ObamaCare 101: An Educational Training on Health Reform. Training Workshop

Transcription

1 ObamaCare 101: An Educational Training on Health Reform Training Workshop

2 About ITUP ITUP is a non partisan, non profit health policy think tank based in Santa Monica, CA. We are funded by generous grants from The California Wellness Foundation, The California Endowment, Blue Shield of California Foundation, California Community Foundation, Kaiser Foundation Hospitals, California HealthCare Foundation, Lucile Packard Foundation for Children s Health, and L.A. Care Health Plan.

3 Federal Health Reform The Patient Protection and Affordable Care Act (ACA) was signed into law on March 23, Major goals of the law include: Increase health care coverage Reduce health care cost and improve affordability Improve people s health

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

5 Insurance Coverage in LA County 351, , ,000 Employment based 685, ,000 Medicaid Uninsured 4,558,000 Medicare 1,725,000 Privately purchased Medicare & Medicaid Healthy Families/CHIP 1,782,000 Other public

6 The Uninsured in LA County by Income 300%+ FPL, 340, % FPL, 252, % Federal Poverty Level [FPL], 632, % FPL, 501, million uninsured in LA County

7 Medicaid Expansion TODAY: 7 million uninsured (under age 65) 2019: Up to 3 million remaining uninsured Covered California Exchange Not eligible: Immigration status Eligible, but not enrolled: Medi Cal Eligible, but not enrolled: Exchange

8 Eligibility in Los Angeles, , , , , , , , , ,000 0 Eligible for subsidized Exchange coverage Newly eligible for Medi Cal Previously eligible for Medi Cal, but uninsured

9 Coverage Expansions: Medi Cal Before the ACA Medi Cal, California s Medicaid program, is the state s health coverage program for parents, dependent children, seniors, and disabled persons with low incomes.

10 Coverage Expansions: Medi Cal Current eligibility categories & income standards in CA: Infants and children (ages 0 19), up to 250% FPL $28,725/year for an individual, $58,875/year for a family of 4 Pregnant women, up to 200% FPL $22,980/year for an individual, $47,100/year for a family of 4 Seniors and persons with disabilities, up to 133% FPL $15,282/year for an individual, $31,322/year for a family of 4 Parents with dependent children, up to 100% FPL $11,170/year for an individual, $23,550/year for a family of 4

11 Public Program Income Limits Medi Cal AIM Pregnant Women Elderly and People with Disabilities Parents Children (ages 1 19) Infants (up to age 1) Federal Poverty Level 0% 50% 100% 150% 200% 250% 300%

12 Coverage Expansions: Medi Cal On January 1, 2014 Medi Cal, California s Medicaid program, will extend to all individuals (citizens and legal permanent residents) ages with incomes up to 133% of the federal poverty level ($15,282 for an individual and $31,322 for a family of four). Increases income standard for parents from 100% to 133% FPL Extends coverage to adults without dependent children (MIAs) to 133% FPL

13 Coverage Expansions: Medi Cal Enrollment The ACA helps to streamline and modernize the enrollment process for Medicaid applicants Processes and accepts applications electronically (online, by telephone, through enrollment counselors) Simplifies income tests and eliminates asset standards for newly eligible individuals and families (MAGI) Consolidates eligibility categories (adults, children, parents, and pregnant women) Improves renewal process (automated, streamlined data sharing) Financing The federal government will pay 100% of the cost of covering new eligibles for , 95% in 2017, 94% in 2018, 93% in 2019, and 90% thereafter.

14 Coverage Expansions: Medi Cal Special Populations Medically needy members with incomes 133% FPL will no longer have a share of cost, will become eligible for full scope Medi Cal Seniors and persons with disabilities will still be subject to assets tests due to high cost of long term care New (< 5 years) Legal Permanent Resident adults between % FPL with no children will receive coverage through the Exchange Undocumented immigrants will only qualify for restricted (emergency) Medi Cal Eligibility Determination County Social Services offices make final eligibility determination

15 Coverage Expansions: Medi Cal Children s Health Insurance Program transition Healthy Families provides insurance to 863,000 children Under the age of 19 Up to 250% FPL Moving all members to Medi Cal in phases throughout 2013

16 Coverage Expansions: Medi Cal Low Income Health Program transition Healthy Way LA and other county based programs provide limited scope insurance to adults Up to 200% FPL (133% in LA County) 600,000+ members (250,000 in LA County) will become eligible for Medi Cal or Covered California on January 1, 2014 Will be automatically enrolled in Medi Cal if eligible no application necessary Continuity of care with existing provider and right to change to a different provider and plan Default to existing provider if no selection is made 75% of members without an assigned provider currently will be default matched to County providers Those ineligible for Medi Cal or Covered California will remain in unmatched programs

17 Coverage Expansions: Medi Cal Medi Cal Managed Care Plans in LA County: o Health Net Molina Health Care o L.A. Care Health Plan Anthem Blue Cross Care 1 st Kaiser Permanente

18 Coverage Expansions: Medi Cal Behavioral Health Options Mental health services are an essential health benefit, and thus will be more accessible. Mental health services for the severely and chronically mentally ill will be available through the county Mental Health Departments. Psychological services for less severe disorders will be provided through the Medi Cal Managed Care plans and their provider networks. Expanded Substance Use Disorder treatment services will become available to all Medi Cal members.

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

20 Insurance Market Reforms September 23, 2010: Insurance plans cannot cancel existing coverage, except for cases of fraud Cannot refuse to sell health insurance to children based on pre existing conditions (i.e. 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 (i.e. wellness visits, mammograms, colonoscopies, vaccinations, etc.) January 1, 2014: Insurance plans cannot refuse to sell health insurance to adults based on pre existing conditions

21 Insurance Market Reforms The ACA limits the ways that insurance companies can charge different premiums for different types of people. Insurance companies can only vary premium costs based on the following: Age (3:1) Geography Family Size

22 Insurance Market Reforms The ACA requires health plans to meet a certain standard of coverage in order to be a qualified health plan. Qualified health plans must cover 10 essential health benefits (equivalent to the Kaiser Small Group HMO): Ambulatory patient services Emergency services Hospitalization Maternity and newborn care Mental health and substance use disorder services, including behavioral health treatment Prescription drugs Rehabilitative and habilitative services and devices Laboratory services Preventive and wellness services and chronic disease management Pediatric services, including oral and vision care

23 Individual Mandate The ACA also requires individuals to have health coverage. Individuals must have health insurance through an employer, union, Exchange plan, individual plan, Veteran s Administration, Indian Health Services, Medicare, or Medi Cal.

24 Individual Mandate Exemptions to the Individual Mandate Financial hardship If available cost of coverage > 8% of household income If household income is below tax filing threshold ($10,000 for an individual/$20,000 for a family in 2013) Religious exemption Undocumented immigrants Incarcerated persons Individual penalty takes effect in 2014 $95 or 1% of income (whichever is more) in 2014 $325 or 2% of income in 2015 $695 or 2.5% of income in 2016 and thereafter

25 Employer Requirements The ACA establishes new options for small employers as of 2014; there is no requirement for small employers of less than 50 full time equivalent employees to offer coverage. Small Employers (< 25 employees): Tax credits for purchasing employee health insurance Up to 35% currently, and up to 50% of cost, beginning in 2014 (for two year period) For firms with: < 25 full time employees Average wages < $50,000 Employer must pay at least 50% of the premium cost

26 Employer Requirements As of 2015: Employers with 50 or more full time equivalent employees must offer health insurance. Large Employers ( 50 employees): Required to offer 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)

27 Health Insurance Terms Premium monthly amount paid for insurance coverage Copay fixed amount paid at the point of service for a covered health care service Deductible amount you owe for health care services before your health insurance begins to pay Coinsurance your share of the costs of a covered health care service Premium Subsidies or Assistance help from the federal government to pay insurance premiums; available to people between 100% 400% FPL Cost Sharing Subsidies reduces the amount you pay when you seek care (copayments or coinsurance); available for people between 100% 250% FPL

28 California s Health Insurance Exchange is: Covered California Enrollment: October 1, 2013 March 31, 2014

29 Covered California One stop shopping for quality, affordable health plans. California s Exchange is an independent, public entity that is governed by a 5 member board and financed by fees on participating health plans. States choose to create their own Exchange or have a federallyadministered Health Insurance Exchange. The goal of an Exchange is to promote: Transparency Competition Price Quality

30 Covered California Covered California will be a State Based Exchange and an Active Purchaser. Features: Online, real time eligibility determinations with automated cross checks of income and immigration status Transparent and comparable price and quality information, with electronic calculators Web based enrollment with online plan/benefit selection

31 Covered California There will be two separate exchanges: 1. For individuals 2. For small employers (SHOP) Who can buy insurance through Covered California? Individuals (citizens & legal permanent residents) and small employers ( 50 employees). Individuals and households with incomes between 100% and 400% FPL qualify for premium subsidies.

32 Covered California SHOP Exchange 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 2017 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. Employees pay the difference in cost above the reference plan.

33 Covered California Benefits All plans must include the 10 essential health benefits Mental and behavioral health conditions will be covered, with services available through the individual plans Follows established limits on cost sharing Copays, deductibles, and out of pocket maximums vary with metal tiers Standardization of plans benefit packages makes them easy to compare

34 Covered California Four tiers of health plans Platinum (90% actuarial value) Gold (80%) Silver (70%) Bronze (60%) Minimum Coverage Plans (Catastrophic Coverage) 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.

35 Covered California Trade Off: Up Front Affordability with Expected Out of Pocket Costs 35

36 Covered California Bridge Plans (Medi Cal Managed Care Plans) Only available to: 1. People on Medi Cal whose income increases > 133% FPL, up to 250% FPL 2. Parents or other household members of children who are enrolled in Medi Cal with incomes between 133% 250% FPL Whole family gets to stay on the same plan, keep same network of providers Continuity of care preserved for customers with changing eligibility Cost must be the lowest cost silver plan

37 Covered California 13 health plans are participating in Covered California. The following plans will be available in Los Angeles: Anthem Blue Cross of CA EPO, HMO Blue Shield of CA PPO Health Net PPO, HMO Kaiser Permanente HMO L.A. Care Health Plan HMO Molina Healthcare HMO SHOP Plans: Blue Shield of CA PPO, HMO Health Net PPO Kaiser Permanente HMO, HSA

38 Covered California Individuals and households with incomes between 100% and 400% FPL qualify for premium subsidies. 100% FPL $11,490/year (individual), $23,550/year (family of 4) 400% FPL $45,960/year (individual), $94,200/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. Subsidies are paid directly from the Treasury to the insurance plans. Consumers do not handle payment of subsidies.

39 Covered California The amount you spend on health insurance premiums will be capped on a sliding scale between 2% and 9.5% of income. Individual earning < 133% FPL spends no more than $297/year (2% of income) Individual earning 400% FPL spends no more than $8,493/year (9.5% of income) Max premium contribution, % of income Max premium contribution, monthly payment (individual) Actuarial value floors Income Level (FPL) <133% 2.00% $27 94% % % $57 94% % % $121 85% % % $193 73% % % $273 70% % 9.50% $364 70%

40 Covered California Premium subsidies are available based on MAGI income information provided at application Equal to the difference between the premium of the second lowest cost Silver plan (reference plan) and the premium cap amount for a household s income Individuals pay the extra cost of more expensive plans and coverage and get the savings of purchasing less costly plans and benefits than the reference plan. Calculated on a monthly basis Example: 40 year old making $28,725 a year ($2,394/month) 250% FPL Full cost of second most affordable silver plan: $294/month Max premium contribution: 8.05% = $193/month Federal subsidy: $294 $193 = $101/month

41 Silver Plan for 40 Year Old Single Individual Plan Share Up to $17,235 Most Affordable $17,236 $22,980 $22,981 $28,725 $28,726 $45,960 Individual $35 $98 $170 $271 Federal Government $236 $173 $101 $0 Individual $57 $121 $193 $294 Second Most Affordable Third Most Affordable Federal Government $236 $173 $101 $0 Individual $64 $127 $199 $301 Federal Government $236 $173 $101 $0

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46 SHOP Rates Averages for 40 year old Employee Health Care 2014 Lowest Silver Plan 2014 Second Lowest Silver Plan 2014 Third Lowest Silver Plan 2014 Average of Three Lowest Priced Silver Plans Average of 2013 Comparable Small Group Plans Difference Between Average Silver Plans & Comparable Small Group Plans Region 15 LA Kaiser Permanente HSA $263 Blue Shield HMO $272 Health Net PPO $288 $274 $311 13% Region 16 LA Blue Shield HMO $287 Kaiser Permanente HSA $290 Health Net PPO $349 $309 $362 17%

47 Covered California Cost Sharing Subsides Reduces out of pocket costs when care is received (coinsurance and copays) For households between % FPL Only available for those choosing Silver Plan coverage

48 STANDARD BENEFIT DESIGNS BY INCOME Coverage Category 94% Silver 87% Silver 73% Silver 70% Silver Eligibility based on income and premium assistance Covers 94% average annual cost Covers 87% average annual cost Covers 73% average annual cost Covers 70% average annual cost Single income ranges Up to $17,235 $17,236 $22,980 $22,981 $28,725 $28,726 $45,960 Annual wellness exam $0 $0 $0 $0 Primary care visit $3 $15 $40 $45 Specialist visit $5 $20 $50 $65 Laboratory tests $3 $15 $40 $45 X rays and diagnostics $5 $20 $50 $65 Imaging 10% 15% 20% $250 Generic drugs $3 $5 $20 $25 Annual out of pocket max individual $2,250 $2,250 $5,200 $6,350 Annual out of pocket max family $4,500 $4,500 $10,400 $12,700

49 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. Employmentbased offer > 9.5% of income Premium subsidies

50 Covered California Filing Taxes and Subsidies (Reconciliation) 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 amount of subsidies received 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.

51 Covered California Open Enrollment: October 1, 2013 March 31, 2014 People can only buy health insurance through Covered California during a specified time period called open enrollment. For people who apply for insurance between October 1 December 15, 2013, coverage will begin on January 1, For people who apply for Covered California between December 16, 2013 March 31, 2014: If eligibility is determined during the first 15 days of a month, coverage begins the 1 st of the following month. If eligibility is determined during the last 15 days of the month, then coverage begins on the 1 st of the second following month.

52 Covered California Exceptions to open enrollment: Job change or loss Marriage Divorce Death in the family Other events that cause people to lose health insurance MUST enroll within 60 days of the life event

53 Enrollment Systems The ACA requires a unified application and online portal for Medi Cal and Covered California options New California Healthcare Enrollment, Eligibility and Retention System (CalHEERS) is the new electronic application and enrollment system in California CalHEERS tool will be used for both Medi Cal and Covered California applications allowing enrollment in either program through a single application and eligibility process. Applications can be filed online, via mail, via telephone, or in person in county offices and through assisters at community organizations Final eligibility determinations for Covered California by Covered California and for Medi Cal by Medi Cal Enrollment begins October 1, 2013; coverage begins January 1, 2014

54 Enrollment Systems New streamlined application procedures Simplified application form Use of Modified Adjusted Gross Income (MAGI) for children, parents, and childless adults simplifies income reporting Line 37 on individual tax return Form 1040 No asset test for MAGI eligibility groups (families and individuals, not aged or disabled) Electronic crosschecks with the IRS, HHS, and Homeland Security to verify income information and citizenship/immigration status

55 Roles in Enrollment Enrollment Systems Certified Enrollment Counselors: trained staff of certified enrollment entities (healthcare clinics, county health departments, nonprofit organizations, etc.) who help consumers fill out and submit applications through CalHEERS. In person Assistors: compensated $58 per successful enrollment Navigators: receive no direct compensation for enrollment assistance, instead receive block grants for outreach and enrollment assistance Brokers: sell insurance to individuals and employers; brokers must present plan options in a fair and balanced way Covered California will have three centralized call centers that will work with county enrollment systems.

56 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

57 Covered CA Outreach & Education Grant Recipients LA Gay and Lesbian Community Services Center CA NAACP Asian Pacific American Legal Center Catholic Charities of California Anaheim Health Medical Center Foundation CSU LA University Auxiliary Services Community Health Councils CA School Health Centers Association Community Black Health Network Ventura County Public Health LA County Federation of Labor LAUSD The Regents of the University of California St. Francis Medical Center of Lynwood Foundation JWCH Institute Valley Community Clinic Bienestar Human Services, Inc. Loma Linda University Medical Center The Actors Fund The East LA Community Union San Bernardino Employment & Training Agency

58 The Remaining Uninsured Despite the ACA, an estimated 29 million American residents may remain uninsured (as of 2019) Up to 3 million in California Approximately half of the remaining uninsured will be eligible for Medi Cal or premium subsidies under the Exchange. The uninsured will primarily be Latino Limited English Proficient Low Income Southern Californians Potential obstacles to universal coverage include limited awareness of eligibility, inability to afford subsidized coverage, and immigration status. The remaining uninsured will continue to rely on community clinics and the county safety net.

59 Special Populations Legal Permanent Residents Eligible for the Exchange and premium subsidies New legal (< 5 years of residency) childless adults between 100% 133% of FPL eligible for premium assistance Eligible for Medi Cal Children up to 250% FPL Parents up to 133% FPL Childless adults up to 100% FPL

60 Special Populations Undocumented Immigrants Not eligible for full scope Medi Cal or the Exchange Eligible for Emergency Medi Cal (limited scope) Not subject to the individual mandate

61 Other Coverage Options Healthy Way LA Unmatched Open to all individuals, regardless of immigration status, 133% FPL ($15,282 for individual) Primary care services at County clinics and community health centers 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 Family PACT Family planning 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

62 Other Coverage Options California Children s Services (CCS) Children (under 21) with specific diseases or disabilities 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 Not limited to services for the qualifying conditions No income limit Healthy Kids (ages 0 5) Comprehensive coverage including vision, dental, prescriptions, and mental health benefits Administered by L.A. Care Health Plan s Children s Health Initiative Up to 400% FPL, regardless of immigration status

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

64 Medi Cal Covered California Bridge Plans Income Eligibility Up to: 250% FPL for kids, 133% FPL for adults, 200% FPL for pregnant women 100% 400% FPL for premium subsidies, all incomes can purchase coverage at retail price 133% 250% FPL Immigration Status Eligibility Full scope for citizens, established LPRs, recent LPR parents & children; Emergency Medi Cal for the undocumented Must be US citizen or Legal Permanent Resident (LPR) (no waiting period) Must be US citizen or Legal Permanent Resident (no waiting period) Enrollment At any time Only during open enrollment, with exceptions for life events Only during open enrollment or within 60 days of eligibility change Premiums None Sliding scale with premium assistance Lower ( cheapest silver plan) Provider Network Limited to Medi Cal providers, mostly managed care Type and size of networks vary with plans Limited to Medi Cal providers, mostly managed care

65 Scenario 1 Adrian is a single father of three children. All of the family members are uninsured. He is 30 years old and makes $34,500 a year. What health program(s) are Adrian and his children eligible for?

66 Federal Poverty Level

67 Scenario 1 Adrian s household income: 146% FPL Adrian s kids are eligible for: Medi Cal Adrian is eligible for: Estimated Premium: Adrian is not eligible for Medi Cal, but he is eligible for subsidized Covered California plans or Bridge plans, plus cost sharing subsidies Monthly silver plan premium if he chooses the 2 nd cheapest silver plan: $109

68 Scenario 2 David and Amber are married and have one child. David makes $39,000 each year and already receives affordable health insurance through his employer. Amber works part time and makes $15,000 per year. Both Amber and their child are uninsured. Will the entire family be eligible to receive premium subsidies through Covered California?

69 Scenario 2 True or False: David can get subsidies through Covered California. Amber and their child qualify for Medi Cal. Amber and their child qualify for subsidies through Covered California. Only Amber s income counts when determining her eligibility. False, unless his premiums > 9.5% of his income. False, their household income = 276% FPL. True, unless David s job offers dependent coverage. False, the entire household s income counts.

70 Scenario 3 Crystal is a 20 year old unmarried woman with no children. She works part time at a local restaurant and makes $12,000 a year. Crystal is undocumented. What options will she have in 2014?

71 Scenario 3 Crystal s household income: Crystal does not qualify for: 104% FPL Full Scope Medi Cal or Covered California But she could qualify for: Healthy Way LA and Family PACT

72 Scenario 4 Sandy is 60 years old and lives with her daughter and two grandchildren. She is not working and has no income. She has several chronic medical conditions and her doctor has advised her that she may need around the clock care soon.

73 Scenario 4 True or False: Sandy qualifies for Covered California with subsidies. False, her income is < 133% FPL, thus she qualifies for Medi Cal. Sandy is subject to assets tests to qualify for Medi Cal. True, but only if she needs long term care. Sandy s daughter s income is included when determining eligibility. False, just Sandy s income counts.

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