The Affordable Care Act: What it Is & How It Will Affect The People You Serve

Transcription

1 The Affordable Care Act: What it Is & How It Will Affect The People You Serve Stephani Becker Illinois Health Matters, Project Director Stephanie Altman Health & Disability Advocates, Programs & Policy Director May 14, 2013

2 About Us celebrating 20 years of helping vulnerable populations thrive Like us on on.fb.me/hdadv Follow us on Chicago-based, state/national in scope Advance health, education, workforce and income equity for people with special health care needs Staff: Lawyers, MSWs, Policy Analysts Client Representation, Medical Legal Collaboration, Training/Consulting to States on Public Benefits and Employment Policy/Advocacy Health and Workforce Equity, Special Education, People with Disabilities, etc. Since 2010, main focus on Affordable Care Act

3 Information Covered Today: 1. Key components of the ACA 2. New paths to health coverage in Health care benefits under new private insurance and Medicaid plans 4. Illinois Uninsured Populations 5. Visualizing Health Reform 6. ACA Impact on Immigrants & Limited English Speakers

4 April 13 Tracking Poll: 4 in 10 Unaware ACA is Still Law Enroll America Research Findings, February 2013

5 Key Components of the Affordable Care Act Available Now Dependent Coverage up to age 26 CountyCare (Early Expansion of Medicaid in Cook County) Consumer protections/transparency No pre-existing condition exclusion for children No lifetime limits Health plans cannot drop people when they get sick Insurers are required to spend 80-85% of premium dollars on patient care (and refund consumers when they spend less!) Preventative Services no co-pay for many services in private insurance & Medicare Small business tax credits Increased primary care rates for Medicaid providers in Closing of Medicare Part D donut hole (entirely by 2020)

6 How Does the ACA Impact Prevention Services? New private plans offered after Sept. 23, 2010 are required to provide these new preventive services (and others) without cost sharing Type of Preventive Service Alcohol Misuse Aspirin Blood Pressure Cholesterol Colorectal cancer Depression Type 2 Diabetes HIV Diet/Obesity Sexually Transmitted Infection (STI) Tobacco Use Breast Cancer/Mammograms Immunizations Developmental screening for children Full list of no cost preventive screenings available on healthcare.gov

7 CountyCare Eligibility Live in Cook County Be years old Have income at or below 133% of the Federal Poverty Level (make less than $15,000-$21,000 per year) Not be eligible for state Plan Medicaid (parent, pregnant, blind or receiving disability income) Not be eligible for Medicare Be a legal immigrant for five years or more or a US citizen

8 CountyCare: Methods to Enroll Apply with Application Assistors by phone or in person By Phone: - Call M-F 8-8, Sat 9-2 In Person: - Stroger Hospital, Provident Hospital and Oak Forest Health Center Two steps to apply -Provide verbal answers to application questions -Submit verification documents Go to: for more information and FAQs

9 CountyCare: Selected Covered Services Hospital emergency room visits Hospital inpatient services Hospital ambulatory services Nursing Facility Services (30 days) (covers post-hospitalization nursing home stays) Physician services Advanced Practice Nurse services Laboratory and x-ray services Prescription Drugs Family planning services and supplies Podiatric Services (for diabetics) EPSDT (for year olds) Dental (for year olds only) FQHCs, RHCs and other Encounter rate clinic visits) Emergency Services (includes poststabilization services) Sub-acute alcoholism and substance use disorder services Mental Health Services (including rehabilitation and clinic option) Medical supplies, equipment, prostheses and orthoses, and respiratory equipment and supplies Home health agency visits Hospice (and palliative) Physical, Occupational, Hearing and Speech Therapy Services Transportation - to secure Covered Services Targeted Case Management (behavioral health)

10 Mental Health/Substance Abuse Services under CountyCare Covers most Medicaid behavioral health covered services PsycHealth coordinates all behavioral health treatment for CountyCare and generates the appropriate referrals ( or ) Preauthorization is not required for emergencies and PsycHealth has waived the requirement for preauthorization of initial evaluation PsycHealth will give client three different referral options. The client can then advise on which one they prefer and referral will be generated.

11 Key Components of the Affordable Care Act Starting in 2014 and beyond State or federal Health Insurance Exchanges new marketplaces with Essential Health Benefits package (Enrollment begins Oct. 1, 2013) Non Profit health insurance CO-OP: Land of Lincoln Health Large Medicaid Expansion to Adults up to 138% FPL No pre-existing condition exclusion Consumer protections no annual limits, no rating by health status or gender only by age, location & smoker/non-smoker Shared Responsibility Provisions Individual Mandate Employer Mandate (for orgs with 50+ FTEs)

12 Income & Pathway to Coverage (Adults) Insured, 6,228,332 Uninsured 1,528,237 <138% FPL Medicaid % FPL Marketplace w/ Tax Credit >400% FPL Marketplace, No Tax Credit

13 Ready, Set Exchange (Marketplace) PENT UP DEMAND: 1.6 million nonelderly adults in Illinois don t have insurance. In 2014, most will be able to access coverage through the Health Insurance Marketplace Exchange, Marketplace No Subsidy, 191, ,692 Marketplace New Medicaid, w/tax Credit 717, ,923 Exchange New Medicaid, W/Subsidy, 618, ,622 Source: American Community Survey

14 Young adults in Illinois are the most likely to be uninsured 3,500,000 35% 3,000,000 2,500,000 29% 25% 30% 25% 2,000,000 1,500,000 19% 16% 13% 20% 15% 1,000, ,000-4% 1% Under to to to to to and over with HI w/o HI % Not Covered 10% 5% 0%

15 Latinos & African Americans in IL are most likely to be uninsured 6,000,000 42% 45% 5,000,000 4,000,000 28% 40% 35% 30% 3,000,000 19% 21% 25% 20% 2,000,000 13% 15% 1,000,000 10% 5% - White not Latino Latino Black not Latino Asian not Latino Other not Latino 0% with HI w/o HI % Not Covered

16 818,488 (25%) of adults in Cook County are uninsured.

17 Medicaid Expansion in 2014 In 2014, anyone up to 138% (133% plus 5% income disregard) FPL is eligible for Medicaid, called newly eligible Medicaid. No disability requirement. Must be under 65, not entitled to or enrolled in Medicare A or enrolled in Part B. Modified gross income (MAGI) and no asset test, which is different from current Medicaid and All Kids Programs. Federal government pays for much greater percentage of this expansion. Most applications will be filed electronically through a Health Insurance Exchange/Marketplace. Others will be filed through more traditional methods. Advocacy Alert: Illinois needs to pass legislation to enact this! SB 26 passed in Senate next up is the House

18 Essential Health Benefits Package: What is it? All non-grandfathered health plans in individual & small group market must cover these essential benefits at a minimum Illinois has chosen BCBS Blue Advantage as the Benchmark Plan supplemented by AllKids for dental and Federal VIP for vision for children. Illinois is currently developing their Medicaid Expansion Benchmark most likely similar to FamilyCare. Ambulatory patient services; Emergency services; Hospitalization; Maternity and newborn care; Mental health and substance use disorder services; Prescription drugs; Rehabilitative and habilitative services and devices; Laboratory services; Preventive and wellness services including chronic disease management; Pediatric services including oral and vision care.

19 What is an Exchange or Health Insurance Marketplace? One stop shop web portal for businesses (w/fewer than 50 employees) & individuals to purchase health coverage/medicaid Benefits will be standardized and must meet minimum standards Plan information and pricing can be easily compared Premium tax credits for those earning up to 400% FPL (about $90k for family of four). Navigators, in person counselors and certified application counselors will be available to help Illinois will run an exchange in Partnership with the Federal Government in Enrollment begins October 2013

20 More on Exchanges/Health Insurance Marketplaces Proposed 165 Qualified Health Plans by 6 carriers in Illinois Plans Organized into 4 Metal Tiers & Some Catastrophic Premium Tax Credits & Cost Sharing Subsidies for those under 400% FPL. Out of pocket limit for those above 400% FPL. Essential Community Providers must be included in networks

21 Making Health Insurance More Affordable Premium Tax Credits are available to individuals and families with incomes between 100% - 400% of the Federal Poverty Level ($23,000 to $94,000/year for a family of four) Individuals must report changes in income in order to assure that the premium tax credit is correct and to avoid a reconciliation at the end of the tax year in which they would have to pay back taxes. In addition, Cost Sharing Subsidies (e.g., help with co-payments for doctor visits and hospital care) are also available to individuals and families with income between % of the Federal Poverty Limit ($59,000 for a family of four)

22 Premium Tax Credit Example Johnson Family w/ Annual Income of $35,300 (150% FPL) Choose a Qualified Health Plan in Illinois Health Insurance Marketplace Annual Premium = $12,500 Out of Pocket Costs = 4% of income Out of Pocket Costs, $1,410 ($118/mo) Tax Credit, $11,090

23 How Federal Subsidies to Purchase Private Insurance Work Premium Tax Credit ( % FPL) Payment: Premium tax credit is paid in advance on a monthly basis directly to health plan Application person applies for tax credit & cost sharing reductions during marketplace open enrollment w/ recent tax return or other documentation of income Reconciliation: person files federal tax return, under or overpayments are reconciled (overpayments capped based on income) Reconciliation: none Cost Sharing Reduction ( % FPL) Payment: Costsharing reductions are paid directly to the plan. Source: NASTAD.org Health Reform Issue Brief

24 Shared Responsibility Provision ( The Individual Mandate ) Requires most individuals (including children) to carry minimum essential health coverage Many exemptions: Religious reasons Undocumented non citizen Household income is below the minimum threshold for filing a tax return (Go to for tax assistant) Unaffordable coverage (insurance premiums exceed 8% of family income) Payment, exemption or penalty is through the federal income tax return:

25 Shared Responsibility Provision ( Employer Mandate ) Beginning January 1, 2014, some businesses will be required to provide minimum-level health insurance coverage to their employees. Businesses with 50 full-time equivalents (FTEs), or fewer, are exempt from this provision and are not penalized even if their employees access a tax credit on their own FTEs are defined as someone working 30 hours or more/week Businesses with more than 50 FTEs could face a financial penalty, depending on whether the employer offers insurance, if at least one full-time employee accesses a tax credit or cost-sharing reduction on his/her own

26 Populations Without Path to Coverage After 2014 Individuals residing in states that choose not to expand Medicaid. People who do not enroll in Medicaid or purchase insurance through the health insurance marketplace, or otherwise. Barriers to eligible but not enrolled include lack of education and outreach and affordability. Non citizens who are lawfully present but have not been in the U.S. for 5 years are generally not eligible for Medicaid but may purchase insurance in Marketplace and may be eligible for premium tax credits and cost-sharing subsidies depending upon income. Undocumented immigrants are not eligible for either Medicaid or allowed to purchase Marketplace plans.

27 High Prevalence of Lack of Insurance Among Non Citizens Peoria/Bloomington Southern Illinois Champaign/Kankakee DuPage County Will/Grundy counties Western Illinois Springfield/Decatur Lake County Rockford/DeKalb Suburban Cook County Central Illinois Kane/McHenry/Kendall counties Chicago Metro East 16% 19% 35% 40% 47% 48% 49% 49% 51% 51% 52% 57% 59% 62% 0% 10% 20% 30% 40% 50% 60% 70%

28 Non-Citizen Eligibility for Medicaid Naturalized Citizens: Same access and requirements as U.S. born citizens. Legal Permanent Residents Residing in US for more than 5 Years: Eligible for Medicaid. Pregnant Women and Children: Eligible for Medicaid Regardless of Citizenship/Immigration Status.

29 Non-Citizen Eligibility for the Marketplace Naturalized Citizens: Same access and requirements as U.S. born citizens. Lawfully Residing in US and reasonably expected to reside in US during entire period of enrollment: Eligible to Purchase Insurance from the State Health Insurance Marketplace. Eligible for premium tax credits. Subject to individual mandate.

30 Data on Non-Citizens 823,750 Non Citizens in Illinois. 430,141 (52%) are Uninsured Total Non-Citizen Number includes: Legal Permanent Residents (LPRs) (eligible and ineligible for Medicaid) Lawfully Present Undocumented New version of Visualizing Health Reform ( has some data on uninsured non citizens

31 Paths to Coverage for Non-Citizens 149,283 uninsured Legal Permanent Residents in Illinois Those who have been in the US less than 5 years may not be eligible for Medicaid but could be eligible for premium tax credits in the marketplace in ,858 uninsured undocumented persons in Illinois No new path to coverage in 2014.

32 # of Legal Permanent Residents Who are Uninsured, By Region Chicago Suburban Cook County DuPage County Kane/McHenry/Kendall counties Lake County Will/Grundy counties Champaign/Kankakee Springfield/Decatur Western Illinois Rockford/DeKalb Central Illinois Metro East Peoria/Bloomington Southern Illinois 8,388 8,386 7,175 4,646 2,671 2,225 2,069 1,776 1, ,980 66, ,000 20,000 30,000 40,000 50,000 60,000 70,000

33 # of Undocumented Non Citizens Who are Uninsured, By Region Chicago Suburban Cook County Kane/McHenry/Kendall counties Lake County DuPage County Will/Grundy counties Rockford/DeKalb Champaign/Kankakee Western Illinois Metro East Central Illinois Peoria/Bloomington Springfield/Decatur Southern Illinois 31,702 21,339 18,288 12,277 8,913 4,772 2,379 2,206 1,568 1, , , ,000 40,000 60,000 80, , ,000

34 Outreach and Enrollment Issues Reaching non-citizens will be difficult for several reasons including limited English speakers; confusion on eligibility; mixed status families; fear of immigration issues. Undocumented non-citizens will continue to need access through county hospitals; public health departments; free and charitable clinics; federally qualified health centers. LPRs may experience disruption in coverage moving from marketplace to Medicaid after 5 years.

35 CLAS: Culturally and Linguistically Appropriate Services National Standards endorsed by HHS Office of Minority Health Provide effective, equitable, understandable, and respectful quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy, and other communication needs. HHS CLAS Blueprint for Healthcare Reform Implementation at asp#clas_standards

36 How To Stay Informed Bookmark Resources in Korean, Chinese, Khmer, Vietnamese, Nepali Sign up for IHM newsletter, Linkedin, Facebook page, Twitter and Blog Stay tuned for information about health care marketplace (Enrollment Oct 2013) Questions? Contact: Stephani Becker Phone: Stephanie Altman Phone: