Massachusetts Health Care Training Forum (MTF

Transcription

1 ACA LEARNING SERIES Impact n Massachusetts & Implementatin Activities t Date Massachusetts Health Care Training Frum (MTF) July 2012 A cllabrative effrt between the Executive Office f Health and Human Services and the Health Cnnectr

2 Agenda 2 Guiding Principles ACA Key Cncepts Basic Health Plan Prpsed ACA Cverage Mdel Eligibility-Related Changes Exchange and Integrated Eligibility System (HIX-IES) MA Implementatin Activities

3 Massachusetts ACA Learning Series 3 The purpse f this ACA Learning Series is t educate staff wh currently assist Cmmnwealth Care, Cmmnwealth Chice, MassHealth and Health Safety Net (HSN) members at Massachusetts hspitals, health centers and cmmunity-based rganizatins Intrduce key cncepts and create awareness Deliver imprtant, detailed infrmatin that will prepare yu fr assisting ppulatins yu serve Prvide yu with specific infrmatin and training t help ppulatins btain cverage ACA Implementatin Activities January 2012 January 2013 January 2014

4 Backgrund: Guiding Principles 4 Creating a cnsumer-centric apprach t ensure that all eligible Massachusetts residents avail themselves f available health insurance subsidies t make health care affrdable t as many peple as pssible. Creating a single, integrated prcess t determine eligibility fr the full range f health insurance prgrams including Medicaid, CHIP, Basic Health Prgram and premium tax credits and cst-sharing subsidies. Offering apprpriate health insurance cverage t eligible individuals by defining bth the ppulatins affected and the health benefits that meet their needs. Wrking within state fiscal realities, maximizing and leveraging financial resurces, such as Federal Financial Participatin (FFP).

5 Backgrund: Guiding Principles 5 Fcusing n simplicity and cntinuity f cverage fr members by streamlining cverage types, thereby making nticing and explanatin f benefits mre understandable, and als minimizing disruptins in cverage. Creating an efficient administrative infrastructure that leverages technlgy and eliminates administrative duplicatin. Building ff the lessns learned since passage f Chapter 58. Creating pprtunities t achieve payment and delivery system refrms that ensure cntinued cverage, access and cst cntainment and imprve the verall health status f the ppulatins served.

6 ACA Key Cncepts 6 Medicaid Expansin The ACA expands cverage fr adults (under age 65) 0-133% FPL wh have nt traditinally been eligible fr Medicaid starting in January Massachusetts will receive additinal federal funding t cver the expanded Medicaid ppulatin. States must prvide at least Benchmark cverage fr the new Medicaid eligibles. This means cverage must at least prvide categries f services included in Essential Health Benefits.

7 ACA Key Cncepts 7 Basic Health Plan Optin (BHP) The ACA prvides states the ptin f establishing a BHP (Sec. 1331) starting in January Cvers nn-medicaid eligible adults (under age 65) % FPL. Certain legal immigrants wh are nt eligible fr Medicaid will be cvered (0-200% FPL). The state wuld receive 95% f the premium tax credits and cst-sharing reductins that wuld have been alltted if these individuals had purchased thrugh the Exchange. Cverage must at least prvide categries f services included in Essential Health Benefits.

8 ACA Key Cncepts 8 Qualified Health Plans (QHPs) Cmmercial insurance prducts available fr purchase thrugh the Exchange. Premium tax credits and cst-sharing reductins available fr eligible individuals and families. Optins fr small emplyers and their emplyees. Exchange will certify qualifying cmmercial insurance plans. Similar t hw the Health Cnnectr currently certifies Cmmnwealth Chice plans thrugh the Seal f Apprval prcess. 8

9 ACA Key Cncepts 9 Advance Premium Tax Credits (APTC) Fr qualifying individuals with incmes up t 400% FPL wh purchase thrugh the Exchange. Amunt ($ value) f the premium tax credit varies by incme, with individuals required t spend up t a certain percentage f their incme n health insurance. Cst-Sharing Reductins (CSRs) Fr qualifying individuals with incmes up t 250% FPL wh purchase thrugh the Exchange. Eligible fr cst-sharing (i.e., cpays, deductibles, c-insurance) reductins t their health plans. Prcess will be seamless t the cnsumer.

10 ACA Key Cncepts 10 Essential Health Benefits (EHBs) The ACA requires that all plans ffered thrugh the Exchange prvide Essential Health Benefits. The US Secretary f HHS has prvided initial guidance t states n hw t define EHBs. EHBs must include items and services within at least 10 categries. The Divisin f Insurance (DOI) will define EHB fr Massachusetts.

11 11 Basic Health Plan (BHP)

12 The Basic Health Plan Optin 12 This ptin permits states t implement a Basic Health Plan (BHP) t prvide direct cverage fr individuals between % FPL and certain legal immigrants between 0-200% FPL in lieu f these individuals purchasing a QHP thrugh the Health Cnnectr. The state purchases benefits n behalf f enrllees similar t MassHealth MCOs and Cmmnwealth Care. This ffers states the pprtunity t ensure cntinuity f cverage fr lw-incme ppulatins. After careful analysis f the financial impact and its effect n members, Massachusetts will take advantage f this ptin. 400% FPL 200% FPL 133% FPL 0% FPL

13 MassHealth Administratin f BHP 13 Basic Health Plan (BHP) will align with Medicaid prgram Psitive impact n members. It will help t reduce cverage gaps, transitin issues and disruptin (ultimately minimize churn). Cntinuity f Cverage Eliminates need t change health plans when peple mve between BHP and Medicaid Expansin (Benchmark). Eliminates cverage gap between prgrams. Mre families cvered in ne place. Mst children and adults under 200% will receive cverage thrugh MassHealth. Cntinuity f Care Eliminates need t change prviders when peple mve between BHP and MassHealth Standard r MassHealth Benchmark. Member Prtectins Aligns appeals, fair hearing rules and prcess.

14 14 Prpsed ACA Cverage Mdel 14

15 N Changes Required by ACA, but 15 N ACA changes in cverage are required fr these ppulatins, hwever MassHealth is actively examining changes that culd further enhance simplificatin f the prgram in the ACA era: Standard/Family Assistance Children <300% FPL MassHealth Parents < 133% FPL MassHealth Pregnant Wmen < 185% FPL MassHealth Limited Children s Medical Security Plan CmmnHealth MassHealth Disabled Adults & Elders Dual Eligibles (Disabled and Elders)

16 Changes Required by ACA 16 ACA changes affect these ppulatins: Year Olds 0-150% FPL Pregnant Wmen % FPL Breast and Cervical Cancer, HIV+ MassHealth Basic MassHealth Essential Cmmnwealth Care Cmmnwealth Chice Medical Security Plan Insurance Partnership Health Safety Net

17 Subsidized Insurance Cverage 17 FPL 400% 300% QHP Federally subsidized at ACA tax credit levels QHP ACA federal tax credit with pssible additinal state subsidy } Administered by Health Cnnectr 200% 133% BHP Medicaid } Administered by MassHealth 0% (Standard and Benchmark) Prpsed ACA Cverage Mdel

18 Transitin Ppulatins 18 FPL 400% Medical Security Plan Health Safety Net Cmm Chice QHP HSN 300% 200% 100% MH Standard MH Family Asst MH Basic MH Essential MH Insurance Partnership Cmm Care Cmm Care Simplified Eligibility BHP Benchmark QHP Wrap BHP BHP MH Standard 0 BCCTP HIV+ Childless Childless Adults MH Adults LTU Indiv Unempl Cmp Small Business Imm 5-yr Bar Imm 5-yr Bar GF Indiv Inelig fr MH Adults Imm 5-yr Bar year lds Ppulatin Prpsed ACA Cverage Mdel

19 Health Cnnectr and the ACA 19 The Health Cnnectr s future fcus will be n cmmercial small and nn-grup health insurance market We will build ff lessns learned frm bth the Cmmnwealth Care and Cmmnwealth Chice prgrams Leverage the pwer f the Exchange t better serve small businesses Wellness Track & rebates Federal tax credits fr small businesses purchasing thrugh the Exchange in 2014 Upgrade shpping with tls prvided by the ACA Real-time eligibility determinatin Reinfrce payment and delivery system refrm Leverage the Health Cnnectr shelf t highlight r fast-track refrm mdels 19

20 20 Sme Upcming Changes Related t Eligibility 20

21 ACA Key Cncept: 21 Lawfully Present Immigrant Currently Nn-citizens are categrized by MassHealth as Qualified Aliens, Aliens with Special Status (AWSS), and Nn-Qualified Aliens fr the purpses f eligibility. Future Lawfully present will replace the state s current definitins f immigratin status fr purpses f eligibility. ACA establishes a cmmn definitin fr immigrant eligibility fr MassHealth, BHP, and QHP. Must be Citizen r Lawfully Present immigrant t access new federal benefits thrugh MassHealth, BHP r the Exchange.

22 ACA Key Cncept: 22 Mdified Adjusted Grss Incme (MAGI) MAGI is a methdlgy that uses federal incme tax rules and cncepts t cunt incme and determine husehld cmpsitin and family size. Uses federal incme tax rules and cncepts f adjusted grss incme (with sme mdificatins), but is nt simply a number ff a tax return. Will replace current incme cunting methds fr nn-disabled and nn-elderly ppulatins in Medicaid and CHIP, and will be used, with slight differences, t determine tax credit and subsidy (cst-share) amunts thrugh the Exchange.

23 Health Insurance Exchange (HIX) Integrated Eligibility System (IES) Overview 23 Integrated Prtals Integrated Eligibility System Phase I: Jan Health and Human Services Prtal Health Prtal Insurance Exchange Prtal HIX will allw cnsumers t shp fr health insurance, apply fr financial assistance, and enrll in private and public plans in real-time. IES will determine eligibility fr the Medicaid and CHIP prgrams - either directly r by talking t MA21 in real time. It will als determine eligibility fr SHOP emplyers and emplyees, and mre. Phase II: 2015 Other EOHHS Prgrams Prtal HIX will allw cnsumers t apply fr ther public assistance prgrams like SNAP and TANF. The IES will determine eligibility fr these prgrams. Result A first-class, 21 st century custmer and partner experience that is cnsumer-fcused, cst-effective, and re-usable by ther states.

24 High-Level Eligibility Systems Prcess 24 Member applies fr benefits N wrng dr single pint f entry Web Prtal Health Insurance Exchange Integrated Eligibility System - HIX/IES Initial Eligibility Screen Citizenship/ Immigratin Status Husehld incme eligibility (MAGI) Verificatin Member Aged r Disabled? (Traditinal Rules) Yes MA21 Eligibility Determinatin N Rule-based Eligibility Engine MassHealth (Medicaid, CHIP and Benchmark) BHP QHP Health Plan Enrllment Federal Data Hub SSA, IRS, DHS etc. State Data DOR, RMV, etc. Carrier Hub Plans, rates, enrllments, etc.

25 25 Massachusetts Implementatin Activities fr Subsidized Ppulatins MassHealth and the Health Cnnectr, alng with ther state agencies are engaged in analysis and planning arund changes t subsidized prgrams and unsubsidized health insurance ptins. MA has been awarded grants t assess and plan fr plicy, prgrams, business peratins and IT systems changes. Fr full a listing f grants received by state gvernment g t: MA must cmply with ACA requirements fr Exchanges t determine eligibility fr and crdinate enrllment in Medicaid, CHIP and state health subsidy prgrams using: A single, streamlined eligibility frm fr all prgrams A secure, electrnic interface Multiple access pints: internet, mail, phne, in persn Massachusetts is fully engaged in implementing natinal refrm and we will keep yu updated..