare Marketplace
• For those who don’t get insurance through
their employer
• Not qualified for Medi-Cal
• Want low cost affordable health insurance
plans
• Want subsidies (tax credits) depending on
income (below 144% of poverty) or below $25
per hour for an individual

22. Exchange (Marketplace)
Individual Mandate
• Conservative ideas from the Heritage
Foundation (let insurers compete and
consumers can choose)
• First implemented in the Massachusetts
Health Connector exchange
• ACA: Consumer choice; plans have the same
basic benefits; managed care features –
restricted networks, high out of network care
costs, tax subsidies (credits)

23. Competition (13)
• California saw reduced insurer participation
from 12 to 10 carriers on its exchange
• Some think it doesn't suggest
disenchantment, but rather that weaker
players are dropping out of a very competitive
market.
• Nationally, HHS Secretary Burwell reported
there will be a 25% increase in the number of
insurers participating in the exchanges.

24. Walmart, Target, Home Depot
• ACA labeled a “job killer” because employers
would rather lay off employees than pay for
health care for part timers.
• Companies have cut benefits for part-timers but
not laid them off.
• Walmart cut benefits for 30,000 employees,
Home Depot, 20,000
• Most cut health for part-timers but many of their
employees pay less for ACA benefits than in
company plans

25. Limited Networks, Providers
• Health insurers offer limited or restricted
networks of providers in their plans
• Many lack accurate information on who are
their providers
• The drastic shortage of primary care
physicians has not materialized
• Care is limited in rural, remote areas

26. Exchange Marketplace Report Card (21)
• Sufficient numbers of enrollees? Met its goal of 8
million enrollments through the exchanges during
the 2014 coverage season (21)
• Attract enough healthy young people to offset
the cost of older or sicker enrollees? Meeting
goal (22).
• Sufficient interest by insurance companies? More
insurers interested. (23)
• Continued challenges: Consumer skepticism,
partisan opposition and court challenges (21)

27. Goal:40% (22)

28. 18 state run exchanges, 8 state/Fed partnerships

29. Which plans were selected 2015 (25)
1. Anthem Blue Cross of
California
2. Blue Shield of California
3. Chinese Community Health
Plan
4. Health Net
5. Kaiser Permanente
6. L.A. Care Health Plan
7. Molina Healthcare
8. Sharp Health Plan
9. Valley Health Plan
10. Western Health Advantage
1. Ambulatory patient services
2. Emergency services
3. Hospitalization
4. Maternity and newborn care
5. Mental health and substance
use disorder services, including
behavioral
health treatment
6. Prescription drugs
7. Rehabilitative and habilitative
services and devices
8. Laboratory services
9. Preventive and wellness
services and chronic disease
management
10. Pediatric services

30. Accountability
• Have sufficient clinicians — doctors, hospitals and other providers
— to meet the needs of the consumers who enroll in their plan
• Ensure that each enrollee has had a preventive health and wellness
visit during the first year of enrollment
• Identify and proactively manage all “at-risk” enrollees
• Determine enrollees’ health status and proactively develop a plan
to manage their individual health care needs
• Promote the use of best practice models for continuity of care and
care coordination that are proven to improve quality of care
• Be transparent about plan performance at the point of enrollment,
specifically regarding standard measures of prevention, access and
clinical effectiveness
• Be certified by the National Committee for Quality Assurance or
URAC (formerly known as the Utilization Review Accreditation
Commission) to meet quality standards

31. Pediatric Dental
• Covered California, the state's health
insurance exchange, has said it will offer five
stand-alone pediatric dental plans for 2014 as
well as what's called a "bundled" plan in
which insurers pair a stand-alone dental plan
with a medical plan.

32. Pediatric Dental
• Anthem Blue Cross of California.
• Blue Shield of California.
• Delta Dental of California.
• Liberty Dental Plan of California.
• Premier Access Dental and Vision.
• Small Business Health Options Program Shop
(SHOP) plans

33. Vision
• Vision benefits will be available for children
embedded in health plans.
• Covered California is considering combining
pediatric vision and dental plans in the future

34. Affordability
• Effective Jan. 1, 2014, insurance companies
may consider only three factors to determine
the cost of your premium: age, geography and
family size. Your health history may no longer
be considered in setting premiums.

35. Subsidies and the Exchange
• 5 million Californians qualify to get insurance on the
Exchange.
• Half of them are eligible for government subsidies,
which are federal tax credits that will offset the cost of
their monthly premium
• The subsidies are available to those who earn $15,850
to about $46,000 a year. A family of four is eligible if
they earn between $32,500 to $94,200 a year
• The more you make, the smaller the subsidy. The less
you make the more assistance you’ll get
• Based on your adjusted gross income plus any tax-exempt
income you might have.

36. What Metal?
• Platinum plans have the highest premium, yet
pay 90% of covered health care expenses.
Bronze plans have the lowest premium, but
pay only 60% of covered health expenses. It’s
important to think about how much health
care you will need when choosing a level.
• Shop and Compare:
https://www.coveredca.com/shopandcompare/#healthplans

37. Health Benefits Exchange Plans
Bronze, Silver, Gold & Platinum (2015)
Bronze 60 Silver 70 Gold 80 Platinum90
Healthcare Cost Coverage 60% 70% 80% 90%
Copay Primary Care Visit $60 $45 $30 $20
Deductible Individual to
$5,000 -
$2,000 -
Family
$10,000
$4,000
None None
Specialty Care Visit $70 $65 $50 $40
Urgent Care Visit $120 $90 $60 $40
Meds Generic $15 $15 $15 $5
Lab 30% $45 $30 $20
ER $300 $250 $250 $150
Max Out of Pocket
$6,250 to
$6,250 to
$6,250 to
Individual to Family
$12,500
$12,500
$12,500
$4,000 to
$8,000
Monthly Premium Monthly
Family of 2*
$896 $1,128 $1,336 $1,484
*Ages 60 years old; Burbank area, LA Care Health Plan

38. Web Live Demonstration
• Covered California

39. Does the ACA Affect You?
• Maybe, I already have health insurance through
my employer, family member or programs such
as Medicare and Medicaid. (85%)
• Yes, my employer doesn’t provide health
insurance
• Yes, I’m below 400% of poverty, ineligible for
Medicaid (due to income) and don’t have health
insurance
• Yes, I was previously ineligible for Medicaid but
now I am eligible
• No, I’m undocumented

40. Covered CA Affordable? +4.2% (24)
• The overall weighted average increase is 4.2 percent
• 16% of Covered California consumers (217,000 people) will
see the premium of their health plan stay constant or
decrease (with most decreases of 1 percent to 3 percent, but
some decreases of up to 14 percent)
• 35 % (489,000 people) will see premiums increase a small
amount — less than 5 percent
• 36% (495,000 people) will see premium increases of 5 percent
to 8 percent (with most of those being about 6 percent)
• 13 % (186,000 people) will see premium increases of more
than 8 % (with almost 90 percent of these in the 8-10 percent
range)

41. Covered CA Premium Increase +4.2%
Premium Increase
1-3%
<5%
+5-8%
>9%

42. Consumer Assistance and Outreach
• Grants to community groups and a
comprehensive advertising campaign aimed at
attracting new consumers and encouraging
them to enroll in the state’s health benefit
exchange
• Network of Certified Enrollment Counselors,
Certified Insurance Agents and county
eligibility workers

43. Covered California Certified Enrollment Entities
• American Indian Tribe or Tribal Organizations
• Chambers of Commerce
• City Government Agency
• Community Clinics
• Community Colleges and Universities
• Faith-Based Organizations
• Labor Unions
• Non-Profit Community Organizations
• Ranching and farming organizations
• Resource partners of Small Businesses
• School Districts
• Tax Preparers
• Trade, industry, and professional organizations
For complete list:
http://hbex.coveredca.com/enrollment-entities/PDFs/Navigator-Funding.pdf

44. Role of Social Worker - Policy
• Social workers should be included in the
interdisciplinary care teams across a broad array
of health care settings
• Social workers are likely the only professionals
devoted to meeting the psychosocial needs of
patients and families
• Social workers extend the team to allow
members to participate at the top of their
licenses
• Social workers are experienced in outreach to
disadvantaged populations

45. Roles of Social Worker - Practice
• Directors, Managers, Elected and appointed
officials
• Clinical social workers – mental and behavioral
health services
• Medical social workers – care coordination and
case management, medically related social
services, patient and family education, discharge
planning, advance care planning, community
outreach and engagement
• Outreach, community organizers, advocates

46. Models of Care
• Accountable Care Organizations
• Integrated comprehensive acute care
• Integrated comprehensive primary care
• Coordinated medical and behavioral health
care

47. Characteristics
• A strong primary care/medical home/health home
foundation
• Multidisciplinary health care teams
• Targeted care coordination interventions (focused
especially on individuals with multiple chronic
conditions)
• Integration with behavioral health and substance use
treatment
• Sophisticated information systems that include
electronic medical records
• Formal partnerships with “medical neighbors”

48. Accountable Care Organizations
(ACOs)
• ACO is a network of hospitals, clinics, physician
practices and other providers who work together
to provide coordinated, integrated care for an
assigned population of individuals and who
receive financial compensation for meeting
specific patient outcomes.
• Goal: Reduce or control the growth of healthcare
costs while maintaining or improving the quality
of care

49. Accountable Care Organizations
(ACOs) (29)
• There were more than 600 ACOs nationwide
at the start of the year, and they are being
touted as a key strategy for curbing U.S.
health-care costs. The fundamental idea is
that doctors and hospitals are rewarded for
keeping and making patients healthy, rather
than a “fee for service” approach where they
earn more for prescribing lots of tests or
scheduling appointments regardless of how a
patient fares.

50. Industry ACO Example (29)
• UW Medicine as well as Providence Health &
Services and Swedish Health Services have each
recruited a network of hospitals and clinics and
formed their own ACOs. Boeing has separate
contracts with each to provide care for Puget
Sound-area employees beginning next year.
• These employer-driven ACO arrangements, with
no insurance company involved, are believed to
be among the first in the nation to use this
approach and could serve as models elsewhere.

51. Integrated Comprehensive Primary Care
Southwest Virginia Community Healthcare Systems, Inc
Patient visit Prim. Care
Physician (PCP)
PCP screens for
behavioral health issue
Positive Negative
Referral to
behavioral
health
consultant
PCP
continue
with
medical
visit

52. Medical Home (28)
• The medical home is the model for 21st
century primary care, with the goal of
addressing and integrating high quality health
promotion, acute care and chronic condition
management in a planned, coordinated, and
family-centered manner.

53. Medical Home Building Blocks (28)
1. Care Partnership Support
Empowers children, youth and families to manage their health and healthcare
2. Clinical Care Information
Assures delivery of effective, efficient clinical care & patient self-management support
3. Care Delivery Management
Promotes clinical care that is consistent with patient and family preference and scientific
evidence
4. Resources & Linkages
Mobilizes community resources to meet patient and family needs
5. Practice Performance Measurement
Addresses the organization and promotion of safe and high quality care
6. Payment & Finance
Matches quality care and NCQA recognition with payment / solid return on investment

55. Medical Home Implementation (28)
• Riverside County Public Health Department
plans to implement a patient centered
medical home at its primary care clinics.
• Ventura County's Medi-Cal beneficiaries are
expected to be assigned to medical homes
through Gold Coast Health Plan
• Los Angeles County community clinics will be
transformed into PCMHs through L.A. Care
Health Plan

56. Social Work Advocacy
NASW and California Deans and Directors got a social worker included
on the California Workforce Investment Board, Health Workforce
Development Council (8)
• 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.
• Change regulations to allow the services of Community Health
Workers/Promotores to be reimbursable with government and
private payers.
• Develop supportive payment structure and policies targeted at
increasing the attractiveness of primary care as a career path and
retention of primary care providers.
• Ensure adequate payment for primary care and preventive services
with appropriate adjustments in payment incentives.

57. Advocate Role of Social Worker
• Be a voice for social work in the health care
plan’s development of ACOs
• Advocate for comprehensive benefits
including psychosocial services
• Advocate for horizontal integration of health
and human services benefits
• Serve as a resource for identifying hard to
reach populations

58. Look Out For
• Be on the look out for creep back to bias
against those with pre-existing conditions or
chronic diseases (high drug costs, limited
networks and specialty hospitals, services)

59. US Supreme Court Cases
• Individual mandate is legal (it’s a tax)
• States can’t be forced to open
exchanges
• Allows closely held private corporations
to be exempt from contraceptive
mandate due to religious beliefs of the
owners (Hobby Lobby). Employers must
let workers know if they remove
coverage

60. Lower Court Cases (10)
• Judge Ronald White, a George W. Bush
appointee, invalidated an Internal Revenue
Service rule interpreting the Patient
Protection and Affordable Care Act to allow
the premium tax credits in states that have
not established their own exchange. “The
court holds that the IRS Rule is arbitrary,
capricious, an abuse of discretion or otherwise
not in accordance with law,” White wrote.

61. The Uninsured Unauthorized (5)
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.

63. Senate Bill 1005
• SB 1005 by Sen. Ricardo Lara (D-Bell Gardens)
would create the California Health Exchange
Program for All Californians, which would be
overseen by Covered California. The federally
funded exchange is not allowed to cover the
undocumented so state funds would be used
for that portion of the population covered in
the new exchange.
• Passed Senate Health Committee, May 2014.

64. My Health LA (27)
• Los Angeles County will provide access to a
primary care doctor for nearly 150,000 uninsured
Los Angeles County residents, including many
who are ineligible for Obamacare coverage
because they lack legal immigration status.
• My Health L.A., as the $61-million program for
the uninsured is called, will assign uninsured
patients to a "medical home" at one of around
150 community clinics

65. Glossary
Accountable Care Organizations ACO
• A network of hospitals, clinics, physician
practices and other providers who work
together to provide coordinated, integrated
care for an assigned population of individuals
and who receive financial compensation for
meeting specific patient outcomes.

66. Glossary
Actuarial Value
• A health insurance plan’s actuarial value is the percentage
of total average costs for benefits that a plan covers. All
Covered California health insurance plans have an actuarial
value assigned to them: Bronze, Silver, Gold or Platinum.
• As the metal category increases in value, so does the
percent of medical expenses that a health plan covers. This
means the Platinum plans cover the highest percentage of
health care expenses.
• These expenses are usually incurred at the time of health
care services — when you visit the doctor or the
emergency room, for example. The health insurance plans
that cover the greatest percentage of health care expenses
also usually have higher premium payments.

67. Glossary
Copayment
• A fixed amount (for example, $15) you pay for
a covered health care service, usually when
you receive the service. The amount can vary
by the type of covered health care service.

68. Glossary
Cost Sharing
• The share of costs covered by your insurance
that you pay out of your own pocket. This
term generally includes deductibles,
coinsurance and copayments, or similar
charges, but it doesn’t include premiums,
balance billing amounts for non-network
providers, or the cost of non-covered services.

69. Glossary
Coinsurance
• Your share of the costs of a covered health care service,
calculated as a percentage (for example, 20 percent) of
the allowed amount for the service.
• You pay coinsurance plus any deductible you owe.
• For example, if the health insurance plan’s allowed
amount for an office visit is $100, and you have met
your deductible for the year, your coinsurance payment
of 20 percent would be $20.
• The health plan pays the rest of the allowed amount.

70. Glossary
Medical Homes (31)
A mode of care that includes
(A) personal physicians;
(B) whole person orientation;
(C) coordinated and integrated care;
(D) safe and high-quality care through evidence informed
medicine, appropriate use of health information
technology, and continuous quality improvements;
(E) expanded access to care; and
(F) payment that recognizes added value from additional
components of patient-centered care. 5

71. Glossary
Out of Pocket Limit
• The most you pay during a policy period (usually
a year) before your health insurance or plan
begins to pay 100 percent of the allowed amount.
• This limit never includes your premium, balance-billed
charges or health care your health
insurance plan doesn’t cover.
• Some health insurance plans don’t count all of
your copayments, deductibles, coinsurance
payments, out-of-network payments or other
expenses toward this limit.

72. Glossary
Premium and Assistance
Premium
• The amount that must be paid for your health insurance or plan.
You or your employer, or both, usually pay it monthly, quarterly or
yearly.
Premium Assistance
• Also known as the Advanced Premium Tax Credit, this is financial
assistance eligible consumers may receive when enrolling in a
Covered California health insurance plan, to assist them in paying
their monthly premium costs.
• The amount of premium assistance an individual may receive is
determined based on his or her income as a percentage of the
federal poverty level. Tax credits are also available to small
businesses with fewer than 25 full-time-equivalent employees to
help offset the cost of providing coverage.

73. Glossary
Subsidy
• Cost-sharing subsidies and premium
assistance reduce the cost of premiums and
out-of-pocket expenses for health coverage
that qualifying individuals and families
purchase through Covered California.

74. ACA Is Changing
• Check various websites for up to date changes
http://www.healthcare.gov/
http://www.chcf.org/publications/2010/05/the-affordable-
care-act-in-california

75. Resources
1. http://www.cfra.org/node/2807
2. www.socialworkers.org
3. http://www.healthexchange.ca.gov
4. http://www.coveredca.com/
5. http://www.californiahealthline.org/articles/
2012/10/24/california-considers-strategies-for-
treating-uninsured-immigrants.aspx

76. Resources
6. http://www.cis.org/california-education
7. http://www.ppic.org/main/publication_show
.asp?i=818
8. http://www.cwib.ca.gov/res/docs/special_co
mmittees/hwdc/meeting_materials/2013/H
WDC%20Report%20-
%20Draft%20012113.pdf

77. Resources
9 http://www.advisory.com/daily-briefing/2014/09/26/hhs-coverage-expansion-is-cutting-
uncompensated-care%20costs-at-hospitals
10
http://www.modernhealthcare.com/article/20140930/NEWS/309309919?AllowView=VDl3UX
k1T3dDZlNCbkJiYkY0M3hlMHFxajBVZEMrOD0=&utm_source=link-20140930-NEWS-
309309919&utm_medium=email&utm_campaign=mh-alert
11 http://www.advisory.com/daily-briefing/
resources/primers/medicaidmap#lightbox/0/
12 http://www.latimes.com/health/la-na-obamacare-latinos-20140925-story.html
13
http://www.modernhealthcare.com/article/20140927/MAGAZINE/309279977&utm_s
ource=AltURL&utm_medium=email&utm_campaign=am&AllowView=VXQ0UnpwZTV
BL2FaL1I3TkErT1lBajNja0U4VUErUmFFQk1IQXc9PQ==?mh

78. Resources
21 http://www.bloombergview.com/quicktake/health-insurance-exchanges
22 http://www.washingtonpost.com/blogs/wonkblog/wp/2014/04/04/facing-obamacare-
deadline-more-young-people-signed-up-in-march/
23 http://www.nytimes.com/2014/05/26/your-money/health-insurance/insurers-once-
on-the-fence-plan-to-join-health-exchanges-in-15.html?_r=0
24 https://www.coveredca.com/PDFs/CC-health-plans-booklet-2015.pdf
25 http://kff.org/health-reform/issue-brief/affordable-care-act-provisions-relating-to-the/

79. Resources
26 U.S. Department of Health & Human Services News Division 202-690-6343
media@hhs.gov www.hhs.gov/news May 07, 2014
27 http://www.latimes.com/local/lanow/la-me-ln-remaining-uninsured-los-angeles-
20141006-story.html
28 http://www.pediatricmedhome.org/
29
http://seattletimes.com/html/localnews/2023842772_acoboeingprovidenceuwxml.html
30
https://www.cms.gov/eHealth/downloads/Webinar_eHealth_December6_HealthITIn
novation.pdf
31 Patient Protection and Affordable Care Act §3502(c).t