Federal Health Reform: From Dazed and Confused to Dazzlingly Confident

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1 Federal Health Reform: From Dazed and Confused to Dazzlingly Confident Aelia Khan Director Texas Consumer Health Assistance Program Texas Department of Insurance May 2011

2 How Federal Health Reform Affects Insurance Coverage What s available now? What questions do you need to ask? What is it? Why is it important? What resources are available? 2

3 Key Features in 2011 Pre-Existing Condition Insurance Plan Federal Health Reform provides: New protections for you and your family Expanded benefits Lower costs New, more affordable coverage options Help with appeals and complaints against your health plan 3

4 Texas Uninsured Population Percentage of Texas Uninsured Population,

5 Pre-Existing Condition Insurance Plan U.S. citizen, national, or legal resident 6 months without coverage Can t get insurance because of pre-existing condition or current health condition or can only get coverage that excludes the pre-existing condition 5

6 PCIP Prior Coverage You do not qualify for PCIP if, within the last six months, you have had any type of health insurance: Texas Health Insurance Pool, the state high-risk pool Medicaid Medicare Insurance through your employer, union, or an association Individual health coverage 6

7 Pre-Existing Condition Proof Denial of coverage Doctor s statement re: condition is insufficient New guidance: For children under 19, medical letter re: condition is sufficient Offer with an exclusionary rider Insurance does not cover the specific medical condition Offer of coverage at a substantially higher rate 7

8 Information Needed to Qualify A recent denial letter (dated within the last six months) from a Texaslicensed insurance company for individual insurance coverage A recent letter (dated within the last six months) from a Texaslicensed insurance agent that states that you are not eligible for individual insurance coverage from one or more insurance companies because of your medical condition A recent letter (dated within the last six months) from a Texaslicensed insurance company that offers individual insurance coverage, but with a rider that eliminates coverage for your medical condition, or If under age 19, a recent letter from an insurance company that offers individual insurance coverage, but at a premium rate that is at least twice the rate available through PCIP or letter from medical doctor, doctor of osteopathy, physician assistant, or nurse practitioner 8

9 PCIP Plan Options Three federal high-risk pool plans Standard, Extended, and Health Savings Account Benefit summaries showcase features How they differ: Premiums Deductibles Prescription deductibles Prescription copays 9

10 PCIP The Options for Texans In-Network Expenses Beneficiary Responsibility Standard Option Extended Option HSA-Eligible Option Monthly Premium $174 - $557 $234 - $749 $181 - $578 Medical Deductible $2,000 $1,000 $2,500 Drug Deductible (formulary) $500 $250 Included in medical Office Visit Copay $25 $25 $25 Drug Copay (formulary) $4/$40/25% ($150 max) $4/$30/25% ($150 max) $4/$30/25% ($150 max) Out-of-pocket limit* $5,950 $5,950 $5,950 *Out-of-pocket limit for out-of-network expenses -- $7,000 10

11 PCIP - Cost 2011 Monthly Premiums for Texas Age Standard Option Extended Option HSA-Eligible Option 0 to 18 $174 $234 $ to 34 $261 $351 $ to 44 $313 $422 $ to 54 $400 $539 $ $557 $749 $578 11

12 PCIP Plans Plan Features Preventive care (100% paid for in-network; no deductible) In-network doctor; preventive diagnosis Annual physicals, flu shots, routine mammograms and cancer screenings Other care pay deductible first and then 20 percent of medical costs for in-network Maximum out-of-pocket for covered services in a calendar year is $5,950 in-network/$7,000 out-of-network No lifetime maximum or cap on the amount PCIP pays 12

13 How to apply to PCIP TEX-CHAP ( ) toll-free Monday Friday 8 a.m. to 5 p.m., Central time Call for assistance when enrolling in PCIP Mail a paper application Fax a paper application Submit an online application Work with an agent 13

14 Health Risk Pool Scenario Michael has been without insurance for the past six months. Although born in Maine, he currently lives in Houston, Texas. He is battling pancreatic cancer. Michael has been turned down by three insurance companies. He says that the state health insurance pool is too expensive. Can he qualify for PCIP coverage? 14

15 PCIP and Texas Participation Texas PCIP enrollment as of February 2011: 1,007 Texas Health Insurance Pool enrollment as of April 2011: 26,385 Note: In 2014, federal and state high-risk pools are expected to end. Transition to Exchanges, the new marketplaces to obtain coverage. 15

16 Federal Health Reform Provisions For plan and policy years that begin on or are renewed after September 23, 2010, FHR: Bans lifetime dollar limits on essential benefits Restricts annual dollar limits on essential benefits Prohibits rescissions Extends dependent care coverage for young adults Prevents denials/exclusions for child s pre-existing condition Provides internal and external appeals 16

17 Grandfathered Plans Existing Coverage as of March 23, 2010 FHR provisions that DO apply Lifetime dollar limit restriction Retrospective rescissions Dependent coverage (with one exception) FHR provisions that DO NOT apply Preventive services with no cost sharing Choice of health care providers and access to emergency care Internal and external appeals (note Texas law) 17

18 Grandfathered Plans Grandfathered Individual Policies FHR Provisions that DO NOT apply Annual dollar limit restriction Elimination of pre-existing condition exclusions for children under 19 18

19 Losing Grandfathered Status Eliminate benefits to diagnose or treat a particular condition Raise coinsurance rates, copays, or deductibles above an allowed amount Reduce employer s share of premium by more than 5 percent Reduce annual dollar limits on benefits or add new annual benefit limits 19

20 Dependent Care Coverage Can t deny children under 19 based on pre-existing condition Continue on parent s health plan until age 26 No requirement that child is financially dependent living with parent in school working unmarried Note: married child covered; not required to cover married child s spouse Texas state law: for fully insured plans, covers dependent grandchildren up to age 25 20

21 Wellness Depending on your age, gender, and plan, you may get these services free Blood pressure, diabetes, and cholesterol tests Many cancer screenings, including mammograms and colonoscopies Counseling on such topics as quitting smoking, losing weight, eating healthfully, treating depression and reducing alcohol use Routine vaccinations against diseases such as measles, polio, or meningitis Flu and pneumonia shots Counseling, screening, and vaccines to ensure healthy pregnancies Regular well-baby and well-child visits, from birth to age 21 Note: may not be applicable to grandfathered plan; must use in-network provider; may be responsible for payment if screening coupled with other office visit 21

22 Wellness Keep children healthy Promote healthy pregnancies Prevent heart disease and obesity Prevent and control breast and other types of cancer 22

23 Seniors Cost of Medicare coverage changing Preventive services available Annual physical, colorectal cancer screening, mammograms Donut hole changes One-time $250 rebate for 2010, tax-free 50 percent discount on Medicare Part D-covered brand-name prescription drugs in 2011 Coverage gap closes in

24 Helping Consumers Toll-free consumer assistance TEX-CHAP ( ) Answer calls in English and Spanish Use Language Line to assist consumers in the language of their choice 24

25 Spanish Español Korean Chinese Vietnamese 25

26 Consumers Helped A Few Examples Dallas Morning News and San Antonio Express News flier inserts led consumers to Texas CHAP Call Center Consumer with disability found health coverage options for himself and Children s Health Insurance Plan (CHIP) coverage for his stepdaughter effective February 1 Helped lung cancer patient find Medicare doctor in north Texas, explained new Medicare wellness provisions, and referred consumer to Medicare for additional help Consumer laid off after employer went bankrupt; discussed PCIP eligibility, pharmaceutical help sites, and other insurance options Consumer has COBRA coverage but wants to buy individual policy; explained COBRA regulation, HIPAA, and health insurance options for people with preexisting condition 26

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29 Resources FHR fact sheets, publications Consumer Help Line Question of the Week Speakers Bureau Newsletter articles FHR toolkits for caseworkers 29

30 Resources TEX-CHAP ( ) toll-free Monday Friday, 8 a.m. to 5 p.m., Central time chap@tdi.state.tx.us 30