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Affordable Care Act Update. Allison Rice Duke AIDS Policy Project Region 7 -- June 13, 2013. Affordable Care Act: The original concept. Affordable Care Act: Supreme Court’s Concept. Affordable Care Act: North Carolina’s Reality. *except documented immigrants in US less than 5 years. - PowerPoint PPT Presentation
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Affordable Care Act Update
Allison RiceDuke AIDS Policy Project
Region 7 -- June 13, 2013
Medicaid Expansion(income up to 133% FPL)
Insurance Marketplace with financial help
(Income 100-400% FPL)
Pre-2010 options(employer, “Old Medicaid,” Medicare, etc.)
Affordable Care Act: The original concept
Medicaid Expansion(income up to 133% FPL)
Insurance Marketplace with financial help
(Income 100-400% FPL)
Pre-2010 options(employer, “Old Medicaid,” Medicare, etc.)
Affordable Care Act: Supreme Court’s Concept
No help for people under 100% FPL*
Insurance Marketplace with financial help
(Income 100-400% FPL)
Pre-2010 options(employer, “Old Medicaid,” Medicare, etc.)
Affordable Care Act: North Carolina’s Reality
*except documented immigrants in US less than 5 years
No Medicaid expansion in 2014
Coming soon: Insurance Marketplace, with subsidies for uninsured people/families with incomes 100-400% FPL
◦ Open enrollment 10/1/2013 – 3/31/2014◦ Coverage begins 1/1/2014
ACA implementation
Empty or Full?
• Employer sponsored insurance
• Medicare• Medicaid• Health Choice
(CHIP)• Ryan White/ADAP
Same or
better
• Insurance Marketplace with subsidies for lower income uninsured
• Free preventive services
• Foster kids keep Medicaid up to age 26
• Medicaid/CHIP: New rules for counting income for (“MAGI”) – based on IRS standards
• Medicare Part D donut hole keeps closing
New
2014 Landscape
• There will still be coverage gaps• Need for wrap-around services that aren’t covered by
insurance
Ryan White & ADAP continue
• Undocumented• Families for whom marketplace insurance is
unaffordable even with subsidies• Married persons who don’t file taxes with spouse• Children in families over CHIP income limit that can’t
qualify for subsidies• Families where a parent has employer-sponsored
insurance that’s deemed affordable, but family coverage is too-expensive
Coverage gaps:
Health Reform & ADAP/Ryan White
Run by Federal Govt.
Open to people* without access to adequate, affordable insurance (public or private)◦ *Except undocumented
“Mandate”: You must have insurance if income is over 133% FPL ($15,282)
Some exemptions; penalty low to start
NC Insurance marketplace: Basics
Must be citizen or legal resident to purchase marketplace insurance
Can’t be eligible for Medicaid, Medicare, other public coverage
Client can’t drop employer-sponsored insurance to get subsidies in marketplace
To get subsidies, must have income 100-400% FPL
Which clients can enroll?
Standardized plans – ◦ Will follow Blue Cross Blue Shield Blue Options plan◦ Comprehensive drug formulary
Essential Health Benefits
Free Preventive Services – ◦ Well woman’s exam, mammogram, immunizations, STI
prevention counseling, smoking screening & cessation, etc.
What will the insurance cover?
• Ambulatory Services• Hospitalization• Maternity & Newborn
Care• Mental
Health/Substance Abuse
• Prescription Drugs
• Emergency Services• Rehabilitative/
Habilitative • Lab Services• Preventive & Wellness
Services & Chronic Disease Management
• Pediatric services
Provider networks
Benefits &
utilization limits
Drug coverage Cost
Plan selection considerations
• Between 100% and 400% FPL• Premium cost: 2% - 9.5% of incomePremium
• Between 100% & 250% FPL• Reduced co-pays, deductibles, etc
Cost sharing reductions
• For all: max ~$6350/year (~$12,700 for families)
• 100-200% FPL 2/3 reduction ~$2117/4233• 200-300% FPL 1/2 reduction ~$3175/6350• 300-400% FPL 1/3 reduction ~$4233/8467
Out of pocket
maximum
Sliding Scale Subsidies
Numbers to remember
100
Under 100 % FPL – no subsidy
Over 100% FPL – help
with premium & cost sharing
133
Over 133% must have “minimum essential
coverage”
250
Under 250% - help with
cost sharing
400
Over 400% can buy
insurance, but no
financial help
• Paid in advance, via reduced premium• Or, person can opt to pay full premium now and take
the credit when taxes are filed.• Credits are “reconciled” at tax time: if overpayment or
underpayment, adjustments made in taxes
Premium Tax
Credit:
• Comes in the form of reductions in co-pays and deductibles so that the plan has a higher value (i.e., it pays for more services).• Example: Person with income between 100 and 150%
FPL ($11,490-$17,235) gets a plan that pays 94% of claims instead of the standard plan that pays 70%
Cost sharing:
How are subsidies paid?
Online & paper applications
Website:◦ Checks
eligibility for Medicaid, CHIP, insurance subsidies
◦ Provides plan comparison
◦ Enrollment online
How will people enroll?
Verification of eligibility
Diagram from NC Institute of Medicine, Examining the Impact of the Patient Protection and Affordable Care Act in North Carolina: Draft Final Report Pending US Supreme Court Decision, p. 64, May 2012
Consumer Assistance
Consumer Assistanc
e
24-hour toll free
call center
Website
Insurance Agents & Brokers
Navigators
Certified Applicatio
n Counselor
Case managers
Friends, family
Navigators• $2.145 million
FQHC:• $4.2 million
Ryan White Part C:• up to $100,000 per
grantee• Capacity development
for • ACA Benefits
Counseling/enrollment• ACA education
Funding for consumer assistance
Navigators• 30 hour online training• Only for funded navigator entities
Certified Application Counselors• Similar online training (probably shorter)• Available to others in community, including
non-funded entities
Training for In-person assisters
Enrollment – What’s the plan?
• Who will help them? What will your role be?• Is there a plan in your larger institution
(hospital, FQHC, etc.)?• How will clients be connected to assistance?
Figure out how your clients will be assisted
• How will they get trained?• How will this work be funded?
Can your staff assist?
• Who else is working on enrollment? • What are the navigator entities? What other
groups/resources exist in your community?
• Not eligible for subsidy, exempt from mandate• Unless other resources/assistance, stay on
Ryan WhiteUnder
100% FPL
• Eligible for subsidy, exempt from mandate• Consider enrollment on case-by-case basis• Possibility of ADAP assistance with costs (2014)
100-133% FPL
• Eligible for subsidy• Subject to mandate• Guidance expected from HRSA on payer of last resort
133% FPL – 400% FPL
Triage – Prioritizing uninsured
Tax based income• Filed taxes?• Filing status
(married must file jointly)
Mechanics of paying for
insurance for clients without bank accounts
Expensive, but not too
expensive employer sponsored insurance
Some Challenges
RW Funds can be used for benefits counseling & enrollment◦ Early Intervention◦ Medical Case Management◦ Non-medical Case Management◦ Health Education/Risk Reduction services◦ Referral for Health Care/Supportive Services
HRSA has put a chart online:◦ http://
hab.hrsa.gov/affordablecareact/outreachenrollment.html
Using Ryan White funds to assist clients in enrollment
Duke Legal Project Health Reform Information site (coming soon)
Hivhealthreform.org Healthcare.gov http://kff.org/health-reform/ http://marketplace.cms.gov/
Information & Resources