HealthCare 201: Essential Updates Before Open Enrollment. Webinar

Transcription

1 HealthCare 201: Essential Updates Before Open Enrollment Webinar

2 About ITUP ITUP is a non-partisan, non-profit health policy think tank based in Santa Monica, CA. W e are f unded by generous grants f rom The C al i f orni a W el l nes s Foundati on, The California Endowment, Blue Shield of California Foundation, California Community Foundation, Kaiser Permanente, and The California HealthCare Foundation.

3 ACA Refresher Medi-Cal Expansion Covered California Insurance Market Reforms Individual & Employer Mandates

4 Coverage Expansions The ACA expands healthcare coverage through two major systems: MEDICAID (MEDI-CAL): public coverage program for low-income Californians COVERED CALIFORNIA: Virtual shopping mall where individuals, families, and employers can purchase affordable health insurance

5 Medi-Cal On January 1, 2014 Medi-Cal extended coverage to all citizens and legal permanent residentsages19-64withincomesupto138%ofthefederal poverty level ($16,105 for an individual and $32,913 for a family of four). Increased income standard for parents from 100% to 138% FPL Extended coverage to adults without dependent children to 138% FPL

6 Medi- Cal Expanded Benefits Mental health services are now more accessible. Mental health services for the severely and chronically mentally ill are available through the county Mental Health Departments. Psychological services for those with less severe mental illness are provided through the Medi-Cal Managed Care plans and their provider networks. Expanded Substance Use Disorder treatment services are available to all Medi-Cal members.

7 Medi-Cal Expanded Benefits Dental services are now more accessible. On May 1, dental benefits for adults were restored. Office visits Cleanings X- rays Fillings Crowns Compl ete dentures Root canals

8 Medi-Cal Enrollment The ACA helps to streamline and modernize the enrollment process for Medi-Cal applicants. Central application and enrollment system for both Medi-Cal and Covered California CalHEERS Electronically processed applications with income and residency information verified electronically Eliminated asset tests Except for seniors, Medi-Medis, and individuals in long-term care Improves renewal process with pre-populated forms

9 California's Health Insurance Exchange is: Covered California, C O V E R E D C A L I F O R N I A One-stop shopping for quality, affordable health plans.

10 Covered California Individuals and households with incomes between 138% and 400% FPL qualify for premium subsidies. 138% FPL - $16,105/year (individual), $32,913/year (family of 4) 400% FPL - $46,680/year (individual), $95,400/year (family of 4) In addition, Individuals and households with incomes between 100% and 250% FPL qualify for cost- sharing subsidies that reduce copays and deductibles, only for enhanced silver plans.

11 Covered California All plans must include the 10 essential health benefits Ambulatory patient services Emergency services Hospitalization Maternity & newborn care Mental health & substance use disorder services Prescription drugs Rehabilitative & habilitative services & devices Laboratory services Preventive & wellness services, chronic disease management Pediatric services, including oral & vision care Standardization of plans benefit packages makes them easy to compare Copays, deductibles, and out-of-pocket maximums vary with metal tiers

12 Covered California Four tiers of health plans Platinum (90% actuarial value) Gold (80%) Silver (70%) Bronze (60%) MinimumCoveragePlans(CatastrophicCoverage) Only available up to age 30 or to those who can prove they are experiencing financial hardship Prices of plans vary within each tier. Plan choices apply for one year you cannot change tiers or plans until annual open enrollment or special enrollment.

13 Open Enrollment People can only buy health insurance through Covered California during a specified time period called open enrollment. Open enrollment for 2014 closed March 31, will reopen in the fall (Nov. 15 Feb. 15). But people with certain life events qualify for special enrollment. Medi- Cal is open year- round.

14 Insurance Market Reforms Insurance plans: Cannot cancel existing coverage, except for cases of fraud Cannot refuse to sell health insurance to individuals based on pre-existing conditions (e.g. asthma, diabetes, etc.) Cannot impose lifetime limits on coverage Must provide coverage for dependent children up to age 26 Must provide recommended preventive services without cost- sharing or co-payments (wellness visits, mammograms, colonoscopies, vaccinations) Can vary premium costs only based on age, location, and family size

15 Individual Mandate The ACA requires individuals to have health insurance. Individuals must have health insurance through an employer, union, Exchange plan, individual plan, Veteran s Administration, Indian Health Services, Medicare, or Medi- Cal. Individual penalty takes effect in 2014: The greater of flat dollar amount or income formula, whichever is more $95 per adult + $47.50 per child or 1% of income in 2014 $325/adult + $162.50/child or 2% of income in 2015 $695/adult + $ /child or 2.5% of income in 2016 and thereafter

16 Employer Mandate In 2015: Employers with 100 or more full-time equivalent employees must offer health insurance. In 2016: Employers with 50 or more full-time equivalent employees must offer health insurance. Or pay fees if a full- time employee uses tax credits in the Exchange Fee of $2,000 per employee, excluding the first 30 employees, for failing to offer insurance to full-time employees Fee of $3,000 per employee for failing to offer affordable coverage (employee contribution is more than 9.5% of income) for each employee who uses tax credits

17 Year 1: Results & Lessons Learned

18 1,395,929 individuals enrolled in plans through Covered California 1,930,000 individuals newly enrolled in Medi- Cal

19 Enrollment (Covered California: April 15, 2014) Covere California / 609 Non-subsidized 88% 1,222,320 Subsidized 57% 1,100,000 1 / 100 / 000 Enrolled 34 % 650, Transitioning to Medi-Cal from LIHP 9 % Individuals Enrolled: 1, ,000 Express Lane Individuals Enrolled: 1I 930/0 00

20 Enrollment (Covered California: April 15, 2014)

21 overed Californi. nrollment 1,- - (Covered California: April 15, 2014) Re ions Base Projection for Total Enrolled (with plan selection) on ,710 Difference Base Projection for 3/31/14 AL_ rformance to date 4 of base projection) 229% Northern CA 22,571 29,139 Greater Bay Area 89, , , % Sacramento 28,726 69,540 40, % San Joaquin 58, ,183 50, % Central Coast 32,602 95,500 62, % Los Angeles 177, , , % Other Southern CA 170, , , % Total 580,000 1,395, , % Specific Counties Fresno 14,500 23,164 8, % Orange 44, ,804 87,412 I 297% San Diego 43, ,900 78, % i San Bernardino 35,692 53,623 17, % Riverside 40,377 69,350 28, % I r

22 Lessons Learned Effective media and grassroots outreach needed Education on health insurance basics and details is key Differences between HMO, PPO, EPO Differences between premiums and cost- sharing obligations How to utilize coverage Tailored education and outreach for different communities, education levels, regions, and nationalities Mixed immigration status families fear legal repercussions of disclosing personal information

23 Challenges Several challenges presented during the first year of open enrollment. Long wait times for assistance Medi- Cal application backlog Tech glitches Provider directory inaccuracies Enrollment counselor certification process limitations Certified Educators not allowed to provide enrollment assistance Adequacy of provider networks Outreach to minority groups

24 Opportunities for Improvement Maximize consumer assistance Expedite Medi-Cal application procedures Improve user-friendliness of website Update provider directory Streamline background check process and enhance trainings for enrollment counselors Combine Educators/Enrollment Counselor certification (Navigators)

25 Essential Updates

26 Covered California People with certain life events qualify for special enrollment. Events that cause people to lose health insurance Job loss or reduction in hours Divorce or death of policy- holder family member Turning 26 and aging out of parent s insurance Becoming ineligible for Medi- Cal Expiration of COBRA Marriage Becoming a citizen or legally present individual Moving to an area with different plans Birth or adoption Exceptional circumstances loss of eligibility for hardship, natural disasters, etc. Error by Covered California or enrollment counselor MUST enroll within 60 days of the life event

27 Special Enrollment Certain special enrollment periods apply only for individuals already enrolled in Covered California: Becoming newly eligible or ineligible for premium subsidies and/or cost- sharing subsidies Demonstration that the plan violated contract

28 Covered California Filing Taxes and Reconciling Subsidies The federal government will determine if an individual or household received the proper amount of premium subsidies when taxes are filed. Actual earned income for the year and the subsidies received vs. entitled to will be examined. Some individuals may be given refunds OR may have to repay a portion of the subsidies they received, depending on their income or other changes during the year. It is extremely important for households to update their income information as frequently as needed during the year. Married couples must file jointly to receive premium subsidies.

29 Covered California While both occur at tax filing, subsidy repayments and the individual mandate are assessed separately. Medi- Cal has no relation to taxes.

30 Covered California Late Premium Payments Have 90 days after first late payment to become current Coverage is active for first 30 days After 30 days, coverage is suspended for a 60 day period Coverage can be reactivated at any time by day 90 by paying full premium balance If full premium balance has not been paid after 90 days, coverage is terminated After termination, must wait until next open enrollment period to re- enroll

31 Covered California 2015 Plan Changes Tier Changes to Plan Bronze Lowered out-of-pocket max to $6,250 Lowered generic drug copay to $15 Silver Lowered out-of-pocket max to $6,250 Lowered drug to $15 generic copay Enhanced Silver Gold Platinum Catastrophic Lowered generic drug copay Increased non-generic drug copays Increased deductible Lowered out-of-pocket max to $6,250 Lowered drug copay to $15 generic No changes Increased deductible/out-of-pocket max to $6,600

32 Covered California An embedded medical and dental plan will be offered in 2015 to children and families. No dental deductible; dental services are not subject to the medical deductible. Preventative dental care (cleanings, x-rays, sealants/ fluoride) are covered with no cost sharing. Cost-sharing subsidies cannot be applied to lower the cost of services like fillings, extractions, and braces.

33 overed California Open Enrollment for Plan Year 2 November 15, 2014 February 15, 201

34 Covered California October November 15: Enrollees mailed redetermination notices From Covered California and the carriers December 15: Enrollees must update information and select plan If information is not updated, then Covered California will use electronic info and reenroll individuals into their current plan

35 Delays Delayed/pending changes: New legal residents (<5 years) who are adults without minor children with incomes between 100% and 138% FPL will be Covered California eligible rather than Medi-Cal eligible. Pregnant women between % FPL can enroll in Covered California with state financial assistance to lower premiums, deductibles, and copays during pregnancy. Bridge plans

36 Medi- Cal Assets Test Medi-Cal enrollees only age 65 or older, disabled, OR individuals in long- term care are subject to assets tests. Cannot have property worth more than: $2,000 for an individual $3,000 for a couple Home you live in, one car, personal effects are exempt If you cannot pass the assets test, you must spend down to qualify for Medi-Cal. Pay medical bills Pay debts, mortgage, car loan Buy clothes, home furnishings, home repairs Liquidate non- liquid assets

37 Medi- Cal Estate Recovery Medi-Cal enrollees only age 55 or older OR members utilizing long-term care services are subject to estate recovery after the death of the beneficiary. The State can make a claim against the estate of a Medi-Cal member equal to the cost of care or what was paid to the managed care plan Exemptions to estate recovery: A spouse is alive (recovery can be made after the death of the spouse) Member had a minor, blind, or disabled child There is nothing left in the estate A lien can be placed on the home of a Medi-Cal enrollee in long-term care Only if s/he does not intend to return home Exempt if a spouse, child under 21 or blind/disabled, or sibling lives in the home

38 Medi- Cal for Former Foster Youth Young people who were in the foster care system on their 18 th birthday qualify for Medi-Cal up to age 26. Regardless of income Regardless of state residency while in foster care Simplified one- page application No recertification until age 26 Exempt from managed care Apply via county social services offices Foster Care Ombudsman available for assistance or

39 Immigration U.S. Citizens and Lawful Permanent Residents (LPRs) have full access to coverage and financial assistance based on income. There is no waiting period or 5-year ban for legal immigrants newly in the U.S. Undocumented Immigrants o o Not eligible for full scope Medi-Cal or Covered California Eligible for Emergency Medi-Cal (limited scope) Deferred Action for Childhood Arrivals (DACA) o Not eligible for Covered California o Eligible for Medi-Cal Temporary Immigrants and Non- immigrants o o May or may not be approved for Medi-Cal Eligible for Covered California

40 Insurance 101

41 Health Insurance Terms Premium monthly amount paid for insurance coverage Example: Michael, age 30, lives in South LA and makes $30,000/year. He pays $194 a month in premiums, after premium assistance is applied, for a Silver plan. Deductible amount you owe for health care services before your health insurance begins to pay Example: Michael has a $2,000 medical deductible and a $250 brand name drug deductible, but most outpatient services are exempt from the deductible. If he is hospitalized, he will have to pay $2,000 before his plan starts paying. Out-of-Pocket Maximum the maximum total costs of health care services you are responsible for in a year Example: Once Michael has paid $6,350 in medical expenses (not including premiums), he hits his out- of- pocket max, and the plan pays any remaining expenses, at no cost to Michael.

42 Health Insurance Terms Copay fixed amount paid at the point of service for a covered health care service Example: Michael pays a $45 copay when he sees his primary care provider, $65 for a specialist, and $19 for generic drugs. Coinsurance your share of the costs of a covered health care service Example: After Michael hits his deductible, he pays 20% of the negotiated rate of hospitalization services.

43 Deductibles Bronze, Silver, and Catastrophic plans have deductibles In Bronze and Catastrophic, 3 non- preventative primary/urgent/ mental health care visits are not subject to the deductible Most outpatient services, generic drugs, and durable medical equipment are exempt from the deductible in Silver plans Prenatal care, preventative care, and child eye exams and glasses are never subject to deductibles or cost sharing

44 Deductibles Bronze Silver Enhanced Silver 73; % FPL Deductible - Medical $5,000 $2,000 $1,600 $500 $0 $0 $0 Enhanced Silver 88; % FPL Enhanced Silver 94; % FPL Gold Platinum Deductible - Brand Drug Out-of- Pocket Max Included in Medical $250 $250 $50 $0 $0 $0 $6,250 $6,250 $5,200 $2,250 $2,250 $6,250 $4,000

45 Out-of-Pocket Maximums $6,250 $6,250 $6,250 $5,200 $2,250 $2,250 $4,000 Medical Deductible Brand-name Drug Deductible Out-of- Pocket Max Bronze Silver Enhanced Silver 73 ( % FPL) Enhanced Silver 88 ( % FPL) Enhanced Silver 94 ( % FPL) Gold Platinum

46 Cost Sharing Bronze Silver Gold Platinum Enhanced Silver 74 Enhanced Silver 88 Enhanced Silver 94 Primary Care $60* $45 $30 $20 $40 $15 $3 Specialist $70* $65 $50 $40 $50 $20 $5 Urgent Care $120* $90 $60 $40 $80 $30 $6 ER $300* $250* $250 $150 $250* $75* $25 Hospital 30%* 20%* $600/day or 20% $250/day or 10% 20%* 15%* 10% Generic Drugs $15* $15 $15 $5 $15 $5 $3 Preferred Brand Drugs $50* $50* $50 $15 $35* $15* $5 Non- Preferred Brand Drugs $75* $70* $70 $25 $60* $25* $10 *after deductible is met

47 Provider Networks Each health plan has its own network of doctors, hospitals, and other providers that contract with the plan to care for enrolled members. Out-of-network means that a provider is not contracted with the health plan to serve its members, and the services may not be paid for by the plan. To minimize costs, patients should seek care from providers in network. To find out which providers are in network, check the health plan s website, call the health plan, and ask the provider.

48 Covered California 10 health plans are participating in Covered California. Anthem Blue Cross of CA L.A. Care Health Plan HMO EPO, HMO Molina Healthcare HMO Blue Shield of CA PPO Sharp Health Plan - HMO Chinese Community Health Valley Health Plan - HMO Plan HMO Western Health Advantage Health Net PPO, HMO HMO Kaiser Permanente HMO

49 Covered California Factors to Consider in Selecting a Plan Premium cost Outpatient providers in network Hospitals in network Drug formulary HMO vs. PPO vs. EPO Premium and cost-sharing trade off How much care do you anticipate using? Do you qualify for cost-sharing subsidies?

50 The Remaining Uninsured

51 2013: 7 million uninsured (under age 65) Medicaid Expansion Covered California 2019: 3.4 million remaining uninsured Not eligible: Immigration status 44% Eligible, but not enrolled: Medi- Cal 28% Eligible, but not enrolled: Exchange 28%

52 The Remaining Uninsured 42% of the remaining uninsured will be eligible for Medi-Cal or premium subsidies. The uninsured will primarily be Latino Limited English Proficient Low-Income Southern Californians

53 State Programs Major Risk Medical Insurance Program (MRMIP) Comprehensive coverage specifically for individuals with pre-existing conditions Must not qualify for other coverage Premiums range from $180-$2,000+ per month Restricted Scope Medi- Cal Emergency coverage only, plus prenatal care and delivery for pregnant women For individuals who do not qualify for Medi-Cal For adults with incomes up to 138% FPL, pregnant women 213% FPL, & children 266% FPL

54 State Programs Access for Infants and Mothers (AIM) Comprehensive care for pregnant mothers, including post-partum care Women between 200% - 300% FPL Must be uninsured and ineligible for Medi-Cal Modest premiums As of July 1, AIM operates under the Department of Health Care Services, renamed Medi-Cal Access Program Family PACT Family planning, reproductive, & sexual health services for uninsured men and women For individuals with incomes up to 200% FPL Must not be eligible for Medi-Cal, or must have no coverage for family planning

55 State Programs California Children s Services (CCS) Children (under 21) with specific diseases or disabilities like cystic fibrosis Covers only services relating to the qualifying conditions Family must have income $40,000, or out-of-pocket medical expenses must be more than 20% of family income, or child must be enrolled in Medi-Cal Genetically Handicapped Persons Program (GHPP) For adults (over 21) with specific qualifying genetic conditions like hemophilia Not limited to services for the qualifying conditions No income limit

56 State Programs Every Woman Counts (EWC) Free clinical breast exams & mammograms for uninsured low-income women 40 or older Free pelvic exams & pap smears for uninsured low-income women 21 or older Treatment for women diagnosed with breast or cervical cancer, with incomes up to 200% FPL Improving Access, Counseling & Treatment for Californians with Prostate Cancer (IMPACT) Provides 12 months of free treatment for low-income men diagnosed with prostate cancer Must be uninsured or underinsured, with incomes up to 200% FPL

57 Local Programs County Indigent Services Health services at county clinics and community health centers For low-income uninsured individuals who don t qualify for Medi-Cal 9 counties provide non-emergency services to the undocumented Healthy Kids Comprehensive coverage including vision, dental, prescriptions, and mental health benefits Modest premiums and copays Ages 0-5 in most areas, up to age 18 in 7 counties All programs vary significantly by county.

58 California Children's Services (CCS) (up to 250% FPL) Family PACT (up to 200% FPL) Healthy Way LA Unmatched (up to 133% FPL) Healthy Kids (up to 400% FPL) Access for Infants & Mothers ( % FPL) Covered CA Without Subsidies (Above 400% FPL) 400% FPL Covered CA With Subsidies ( % FPL) 300% FPL You may also be eligible for Medi-Cal Medically Needy, Cancer Screening & Treatment, AIDS Drug Assistance Program etc) 250% FPL 200% FPL (up to 250% FPL for Children) (up to 200% FPL for Pregnant Women) Genetically Handicapped Persons Program (GHPP) (all income levels) 133% FPL Medi-Cal (up to 138% FPL for all other groups) 0% FPL

59 FAQs & Resources

60 Covered California If you have an offer of employment-based coverage, you cannot access subsidies in Covered California. UNLESS The offer for the employee only > 9.5% of household income. Employment- based offer > 9.5% of income Premium subsidies

61 SHOP Exchange Covered California For small employers that would like to offer health coverage to employees Open to employers with 50 employees in 2014, will expand to employers with 100 employees in 2016 Up to 50% refundable tax credit for small, low- wage employers (< 25 employees with average wages < $50,000) with a two year limit Employers will choose the level of coverage (share of employees medical costs covered) and the reference plan. Employees will choose the plan giving employees a choice of insurance carriers amongst two tiers. Employees pay the difference in cost above the reference plan.

62 Averages for 40-year-old Employee Health Care Average n Wore we Lowest Second- Third-.Average of 2013 Between 5i hver Lowest Lamm st of Throe Cornparsb1 Average Plan Silver Silver Srna II Silver Pla ns & Plan Plan Prited Group. Comparable Silver Plans Small Group Plans Plans Region 3 Saorarnerrto County Kaiser Western Health Perrianente Advantage HSA HSA. $295 $32 Health Net PPO $365 $329 $ % Region 4 San Frarmisoo County Chinese Kaiser Community Permanents Men HSA. Health Net PPO $316 $ % $223 $326 $399 Region Alameda County Kaiser Permanente HSA $310 Health Net PPS $3611 Blue Shie'd HMO $474 $384 $340 12% Region 15 Los Angeles Count)? d partial) Kaiser Permanente HSA E k e e HY Health Net PPG $274 $ % 5263 $272 $288

63 Troubleshooting For questions about coverage, call your insurance company. If you have a complaint, file a grievance or appeal with the insurance plan. For Medi- Cal eligibility issues, contact your county DPSS office. For benefits issues, contact the managed care plan. Persistence is key.

64 Roles in Enrollment Change Coming Certified Enrollment Counselors: Can continue $58/enrollment payment in 2015 or transition to the Navigator program After open enrollment, there will be no compensation available Navigator Program Integrated education, outreach, and enrollment program pays application counselors through performance grants 16.9 million in awards to approx. 135 organizations 25% of award is paid before open enrollment, remainder upon meeting enrollment milestones with bonuses for exceeding goals

65 Enrollment Systems To become a certified enrollment counselor: Call Or assisterinfo@ccgrantsandassisters.org Training is free and can be online or in person Counselors must be connected to a Certified Enrollment Entity

66 Resources Health plan help: Health Care Options Department of Managed Health Care Access & eligibility issues: Department of Insurance Health Consumer Alliance (800) Medi- Cal questions: Medicare questions: Managed Care Ombudsman Center for Health Care Rights

67 For resources and additional information, contact us at: (310)