Pathways to Health Coverage & Health Care An Affordable Care Act, BadgerCare, and Community Health Center primer for AmeriCorps members
What do you know about the Affordable Care Act?
What was the ACA intended to do? Problems 18 20% uninsured rate Affordability Jobs Already sick 70 million Americans in medical debt Solutions in the ACA Mandatory health insurance Individual Marketplace Elimination of caps MA Expansion Guaranteed Issue
In Short The Patient Protection and Affordable Care Act
Patient Protection AKA Health Insurance Reforms Allows young adults to stay on parents policies until they are 26 Eliminates lifetime limits Phases out annual limits (gone in 2014) Many preventive care services must be offered without co-pay or deductible 80% of your premium most go to care (MLR) Minimum Essential Benefits No denials for pre-existing conditions!
and Affordable Care Act! Individual Marketplace Subsidies for low-income individuals Tiers of coverage New Funding for Community Health Center expansion Hooray! Medicaid Expansion State choice
ACA Creates New Marketplaces Avenues to Health Insurance Exempt TRICARE Military Uninsured Government Coverage VA Some Veterans Medicare Seniors and SSDI Insured Private Coverage Individuals and Self-Employed Small Groups 1-50 FTEs Medicaid < 100% of FPL, EBD, SSI, Pregnant Women & Children Individual Marketplace SHOP Marketplace Insured Products HMOs PPOs FFS Etc. Providers Doctors Specialists Hospitals Clinics Rx Drugs Etc. Credit: Community Advocates Public Policy Institute Large Groups 50+ FTEs Self- Insured Employer
1. Create an account
2. Apply The Marketplace will ask you a series of questions in order to determine your eligibility Premium: $300 WITH ATPC: Now is $76 Co-Pay: $20 PCP WITH CSR: Now is $0
3. Pick a Plan Which Qualified Health Plan? Which Metal Tier? How much can I afford with or without APTCs and CSRs? Is my current doctor in network? Are my specific medications covered?
Credit: Center for Budget and Policy Priorities
Qualified Health Plans in Wisconsin The individual plans sold by health insurance companies on the Marketplace are known as Qualified Health Plans 1. Aspirus Arise 2. Common Ground Healthcare 3. Dean Health Plan, Inc. 4. Group Health Cooperative of South Central Wisconsin 5. Gundersen/Unity 6. Medica Health Plan 7. MercyCare HMO, Inc. 8. Physicians Plus Insurance 9. Security Health Plan of Wisconsin, Inc. 10. Network Health Plan 11. Children s Health plan http://www.wha.org/pdf/exchangeparticipationbycounty8-3-17.pdf
Metal Tiers Plans sold on the Health Insurance Marketplace are divided into four metal tiers, and some offer catastrophic coverage.
Premium Tax Credits Individuals with lower incomes can receive discounts on their health insurance premium. These are refundable or advance-able, but must be reconciled at the end of the year.
Cost Sharing Reductions Individuals with lower incomes can also receive discounts on their deductibles and co-pays. They further stretch the value of one s health insurance. These do not need to be reconciled. Income Level Actuarial Value 100-150% FPL 94% 150-200% FPL 87% 200-250% FPL 73%
Family Size Annual 100% FPL 120% FPL 135% FPL 150% FPL 185% FPL 200% FPL 250% FPL 300% FPL 1 $12,060 $1,005. 00 $1,206. 00 $1,356. 75 $1,507. 50 $1,859. 25 $2,010. 00 $2,512. 50 $3,015.00 2 $16,240 $1,353. 33 $1,624. 00 $1,827. 00 $2,030. 00 $2,503. 66 $2,706. 66 $3,383. 33 $4,059.99 3 $20,420 $1,701. 67 $2,042. 00 $2,297. 25 $2,552. 51 $3,148. 09 $3,403. 34 $4,254. 18 $5,105.01 4 $24,600 $2,050. 00 $2,460. 00 $2,767. 50 $3,075. 00 $3,792. 50 $4,100. 00 $5,125. 00 $6,150.00 5 $28,780 $2,398. 33 $2,878. 00 $3,237. 75 $3,597. 50 $4,436. 91 $4,796. 66 $5,995. 83 $7,194.99 6 $32,960 $2,746. 67 $3,296. 00 $3,708. 00 $4,120. 01 $5,081. 34 $5,493. 34 $6,866. 68 $8,240.01 What s FPL?
An Example
https://downloads.cms.gov/files/effectuated-enrollment-snapshotreport-06-12-17.pdf 4. Enroll! In order to start receiving benefits, you must enroll in that plan and begin making premium payments. Enrollment Numbers through OE4 (January 31, 2017): 242,863 were determined eligible for the Marketplace 216,355 selected a QHP 83% received financial assistance 206,898 effectuated their coverage (84%) *effectuated: paid first month s premium
Benefits, explained
Benefits, explained
5. Effectuate & Use Your Coverage!
Individual Mandate With some notable exceptions, the majority of Americans will be required to have health coverage for at least 9 months of each year or risk paying a penalty.
When Can You Enroll? Open enrollment begins November 1st, 2017 and ends December 15, 2017 Applies to all individual plans BadgerCare enrollment is year round! Special enrollment periods are year round!
What is a Special Enrollment Period? If a person or family experiences a qualifying life event or in certain other circumstances related to the enrollment process, they may be eligible for a Special Enrollment Period (SEP) This SEP will allow them to enroll in health insurance coverage through the Health Insurance Marketplace outside of a open enrollment period. The individual or family will typically have 60 days from the qualifying life event or approval of their SEP request to enroll in new Marketplace coverage
Special Enrollment Periods Marriage Marriage with Dependent Gained Divorce (if loss of MEC) Death (if loss of MEC) Birth Adoption Placement for Adoption Foster Care Placement Permanent Move to New Service Area Becoming Lawfully Present Gaining AI status Income change resulting in change in APTC eligibility (if enrolled) Individual plan nonrenewal outside of open enrollment Errors, misrepresentation or inaction by enrollment assister QHP misrepresentation or contract violation Technical problems Immigration status error Release from Prison Website display error Involuntary loss of ESI Unresolved casework Loss of Dependent Status Medicaid/Marketplace Expiration of COBRA transfer issues Natural Disaster Serious Medical Condition Victims of Domestic Violence Loss of Hardship exemption http://www.healthreformbeyondthebasics.org/wpcontent/uploads/2015/06/sep-reference-chart.pdf
What doesn t trigger a SEP? Voluntarily dropping other coverage Loss of eligibility for coverage when one was not actually enrolled in it Being determined newly eligible for subsidies if you aren t currently enrolled in a QHP Income change (unless your income moves above 100% FPL) Being terminated from coverage Divorce or death of a family member without it resulting in a loss of MEC
Who Can Help Me? The State and Federal Government train and certify individuals who can help you apply for health insurance through the Marketplace: Certified Application Counselors Navigators Non-Navigator Enrollment Assisters Agents & Brokers Find them here: www.enrollwi.org www.localhelp.healthcare.gov
Recap 4 th Open Enrollment Period 773,875 Wisconsin BadgerCare and Marketplace Enrollment # 822,719 805,471 794,083 9.10% Wisconsin Uninsured Rate 7% 5.70% 139,815 207,349 239,034 242,863 2013 2014 2015 Uninsured Rate 2014: END OE1 2015: END OE2 2016: END OE3 2017: END OE4 MP enrollmetn BC enrollment
What s all this talk about repeal? Mandates Affordability Tools & Pay Fors - Individual - Employer - APTCs? - CSRs? - Medical Device Tax? - Cadillac Tax? Medicaid??
What do you know about BadgerCare?
BadgerCare Basics BadgerCare is the name for Wisconsin s Medicaid program which offers health coverage to individuals with low-incomes. 400%FPL 300%FPL 200%FPL 100%FPL Adults Children Pregnant Women
MEDICAID in Wisconsin Covers
What Does BadgerCare Cover? Case management services Chiropractic services Dental services Family planning services and supplies HealthCheck (Early and Periodic Screening, Diagnosis and Treatment) for people under 21 years of age. Some Home and communitybased services Home health services or nursing services if a home health agency is unavailable Hospice care Inpatient hospital services other than services in an institution for mental disease Inpatient hospital, skilled nursing facility, and intermediate care facility services for patients in institutions for mental disease who are: Under 21 years of age Under 22 years of age and was getting services when you turned 21 years of age 65 years of age or older Intermediate care facility services, other than services at an institution for mental disease Laboratory and X-ray services Medical supplies and equipment Mental health and medical day treatment Mental health and psychosocial rehabilitative services, including case management services, provided by staff of a certified community support program Nurse midwife services Nursing services, including services performed by a nurse practitioner Optometric/optical services, including eye glasses Outpatient hospital services Personal care services Physical and occupational therapy Physician services Podiatry services Prenatal care coordination for women with high-risk pregnancies Prescription drugs and over-thecounter drugs Respiratory care services for ventilator-dependent individuals Rural health clinic services Skilled nursing home services other than in an institution for mental disease Smoking cessation treatment Speech, hearing, and language disorder services Substance abuse (alcohol and other drug abuse) services Transportation to obtain medical care Tuberculosis (TB) services
When Can You Enroll?
How Can I Enroll?
Who Can Help Me? The Wisconsin Income Maintenance Consortia are responsible for processing BadgerCare, FoodShare and Medicaid Applications. Income Maintenance staff are the only individuals who can make an eligibility determination, however anyone can help an individual to apply.
Where are we now? BadgerCare https://www.dhs.wisconsin.gov/badgercareplus/bcpstate-july.pdf
What do you know about Community Health Centers?
50 Years of Community Health Centers
A Social Movement
Wisconsin s Health Centers 18 Community Health Centers 97 physical locations 308,763 patients served in 2016 40% 7% 53%
Fun Facts! Community Health Centers see everybody! are governed by their patients! are totally accessible to the community! provide all primary, preventive, enabling, oral and behavioral health care! offer discounts to uninsured patients! are publically accountable! and
HRSA Family Tree Health Resources & Services Administration (HRSA) Office of Rural Health Policy Bureau of Primary Health Care Bureau of Health Professions Bureau of Clinician & Recruitment Services Wisconsin Office of Rural Health Community Health Centers Shortage Designation Branch National Health Service Corps State/Regional Primary Care Associations Primary Care Offices National Cooperative Agreements AHECs
Thank you! Lisa Olson lolson@wphca.org 608-277-7477