Open Enrollment: Considerations for HIV/AIDS Programs Amy Killelea, NASTAD Xavior Robinson, NASTAD October 9, 2014
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Presentation Outline 1. Qualified Health Plan Enrollment a. Dates and Deadlines 2. Re-enrollment Considerations 3. Maintaining Access to Insurance for Clients 4. Coordination with Medicaid Enrollment
Health Resources and Services Administration HIV/AIDS Bureau Policies The Ryan White Program is the payer of last resort and grantees must vigorously pursue client eligibility for public and private insurance Grantees may not dis-enroll clients from services for failure to enroll in public or private insurance coverage HRSA encourages state ADAP/Part B Programs to use their Ryan White funding to help clients access insurance, as long as: Formulary includes at least one drug in each class of core ARVs from the HHS Clinical Guidelines It is cost-effective in aggregate as compared to purchasing medications Other Ryan White Program grantees may also use their funds to help clients with the cost of insurance Ryan White Program funds may be used to cover services not covered or inadequately covered by public and private insurance HRSA is considering allowing ADAP insurance purchasing programs to cover client tax liabilities associated with an overpayment of the premium tax credit 4
25,000 ACA coverage transitions facilitated by State HIV Programs VT NH WA OR NV CA ID UT MT WY CO ND SD NE KS MN WI IA MO IL MI IN KY NY OH WV PA VA ME CT NJ DE MD AK AZ NM TX OK AR LA MS TN AL GA SC NC DC FL HI Medicaid QHPs Total 12,004 13,129 25,133
Qualified Health Plan Enrollment
Re-enrollment Considerations: Products vs. Plans Source: Manatt Health Solutions
Qualified Health Plan Enrollment: Key Dates and Deadlines 2014 Benefit Year Oct. Nov. Dec. 2015 Benefit Year Jan. Feb. Mar. November 15, 2014 Open enrollment for the 2015 benefit year begins December 31, 2014 2014 benefit year concludes January 1, 2015 First day of the 2015 benefit year earliest possible coverage effective date for 2015 February 15, 2015 Open enrollment for the 2015 benefit year ends Medicaid CONTINUOUS ENROLLMENT
Qualified Health Plan Enrollment: Coverage Effectuation Deadlines Qualified Health Plan Selection Period Coverage Effective Date November 15 December 15, 2014 January 1, 2015 December 16, 2014 January 15, 2015 February 1, 2015 January 16 February 15, 2016 March 1, 2015
Accessing Plan Information States have several options to obtain plan information ahead of open enrollment: o Federally facilitated Marketplace will have 2015 benefit year plan information finalized by November 3, 2015. Plan information may not be publically available until November 15 o States may request plan information from state departments of insurance (state rules with regard to availability of information vary) o States may request plan information directly from issuers
Qualified Health Plan Enrollment: Switching QHPs During Open Enrollment Four Requirements Individuals have to switch to a plan offered by the same issuer The plan has to be offered at the same metal level and the same cost-sharing reduction level The change must be because of a limited provider network Consumers must request the change during the open enrollment period Program Considerations For assistance with QHP plan assessment, and Cost-Effectiveness Modeling check out: NASTAD Webinar on QHP Plan Assessment NASTAD Plan Assessment Tools Issue Brief NASTAD Cost-Effectiveness Model and Companion Document
Qualified Health Plan Enrollment: The Individual Mandate The individual mandate provision of the ACA requires that individuals and members of their family: Have minimum essential coverage (MEC); Have an exemption from the responsibility to have minimum essential coverage; or Make a shared responsibility payment when the individual files taxes.
Qualified Health Plan Enrollment: What Counts as MEC? Coverage Counts as Minimum Essential Coverage? Option for premium tax credits and cost sharing reductions to purchase QHP? Full Medicaid YES NO Limited Medicaid (e.g., Spend down) Affordable & comprehensive employer coverage NO YES YES NO COBRA YES YES TRI CARE YES NO VA Coverage YES YES
Individual Mandate Exemptions (incomplete list) Exemption Below tax filing threshold ($10,150 for an individual in 2014) Hardship exemption (includes homelessness, natural disaster, and situation where person would have been eligible for Medicaid state had expanded) Unaffordable coverage (defined as over 8% of household income) Short coverage gaps (a gap that last less than three months) Indian Tribes Insular areas and territories How to Apply No need to apply; exemption is automatic Marketplace application OR federal tax return Note: to be found eligible for the non- Medicaid expansion state exemption, a person must receive a Medicaid denial. Marketplace application Note: a person eligible for an exemption because coverage is unaffordable based on expected income may qualify to buy catastrophic coverage through the Marketplace. Federal tax return Marketplace application OR federal tax return No need to apply; exemption is automatic
Individual Shared Responsibility Payments Payment Assessment (whichever is greater) Percentage of household income Minimum Penalty for Individuals 2014 2015 2016 1% 2% 2.5% $95 $325 $695 Program Considerations Part B/ADAP funds may not be used to cover individual shared responsibility payments
Vigorously Pursuing Vigorously Pursuing Best Practices Implement client eligibility screening policy Document client contact Require attestation if client does not enroll in coverage Require client to accept full premium tax credit amount in advance and to acknowledge need to report changes in income to the Marketplace
Qualified Health Plan Enrollment: Potential Challenges and Strategies Potential Challenges Strategies Marketplaces may experience significant technical glitches Programs worked directly with plans to enroll clients, urging enrollment staff to build in extra time Programs assisted clients with paper and telephone enrollment Participation in ACA enrollment may be limited or prohibited by state employees Payment coordination issues Insurance companies State bureaucracies Clients resistance to transition to new health coverage Programs worked with community organizations and coalitions to coordinate client education, and enrollment efforts Programs cultivated relationships with internal champions within insurance companies Programs contracted out payment duties Programs used effective messengers and partnered with community organizations Programs required written attestation from clients who refused to transition
Qualified Health Plan Enrollment HIV/AIDS Program Considerations Ensure that enrollment staff and clients are aware of coverage effectuation deadlines Encourage clients to update Marketplace eligibility information Leverage the lessons learned from the first open enrollment period
Re-enrollment and Redetermination Considerations
Re-enrollment and Redeterminations: Background and Notification The ACA directs the Department of Health and Services to develop a process for the automatic re-enrollment into qualified health plan, and redetermination of federal subsidies in cases where enrollees take no action at the conclusion of the benefit year. Re-enrollment and Redetermination Notices 1. Explanation of redetermination and re-enrollment process; 2. Projection of 2015 premium tax credits and cost- sharing reductions; OR 3. Request to update Marketplace eligibility information.
Re-enrollment Hierarchy 1 2 Remain in existing Plan If existing plan is no longer offered Plan at same metal level as existing plan within same product 3 Plan at one metal level higher or lower than current QHP within same product 4 Any available plan in the product
Re-enrollment and Redeterminations: HIV/AIDS Program Considerations Assess 2015 qualified health plans Ensure that outreach and enrollment staff are aware of re-enrollment and redeterminations process, and understand that it is among the least favorable enrollment opportunities
Maintaining Access to Insurance
Maintaining Access to Insurance: QHP Payment Considerations Coverage begins with initial on-time payment of premium by consumer Marketplace plans must accept: paper check, Electronic Funds Transfer, cashier s check, money order, and pre-paid debit card Insurer sets deadline for payment of first premium Insurance may be cancelled for failure to pay first premium by specified deadline set by plan NOTE: unlike 90 day grace period once coverage begins, there is no initial grace period for late premium payments
Maintain Access to Insurance: Grace Periods Plans must allow a period for non-payment of premiums before coverage is terminated For people receiving premium tax credits and costsharing reductions: 3 month grace period after first month s premium paid For people NOT receiving premium tax credits and costsharing reductions: plan sets grace period NOTE: grace periods only apply after first month s premium payment is received
Coordination with Medicaid Enrollment Income fluctuations Subsidies to Purchase QHP (income between 139 and 400% FPL) Medicaid (income up to 138% FPL) Considerations to mitigate churn: Eligibility for premium tax credits and cost-sharing is based on ANNUAL income If a person switches from a QHP to Medicaid and back to a QHP, he/she will get credit for any cost-sharing charges paid before moving to Medicaid BUT only if the the person re-enrolls in the same Marketplace plan from same insurer This rule also applies any time someone re-enrolls in the same Marketplace plan they had during the same year. State Medicaid policies (e.g., 12 month eligibility)
Resources National Alliance of State & Territorial AIDS Directors (NASTAD), www.nastad.org Amy Killelea, akillelea@nastad.org Xavior Robinson, xrobinson@nastad.org HIV Health Reform, http://www.hivhealthreform.org/ Treatment Access Expansion Project, www.taepusa.org HIV Medicine Association, www.hivma.org HRSA/HAB ACA and Ryan White Resources, http://hab.hrsa.gov/affordablecareact/ Health Care Reform Resources State Refo(ru)m, www.statereforum.org Kaiser Family Foundation, www.kff.org Healthcare.gov, www.healthcare.gov
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