Health Care Transition and The Affordable Care Act: New Options for Young Adults

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1 Health Care Transition and The Affordable Care Act: New Options for Young Adults Rebecca Boudos, MSW Transition Specialist, Transition Team Spina Bifida Program Parag Shah, MD, MPH Medical Director, Transition Team Ann and Robert H. Lurie Children s Hospital of Chicago Chicago, IL Sarah O Connor Health & Disability Advocates Chicago Medical-Legal Partnership for Children Senior Attorney

2 Disclosures We have no financial or commercial disclosures relating to this presentation.

3 Information Covered Today: 1. Healthcare system and the approach to Transition 2. Key components of the ACA 3. New paths to health coverage in Health care benefits under new private insurance and Medicaid plans 5. Trends in health care delivery 6. Illinois Uninsured Populations 7. ACA Impact on Immigrants 8. New Health Care Options for Transition Aged Youth

4 The Medical-Legal Partnership Model Lawyers and health care providers partnering to provide comprehensive patient care Identify legal issues impacting health and economic security Develop collaborative strategies to address the medical-legal needs of emerging adults Transition clinics legal and medical transitions

5 Transitions HEALTH CARE TRANSITION the purposeful, planned movement of adolescents and young adults with chronic physical and medical conditions from child-centered to adult-oriented health care systems. (AAP Clinical Report 2011) 1

6 Why HealthCare Transition? 12-20% of youth in IL are thought to have special health care needs Over 90% of youth with chronic illnesses survive into their 20 s More than ½ million YSHCN make the transition into adulthood Outcomes including clinical markers (HgbA1c etc.), utilization of high-cost settings, and morbidity and mortality increase during the transition period A systematic preparation leads to better clinical outcomes (adherence, hospitalizations, clinical markers etc.) High priority for IOM. MCHB, AAP, AAFP etc. *American Academy of Pediatrics. Survey: Transition Services Lacking for Teens with Special Needs. AAP News. Vol 30;

7 Known Barriers Pediatric Providers have reported Lack of adult physicians to care for young adults with chronic illness Lack of adult physicians with knowledge of pediatric diseases Poor reimbursement Their own reluctance Adult Providers have reported Lack of training Difficulty meeting psychosocial needs Lack of time and reimbursement Lack of coordinated transfer from pediatric practices Families and Patients have reported Differences in culture between pediatric and adult health care models Nervousness about going to somebody that doesn t know anything about me

8 AAP Clinical Algorithm1

9 Six Core Elements 4 1. Develop a transition policy 2. Identify youth that are going to be difficult to transition 3. Assess youth for transition readiness CHECKLIST 4. Develop tools for transition a. Portable medical summary b. Emergency plan 5. Transfer care a. Summary b. Communication with new provider c. Condition fact sheet if necessary 6. Completion of Transition Continue to be a resource

10 Checklist Example

11 Transition Assessment of Youth OTHER ITEMS Guardianship/Health Care Power or Attorney Community Resources PUNS DRS Services Recreation and Leisure Living arrangements Career/Vocation Post-high school transition DRS Vocation Rehab College- Office for Students with Disabilities Work Programs Insurance, Benefits, and future financial planning Adult Health Insurance options SSI/SSDI Special Needs Trusts

12 Why does health insurance matter? Without health insurance medical care would be too expensive and many doctors require you to be in-network to be seen. Young adults and increased risk of being un-insured (2x the average rate) Health insurance can change during transition into adult hood SSI does not have same eligibility criteria for children and adults Programs like DSCC only cover until age 21 The Affordable Care Act will mandate that everyone enroll in a plan or else there will be penalties Your health care treatment may be impacted if your health insurance is not in network with your current providers or future adult providers You may be eligible for various new options under the ACA and it is important to be educated

13 Insurance Security for Young Adults The Affordable Care Act ensures young adults have quality, affordable health insurance choices regardless of how their lives change, particularly as young adults frequently change jobs, move, or hold part-time or temporary jobs

14 Key Components of the Affordable Care Act Available Now Dependent Coverage up to age 26 Any foster child at age 18 can stay on Medicaid until 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)

15 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

16 Key Components of the Affordable Care Act Starting in 2014 and beyond State or federal Health Insurance Marketplace new marketplaces with Essential Health Benefits package (Enrollment began 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)

17 Income & Pathway to Coverage (Adults)

18 What if You Already Have Insurance?

19 How Do You Enroll in Medicaid and the Marketplace? Get Covered Illinois is the name of the Illinois Marketplace website. This website will direct people based upon their demographic information to either the ABE (Application for Benefits Eligibility) system to apply for Medicaid (and other state benefits) or the Marketplace (to select an insurance plan and get financial help to pay for it)

20 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 Exchange, 191,692 Exchange w/subsidy, 717,622 New Medicaid, 618,923 Source: American Community Survey

21 Young adults in Illinois are the most likely to be uninsured

22 Latinos & African Americans in IL are most likely to be uninsured

23 818,488 (25%) of adults in Cook County are uninsured.

24 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 GetCoveredIllinois.gov. Others will be filed through more traditional methods.

25 Medicaid: Integrated Care Program Shift toward managed care New Medicaid program for older adults and adults with disabilities aged 19 and older living in one of these counties DuPage, Kane, Kankakee, Lake, Will, or suburban Cook. Will expand to Chicago. As of February ,079 individuals enrolled in the Integrated Care Program. Enrollees must pick a PCP for their medical home with one of the two health plans - Aetna Better Health or IlliniCare Health Plan. Provider networks are different then those with Medicaid not in a managed care plan.

26 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.

27 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 credit subsidies for those earning up to 400% FPL (about $46k for individual; $90k for family of four). Navigators, in person counselors and certified application counselors will be available to help

28 Making Health Insurance More Affordable Premium Tax Credits are available to individuals and families with incomes between 100% - 400% of the Federal Poverty Level ($15,000 to $46,000 for an individual; $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 ($29,000 for an individual; $59,000 for a family of four)

29 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

30 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.

31 Some Key Issues for Transition-Aged Youth Adult Medicaid is no longer tied to SSI eligibility May remain as dependents on parents insurance through age 26 College Insurance Plans minimum coverage requirements Private Insurance through the market exchange Employer-based Challenge for low-income college students moving to a state that does not have Medicaid expansion

32 Dependent Coverage for Young Adults Children up to age 26 can stay on their parents plan even if they are: Married Not living with their parents Live in a different state as their parents Attending school Not financially dependent on their parents Eligible to enroll in their employers plan A college graduate

33 Choices for Young Adults Over Age 19 Continue on parent s plan until age 26 Use the Marketplace to purchase a Quality Health Plan or Catastrophic coverage plan (this plan is available up to the age of 30) if over 138% FPL If in college in another state, the individual can choose which state Marketplace to utilize for enrollment (their home state or the one where they attend school) Obtain health coverage through employment (if an option) Obtain Medicaid if below 138% FPL

34 Issues Affecting College Students: College students attending school in a state that has not expanded Medicaid must either: Stay on parents private health insurance Enroll in the Marketplace (either in Illinois or the state where they attend school) Enroll in college insurance plan

35 CASE EXAMPLE 1 Joseph is a 19 year old with complex congenital heart disease. He has no physical limitations or cognitive limitations. He does get frequently hospitalized for flareups and requires 3 medications, sees a cardiologist, pulmonologist, and PCP at least 4 times/year and needs imaging at least once per year Joseph is planning on going out of IL for college to New York His parents have BC/BS through their employer by which he is currently covered

36 CASE 1: OPTIONS Remain covered under parents BC/BS plan College Health Plan Now adheres to minimum standards Exchange In New York Unknown cost sharing, tax credits

37 Case 1: Discussion Points He likely requires a complex network of care and should make sure that providers he needs will be accessible under any plan he chooses Parents plan may be local College plan may not include complex network of providers

38 Case Example 2 Susan is a 21 year old girl with Cerebral Palsy and Seizure disorder who is living at home. She sees a neurologist and physiatrist and takes 2 anti seizure medications. She is currently working and earns $12000 per year. Her employer does not offer health insurance Her parents are currently insured through Medicaid expansion in IL

39 Case Example 2: Susan Options Medicaid Not eligible for Exchanges

40 Resources Subsidy calculator

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