Consumer Perspective on the Health Insurance Marketplace and Medicaid Expansion. Laval Miller-Wilson Temple University School of Law April 20, 2013

Transcription

1 Consumer Perspective on the Health Insurance Marketplace and Medicaid Expansion Laval Miller-Wilson Temple University School of Law April 20, 2013

2 PHLP: Oldest & Only Non-Profit Law Firm Focused Exclusively on Health MISSION: Ensuring low income Pennsylvanians access to health services for preventive care AND for treatment of acute or chronic conditions Traditionally focused on the uninsured and publicly funded health care programs 2

3 PHLP s Constituency Pennsylvanians Without Health Insurance (1,372,100 or 12% of Pennsylvanians) Pennsylvanians in Medicaid (2,199,371; 45% are children) Low-Income Medicare Enrollees Earning Less Than $11,490 per year (approx. 500,000) Kids in Children s Health Insurance Program (CHIP) (191,508) Disabled Adults in Home & Community Waiver Programs (23,716) 3

4 Health Insurance System Outline 4 Publicly Financed Medicaid (2.1 Million /15%) CHIP (191,508) PA Fair Care (High Risk) (4,816) Medicare (1.8 Million / 14%) Privately Financed ER-based Group Policies (6.6 Million / 54%) Individual Policies (581,700 / 5%) Continuation: COBRA & HIPPA; mini- COBRA Non-Insurance Based Veterans Health Admin. Uninsured / Underinsured Health Centers (FQHC) County MH/MR ER (EMTALA; charity care) Rx Assistance Programs (needymeds.org)

5 PHLP s Goals Increasing understanding and awareness among Pennsylvanians, their family members, advocates and providers about public health programs (e.g., benefits, how to access them) Ensuring people in public health programs get help when denied medically necessary services 5

6 PA s Health Insurance Marketplace Will Be Operated by the Federal Government

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8 Key Function of Marketplace Determines eligibility for tax credits and costsharing reductions to help with health care costs Tax credits to reduce premium costs: are available to eligible consumers with HH income between 100% and 400% FPL the credit is paid each month to the insurer and reduces the premium amount the consumer owes 8

9 Who Is Not Eligible for Premium Tax Credits? Anyone who has affordable employer-based health insurance Anyone 65 or older Anyone on Medicare or Medicaid Anyone who is not a citizen or a legal permanent resident Persons incarcerated 9

10 Amount of Premium Tax Credits Varies Depending on Income Income Level Premium as a Percent of Income % FPL 2% of income % FPL 3-4% of income % FPL 4 6.3% of income % FPL % of income % FPL % of income % FPL 9.5% of income 10

11 Maximum Premium Contribution for Individual Coverage (2013 FPL) Percent of Poverty Income Maximum Premium Contribution Annual Dollars Annual Monthly Up to 133% $15,282 $306 $26 Up to 150% $17,235 $690 $58 Up to 200% $22,980 $1,448 $121 Up to 250% $28,728 $2,313 $193 Up to 300% $34,470 $3,275 $272 Up to 400% $45,960 $4,367 $364 11

12 Example of Premium Tax Credit for Single Person Pat is a 45-year-old woman with an income of $1,436/month or $17,235/year (150 percent of poverty) Under the ACA, Pat would not be required to spend more than 4% of her income on annual premiums ($690 total or $58/month) The premium cost of a Silver Plan in Pat s area is projected to be $5,733/year If Pat joins that plan, her tax credit is paid to the plan i.e., $5,043 (the $5,733 premium minus the $690 of what Pat must pay) Plus-Pat has reduced cost-sharing for co-pays, deductibles, etc as she is <250% FPL 12

13 How the Coverage Levels Differ 13

14 Most Americans Are Unaware of 2014 Options 72% lack awareness of these new options for insurance 78% of uninsured adults lack awareness. 83% of the Medicaid expansion population lacks awareness. 14 Enroll America

15 Marketplace Enrollment First Open Enrollment October 1, 2013 to March 31, 2014 Coverage starts Jan. 1, 2014 (if enroll by 12/15) Annual Open Enrollments October 15 th to December 7 th Coverage starts January 1 st Special Enrollment Periods Exist 15

16 Negative Experiences Frame Consumers Expectation 44% have shopped for health insurance outside their job. Of these, most found it hard to: find a plan they could afford (77%) understand all of the fine print and details (70%) find a plan that covered all of the care they need (66%) know where to look for a plan (55%) 17 % have been denied for a pre-existing condition. 55% did not find and get a plan last time they looked 16 Enroll America

17 How People Feel about Health Insurance Shopping 17 Enroll America

18 Helping People Move to Where They Want to Be 18 Enroll America

19 Answering Their Questions Why do I need health insurance? How do I get health insurance? Which type of health insurance is right for me (and my household)? Will it be affordable? Will enrollment be simple? 19

20 Opportunities for Outreach, Counseling & Representation Distribute fair and impartial information Help people apply for and enroll in QHPs Counseling and representation for eligibility appeals (fair hearings) Provide referrals for an enrollee with a grievance, complaint or question about their health plan 20

21 January 1, 2014 An important day, but just one day.

22 22 Medicaid Expansion in Pennsylvania

23 Medicaid Expansion

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25 Statements by Governor Corbett Can't recommend it to the Legislature at this time because I believe we need to get some reforms... an expansion is not sustainable in Pennsylvania Do not trust the feds to honor their funding promises "We have to look at the cost [of coverage] Our average cost is already $7,400, which is $3,000 higher than the other states 25

26 Medicaid in PA/Medical Assistance Joint Federal/State Program Run by the PA Department of Public Welfare Annual Operating Budget of $19.5 Billion Broad array of health and long term care services not typically covered by private insurance (e.g., transportation, skilled nursing for children)

27 Who s Now Covered By Medicaid in Pennsylvania? Medicaid Does Not Cover All Low Income Persons Equally Children (most generous, but varying levels) Individuals With Disabilities (up 250% FPL) Pregnant Women (up to 187% FPL) Parents with Children (up to 47% FPL) Elderly (65 and Over, up to 100% FPL) 27

28 Family of Three Led by Low Income Single Mother Low-Income = Earning $2,165/month or $12,980/year (133 % or poverty) Medicaid Does Not Cover Members Equally Three-year old child eligible for Medicaid (because HH income for children between ages 1 5 is 133% of poverty) Eight-year-old child not eligible (because HH income for children between 6-19 is 100% poverty, but eligible for CHIP) Mother is not eligible for standard Medicaid coverage (because HH income for parents must be less than 40% of poverty) 28

29 Changes to Medicaid Eligibility Below 133% (138%) of FPL - Includes standard 5% income disregard $15,232 for a family of one; $31,322 for a family of four Eliminates Asset Tests Same income standard across all states Primarily childless adults and parents Under age 65 Different benefits package: not LTC

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31 31 50% of Counties Have > 15% MA

32 Federal Funding PA s current Federal Match (FMAP) = 54% Enhanced FMAP for Newly-Eligible Individuals on 100% 100% 100% 95% 94% 93% 90%

33 FY Medicaid Enrollees and Expenditures by Category of Assistance Medicaid Enrollees and Expenditures Number of Eligible People Expenditures 333,233 15% Elderly $4,465,109 26% 501,253 23% Disabled $943,548 $7,902,875 47% 1,235,560 57% Families $3,842,831 23% 97,569 5% Adults w/o Children $738,717 4% (Dollar Amounts in Thousands) 10

34 Does Medicaid Work? The Oregon Health Study, a landmark examination of people's health and access to care, found Medicaid is great insurance, especially for people who do not have any!