ACA LEARNING SERIES Impact n Massachusetts & Implementatin activities t date Massachusetts Health Care Training Frum (MTF) April 2012 A cllabrative effrt between the Executive Office f Health and Human Services and the Health Cnnectr
Agenda 2 ACA Key Cncepts Exchange and Integrated Eligibility System MA Implementatin Activities fr Subsidized Ppulatins
Massachusetts ACA Learning Series 3 The purpse f this ACA Learning Series is t educate staff wh currently assist Cmmnwealth Care, Cmmnwealth Chice, MassHealth and HSN members at Massachusetts hspitals, health centers and cmmunity-based rganizatins Intrduce key cncepts and create awareness Deliver imprtant, mre detailed infrmatin that will prepare yu fr assisting ppulatins yu serve Prvide yu with specific infrmatin and training t help ppulatins btain cverage ACA IMPLEMENTATION January 2012 January 2013 January 2014
Backgrund: Guiding Principles 4 Creating a cnsumer-centric apprach t ensure that all eligible Massachusetts residents avail themselves f available health insurance subsidies t make health care affrdable t as many peple as pssible. Creating a single, integrated prcess t determine eligibility fr the full range f health insurance prgrams including Medicaid, CHIP, ptentially the Basic Health Prgram and premium tax credits and cst-sharing subsidies. Offering apprpriate health insurance cverage t eligible individuals by defining bth the ppulatins affected and the health benefits that meet their needs. Wrking within state fiscal realities, maximizing and leveraging financial resurces, such as FFP. Fcusing n simplicity and cntinuity f cverage fr members by streamlining cverage types, thereby making nticing and explanatin f benefits mre understandable, and als minimizing disruptins in cverage. Creating an efficient administrative infrastructure that leverages technlgy and eliminates administrative duplicatin. Building ff the lessns learned since passage f Chapter 58. Creating pprtunities t achieve payment and delivery system refrms that ensure cntinued cverage, access, and cst cntainment and imprve the verall health status f the ppulatins served.
Backgrund: ACA Key Cncepts 5 Medicaid Expansin The ACA expands cverage t adults 0-138% FPL wh have nt traditinally been eligible fr Medicaid. They can nw be cvered under the Medicaid State Plan starting in January 2014 Massachusetts, as a state that has already expanded t this ppulatin, will receive 75-93% FMAP frm CY2014 t CY 2019, and 90% FMAP frm CY 2020+ States must prvide at least Benchmark cverage fr the new State Plan-eligibles Basic Health Plan Optin (BHP) The ACA prvides states the ptin f establishing a BHP (Sec. 1331) Tax Credits The state wuld receive 95% f the premium tax credits and cst sharing reductins that wuld have been alltted if these individuals had purchased thrugh the Exchange The BHP must prvide at least the Essential Health Benefits package The ACA prvides advanced tax credits t eligible individuals with incmes up t 400% FPL wh purchase thrugh the Exchange The amunt ($ value) f the tax credit varies by incme, with individuals required t spend a certain percentage f their incme n health insurance Essential Health Benefits (EHBs) The ACA requires all plans ffered thrugh the Exchange t prvide Essential Health Benefits The US Secretary f HHS has prvided initial guidance t states n hw t define EHBs
ACA Key Cncepts 6 Medicaid Expansin The ACA expands cverage fr adults (under age 65) 0-138% FPL wh have nt traditinally been eligible fr Medicaid starting in January 2014. Massachusetts will receive additinal federal funding t cver the expanded Medicaid ppulatin. States must prvide at least Benchmark cverage fr the new Medicaid eligibles. This means cverage must at least prvide categries f services included in Essential Health Benefits.
ACA Key Cncepts 7 Basic Health Plan Optin (BHP) The ACA prvides states the ptin f establishing a BHP (Sec. 1331). Cvers nn-medicaid eligible adults (under age 65) 139 200% FPL. The state wuld receive 95% f the premium tax credits and cst-sharing reductins that wuld have been alltted if these individuals had purchased thrugh the Exchange. The BHP must prvide at least the Essential Health Benefits package.
ACA Key Cncepts 8 Qualified Health Plans (QHPs) Cmmercial insurance prducts available fr purchase thrugh the Exchange. Premium tax credits and cst-sharing reductins available fr eligible individuals and families Optins fr small emplyers and their emplyees Exchange will certify qualifying cmmercial insurance plans similar t hw the Health Cnnectr currently certifies Cmmnwealth Chice plans thrugh the Seal f Apprval prcess.
ACA Key Cncepts 9 Tax credits and cst-sharing reductins The ACA prvides advanced premium tax credits t eligible individuals with incmes up t 400% FPL wh purchase thrugh the Exchange. The amunt ($ value) f the premium tax credit varies by incme, with individuals required t spend up t a certain percentage f their incme n health insurance. Qualifying individuals with incmes up t 250% will be eligible fr cst-sharing (i.e. cpays, deductibles, c-insurance) reductins t their health plan. This will be seamless t the cnsumer. Final federal rules frthcming.
ACA Key Cncepts 10 Essential Health Benefits (EHBs) The ACA requires that all plans ffered thrugh the Exchange prvide Essential Health Benefits. EHBs must include items and services within at least the fllwing 10 categries listed n the fllwing slide. The US Secretary f HHS has prvided initial guidance t states n hw t define EHBs. Health Cnnectr and DOI are hlding pen stakehlder meetings n this decisin making prcess. Inf is available n DOI website http://www.mass.gv/cabr/dcs/di/market-refrm-meetings.pdf
11 Essential Health Benefits (EHBs) required Items and Services as defined by ACA 1. Ambulatry patient services 2. Emergency services 3. Hspitalizatin 4. Maternity and newbrn care 5. Mental health and substance use disrder services, including behaviral health treatment 6. Prescriptin drugs 7. Rehabilitative and habilitative services and devices 8. Labratry services 9. Preventive and wellness services and chrnic disease management 10. Pediatric services, including ral and visin care.
Health Insurance Exchange (HIX) Integrated Eligibility System (IES) Overview 12 Integrated Prtals Integrated Eligibility System Phase I: Jan. 2014 Health and Human Services Prtal Health Prtal Insurance Exchange Prtal HIX will allw cnsumers t shp fr health insurance, apply fr financial assistance, and enrll in private and public plans in real-time. IES will determine eligibility fr the Medicaid and CHIP prgrams - either directly r by talking t MA21 in real time. It will als determine eligibility fr SHOP emplyers and emplyees, and mre. Phase II: 2015 Other EOHHS Prgrams Prtal HIX will allw cnsumers t apply fr ther public assistance prgrams like SNAP and TANF. The IES will determine eligibility fr these prgrams. Result A first-class, 21 st century custmer and partner experience that is cnsumer-fcused, cst-effective, and re-usable by ther states.
Functinal View f a New Eligibility System 13 Member applies fr benefits N wrng dr single pint f entry Web Prtal Health Infrmatin Exchange Integrated Eligibility System - HIX/IES Initial Eligibility Screen Sme examples: Citizenship/ Immigratin Status Husehld incme eligibility (MAGI) Verificatin Member Aged r Disabled? (Traditinal Rules) Yes MA21 Eligibility Determinatin N Rule-based Eligibility Engine MassHealth (Medicaid, CHIP and Benchmark) BHP QHP Health Plan Enrllment Federal Data Hub SSA, IRS, DHS etc.
HIX/IES Prject Apprach 14 In Phase I the HIX / IES slutin will require updating, leveraging, r replacing existing MA state systems: Leverage the existing Health Cnnectr site MAhealthcnnectr.rg Leverage current self-service slutins fr Medicaid members (VG) Integrating with and pulling rules ut f MA21
HIX/IES Impact 15 Yu re prbably wndering Will there be real-time eligibility and real-time enrllment? YES Will there still be paper applicatins? YES Will there still be MECs and walk-ins? YES Will the ntices change? YES Will the way I d my wrk change? YES
16 Massachusetts Implementatin Activities fr subsidized ppulatins MassHealth, the Health Cnnectr, alng with ther state agencies are engaged in analysis and planning arund changes t subsidized prgrams (and unsubsidized health insurance ptins) MA has been awarded grants t assess and plan fr plicy, prgrams, business peratins, and IT systems changes. Fr full a listing f Cmmnwealth grants g t: www.mass.gv/natinalhealthrefrm MA must cmply with ACA requirements fr Exchanges t determine eligibility fr and crdinate enrllment in Medicaid, CHIP, and state health subsidy prgrams using: A single, streamlined eligibility frm fr all prgrams A secure, electrnic interface Multiple access pints: internet, mail, phne, in persn Massachusetts is fully engaged in implementing natinal refrm and we will keep yu updated.