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1 Update: Click to edit Master title style Texas and the Affordable Care Act Click Anne Dunkelberg, to edit Associate Master Director subtitle style Center for Public Policy Priorities Monday, January 13, 2014 CPPP.org 1

2 About CPPP: CPPP was born from faith and a vision of social justice in 1985 when a Congregation of Benedictine Sisters in Boerne, Texas, founded the center to improve health care access for the poor. 2

3 Most Uninsured Texans are Working- Age Adults, ,000 3% of Texas Seniors uninsured <2/3 are below 200% FPL 1.2 million Rate: 16.4% of million uninsured Texans (24.6% of all ages) Children half as likely as Texas adults to be uninsured 5.1 million Rate: 32.1% of are Uninsured Source: U.S. Census, March 2013 CPS 3 3

4 Texas Uninsured by Income % of the 6.4 million uninsured have incomes <400% FPL % FPL $69,150-$92, % FPL $57,625-$69,150 >400% FPL >$92, K 477K 781K Million <100% FPL <$23,050/yr for family of four 6.4 million includes 1.8 million non-us citizens; ~60% of these (about 1.1 million) likely undocumented % FPL $46,100-$57, K 901K % FPL $34,575-$46, K 486K % FPL $28,813-$34, % FPL $23,050-$28,813 Annual income limits given for a family of four, 2012 federal poverty level U.S. Census, 2012 CPS 4

5 Texas ACA Enrollment Opportunity But: Assumes ACA Medicaid expansion, which accounts for about half of projected coverage gains Cline M, Murdock S. Estimates of the Impact of the Affordable Care Act on Counties in Texas. Hobby Center for the Study of Texas, Rice University, Report to Methodist Healthcare Ministries, April

6 The Marketplace is Just One of the ACA s Key 2014 Reforms Medicaid expansion: US citizens to 133% FPL ($15,300 individual; $31,300 for 4 in 2013). State option. Private health insurance market reforms: can t be turned down or charged more based on health status; no pre-existing condition waiting periods; standard minimum benefits for individuals and small employers; no annual or lifetime maximums, etc. Health Insurance Marketplace: private insurers options can be compared and purchased. Sliding scale help with premiums Sliding scale help with deductibles/co-pays and out-of-pocket caps Individual mandate to have coverage (with several exceptions). Employer penalties possible in 2015 if employees get sliding-scale help in Marketplace, but exemption for all employers with 50 or fewer FTE workers. 6

7 Family Income ACA Support Fitted to Your Income >$94,200 for a family of four; >400% of FPL Job-based coverage, or Full-cost coverage in the Marketplace $70,650-$94,200; % of FPL $47,100-$70,650; % of FPL $31,322-$47,100; % of FPL CHIP Job-based coverage, or Subsidized Marketplace coverage: premiums capped at 2% - 9.5% of income <$31,322 for a family of four; < 133% FPL Medicaid Children Family income based on 2013 federal poverty income levels for a family of four Coverage Gap below poverty line ($23,550 for family of four) Adults (not eligible for Medicare or Medicaid today) 7

8 Marketplace Administration State-based Partnership Federally facilitated Source: The Commonwealth Fund, 8

9 Who Is Eligible for the Marketplace? To buy coverage U.S. citizen or legal resident Not incarcerated (unless pending disposition of charges) For financial help: lower premiums and out-of-pocket Income from % of the poverty level, generally Not eligible for other minimum essential coverage 9

10 Texas Marketplace Eligible 2,049,000 Texans eligible for premium subsidies in the Texas Marketplace. (Includes both uninsured and people with individual market coverage today) 3,143,000 Potential Marketplace size Estimates of total eligible, NOT projections of who will actually enroll Kaiser Family Foundation, State-by-State Estimates of the Number of People Eligible for Premium Tax Credits Under the Affordable Care Act, November 5,

11 Marketplace Timeline Open enrollment begins Coverage can start (must enroll by 12/23/13 for a 1/1/14 start date) Open enrollment ends 11

12 INFORMATION NOW: HealthCare.gov & CuidadodeSalud.gov Available 24/7: ; TTY: , or chat online 12

13 Marketplace Provides No Wrong Door In-person Assistance: Agents/Brokers Navigators Certified Application Counselors 13

14 Premium Help: Who is Eligible? Main Target: Individuals and families between 100 and 400 percent of poverty, ineligible for other coverage. Two additional groups: 1) People who would have to spend more than 9.5% of income to participate in employer plan or whose employer plan has less coverage than the bronze exchange plan 2) Lawful immigrants below 100% of poverty who are not Medicaid eligible 14

15 % FPL Monthly Premium for a Single 27-Year-Old at Varying Income Levels, Houston, TX (Rating Area 10) Annual Income Second- Lowest Cost Silver Plan Before Subsidies Monthly Tax Subsidy Second Lowest-Cost Silver Plan After Subsidies Lowest Cost Bronze Plan Before Subsidies Lowest Cost Bronze Plan After Subsidies 133% $15,282 $ $38.20 $ % $17,235 $ $57.45 $0.00 $ $ % $22,980 $80.46 $ $ % $28,725 $8.40 $ $ % $34,470 $0.00 $ $ CPPP analysis of US HHS ( ) data.

16 Marketplace Coverage Levels All plans have essential health benefits % covered by plan Platinum Gold 80% 90% % paid by enrollee 10% 20% Silver Bronze 70% 60% 30% 40% 0% 20% 40% 60% 80% 100% Plus, Catastrophic plan for people under 30, or if no other coverage is affordable 16

17 10 Essential Health Benefits standard floor for coverage for individuals and small employers* 1. ambulatory services 2. emergency services 3. hospitalization 4. maternity care 5. mental health and substance use disorder services 6. prescription drugs 7. rehabilitative and habilitative services and devices 8. laboratory services 9. preventive and wellness services 10.pediatric dental and vision care * Grandfathered plans those created before March 23, 2010 are exempt 17

18 Insurers in the Texas Marketplace 11 Insurers in the Texas Individual Marketplace Aetna Ambetter from Superior Health Plan Blue Cross Blue Shield of Texas Cigna CommunityFirst Community Health Choice Firstcare Health Plans Humana Molina Healthcare of Texas Scott & White Health Plan Sendero Health Plan insurers in green offer plans in Blanco County 18

19 The Individual Mandate If you are uninsured but have access to affordable coverage, you must purchase insurance for yourself, or pay a tax. Coverage that satisfies the individual mandate: o Job-based coverage o Medicare o Medicaid/CHIP o VA o Tricare o Plans bought in the Marketplace o Individual market plans purchased directly from insurers 19

20 Exemptions and Penalties Exemptions to mandate/penalty if you: Are uninsured for less than 3 months of the year Enroll in the Marketplace by March 31, 2013 (even if coverage doesn t start until May 1) Coverage costs more than 8% of income Are not required to file a tax return because income is too low Would qualify for Medicaid, but state has not to expanded Medicaid (must get an exemption certificate from the Marketplace) And others Penalties: 2014 Penalty is $95 per adult and $47.50 per child (up to $285 a family) or 1% of family income, whichever is greater 2015 Penalty is $325 per adult and $ per child (up to $975 a family) or 2% of family income, whichever is greater 2016 and Beyond Penalty is $695 per adult and $ per child (up to $2,085 a family) or 2.5% of family income, whichever is greater 20

21 Governor s ACA Opposition Recent Issues Perry September letters TDI: develop Navigator Rules first year cost of compliance for navigator entity $963 - $1,457, plus $323 - $976 cost per individual navigator 40-hour state training requirement (on top of the hour federal training requirement already fulfilled). Compare to THHSC Medicaid/CHIP navigators (4 hours free HHSC training to help people enroll in Medicaid, CHIP, SNAP, TANF), Community Medicare counselors in HICAP (also certified by TDI) 25 hours of free training. applies well beyond navigator grantees under the Affordable Care Act; could prevent helping consumers understand and compare benefits so that consumers can make THEIR OWN informed insurance choice. HHSC: Governor wants a Medicaid block grant Keep collecting asset information Roll back kids 6-month continuous coverage (Texas 2001 law) to just one 6-month segment per year No out-of state foster kids get Medicaid from

22 More than 1.1 million people enrolled through HealthCare.gov, prior to the Dec. 24 deadline. In other words: Enrollment in the federal exchange was about nine times as high in December than all of October and November. Add state enrollment data, enrollment grew from 90,000 in October to just about 2 million private insurance enrollees through late December. Plus 4.3 million new enrollees in Medicaid or CHIP, the Children's Health Insurance Program. Plus 3.1 million young adults (those up to the age of 26) who have enrolled in their parents' workplace plans since September /28/13: Texas >457K applications, 180K with subsidy, 47K sent to Medicaid-CHIP. 118K enrolled in private plan. Lag behind CA, NY, FL mh-10-million-insured ,0, story#ixzz2qIMfAl4u The Numbers 22

23 The Texas Coverage Gap 23

24 Status of State Medicaid Expansion Decisions, as of December 11, 2013 WA OR NV CA ID AZ UT MT WY CO NM ND SD NE KS OK MN WI* IA* IL MO AR* MS MI* OH IN* KY TN AL VT NY PA* WV VA NC SC GA ME NH MA CT RI NJ DE MD DC AK HI TX LA FL Implementing Expansion in 2014 (26 States including DC) Seeking to Move Forward with Expansion post-2014 (2 States) Not Moving Forward at this Time (23 States) NOTES: *AR and IA have approved Section 1115 waivers for Medicaid expansion; MI has a pending waiver for expansion and plans to implement in April 2014; IN and PA have pending waivers for Medicaid expansion plans that would be implemented post-2014; WI amended its Medicaid state plan and existing Section 1115 waiver to cover adults up to 100% FPL in Medicaid, but did not adopt the expansion. SOURCES: State decisions on the Medicaid expansion as of December 11, Based on data from CMS, available at: Levels/medicaid-chip-eligibility-levels.html. Data have been updated to reflect more recent activity.

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26 Texas Medicaid/CHIP: Who is Helped Today Disabled, 422,467 CHIP, 591,756 January 2013, HHSC data Elderly, 326,501 Poor Parents, 144,040 TANF Parent, 83,772 Maternity 86,975 Medicaid Children, 2,547,199 Total enrolled 1/1/2013: 3.6 million Medicaid; 592,000 CHIP 1 in 7 Texans, but 42% of Texas kids 26 26

27 Income Caps for Texas Medicaid and CHIP, % 200% 150% 100% 50% 0% $35,317/yr $35,317/yr 185% 185% Pregnant Women $25,390/yr 133% $19, % $2,256 $3,696 12% 19% Newborns Age 1-5 Age 6-18 TANF parent of 2, no income Working Parent of 2 $8,376* 75% SSI (aged or disabled) $25,128* 225% Long Term Care $38, % CHIP Mandatory Optional indicates Texas Choices to go ABOVE federal minimum Income Limit as Percentage of Federal Poverty Income Annual Income is for a family of 3, *except Individual Incomes shown for SSI & Long Term Care 27

28 Medicaid Expansion Will Significantly Increase Eligibility for Parents in Many States Medicaid Eligibility Levels for Parents, January 2013: 133% NOTE: Ten states (CT, IL, ME, MA, MN, NJ, NY, RI, VT, WI) and DC already offer coverage to parents at or above 133% FPL; under the ACA an income disregard of 5 percentage points will be applied to this limit increasing the effective income limit to 138% FPL. SOURCE: Based on the results of a national survey conducted by the Kaiser Commission on Medicaid and the Uninsured and the Georgetown University Center for Children and Families, 2013.

29 Family Income About 1.5 Million Uninsured Texas Adults are Eligible for Medicaid Expansion Experts and Texas HHSC estimate million uninsured U.S. citizen adults in Texas would be eligible for the Medicaid expansion in % FPL $25,975 for family of 3 133% FPL $25,975 for family of 3 With Medicaid Expansion Marketplace with Subsidies Medicaid $0 Parents and Childless Adults 29

30 Family Income Texas Coverage Gap: Medicaid Hole in the ACA Coverage System With Medicaid Expansion vs. Without Medicaid Expansion 133% FPL $25,975 for family of 3 Marketplace with Subsidies Marketplace with Subsidies Marketplace with Subsidies 100% FPL Medicaid Coverage Gap Coverage Gap $19,530 for family of 3 19% FPL $0 Parents and Childless Adults Childless Adults Medicaid Working Parents $3,696 for family of 3 30

31 Without Medicaid Expansion, Only Half as Many Texas Uninsured Gain Coverage 6.1 million uninsured Michael E. Cline, Ph.D., and Steve H. Murdock, Ph.D., Rice University, Estimates of the Impact of the Affordable Care Act on Counties in Texas, April

32 The Coverage Gap Unless our leaders take action, on January 1, 2014: an uninsured parent with two children living on $18,000 will have NO help from ACA for health coverage, but another uninsured parent with 2 children earning $20,000 a year will qualify for full coverage on a sliding scale for $33 a month or less. About 1 million U.S. citizen adults are uninsured in Texas and will have no coverage options. 32

33 Large Urban Counties & Medicaid Expansion : Share of $6 billion new statewide annual federal health care spending Yearly Avg. $222 NEW Fed $ million Uninsured NOW El Paso Dallas Harris Lubbock Travis $580.1 million $935.3 million $77.7 million $224.1 million 208, ,492 1,025,922 66, ,067 Estimated # Gaining Medicaid 51, , ,165 19,693 55,676 Sources: Texas HHSC projections of ACA Medicaid expansion costs; THHSC historical Medicaid spending by county, Cline & Murdock estimates of ACA insurance gains by county. 33

34 Coverage Gap Advocacy A diverse network of Texans and Texas organizations are working to help Texans in the Gap Group tell their stories and seeking inclusion of Texas working poor in the ACA s health reforms. For individuals: For organizations: 34

35 FAMILY BUDGETS 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 updates, visit our website. CPPP Center for Public Policy Priorities 7020 Easy Wind Drive, Suite 200 Austin, TX P F CPPP.org 35