Regional Healthcare Coverage Coalition (RHCC) Dell Children s Medical Center Pat Hayes Conference Center Auditorium July 24, :00 a.m.-11:00 a.m.

Transcription

1 Regional Healthcare Coverage Coalition (RHCC) Dell Children s Medical Center Pat Hayes Conference Center Auditorium July 24, :00 a.m.-11:00 a.m. Agenda Welcome & Announcements Claudia Lindenberg Director of Patient Services Central Health Healthcare Reform Anne- Marie Price Director of Government Affairs Central Health Pre-Existing Condition Insurance Plan Celeste Ensign Assistant Vice President Cardon Outreach Closing Announcements Kit Abney Spelce Director insure-a-kid 2012 Meeting Dates: Tuesday, Oct. 23, 2012 Dell Children s Auditorium, 9:00 11:00 Visit for Resources and Events.

2 Texas Has a Health Care Spending Problem, Not a Medicaid Problem: Issues and Prospects in the post Supreme Court Moment July 10, 2012 UTMB s 2012 Health Policy Lunch and Learn Lectures Galveston, Texas Anne Dunkelberg, Assoc. Director, dunkelberg@cppp.org Center for Public Policy Priorities 7020 Easy Wind Drive Austin, Texas (512)

3 Presentation Overview Review of ACA key components Medicaid top details Medicaid interactions with exchanges Supreme court Decision overview Different Justices, different components Medicaid decision details Questions raised and interpretations being circulated US HHS Agency role What this means for Texas TX Uninsured and ACA Census confusion: CPS vs. ACS Further Confusion: Urban Institute Without Medicaid expansion, <100 FPL no access to premiums subsidies in HIX, and even subsidies may be unaffordable for Big Picture: the challenge is health care spending, not Medicaid. 2

4 Source: US Census 3/2011 CPS 3

5 Medicaid Now (U.S) Health Insurance Coverage 31 million children & 17 million adults in low-income families; 14 million elderly and persons with disabilities Assistance to Lowincome Medicare Beneficiaries 8.8 million aged and disabled 19% of Medicare beneficiaries Long-Term Care Assistance 1 million nursing home residents; 2.8 million community-based residents MEDICAID Support for Health Care System and Safety-net $16B in Disproportionate Share Hospital payments; 40% of community health center revenues SOURCE: Kaiser Commission on Medicaid and the Uninsured, 2009 Biggest Source of Federal Funds in State Budgets Federal share ranges 50% to 76%; 43% of all federal funds to states 4

6 Texas Medicaid/CHIP: WhoisHelped Today Disabled, 415,969 CHIP, 561,462 January 2012, HHSC data 25.2 million Texans 7.4 million under 19 Elderly, 342,177 Poor Parents, 140,295 Medicaid Children, 2,523,329 TANF Parent, 82,964 Maternity 83,453 Total enrolled 1/1/2012: 3.6 million Medicaid; 561,000 CHIP 1 in 7 Texans, but 42% of Texas kids 5 5

7 Income Caps for Texas Medicaid and CHIP, 2012 $35,317/yr $35,317/yr $25,128 $38, % 185% $25,390/yr $19,090 $8, % 200% 133% 100% $2,256 $3,696 12% 19% 75% Income Limit as Percentage of Federal Poverty Income Annual Income is for a family of 3, except Individual Incomes shown for SSI and Long Term Care 6

8 2014: Health Reform Building Blocks Build on current system: Vast majority of Americans still get coverage through their employer. Medicaid expansion: US citizens to 133% FPL ($14,404 individual; $29,327 for 4). Reform Private Health Insurance: standard minimum benefits, can t charge more based on health status, limits on premium increases as people age, no denial of coverage, no excluding pre existing conditions, no annual or lifetime maximums. New Health Insurance Exchanges where private insurers options can be compared and purchased. Open to people without job based coverage and small employers, and all members of Congress will get coverage thru exchange. Sliding scale premium assistance in the exchange up to 400% of FPL ($88,200 for family of 4). Sliding scale deductibles/co pays and out of pocket caps in the exchange to increase affordability & reduce medical bankruptcy. Individual mandate to have coverage (with major exemptions). Some requirements for employers to contribute if their employees get sliding scale help in exchange, with exemption for all employers with 50 or fewer workers. 7

9 Health Reform Building Blocks Medicaid Expansion Eligibility up to 133% of the federal poverty level ($29,700/yr for family of four) Adds 1.4 million TX adults (near term) Must further upgrade eligibility system for full on line function and interoperability with Exchange 100% federal funding Max state share of 10% starts

10 Health Reform Building Blocks More Medicaid Provisions States can t reduce kids Medicaid CHIP income limits before 2019 Also can t reduce adult coverage before 2014 (when HIX fully operational) Medicaid primary care fees increased to Medicare levels in 2013 and 214, full federal funding. Eligibility rules (except SSI related aged and disabled) must change to fed standard based on US tax income rules (MAGI). Ends asset test and F2F interview

11 The SCOTUS Decision Unanimous: The fact that Congress chose not to LABEL the individual mandate s free rider penalty as a TAX is sufficient to exempt from the AIA Commerce Clause Rejected as basis for IM: Roberts, Alito, Kennedy, Scalia, Thomas But IM is a Tax, and Congress can Tax: Roberts, Breyer, Ginsburg, Kagan, Sotomayor Medicaid expansion mandate with all Medicaid funds at risk for states not implementing unduly coercive : Roberts, Alito, Breyer, Kagan, Kennedy, Scalia, Thomas BUT rest of ACA is OK, as long as the Medicaid expansion becomes a state option, and states opting out do not put the rest of their Medicaid $ at risk: Roberts, Breyer, Ginsburg, Kagan, Sotomayor 10

12 What Court said & What it means Roberts: the expansion is a New Program ; and states could not have foreseen this shift in kind, not merely degree BUT the decision maintains: all other aspects of the ACA; and The federal Medicaid law in all other respects. NO effect on earlier federally mandated Medicaid expansions Congress can still adopt future publicly funded health expansions (under the Spending Clause) 11

13 Questions, and What Experts are Opining No references at all in Roberts majority opinion to changing any other ACA Medicaid provisions. HHS/CMS will eventually provide guidance on ALL these questions States that expand must abide by all Medicaid provisions of the ACA in order to get the enhanced fed $ for the expansion. States NOT expanding are still bound by all provisions of the fed Medicaid law, and still put their Medicaid fed funds for their existing programs at risk for non compliance (this is same as pre ACA law) 12

14 Questions, and What Experts are Opining The ACA s other new Medicaid provisions still are in force for all states, including: Increased primary care Medicaid rates Phasing down of DSH Mandatory coverage of birthing centers, smoking cessation for pregnant women New community services and supports options Expansion of Medicaid for youth aging out of foster care to 26 th birthday. 13

15 Questions, and What Experts are Opining Can a state expand to an income <133% FPL? NASMD: No: binary all as written or nothing option) Community Catalyst: No, states must comply with all ACA terms of the expansion, or risk no 100%/90% match Do MOE Stability Protections still apply, and to all states? YES, only the HHS Secy s ability to nuke entire Medicaid $$ altered by Court. All other Medicaid provisions unchanged by decision GWU, GU CCF, CC, NASHP) Is MAGI conversion required in opt out states? How does no Wrong Door work if state opts out? Could a State drop expansion in out years? Will rules from US HHS address this? 14

16 More Questions US HHS/CMS will Likely Clarify Any due dates for deciding on Medicaid? Will the shift of kids in Medicaid and CHIP to (Medicaid below 133%, CHIP above) still happen if a state opts out of the expansion? Are expansion group Medicaid enrollees entitled to same legal protections as rest of Medicaid? How can/will 1115 waiver authority be used to allow expanding states to depart from the general requirements of the ACA (e.g., to cover below 133% FPL) 15

17 Linking Americans to Coverage (2014) FPL Unsubsidized 400% 300% Exchange Subsidized 200% 133% 100% 200% 185% 133% Medicaid Expansion 74% Basic Health or Exchange 2014 Children Pregnant Women 20% Parents Seniors & People with Disabilities Medicaid and CHIP (Texas 2011 eligibility levels) Uninsured or insured via other coverage source 0% 0% Adults w/o Children Undocumented Immigrants 16

18 Americans Coverage in 2019: If nothing changed compared to health reform law Uninsured 57 million 20% Medicaid/CHIP 32 million 11% Uninsured 26 million 9% Private Exchanges 23 million 8% Medicaid/CHIP 48 million 17% Nongroup & Other 30 million 11% Employer 161 million 58% Nongroup & Other 27 million 10% Employer 156 million 56% Without Reform 2019 Under Reform Million U.S. Residents Under Age 65 Source: Congressional Budget Office, March 2012 Estimate of the Effects of the Affordable Care Act on Health Insurance Coverage 17

19 Texas Uninsured by Income % of 6.2 million uninsured have incomes <400% FPL % FPL $67,050-$89, % FPL $55,875-$67,050 >400% FPL >$89, K 421K 656K Million <100% FPL <$22,350/yr for family of four 6.2 million includes 1.7 million non US citizens; ~2/3 of these (about 1.1 million) likely undocumented % FPL $44,700-$55, K 921K 525K 614K % FPL $22,350-$27, % FPL $33,525-$44, % FPL $27,938-$33,525 Annual income limits given for a family of four, 2011 federal poverty level U.S. Census, 2010 CPS18

20 Uninsured Texans by Age Group, ,000 4% of Texas Seniors uninsured twice the US average 63% are below 200% FPL 65+ <2/3 are below 200% FPL million Rate: 16.8% of 0-18 are uninsured 6.2 million uninsured Texans million Rate: 31.8% of are Uninsured Source: U.S. Census, March 2011 CPS 19 19

21 How Could 2010 Uninsured Texans Gain Coverage If Reform were Fully Implemented Today? Of the 6.2 Million Uninsured Texans in million (adults and kids) may get help with coverage in the exchange 610,000+ would qualify for exchange coverage at full cost 1.4 million U.S. citizen adults would newly qualify for Medicaid 600,000 kids qualify for Medicaid or CHIP right now BUT: 1.1 to 1.8 million would remain uninsured (CBO) K 600K 1.1M 1.4M 2.6M 3 uninsured Texans gain private exchange coverage for each 2 gaining through Medicaid/CHIP 20 20

22 All Carrot and No Stick? Or is the carrot too big to refuse? Confusion factors in Reading the Estimates: US Census now has 2 different surveys estimating uninsured: ask different questions, and get different answers. Many estimates of Medicaid expansion are based not on raw Census numbers but on Urban Institute model (that builds on census), yielding a third set of numbers. Range of assumptions about what % of eligible folks actually enroll (take up rates) drive HUGE differences in estimates. 21

23 All Carrot and No Stick? Or, is the carrot too big to refuse? Texas HHSC has projected from : assuming over 90% take up by newly eligible adults that Texas would have to put up $5.8 billion in new Medicaid state share, and would draw down $76.3 billion in federal match. Urban Institute (for Kaiser, also used by Bloomberg): 1.7 million uninsured adults in Texas below 133% FPL who don t qualify for Medicaid today, would be left uncovered if Texas does not expand. Models 57% and 75% take up rates (again %, 1.8 million enroll; Texas uninsured adults below 133% FPL drop by 49%; federal govt. pays $52.5 billion (95.3% of costs); state pays $2.6 75%, 2.5 million enroll; Texas uninsured adults below 133% FPL drop by 74%; federal govt. pays $62 billion; state pays $4.5 billion (5.1% over baseline without expansion). 22

24 If Texas Opts Out What we would leave on the table... Bloomberg analysis (using the UI model and historical Medicaid spending by health care sector) projects that in the first five years ( ), $46 billion would go to Texas health care sectors, including: $8.6 billion to Medicaid Managed care plans $4.2 billion to nursing homes $7.8 billion to hospitals $4.9 million to home health providers...meaning these sectors will lose out on these amounts in the expansion is not taken in Texas. 23

25 If Texas Opts Out ACA makes sliding scale premium assistance available only to persons above 100% FPL (exception: legal immigrants excluded from Medicaid) This means uninsured Texas adults below 100% FPL would have NO assistance available in UI/KFF estimates 1.75 million uninsured TX adults under 133% FPL, 1.33 of these with incomes below 100% FPL. Those from % FPL would be eligible for premium assistance, but because the system was designed with assumption that this group would have Medicaid, some of these near poor will have difficulty affording the coverage even with a cap on premiums of 2% of family income. Costs of care for uninsured poor Texas adults will continue to be carried primarily by local property taxpayers, secondarily by other charity care providers, and without benefit of the 90%+ federal matching dollars. 24

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27 Total Spending for Health Care Under CBO s Extended Baseline Scenario (Percentage of gross domestic product, without significant changes in policy) 26

28 WHY IS HEALTH SPENDING IN THE UNITED STATES SO HIGH? 27

29 Center on Budget and Policy Priorities Medicare and Medicaid Controlled Costs Better than Private Insurance Over the Last Decade Average Annual Growth Rate, % 8% 7% 6% 5% 4% 3% 2% 1% 0% 4.6% Medicaid Per Beneficiary 5.1% Medicare Per Beneficiary 7.2% Private Per Capita, Comparable to Medicare 7.7% Private Employer Insurance Premiums 6 cbpp.org 28

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31 Health Reform: The Big Picture Or, Why ACA is worth Keeping, In Spite of Flaws First ever system for making comprehensive care available to all (lawfully present) Americans at an affordable price. Profits in health insurance marketplace will no longer be based on avoiding risk, leaving Texans uninsured. Lays a foundation for controlling health costs and improving quality of care. 30

32 Texas Well and Healthy Texas Coalitions & Campaigns Working on ACA Implementation and Medicaid CHIP Support 31

33 Collaborative campaign of 4 non profits in TX Our goal: educate Texans about health care options Website: Facebook: 32

34 Use of This Presentation The Center for Public Policy Priorities encourages you to reproduce and distribute these slides, which were developed for use in making public presentations. If you reproduce these slides, please give appropriate credit to CPPP. The data presented here may become outdated. For the most recent information or to sign up for our free E Mail Updates, visit CPPP Center for Public Policy Priorities 900 Lydia Street Austin, TX P 512/ F 512/

35 2012 Poverty Guidelines for the 48 Contiguous States and the District of Columbia 2011 Tax Filing Thresholds (Below this income, exempt from penalty) Persons in family/household Poverty guideline 1 $11,170 $9, ,130 Married Joint filers $19, ,090 Head of Hshld $12, ,050 Widow/er & dependent child 5 27,010 $15, , , ,890 For families/households with more than 8 persons, add $3,960 for each additional person. 34

36 Premium Help: Max % of Family Income for Premiums in Exchange Income for a Family of Four From: To: Max % Income for Premiums $22,000 (100% FPL) $29,000 (133% FPL) %; ($37 to $73/month) $29,000 $33,000 (150% FPL) % (< $110/month) $33,000 $44,000 (200% FPL) % (< $231/month) $44,000 $55,000 (250% FPL) % (< $371/month) $55,000 $66,000 (300% FPL) % (< $522/month) $66,000 $77,000 (350% FPL) 9.5% (< $610/month) $77,000 $88,000 (400% FPL) 9.5% (< $695/month) 35

37 Out of Pocket Costs: Share of Health Costs Covered under Exchange Plans Income for a Family of Four From: $29,000 $33,000 To: $33,000 (150% FPL) $44,000 (200% FPL) Avg. Share of Costs Covered 94% 85% Out of Pocket MAX as % of income (not incl. premiums) $1,983/indiv. $3,967/family $44,000 $55,000 $55,000 (250% FPL) $66,000 (300% FPL) 73% 70% $2,975/indiv. $5,950/family $66,000 $77,000 $77,000 (350% FPL) $88,000 (400% FPL) 70% 70% $3,987/indiv. $7,973/family 36

38 Examples of Family Costs: Premiums, Out of pocket help, and Out of pocket Caps Family of 4 Income, with Coverage through Exchange, 2014 and later Maximum Yearly Premiums Average % of health costs covered by plan ( Actuarial Value ) Cap on Uncovered spending (not including premiums) 150% FPL: $33,075 $880 94% $3, % FPL: $55,125 $4,465 73% $5, % FPL: $77,175 $7,332 70% $7, % FPL: $99,225 (No Financial Assistance) None Buyer s Choice; 60-90% Upper Limit on TOTAL Family Spending (% of income) $4,847 (15%) $10,415 (19%) $15,305 (20%) $11,900 n/a 37 37

39 State Budget Effects of ACA Medicaid expansion Budget No coverage costs Budget No costs for new adults. Federal government pays 100% cost of new Medicaid adults from Welcome Mat Effect: States expect to see increased Medicaid, CHIP enrollment by uninsured kids who are already eligible today once 2014 expansions begin. State share: ~ 39 cents on dollar for Medicaid Budget First budget with any new adult Medicaid costs: the state starts paying 5% in 2017, topping out at 10% share in State s share of CHIP match drops to 5 cents on dollar 38

40 Presentation to the House Appropriations Subcommittee on Article II: Affordable Care Act Thomas Suehs Executive Commissioner July 12, 2012

41 Affordable Care Act In March 2010, the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation i Act were signed into federal law, collectively known as the Affordable Care Act (ACA). Following challenges by 26 state attorneys general and the National Federation of Independent Business, the Supreme Court of the United States considered, among other questions: Whether the law's individual mandate to purchase health insurance was constitutional, and Whether the Medicaid expansion was unconstitutionally coercive for states t On June 28, 2012, the U.S. Supreme Court ruled the individual mandate constitutional, o but determined e ed that Medicaid d expansion was optional for the states. Page 2

42 Next Steps Based on the court decision, states are seeking guidance on a number of provisions related to the Medicaid expansion and eligibility changes, such as: Do the ACA eligibility determination changes (Modified Adjusted Gross Income [MAGI]) apply to existing i Medicaid id and CHIP programs starting January 2014? Do Maintenance of Effort requirements still apply? Willth there be new flexibility for states t choosing to implement a Medicaid expansion: Later start date? Lower FPL levels? Phased-in implementations? HHSC is currently assessing impacts and considering options related to the changes in the Medicaid provisions of the law as a result of the court decision. Page 3

43 Key ACA Provisions Some key yprovision of ACA include: All U.S. citizens and legal residents must obtain health coverage that meets federal standards (individual mandate) Eliminates lifetime and annual benefit limits/restrictions Prohibits pre-existing existing conditions exclusions Allows dependent coverage up to age 26 Eliminates out-of-pocket expenses for preventive services Creates Health Benefit Exchanges to serve as marketplaces for individuals and small business employees to compare and purchase health coverage Medicaid Expansion The Court upheld the Medicaid expansion up to 133 percent of the Federal Poverty Limit (FPL), with limitations, effectively making it optional for states to implement If a state decides not to participate in the Medicaid expansion, the state can continue receiving funds for its existing Medicaid program Page 4

44 ACA Provisions Implemented to Date Allow children enrolled in Medicaid and CHIP to elect hospice care without waiving their rights to treatment for their terminal illness Made freestanding birthing centers eligible for Medicaid reimbursement Claim federal matching funds for school and state employees children enrolled in CHIP Added tobacco cessation counseling as a Medicaid benefit for pregnant women Made drug rebate formulary changes Implemented a pharmacy carve-in for Medicaid and CHIP MCOs Several program integrity provisions Page 5

45 ACA Provisions in Planning Phase Program Integrity provisions (3/1/13) Changing provider enrollment requirements in Medicare, Medicaid, and CHIP; Changing claims payment processes; Increasing audit activities; Increasing state reporting requirements; Health care acquired conditions Temporary Primary Care Provider Rate Increases (1/1/13 12/31/14) Dual eligibles (Medicare/Medicaid) Integrated Care Demonstration Project shared savings initiative (1/1/14) Medicaid and CHIP eligibility changes (1/1/14) Medicaid idand dchip interface with ihhealth lhbenefit Exchange Other Medicaid and CHIP eligibility changes are under review based on court decision on ACA lawsuit LTSS Balancing Incentives Payment Program Option (10/1/12) Page 6

46 Mdi Medicaid idexpansion Population lti Exchange Sliding Scale Subsidies and Cost Sharing ACA Medicaid Expansion Level (133% FPL) Population that would receive coverage under ACA Medicaid expansion Childless Adult 12% FPL 74% FPL 220% FPL Current Medicaid Parent SSI Adult Long Term Care The chart to the left shows the group of uninsured low income adults that would receive coverage in the ACA Medicaid Expansion. Note: The ACA expands Medicaid coverage for adults under age 65 (up to 133% FPL). However, subsidies are available to adults through the Exchange beginning at 100% FPL. Annual Income Levels FPL Level Individual Family of 3 12% $1,340 $8,265 74% $2, $14, % $11,170 $19, % $14,856 $25, % $44,680 $76,360 Page 7

47 Texas Health Care Coverage Post ACAI Implementation Unsubsidized In or Out of Exchange Unsubsidized In or Out of Exchange Unsubsidized In or Out of Exchange Unsubsidized In or Out of Exchange Unsubsidized In or Out of Exchange Unsubsidized In or In Out or of Out Exchange of Exchange Unsubsidized In or Out of Exchange Sliding Scale Health Insurance Subsidies, through Exchange 400% FPL Sliding Scale Health Insurance Subsidies, through Exchange 400% FPL Sliding Scale Health Insurance Subsidies, through Exchange 400% FPL Sliding Scale Health Insurance Subsidies, through Exchange 400% FPL Sliding Scale Health Insurance Subsidies, through Exchange 400% FPL Sliding Scale Health Insurance Subsidies, through Exchange 400% FPL Sliding Scale Health Insurance Health Subsidies, through Insurance Exchange Subsidies, 400% FPL through Exchange 400% FPL % of Federal Poverty Le vel CHIP Current Medicaid 185% FPL CHIP 200% FPL Current Medicaid 133% FPL CHIP 200% FPL NEW Optional Medicaid Current Medicaid 100% FPL CHIP Current Medicaid 185% FPL Current Medicaid 74% FPL NEW Optional Medicaid 133% FPL 12% FPL NEW Optional Medicaid 133% FPL 133% Page 8

48 Texas Health Insurance Estimates (2010 Population) Page 9

49 Texas Health Insurance Estimates (2010 Population) Page 10

50 Texas Health Insurance Estimates (2010 Population) Page 11

51 ACA Cost Estimate Increased Enrollment Due to ACA Includes costs for individuals currently eligible for Medicaid, but not enrolled. Medicaid enrollment is expected to increase due to the individual mandate. Regular state/federal match applies (no enhanced federal funding). GR cost is $193 million in FY 2014 and $1.8 billion through FY Partial lprimary Care Provider (PCP) Rate Increase Includes costs for mandatory increase to the Medicare rate for certain primary care services and providers. Regular state/federal match rate for 2% of increase for individuals who are currently enrolled or currently eligible but not enrolled. GR cost is $4 million in FY 2013 and $595 million through FY Page 12

52 ACA Cost Estimate Full Primary Care Provider (PCP) Rate Increase Includes costs for an increase equal to the Medicare rate for primary care services delivered by any Medicaid provider. 100% federal match for Medicaid PCP rate increase for 2-3 years ( ). Regular state/federal match rate for individuals eligible under current income limits and family composition. GR cost is $22 million in FY 2013 and $915 million GR through FY ACA Expansion Adults Includes costs for expanding the Medicaid income limit to 133% of the FPL. GR cost is $92 million in FY 2014 and $1.3 billion through FY Federal funding amount is $2.4 billion in FY 2014 and $24 billion through FY Page 13

53 ACA Cost Estimate General Revenue e Expenditures (millions $) Medicaid Expenditures Estimate by Level of ACA Implementation $2,000.0 General Revenue Expenditures millions $ $1,864.0 $1,800.0 $1,600.0 $1,400.0 $1, $1,200.0 $1,000.0 $1,027.6 $ $600.0 $400.0 $347.4 $200.0 $25.7 $ Full PCP Rate Increase $21.7 $37.4 $216.0 $308.0 $332.0 Partial PCP Rate Increase $4.0 $24.9 $136.6 $205.7 $223.7 ACA Expansion Adults $ $91.9 $217.6 $305.4 $723.2 Increased Enrollment Due to ACA $ $193.2 $457.5 $563.1 $585.1 Page 14

54 ACA Cost Estimate Medicaid Expenditures Estimate by Level of ACA Implementation General Reven nue Expenditure es (millions $) $18,000.0 General Revenue Expenditures millions $ $16,417.0 $16,000.0 $14,891.9 $13,586.2 $14,000.0 $12, $11,158.1 $11,967.4 $10,000.0 $8,000.0 $6,000.0 $4,000.0 $2,000.0 $ Full PCP Rate Increase $21.7 $37.4 $216.0 $308.0 $332.0 Partial PCP Rate Increase $4.0 $24.9 $136.6 $205.7 $223.7 ACA Expansion Adults $ $91.9 $217.6 $305.4 $723.2 Increased Enrollment Due to ACA $ $193.2 $457.5 $563.1 $585.1 Existing Medicaid Program $11, $11, $12,558.6 $13,509.7 $14,553.0 Page 15

55 ACA Cost Estimate Medicaid Expenditures Estimate by Level of ACA Implementation $12,000.0 Federal Funds Expenditures (m millions $) $10,000.0 $8,000.0 $6,000.0 $4,000.0 $2,000.0 Federal Funds Expenditures millions $ $10,179.2 $10,060.5 $616.3 $3,786.4 $7,332.2 $ Full PCP Rate Increase $368.3 $651.9 $614.2 $595.9 $619.4 Partial PCP Rate Increase $248.0 $438.4 $333.6 $426.4 $441.6 ACA Expansion Adults $ $2,389.3 $5,658.0 $7,939.9 $7,954.8 Increased Enrollment Due to ACA $ $306.8 $726.4 $1,098.3 $1,163.4 Page 16

56 ACA Cost Estimate Medicaid Expenditures Estimate by Level of ACA Implementation Federal Fund ds Expenditures (millions $) $35,000.0 $31,609.2 Federal Funds Expenditures millions $ $30,000.0 $29,951.6 $25,821.0 $25,000.0 $20,860.2 $20,000.0 $16,736.8 $15,000.0 $10,000.0 $5,000.0 $ Full PCP Rate Increase $368.3 $651.9 $614.2 $595.9 $619.4 Partial PCP Rate Increase $248.0 $438.4 $333.6 $426.4 $441.6 ACA Expansion Adults $ $2,389.3 $5,658.0 $7,939.9 $7,954.8 Increased Enrollment Due to ACA $ $306.8 $726.4 $1,098.3 $1,163.4 Existing Medicaid Program $16, $17,073.8 $18, $19,891.2 $21, Page 17

57 Changes Since First ACA Cost Estimate New and updated information resulted in several changes to the cost estimate: Reduced uptake rates from 91-94% to 85%: Recognition that the Individual Mandate isn t enforceable for Medicaid population. Caseload growth in Children s Medicaid has reduced the percentage of eligible but not enrolled children in Texas over the past two years. Reduced caseload growth trend: The original model assumed caseload growth at 2% annually; updated model uses 1.2% to reflect recent stabilization of Medicaid caseload growth. Caseload phase-in: The original model included no phase-in; the updated model assumes 50% and 75% for the first two years to reflect lack of enforceable Individual Mandate for this population. Implementation date: The new model uses an implementation date of January 2014 rather than the start of FY 2014, subtracting four months of costs. Provider rate increases: The reductions in caseload described above result in a lower cost of the primary care provider rate increases. Medical costs: Original model assumed medical cost growth at 6% annually. Updated model uses 4% reflecting recent national declines in medical cost growth and the impact of Cost Containment steps taken in the last two years in Texas. Page 18

58 Businesses Will Push Perry to Rethink Medicaid Expansion By JAY HANCOCK KHN Staff Writer JUL 18, 2012 Texas Gov. Rick Perry says he rejects the "Obamacare power grab" and will block measures expanding health insurance to millions in his state. The country s second-biggest health insurer is betting he won t succeed. The same day last week that Perry said expanding Medicaid would be like "adding a thousand people to the Titanic," WellPoint Inc. disclosed an agreement to buy Texas s biggest Medicaid managed care company for $4.9 billion. The purchase of Amerigroup, which operates in 12 other states besides Texas, is WellPoint s attempt to cash in on the health act s addition of 17 million Americans to Medicaid, the state and federal program for the poor. The Supreme Court decision allowing states to block Medicaid growth without a penalty, however, threatens the profits of companies hoping to manage care for the new beneficiaries. Perry is one of more than half a dozen Republican governors resisting the federal Medicaid windfall set to begin in But if there s one thing more powerful than Republican governors' dislike of the Affordable Care Act, many believe, it may turn out to be the business interests in their own states. "Once the headlines die down, every hospital in Texas is going to look at Perry and say, 'Please tell me why we're not taking money from the federal government to offset my uncompensated care,'" said Thomas Carroll, who follows health insurance stocks for investment firm Stifel Nicolaus. "That is a question that Rick Perry absolutely cannot answer."

59 A higher portion of Texans lack coverage than residents of any other state. A Texas Medicaid expansion would generate $100 billion in federal money for the state over a decade, according to the state Health and Human Services Commission, and furnish coverage to an estimated 2 million Texans. At the same time it would generate nearly $1 billion in annual Texas revenue for Amerigroup and WellPoint, calculates Carroll. Quiet for now, insurers are expected to join hospitals and patient advocates to fight for Medicaid expansion and what are enormous amounts of money, even by Washington standards. Nowhere are the dollars bigger than in Perry's state, where one in four lacks health coverage. "Fights seem to follow the money, and there is a lot of money at stake in Texas on this," said Phil King, a Republican state representative from outside Fort Worth who opposes the Medicaid expansion. "Maybe you need to rename this 'The Full-Employment Act for Lobbyists.'" With world-renowned medical institutions such as the University of Texas and a large part of its Medicaid coverage handled by private insurers such as Amerigroup, the state's health industry is "just behind oil and gas" in size and influence, said Vivian Ho, a health economist at Rice University. "Given how much Amerigroup has to gain from a Medicaid expansion in Texas, they may be one of the most effective organizations to lobby Perry and the state legislature to fund the expansion." Founded in the mid-1990s in Virginia Beach, Va., Amerigroup contracts with 13 states to manage Medicaid care, generally for a fixed fee per member. Now grown to Fortune 500 size, the company had twice as many Texas members last year , as in any other state. Amerigroup and merger partner WellPoint both have strong ties to Texas politicians. Amerigroup s Texas political action committee donated $20,000 to Perry's 2010 gubernatorial campaign, has given thousands more to numerous legislators and had $89,000 in the bank as of June 25, public records show. Two years ago Amerigroup s foundation presented its "Champion for Children" award to Texas Sen. Judith Zaffirini, a Democrat from Laredo who sits in the senate s Medicaid subcommittee. An Amerigroup spokeswoman declined to comment on Texas politics. Officials from WellPoint and the Texas Association of Health Plans did not return phone calls. After years of rapid growth, managed care plans such as Amerigroup cover most Texas Medicaid beneficiaries. While patient advocacy groups say for-profit plans such as Amerigroup and UnitedHealthcare prompt more caregiver and patient

60 complaints than not-for-profit rivals, they re primarily concerned with achieving any coverage for Texas s 6 million uninsured. "In Texas we re operating fairly low on the pyramid in the hierarchy of needs," said Anne Dunkelberg, associate director of the Center for Public Policy Priorities in Austin. "If we don t do the Medicaid expansion we re going to be leaving somewhere in the neighborhood of 1.5 to 2 million adults without access to affordable coverage." Perry and his allies, however, argue that Medicaid is damaged beyond repair. Even though Washington will pay for all of the health act s Medicaid expansion for three years and eventually 90 percent, they say, the move will prove too expensive for Texas. "It is such an inefficient system," said King, who like many Republicans wants Washington to cede control so Texas can design Medicaid to its own needs. "It is exceptionally ridden with fraud, and it doesn t provide a very high quality of health care." But not all Republicans are falling immediately in line with the governor. "The legislature will be very much involved in the decision making on this," House Speaker Joe Straus told reporters after emerging from a budget hearing last week. "We will listen to all the stakeholders." "We will hold hearings soon to evaluate our options," said Jane Nelson, chairwoman of the Senate Health and Human Services Committee. On Thursday, the Texas Health and Human Services Commission slashed estimates of what Medicaid expansion would cost the state by 40 percent, undercutting those who say Texas can t afford it. The old estimate was $26 billion to $27 billion over a decade; the new one is $15 billion to $16 billion. The lobbying has only begun. Many believe that Perry and other governors will eventually accept Medicaid expansion, that their stance is only a prelude to bargaining with Washington for flexible terms. Winning the expansion is "priority one," said John Hawkins, a lobbyist for the Texas Hospital Association, adding that his group has approached insurers to discuss joint efforts. WellPoint and Amerigroup, too, seem confident that gubernatorial resistance is only temporary. "When you step back from all this, there are billions of dollars in federal money that are going to flow to the states," Amerigroup CEO Jim Carlson told financial analysts on a conference call to discuss the merger. "We think states are going to need to take it."

61 Human services chief: Why Medicaid expansion won't work for Texas By Tom Suehs SPECIAL TO THE AMERICAN-STATESMAN Published: 6:32 p.m. Saturday, July 21, 2012 Do you know how much a Medicaid client pays for an emergency room visit? How about if the visit isn't for an emergency? The answer to both questions is the same: nothing. Not one dime. The Texas Medicaid program paid $467 million for almost 2.5 million emergency visits in 2009, and half of those visits weren't even for emergencies. Yet federal law makes it virtually impossible for states to charge even small co-pays to discourage unnecessary emergency room use by Medicaid clients. This is just one small reason why Medicaid is broken. If we want true reform of our health care system, we should start by reducing the convoluted maze of federal regulations that often prevents states from ensuring that Medicaid makes the most of limited tax dollars. Reform at the federal level must begin with the formula used to determine how much federal funding each state gets for Medicaid. The current model penalizes states whose economies are growing faster than those of their counterparts. Under current law, Texas gets 6.8 percent of federal Medicaid dollars but has 10 percent of the nation's residents living below the poverty line. If the federal formula were changed to look at both a state's income and its need, as recommended by the U.S. General Accounting Office years ago, Texas would stand to gain about $6 billion a year. Some critics will point out that Texas could increase its share of federal funding by expanding its Medicaid program. But that's a perversion of good public policy. Medicaid already consumes a quarter of our state budget, and it provides health care for 1 out of every 4 children in Texas, pays for more than half of all births and covers two-thirds of people in nursing homes. The current federal funding formula is inherently flawed and forces states to spend more to get more. It's time to put the brakes on out-of-control Medicaid spending and move to block grants that allow states to develop effective programs that meet their unique needs. Moving Medicaid to a federal block grant program would mean that states would get a set amount of federal Medicaid funding each year. Instead of dictating that states follow thousands of pages of arcane regulations, the federal government would set goals that states had to achieve to show that their low-income residents had access to health care. In exchange for increased responsibility for achieving those goals, states would have increased flexibility to design and operate their state programs without having to play "Mother, May I?" with the federal government every time they wanted to make even a minor change in their Medicaid programs.

62 And what would Texas do with this newfound freedom? For starters, we'd design a program that encourages healthy, responsible behaviors instead of rewarding bad ones. Private insurance plans charge a higher co-pay for an emergency room visit than for going to a doctor's office because they want to create an incentive to choose the right level of care for the situation. Medicaid should do the same. Requiring Medicaid clients to pay even small copays for going to the emergency room for a cold will help reduce inappropriate ER use and save millions of dollars. Texas would increase accountability among the doctors, clinics and hospitals that provide Medicaid services, too. Under the current structure, Medicaid pays the most to doctors who perform the most procedures and to the hospitals that have the highest costs. What if Medicaid could look at how effective a doctor was and reward those who deliver the best results? And shouldn't hospitals be rewarded for saving the state money instead of penalized for it? These types of changes would mean lower costs to the state overall and a higher quality of care for those on Medicaid. We also would look to make better use of Medicaid funding by increasing the focus on preventive care. Late last year, Texas received federal approval after six months of negotiations, which is lightning-fast by federal standards to repurpose some Medicaid payments to hospitals that weren't tied to the treatment of a specific patient. Under the new plan, Texas will allow hospitals and other providers to form regional partnerships that can get funding for projects that expand access to basic health services and reduce the use of emergency rooms and other more costly care. This will make better use of Medicaid dollars and support local health solutions. A hospital in Hidalgo County might add a nurse hot line for diabetes patients while one in Travis County could expand clinic hours in low-income neighborhoods. Our plan means decisions about how to best meet a community's health will be made by local officials rather than in Washington. Instead of talking about whether we should expand Medicaid, we should shift the discussion to rebuilding the program from the ground up. Let's keep what's working, and throw out what's not. Let's build a program that strips away the red tape and bureaucracy so that family doctors can spend more time practicing medicine than accounting. The federal government has set the rules for the program for more than 40 years. The result has been runaway costs and a payment system that rewards quantity over quality. It's time to give states a shot at enacting true Medicaid reform. Find this article at: html

63 The Pre-Existing Condition Insurance Program

64 Pre-Existing Condition Insurance Plan Eligibility Guidelines Three essential rules: Applicants must be residing in the US legally Applicants must have had 6 continuous months of being uninsured Applications must have a pre-existing condition 2012 Cardon Outreach 2

65 Pre-Existing Condition Insurance Plan Proving a Pre-Existing Condition As of May 1, 2012: Have a denial letter from a commercially available health insurance company dated in last 12 months Have a letter from a licensed health insurance broker stating individual is uninsurable If under the age of 19, have a letter from a doctor stating individual s condition 2012 Cardon Outreach 3

66 Pre-Existing Condition Insurance Plan Options in Texas Texas program run by the feds which means: All applications are handled through the New Orleans office Commercial health insurance denial or broker letter required Effective August 1, 2012 enrollees are moved to UHC Options PPO network If a completed application is received in New Orleans before 15 th of the month, coverage begins on first of next month - if not then coverage begins on the first of the month after the next month If a completed application is received in the second half of the month, the individual may write a letter a submit it with the application requesting coverage begin on the first of the following calendar month 2012 Cardon Outreach 4

67 Pre-Existing Condition Insurance Plan Cost to the Individual Monthly Premiums based on age: 2012 Cardon Outreach 5

68 Pre-Existing Condition Insurance Plan How to Apply Options: Call Monday thru Friday, 8 am to 11 pm Eastern time Apply online at Mail a completed application to: National Finance Center Pre-Existing Condition Insurance Plan P.O. Box New Orleans, LA Cardon Outreach 6

69

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71 Pre-Existing Condition Insurance Plan You may qualify for low-cost insurance through a government-funded Pre-Existing Condition Insurance Plan (PCIP), if you meet the following guidelines: Legally reside in the United States Have not had any health insurance in the last 6 months Have received a denial from a health insurance company or a letter from a licensed health insurance broker stating you are not insurable o The exception to this rule is if you are under the age of 19, then a letter from a doctor stating the incapacitating condition can be used* Coverage under the PCIP requires a monthly premium, co-pays and deductibles just like any other health insurance plan. The amount of the monthly premium is based on age and is as follows for residents of Texas: Standard Plan Extended Plan Health Savings (base rate) (lower copays, etc.) Account Plan (HSA) Age Rate Age Rate Age Rate 0-18 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $442 Calendar year out of pocket maximum: $5950 in network / $7000 out of network Applications can be submitted by submitting your application by phone, online or by mail. Call Monday through Friday, 8 am to 11 pm Eastern Time Online at Mail a completed application to: National Finance Center Pre-Existing Condition Insurance Plan P. O. Box New Orleans, LA *The doctor s letter must include your name and health condition, as well as your doctor s name, license number, state of license and signature. Eligibility will begin on the first day of the calendar month after a completed application is received.

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74 BEFORE YOU START: What to Expect from Your Pre-Existing Condition Insurance Plan Application The Pre-Existing Condition Insurance Plan provides a new health coverage option to people who meet these requirements: Have been without health coverage for at least six months Have a pre-existing condition or have been denied health coverage because of their health condition Are U.S. citizens or are residing in the U.S. legally You pay a monthly premium and an annual deductible for Pre-Existing Condition Insurance Plan (PCIP) coverage. Benefits include primary and specialty care, hospital care, and prescription drugs. You have three plan options to meet your health care needs: the Standard Option, the Extended Option, and the Health Savings Account Option. After you complete this application, you ll mail it to the address on page 7. We ll mail you a letter in about 2 3 weeks letting you know whether your application is approved or if we need more information. If you re approved, your coverage effective date will be based on the date we got your complete application. If we get your application and documentation on or before the 15th of the month, your coverage will be effective the first day of the next month. If we get your application after the 15th, your coverage will be effective the first day of the second month, unless you choose to have your coverage start on the first day of the next month. If we approve your application, we will let you know how to choose an earlier effective date. Coverage always begins on the first day of the month. Example: We get your complete application and supporting documents on... Your coverage starts... March 1 15 April 1 March May 1 OR April 1 (if you ask for coverage to start sooner) For more information, visit or call (TTY ). Application for Coverage in the Pre-Existing Condition Insurance Plan INSTRUCTIONS (11/11)

75 Form Approved OMB No Pre-Existing Condition Insurance Plan Application Please complete this application in full in blue or black ink. You must answer every question. Section 1: Information about the Person Applying for Coverage Last Name First Name Middle Initial Maiden Name (if applicable) Age Date of Birth (mm/dd/yyyy) Social Security Number (if you have one) Gender Male Phone Number with Area Code Address (if you have one) Female Permanent Address City State Zip Code Mailing Address (only if different from your Permanent Address) City State Zip Code Section 2: Information about the State Where You Live To be eligible for this coverage, you must live in a state that is served by the Federally-run Pre-Existing Condition Insurance Plan. What state do you live in? Section 3: Information about Your Citizenship or Immigration Status Check one of the following boxes: I am a citizen of the United States. You must provide your Social Security Number in Section 1, because you re attesting that you are a U.S. citizen. We ll match your information, including your Social Security Number, with information in Federal records. I am a noncitizen national of the United States. You must provide a copy of a document that confirms your status as a noncitizen national, such as a copy of a U.S. passport that shows your national status. I am a noncitizen who is lawfully present in the United States. You must provide a copy of your immigration document, including a document that has your Alien Registration Number or I-94 Number, to verify your current immigration status. A list of acceptable documents is on page 6 of this form. Application for Coverage in the Pre-Existing Condition Insurance Plan (11/11) 1

76 Name Section 4: Information about Your Medical Condition or Diagnosis Check the box that applies to you: I have a medical condition, disability, or illness, or I had a medical condition, disability, or illness in the past. NOTE: You must provide a copy of a letter from a doctor, physician assistant, or nurse practitioner dated within the past 12 months stating that you have or had a medical condition, disability, or illness. This letter must include your name and medical condition, disability, or illness and the name, license number, state of licensure, and signature of the doctor, physician assistant, or nurse practitioner. I ve been denied health coverage. Because I have a medical condition, I received either a denial letter from an insurance company for individual insurance coverage (not health insurance offered through a job) in my state that is dated within the past 12 months, or I received a letter dated within the past 12 months from an insurance agent or broker licensed in my state that tells me I m not eligible for individual insurance coverage from one or more insurance companies because of my medical condition. NOTE: You must provide a copy of the insurance company s denial letter or a copy of the agent or broker s letter. I ve been offered individual health coverage with an exclusionary rider. I received an offer of individual insurance coverage (not health insurance offered through a job) that I didn t accept from an insurance company in my state that is dated within the past 12 months. This offer of coverage has a rider that says my specific medical condition won t be covered if I accept the offer. NOTE: You must provide a copy of your offer of coverage with the rider that shows that your specific medical condition won t be covered. Note that if you currently have insurance coverage that doesn t cover your specific medical condition, you aren t eligible for the Pre-Existing Condition Insurance Plan. I m under age 19, or I live in Massachusetts or Vermont, and I ve been offered individual health coverage for a high premium as described below. I have a medical condition, and I received an offer of individual insurance coverage (not health insurance offered through a job) that I didn t accept from an insurance company in my state that is dated within the past 12 months. This offer of coverage shows a premium that s at least twice as much as the Pre-Existing Condition Insurance Plan premium (the monthly payment you make to an insurer to get and keep insurance) for the Standard Option in my state. NOTE: You must provide a copy of the insurance company s letter showing the premium for the individual coverage you were offered, but did not accept. To find out if the premium you were offered is twice as much as the premium in the Pre-Existing Condition Insurance Plan for the Standard Option in your state, visit or call (TTY ). Application for Coverage in the Pre-Existing Condition Insurance Plan (11/11) 2

77 Name Section 5: Information about Your Other Coverage To be eligible for the Pre-Existing Condition Insurance Plan, you must have been without other health coverage for at least 6 months from the date of this application. Have you had any of the following types of coverage at any point in the past 6 months? You must answer each question. 1. Individual or job-based health plan, including COBRA? Yes No 2. Medicare (Part A and/or Part B)? Yes No 3. Medicaid? Yes No 4. Children s Health Insurance Program (or CHIP)? Yes No 5. A state high risk pool? Yes No 6. TRICARE (military health insurance)? Yes No 7. Health coverage provided by a public health plan established by a state, the U.S. government such as coverage provided to veterans enrolled in VA health care, or a foreign country? Yes No 8. FEHBP (health insurance for Federal employees or retirees), including Temporary Continuation of Coverage (TCC)? Yes No 9. Health benefit plan provided to Peace Corps workers? Yes No 10. Services provided by the Indian Health Service or by a Tribe or Tribal organization for treating your medical condition? Yes No Application for Coverage in the Pre-Existing Condition Insurance Plan (11/11) 3

78 Name We also want to know about any health coverage you had in the past year. If you had health coverage from more than two insurance companies or providers in the past year, you only need to identify the two most recent ones. If you didn t have coverage, you can leave this section blank. Name of Insurance Company or Program that Provided Your Health Coverage: Insurance Company Address: City: State: Zip Code: Insurance Company Phone Number with Area Code: Employer Name (if coverage was provided by the employer): Coverage Start Date: (mm/dd/yyyy) Coverage End Date: (mm/dd/yyyy) Reason Your Health Coverage Ended (check all that apply): Because you or someone in your family lost or left their job. Because your insurance company stopped covering dependents. Because you or someone in your family stopped working full-time and were no longer eligible for benefits. Because you moved out of the insurance company s service area. Other (state the reason your coverage ended): Information for any other health coverage in the past 12 months: Name of Insurance Company or Program that Provided Your Health Coverage: Insurance Company Address: City: State: Zip Code: Insurance Company Phone Number with Area Code: Employer Name (if coverage was provided by the employer): Coverage Start Date: (mm/dd/yyyy) Coverage End Date: (mm/dd/yyyy) Reason Your Health Coverage Ended (check all that apply): Because you or someone in your family lost or left their job. Because your insurance company stopped covering dependents. Because you or someone in your family stopped working full-time and were no longer eligible for benefits. Because you moved out of the insurance company s service area. Other (state the reason your coverage ended): Application for Coverage in the Pre-Existing Condition Insurance Plan (11/11) 4

79 Name Section 6: Choosing Your 2012 Plan Option Check the box of the plan option you choose. Get more information about these options including premiums, benefits, and cost-sharing at Standard Option (Higher Deductible, Lower Premiums) $2,000 in-network/$3,000 out-of-network deductible for medical care $500 formulary/$750 non-formulary deductible for prescription drugs 2012 Extended Option (Lowest Deductible, Higher Premiums) $1,000 in-network/$1,500 out-of-network deductible for medical care $250 formulary/$375 non-formulary deductible for prescription drugs 2012 Health Savings Account Option (Highest Deductible, Lower Premiums) $2,500 in-network/$3,000 out-of-network deductible combined for both medical care and prescription drugs Section 7: Verify Your Understanding of this Application and Sign It 1. I understand that my coverage won t start until (a) this completed application and all required documents are received and approved, and (b) I m billed for the first month s premium and my payment is received and processed. 2. I understand that it s my responsibility to inform the Pre-Existing Condition Insurance Plan of any changes that may affect my eligibility, including any health insurance coverage I may get in the future. 3. I understand that, if I move out of the area served by the Pre-Existing Condition Insurance Plan, I must notify the Plan so I can disenroll. 4. I understand that if I voluntarily disenroll from the Pre-Existing Condition Insurance Plan or if I m disenrolled involuntarily (for example, because I didn t pay my premium on time), I can t re-apply for enrollment until at least 6 months after my coverage ends. 5. I understand and agree to the release of the information on this application to the U.S. Department of Agriculture s National Finance Center, other Federal agencies, and Federal contractors to determine my eligibility and enroll me in the Pre-Existing Condition Insurance Plan. 6. I understand that, by signing below, I certify that all information and documents provided as part of this application are complete, accurate, and true to the best of my knowledge. I understand that, if this application has intentional material misstatements or omissions, the Pre-Existing Condition Insurance Plan may, during the first 2 years of my enrollment, (a) cancel my enrollment as though it were never effective and refund my premiums, less any claims that were paid on my behalf, and/or (b) take any other action available by law. Please sign and date below: Signature Today s Date (mm/dd/yyyy) Full Name If you are a parent or legal guardian or an authorized representative of the person applying for coverage, you must sign above and provide the information below: Phone Number with Area Code Mailing Address City State Zip Code Your Relationship to the Person Applying for Coverage: Parent Legal Guardian Legally Authorized Representative Application for Coverage in the Pre-Existing Condition Insurance Plan (11/11) 5

80 Section 8: How You Heard about the Pre-Existing Condition Insurance Plan OPTIONAL: Tell us how you heard about the Pre-Existing Condition Insurance Plan (check all that apply). Family Member or Friend Coworker or Colleague Mail Solicitation Internet Search Internet Article Radio Publication (newspaper, magazine or journal) Healthcare Provider Insurance Company Insurance Broker Public Event Other Television Section 9: Application Checklist I ve completed this entire application and answered every question. I ve signed and dated this application. I ve included a copy of one of these documents: An insurance company s denial letter An insurance agent or broker s letter An insurance company s letter offering coverage with a rider A letter from a doctor, physician assistant, or nurse practitioner A letter from an insurance company showing the premium quote I was offered for coverage. U.S. Citizens Only: I ve provided my Social Security Number. U.S. Noncitizen Nationals Only: I ve included a copy of a document that confirms my status as a noncitizen national, such as a copy of a U.S. passport that shows my national status. Noncitizens Only: I ve included a copy of my immigration documents, including at least one with my Alien Registration Number or I-94 Number that will be used to verify my status. I ve provided a copy of one of these documents: I-327 (Reentry Permit) I-94 (Arrival/Departure Record) with Unexpired Foreign Passport I-551 (Permanent Resident Card) Unexpired Foreign Passport for Visa Waiver I-571 (Refugee Travel Document) Program travelers I-766 (Employment Authorization I-20 (Certificate of Eligibility for Document) Nonimmigrant (F-1) Student Status) accompanied by I-94 and an Unexpired Machine Readable Immigrant Visa (with Foreign Passport Temporary I-551 Language) affixed to Unexpired Foreign Passport DS-2019 (Certificate of Eligibility for Exchange Visitor (J-1) Status) accompanied Temporary I-551 Stamp (on passport or I-94) affixed to I-94 or Unexpired Foreign Passport by I-94 and an Unexpired Foreign Passport Other Document with an I-94 or Alien Number Application for Coverage in the Pre-Existing Condition Insurance Plan (11/11) 6

81 Mail in Your Completed Application The Official Processing Center for the Pre-Existing Condition Insurance Plan is in New Orleans, Louisiana. Mail your application and all required documents to: National Finance Center Pre-Existing Condition Insurance Plan P.O. Box New Orleans, LA Don t send any payment with this application. If you re eligible, we ll mail you a letter that includes the amount of your monthly premium and instructions for making your first premium payment to complete your enrollment. If you have questions or need help completing this application, call (TTY ), or visit Privacy Act and Paperwork Reduction Notice Section 1101 of the Patient Protection and Affordable Care Act, Public Law , authorizes us to collect the information on this form. The information you provide will allow the United States Department of Health and Human Services through the United States Department of Agriculture s National Finance Center to determine if you re eligible for the Pre-Existing Condition Insurance Plan. We are required to ask for your Social Security Number if you attest that you re a U.S. citizen. We match your information, including your Social Security Number, against Federal records, such as those maintained by the Social Security Administration. We perform this match by computer to confirm your information and verify whether you are eligible for the Pre-Existing Condition Insurance Plan. Only individuals who are citizens or nationals of the United States or are otherwise lawfully present in the United States are eligible for this program. If you don t provide this information, we won t be able to make a decision on your application. Paperwork Reduction Act Statement. This information collection meets the requirements of 44 United States Code 3507, as amended by section 2 of the Paperwork Reduction Act of You do not need to answer these questions unless we display a valid Office of Management and Budget control number. The valid OMB control number for this information collection is We estimate that it will take about 1 hour to read the instructions, gather the facts, and answer the questions. You may send comments on our time estimate to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C , Baltimore, Maryland Send only comments relating to our time estimate to this address, not your application form. Application for Coverage in the Pre-Existing Condition Insurance Plan (11/11) 7

82 ANTES DE EMPEZAR: Lo que debe esperar de su solicitud para el Plan de Seguro para Condiciones Preexistentes El Plan de Seguro para Condiciones Preexistentes ofrece una nueva opción de cobertura para las personas que cumplen con los siguientes requisitos: Han estado sin cobertura de salud por lo menos seis meses Tienen una condición preexistente o se les ha negado cobertura de salud a causa de su estado de salud Son ciudadanos o residen legalmente en los Estados Unidos Usted paga una prima mensual y un deducible anual por la cobertura del Seguro para Condiciones Preexistentes. Los beneficios incluyen medicamentos recetados, atención primaria, especializada y hospitalaria. El plan le ofrece tres opciones: La Opción Estándar, Opción Extendida y Opción de Cuenta de Ahorros Médicos. Después de completar la solicitud, podrá enviarla por correo a la dirección en la página 6. Le enviaremos por correo una carta en alrededor de 2-3 semanas que le permite saber si su solicitud ha sido aprobada o si necesitamos más información. Si es aprobado, el comienzo de su cobertura se basará en la fecha que hayamos recibido su solicitud con toda la información necesaria. Si recibimos su solicitud, con todos los documentos, en o antes del día 15 del mes, su cobertura comenzará el primer día del mes siguiente. Si recibimos su solicitud, con todos los documentos necesarios, después del día 15 y en o antes del último día del mes, su cobertura comenzará el primer día del segundo mes, a menos que usted decida que la cobertura comience el primer día del mes siguiente. Si aprobamos su solicitud, le informaremos cómo elegir una fecha más temprana para el inicio de su cobertura. La cobertura siempre comienza el primer día del mes. Ejemplo: Si recibimos su solicitud y todos los documentos necesarios del 1 al 15 de marzo del 16 al 31 de marzo Su cobertura comenzará... el 1 de abril el 1 de mayo o el 1 de abril (si pide que su cobertura comience antes) Para más información visite o llame al (TTY ). Instrucciones para Llenar su Solicitud para el Plan de Seguro para Condiciones Preexistentes (11/11)