The Patient s Perspective

Transcription

1 The Patient s Perspective Tom Donohoe, MBA Director, UCLA Pacific AIDS Education and Training Center Associate Director, Center for Health Promotion and Disease Prevention David Geffen School of Medicine at UCLA Educational Objectives At the end of this section, participants will be able to: Explain the basic concepts of Medicaid Expansion and Marketplaces Review the rights, responsibilities, and decisions of impacted consumers in 2013, 14, and 15 Consider the decision making process for impacted consumers through interactive cases Affordable Care Act (ACA) & Patients Elimination of pre existing condition exclusions Expansion of Medicaid to non disabled adults with incomes of up to 138% of FPL Subsidies to purchase insurance through exchanges for people with income % FPL MORE PATIENTS ARE ELIGIBLE FOR MEDICAID AND MARKETPLACE EXCHANGES 1

2 What do people think (April 2013)? 42% are Unaware ACA is still the law in the United States It has been overturned by Supreme Court (7%) It has been repealed by Congress (12%) Don t know/refused (23%) How much have people heard (June 2013)? What Uninsured..have heard about Marketplaces: A lot (4%) Some (8%) Only A Little (32%) Nothing at all (55%) Kaiser Health Tracking Polls April and June reform/poll finding/kaiser health tracking poll april 2013/ reform/poll finding/kaiser health tracking poll june 2013/ 2013 Federal Poverty Level 138% FPL=$15,856 CoverageforAll.org Medicaid Expansion & Marketplaces Medicaid Expansion States (Medicaid) 138% of Federal Poverty Level (FPL) $15,856 (Individual) $32,500 (Household of 4) 100% 138% Immediate (or deferred) Premium Tax Credits 400% $11,490 (Individual) $23,550 (Household of 4) $45,960 (Individual) $94,200 (Household of 4) 100 % 138% Subsidies 250% Silver Plan $11,490 (Individual) $23,550 (Household of 4) $28,725 (Individual) $58,875 (Household of 4) 2

3 TAX Penalty Phase In Percentage Set Dollar of Income or Amount % $ % $ % $695 Whichever is GREATER Health Insurance Terminology I Premium Deductible Co pay/co insurance Total out of pocket expense Premium assistance/tax credit Cost sharing subsidies Tax Time: Reconciliation Health Insurance Terminology II Qualified Health Plans (QHPs) by Metal Group Metal % Total Costs Covered Deductible? Platinum 90% No deductible Gold 80% No deductible Silver 70% Bronze 60% HMO PPO EPO Plan Types Health Maintenance Organization Preferred Provider Organization Exclusive Provider Organization 3

4 ACA and Immigrants Exchanges/Marketplaces All lawfully present residents are eligible for Health Care Reform subsidies (premium tax credits and cost sharing reductions) Undocumented immigrants (including children and pregnant women) are not eligible for these subsidies or even the full priced health insurance plans in the Exchange marketplace Medicaid Expansion/Eligibility: Most lawfully present residents must wait 5 years for federal Medicaid, unless state picks up federal option for those under 18 or pregnant, or has other state funded programs. Refugees, survivors of trafficking and other humanitarian groups are federally eligible with no wait. Undocumented immigrants only eligible for emergency Medicaid and, in some states, prenatal services. Source: A Quick Guide to Immigrant Eligibility for ACA and Key Federal Means tested ProgramsNational Immigration Law Center Case Study: Pedro Pedro is a 28 year phone sales representative who estimates he will make ($12,065 or 105% FPL) in He lives and receives his medical care at a health department clinic serving the uninsured. He lives in a state this is NOT expanding Medicaid. Case Study: Dewayne Dewayne is a 40 year old construction worker who estimates he will make $19,000 (or 165% FPL) in He was born and receives his medical care at a county health department clinic in Los Angeles, California (a Medicaid expanding state.) 4

5 State Based Marketplace Exchange: Covered California (CoveredCA.com) 38 Covered California marketplace opens Case Study: Dewayne SILVER (eligible for Federal Subsidy) Premium: $75/month (of a $294/month premium as per Covered California calculator) Copays: Primary Care Visit: $15 Generic Drugs: $5 Lab Test $15 Imaging: 15% Deductible: $500 Out of pocket maximum: $2250 Case Study: Tonya Tonya is a single 52 year old hotel worker born and living in south Los Angeles. She thinks she will make $21,027 in 2014 (183% FPL), but has no health insurance. She says she always wanted it, but could never afford the rates for someone my age. She has not seen a doctor for years, but sometimes goes to an Urgent Care clinic to get antibiotics. She would especially like health insurance now as she recently inherited a home from her parents and worries that just one visit to the ER/hospital could bankrupt her or cause her to lose this home. She has had a cough but believes she is in pretty good health. However, Tonya does not know that she is living with latent TB infection. 5