Healthy Indiana Plan 2.0: Introduction, Plan options, Cost sharing, and Benefits

Transcription

1 Healthy Indiana Plan 2.0: Intrductin, Plan ptins, Cst sharing, and Benefits

2 Objectives After reviewing this presentatin, yu will understand the fllwing aspects f HIP 2.0: Prgram features, including the POWER accunt Plan ptins HIP Basic HIP Plus HIP Link HIP State Plan Cst sharing requirements Benefits 2

3 Terminlgy Cst Sharing Deductible Cpayment Federal Pverty Level (FPL) Affrdable Care Act Federal Health Insurance Marketplace Preventive Services The csts a member is respnsible fr paying fr health services when cvered by health insurance. A frm f cst sharing. A deductible is a dllar amunt that is paid fr initial medical csts befre health insurance starts t pay. HIP 2.0 has a $2,500 deductible that is funded by a cmbinatin f state and member cntributins. A frm f cst sharing. Cpayments r cpays refer t a specific dllar amunt that an individual will pay fr a particular service, regardless f the ttal cst f the service accessed. The payment may be cllected at the time f service r billed later. The HIP Basic plan requires cpayments fr mst services frm $4 fr a dctrs visit r prescriptin t $75 fr a hspital stay. Determined annually by the federal gvernment. The federal pverty level fr 2014 is $973 per mnth fr an individual and $1,988 per mnth fr a family f fur. 75% f the federal pverty level is equal t.75 x the federal pverty level fr the family size. Federal law passed in 2010, requires mst individuals t have health insurance r face a tax penalty. Individuals with incme ver the federal pverty level can purchase insurance plans thrugh the federal gvernment s Health Insurance Marketplace. Thse with incmes between 100% and 400% FPL may receive federal tax subsidies t help pay fr cverage. Health care services recmmended t identify health cnditins s they can be treated befre they becme serius. 3

4 Healthy Indiana Plan (HIP) Fundamentals Cvering Hsiers since 2008 Natin s first cnsumer-directed health care prgram fr Medicaid recipients Small demnstratin prgram with limited enrllment Health cverage benefits mdeled after an emplyerspnsred health insurance plan Cverage is prvided by ne f three managed care entities (MCE) as chsen by the member Members may chse Anthem, MDwise, r MHS Pineering the Persnal Wellness and Respnsibility (POWER) accunt Each member has a health savings-like accunt called the POWER accunt that helps pay fr initial medical expenses Members and the State cntribute t ensure there is enugh mney t cver initial health expenses There are incentives t manage the accunt & penalties fr members nt making cntributins 4

5 Healthy Indiana Plan (HIP): Intrducing HIP 2.0 Prvide private marketlike health insurance fr healthy adults N limit n number f members Build n existing Healthy Indiana Plan 5

6 HIP 2.0: Persnal Respnsibility HIP member and the State make cntributins t POWER accunt Cvers the first $2,500 f health care services received each year Member prtin f annual cntributin des nt t exceed $300 per year Members wh d nt make their mnthly cntributin face penalties Incme ver 100% federal pverty level (FPL): Member is subject t a 6 mnth lckut perid in which they may nt receive HIP benefits Incme less than r equal t 100% FPL: Reduced benefits Must make cpayments fr each health service Failure t pay the netime mnthly cntributin will make receiving health care mre expensive fr the member Prtin f unused POWER accunt funding can be rlled ver Must receive recmmended preventive care each year May use rll ver amunt t reduce mnthly POWER accunt cntributin in HIP Plus the fllwing year 6

7 HIP 2.0: Basics Wh is eligible fr HIP 2.0? Indiana residents Age 19 t 64 Incme under 138% f the federal pverty level (FPL) Nt eligible fr Medicare r ther Medicaid categries Includes Individuals currently enrlled in: Family planning services (MA E) Healthy Indiana Plan (HIP) Hsier Healthwise (HHW) Parents and Caretakers* (MAGF) 19 and 20 year lds (MA T) Mnthly Incme Limits fr HIP 2.0 Plans # in husehld HIP Basic Up t 100% FPL HIP Plus Up t ~138% FPL** 1 $973 $1, $1,311 $1, $1,650 $2, $1,988 $2, *Adults with children must make sure their children have minimum essential cverage t be eligible fr HIP **133% + 5% incme disregard, incme limit fr HIP prgram. Eligibility threshld is nt runded. 7

8 HIP 2.0 Plans HIP Plus Initial plan selectin fr all members Benefits: Cmprehensive, including visin and dental Cst sharing: Must pay affrdable mnthly POWER accunt cntributin: $3-$25, based n incme N cpayment fr services* HIP Basic Fall-back ptin fr members with husehld incme less than r equal t 100% FPL nly Benefits: Reduced Cst sharing: N POWER accunt cntributin Must pay cpayment fr all services, visits, and prescriptins HIP State Plan Optin fr individuals with certain health cnditins Benefits: Cmprehensive, with sme additinal benefits Cst sharing: HIP Plus OR HIP Basic cst sharing HIP Link Mre infrmatin cming sn! T help member pay fr emplyer-spnsred health insurance 8 *EXCEPTION: Using Emergency Rm fr rutine medical care

9 HIP 2.0: Treatment f Unique Ppulatins Medically Frail Pregnant Wmen Native Americans Transitinal Medical Assistance (TMA) Individuals with a disability determinatin, certain cnditins impacting their physical r mental health r their ability t perfrm activities f daily living such as dressing r bathing will receive enhanced benefits HIP Basic r HIP Plus cst sharing will apply but access t visin, dental, and nn-emergency transprtatin benefits is ensured regardless f cst sharing ptin Pregnant wmen will have n cst sharing in either HIP Plus r HIP Basic nce their pregnancy is reprted and will receive additinal benefits available nly t pregnant wmen By federal rule, Native Americans are exempt frm cst sharing. Can receive HIP benefits withut required cntributins r emergency rm cpayments Individuals wh n lnger qualify as lw-incme parents r caretakers due t an increase in pay are eligible fr a minimum f six mnths even if incme is ver 138% FPL 9

10 HIP PLAN OPTIONS AND BENEFITS 10

11 HIP 2.0: Plan Optins HIP Plus Offers best value fr members. Cmprehensive benefits including visin and dental. T be eligible, members pay a lw mnthly cntributin twards their prtin f the first $2,500 f health services. Cntributins are based n incme and will nt exceed $300 per year. N cpayment required when visiting dctrs r filling prescriptins. HIP Basic Fallback ptin fr lwerincme individuals. HIP Basic benefits that cver the essential health benefits but nt visin and dental services fr adults. Members pay between $4 and $75 fr mst health care services. Receiving health care is mre expensive in HIP Basic than in HIP Plus. HIP Link Cming Sn! Members receive help paying fr the csts f emplyer-spnsred health insurance. Members have a participating emplyer are eligible fr the emplyer-spnsred health insurance. Member may chse HIP Link r ther HIP plans. HIP Link will be an ptin n the cverage applicatin. Other benefit and cst sharing ptins: Individuals wh qualify may receive additinal benefits thrugh the HIP State Plan Basic & HIP State Plan Plus ptins, r have cst sharing eliminated per federal requirements. 11

12 Incme Eligibility fr HIP 2.0 Plans May be eligible fr HIP Link yes Cming sn! START: Applicant has husehld incme under apprximately 138% FPL Des emplyer ffer health insurance cverage? n OR Is applicant husehld incme apprximately 100% FPL r lwer? yes May be eligible fr HIP Plus OR HIP Basic** n May be eligible fr HIP Plus Mnthly Incme Eligibility Threshlds # in husehld Up t 100% FPL Up t ~138% FPL* 1 Up t $973 Up t $1, Up t $1,311 Up t $1, Up t $1,650 Up t $2, Up t $1,988 Up t $2, *133% + 5% incme disregard, incme limit fr HIP prgram. Eligibility threshld is nt runded. **HIP Basic serves as default plan if member des nt make POWER accunt cntributin. 12

13 HIP Plus HIP Basic HIP Plus vs. HIP Basic fr Members Less than r equal t 100% FPL Mre affrdable Predictable mnthly payments Mre benefits Optin t earn reductins t future mnthly cntributins May reduce payment by up t 100% May be mre expensive Unpredictable csts Fewer benefits Ptential t reduce future mnthly cntributins fr HIP Plus enrllment, but these reductins are capped at 50% 13

14 HIP 2.0: State Plan Available fr certain qualifying individuals Benefits equivalent t current Medicaid benefits HIP Plus benefits plus additinal benefits, including transprtatin t dctr appintments State Plan benefits replace HIP Basic r HIP Plus benefits State Plan benefits are the same, regardless f HIP Basic r HIP Plus enrllment Keep HIP Basic r HIP Plus cst sharing requirements Thse eligible fr Transitinal Medical Assistance have guaranteed eligibility fr 6 mnths regardless f reprted changes in incme 14

15 HIP 2.0: Plan Variatins Ppulatin Benefits Cst Sharing Other Adults incme 100% FPL Adults incme between 100% and ~138% FPL Lw-incme Parents r Caretaker Adults Lw-Incme 19 & 20 Year Olds Medically Frail Pregnant Wmen HIP Basic r HIP Plus HIP Plus State Plan Benefits State Plan Benefits State Plan Benefits HIP Basic r HIP Plus HIP Basic r HIP Plus HIP Plus HIP Basic r HIP Plus HIP Basic r HIP Plus HIP Basic r HIP Plus Nne Native Americans HIP Plus** Nne in HIP Plus Transitinal Medical Assistance HIP Basic r HIP Plus HIP Basic r HIP Plus All 19 & 20 year lds receive EPSDT* Receive additinal benefits nly available t pregnant wmen. May chse t mve t State Plan Benefits (MAGP). By federal law exempt frm cst sharing May receive HIP Basic if incme ver 100% FPL * Early Peridic Screening Diagnses and Testing (EPSDT) as a benefit available t thse 20 years ld and yunger that prvides visin, dental, hearing aids, therapy, and preventive services **Benefit package subject t change 15

16 HIP 2.0: Essential Health Benefits Essential Health Benefits Ambulatry (Dctr Visits) HIP Plus HIP Basic HIP State Plan Cvered Includes cverage fr Temprmandibular Jint Disrders (TMJ) 100 visit limit fr hme health Cvered N TMJ cverage 100 visit limit fr hme health Cvered - Includes TMJ cverage & chirpractic services. Hme health limit des nt apply Emergency* Cvered Cvered Cvered Hspitalizatin Cvered - Includes Bariatric Surgery Cvered - N Bariatric Surgery Cvered - Includes Bariatric Surgery Maternity Cvered Cvered Cvered Mental Health Cvered Cvered Cvered Labratry Cvered Cvered Cvered Pharmacy Cvered Cvered- Generic Preferred Cvered Rehab & Habilitatin Cvered 75 visits annually f physical, speech and ccupatinal therapies 100 day limit fr skilled nursing facility Cvered 60 visits annually f physical, speech and ccupatinal therapies 100 day limit fr skilled nursing facility Cvered - Requires prir authrizatin but nt limited t 60/75 visits annually Skilled nursing facility limit des nt apply Preventive Cvered Cvered Cvered Pediatric Early Peridic Screening Diagnsis and Testing (EPSDT) services cvered fr 19 & 20 year lds *Includes emergency-related transprtatin 16

17 HIP 2.0: Other Benefits Other Benefits HIP Plus HIP Basic HIP State Plan Adult Visin Cvered Nt Cvered Cvered Adult Dental Cvered Limited t 2 cleanings per year and 4 restrative prcedures Nt Cvered Cvered Transprtatin Nt Cvered Nt Cvered Cvered Medicaid Rehabilitatin Optin (MRO) Pregnancy-Only Nt Cvered Nt Cvered Cvered Additinal benefits fr pregnant wmen including transprtatin and chirpractic services. Additinal benefits fr pregnant wmen including transprtatin, visin, dental and chirpractic services. Pregnant wmen receive access t all pregnancy nly benefits n HIP Plus r HIP Basic plan and full State Plan benefits. 17

18 HIP 2.0 COST SHARING - REQUIRED CONTRIBUTIONS AND COPAYMENTS 18

19 POWER Accunt Unique feature f the Healthy Indiana Plan (HIP) Health savings-like accunt Members receive mnthly POWER accunt statements Used t pay fr the first $2,500 f service csts HIP Plus: Members make mnthly cntributins t POWER accunt Cntributin amunt based n incme and des nt exceed $300 per year Members exempt frm mst ther cst sharing If members leave the prgram early they may still be respnsible fr unpaid POWER accunt cntributins, depending n the cst f health care services received Rllver: All members may reduce future HIP Plus POWER accunt cntributins Must have remaining cntributin in POWER accunt and/r Receive required preventive services 19

20 POWER Accunt HIP Plus POWER accunt Pays fr $2,500 deductible Member cntributes May duble rllver HIP Basic POWER accunt Pays fr $2,500 deductible Cannt be used t pay HIP Basic cpays Capped rllver ptin Year-End Accunt Balance Unused member cntributin rllver t ffset next year s required cntributin Amunt dubled if preventive services cmplete up t 100% f cntributin amunt Example: Member has $100 remaining in POWER accunt. It is credited t next year s accunt. Credit is $200 if preventive services were cmpleted. Year-End Accunt Balance If preventative services cmpleted, members can ffset required cntributin fr HIP Plus by up t 50% the fllwing year Members may nt duble their rllver as in HIP Plus Example: Member receives preventive services and has 40% f riginal accunt balance remaining at year end. May chse t mve t HIP Plus the fllwing year and rll ver reduces required cntributin by 40%. 20

21 HIP Plus: POWER Accunt Cntributin (PAC) Lw, flat rate cntributins Emplyers & nt-fr-prfits may assist with cntributins Emplyers may pay up t 50% f member PAC Nt-fr-prfits may pay up t 75% f member PAC Payments made directly t member s selected managed care entity Spuses split the standard mnthly PAC amunt Mnthly HIP 2.0 POWER accunt cntributins (PAC) FPL Mnthly Incme, Single Individual Mnthly PAC*, Single Individual Mnthly Incme, Husehld f 2 Mnthly PAC, Spuses** <22% Less than $214 $3 Less than $289 $1.50 each 23%-50% $ t $487 $8 $ t $656 $4 each 51%-75% $ t $730 $15 $ t $984 $7.50 each 76%-100% $ t $973 $20 $ t $1,311 $10 each 101%-138% $ t $1, $25 $1, t $1, $12.50 *Amunts can be reduced by ther Medicaid r CHIP premium csts **T receive the split cntributin fr spuses, bth spuses must be enrlled in HIP 21

22 Nn-payment Penalties Members remain enrlled in HIP Plus as lng as they make POWER accunt cntributins and are therwise eligible Penalties fr members nt making the PAC cntributin: 100% FPL Mved frm HIP Plus t HIP Basic >100% FPL Dis-enrlled and lcked ut fr six mnths Cpays fr all services Accunts will be referred t the federal Health Insurance Marketplace 22

23 Exceptins t Nn-payment Penalties Exceptins t penalties fr select HIP Plus members ver 100% FPL wh stp paying their POWER accunt cntributins Native Americans* N required cntributins N cpayments fr using the emergency rm fr rutine care Individuals qualified fr Transitinal Medical Assistance Mve t HIP Basic HIP Basic cpayments apply *Benefit package subject t change 23

24 HIP Basic Plan: Cst Sharing When members with incme less than r equal t 100% FPL d nt pay their HIP Plus mnthly cntributin, they are mved t HIP Basic. HIP Basic members are respnsible fr the fllwing cpayments fr health and pharmacy services. Service HIP Basic Cpay Amunts 100% FPL Outpatient Services $4 Inpatient Services $75 Preferred Drugs $4 Nn-preferred drugs $8 Nn-emergency ER visit Up t $25 Cpayments may nt be mre than the cst f services received. 24

25 HIP Plus Cntributins Are Nt Premiums Unlike premiums, members wn their cntributins If members leave the prgram early, the prtin f the unused balance they are entitled t is returned t them Members will we their share f the $2,500 deductible fr the health care expenses that they incur if they leave early Maximum member share f the $2,500 deductible is $300 Members remaining in the prgram may be eligible t receive a rllver f their remaining cntributins Rllver is applied t the required cntributin fr the fllwing year 25

26 5% f incme limit All member cst sharing is subject t a 5% f incme limit Members are prtected frm paying mre than 5% f their quarterly incme tward HIP cst sharing requirements, including: Mnthly cntributins Emergency Rm cpayments HIP Basic cpayments Members meeting their 5% f incme limit n a quarterly basis will have all cst sharing respnsibilities eliminated fr the remainder f the quarter RECOMMENDATION: Members shuld keep recrd f their expenses and if they think they have met their 5% f incme limit, they shuld cntact their managed care entity (e.g. Anthem, MDwise, MHS) 26

27 HIP Emplyer Benefit Link COMING SOON! NEW EMPLOYER PLAN OPTION Families can chse t enrll in emplyer-spnsred health insurance Emplyer must sign up and cntribute 50% f member s premium POWER ACCOUNT Member makes cntributins t POWER accunt Defined cntributin frm State t allw individuals Pay fr emplyer plan premiums & Defray ut-f-pcket expenses Prmte family cverage in private market Prmte HIP member health cverage chices Leverage POWER accunt ptential 27

28 HIP SUMMARY 28

29 Summary After reviewing this presentatin, yu shuld understand the fllwing aspects f HIP 2.0: Prgram features, including the POWER accunt Plan ptins HIP Basic HIP Plus HIP Link HIP State Plan Cst sharing requirements Benefits 29

30 HIP SUPPLEMENTAL MATERIAL 30

31 Primary HIP Eligibility Categries HIP Plus (MARP) Husehld incme up t ~138% FPL Best value plan Pay mnthly POWER accunt cntributin N cpayments fr mst medical services HIP Basic (MARB) Husehld incme less than r equal t100% FPL Exceptin: Transitinal Medical Assistance* N POWER accunt cntributin Pay cpayments fr mst medical services HIP State Plan Plus (MASP) Incme under 138% FPL and: Medically Frail, OR Lw-incme Parents/Caretakers, OR Lw-incme 19 & 20 year lds Make mnthly POWER accunt cntributin HIP State Plan Basic (MASB) Less than r equal t 100% FPL and: Medically Frail, OR Lw-incme Parents/Caretakers, OR Lw-incme 19 & 20 year lds *N husehld incme limit fr first six mnths. Incme cannt exceed 185% FPL fr additinal six mnths f cverage. Individual may have additinal cverage ptins if als medically frail. 31

32 HIP & HIP 2.0 Cmparisn Original HIP HIP 2.0 Effective Date January 1, 2008 January 1, 2015 Eligibility Other Cverage In 2014, incme less than r equal t 100% FPL , incme equal t r less than 200% FPL Individuals cannt be cvered under Medicare r have ther minimum essential health cverage Under ~138% FPL Individuals cannt be cvered under Medicare r ther Medicaid categries POWER Accunt $1,100 $2,500 Benefit Limits Plan Optins Annual limit: $300,000 Lifetime limit: $1 millin Nne all members in the same prgram N annual r lifetime cverage limit 3 prgram ptins: HIP Basic, HIP Plus, and HIP Link 32

33 2014 Mnthly Incme by Federal Pverty Level Husehld Size 22% 50% 75% 100% 133% ~138% FPL* 200% 1 $214 $487 $730 $973 $1,294 $1, $1,945 2 $289 $656 $984 $1,311 $1,744 $1, $2,622 3 $363 $825 $1,237 $1,650 $2,194 $2, $3,299 4 $438 $994 $1,491 $1,988 $2,644 $2, $3,975 5 $512 $1,163 $1,745 $2,326 $3,094 $3, $4,652 6 $587 $1,333 $1,999 $2,665 $3,544 $3, $5,329 7 $661 $1,502 $2,252 $3,003 $3,994 $4, $6,005 8 $735 $1,671 $2,506 $3,341 $4,444 $4, $6,682 Fr each additinal persn, add: $75 $170 $254 $339 $450 $ $677 *133% + 5% incme disregard, incme limit fr HIP prgram. Eligibility threshld is nt runded. 33

34 Minimum Essential Cverage Individual Mandate Affrdable Care Act (ACA) requirement All individuals must maintain Minimum Essential Cverage (MEC) fr themselves and their dependents Adults may nt be eligible fr HIP if they d nt have MEC fr their children Understanding MEC List f cverage types determined by the federal gvernment Cverage types may change Sme cverage types nly classified as MEC in 2014 Types f cverage nt currently cnsidered MEC may apply fr recgnitin as MEC Exemptins frm MEC Individuals may receive an exemptin frm the requirement t maintain MEC 34

35 Federal List f Minimum Essential Cverage Types In rder t meet Individual Mandate requirements, all Americans must have at least ne f the fllwing: Gvernment spnsred health cverage Medicare Prgram Mst Medicaid Prgrams Children s Health Insurance Prgram Veterans Administratin prgrams: including TriCare and CHAMP VA Cverage fr Peace Crps Vlunteers Emplyer-spnsred health insurance cverage Individual market health cverage Grandfathered health plan Refugee medical assistance Medicare advantage plans Additinal cverage as specified Any health cverage nt recgnized may apply t be Minimum Essential Cverage. The federal gvernment will maintain a list f recgnized types f minimum essential cverage. HIP 2.0, pending apprval frm the federal gvernment r they will need t receive an exemptin r pay the tax penalty. 35

36 NOT Minimum Essential Cverage (MEC) Individuals may have health insurance cverage that is nt cnsidered MEC, such as: Certain Medicaid Prgrams Examples: Optinal family planning services Pregnancy related services Emergency medical services Limited-scpe cverage, r ffered n a separate plicy frm primary health cverage Examples: Accidental death and dismemberment cverage Benefits prvided under certain health flexible spending arrangements Cverage fr emplyer-prvided n-site medical clinics Autmbile liability insurance Wrkers cmpensatin Lng-term care benefits Disability insurance Credit-nly insurance Visin benefits General liability insurance Fixed indemnity insurance Medicare supplemental plicies TRICARE supplemental plicies Similar supplemental cverage fr a grup health plan Separate plicies fr cverage f nly a specified disease (example: cancer nly plicies) They will need t either: Obtain cverage that IS MEC Obtain an exemptin Pay the tax penalty 36