Transcript Health Care Reform & PLWHA in North Carolina

Allison Rice
Duke AIDS Policy Project
Region 7 -- June 13, 2013
Pre-2010
options
(employer,
“Old
Medicaid,”
Medicare, etc.)
Medicaid
Expansion
(income up to
133% FPL)
Insurance
Marketplace with
financial help
(Income 100-400%
FPL)
Pre-2010
options
(employer,
“Old
Medicaid,”
Medicare, etc.)
Insurance
Marketplace with
financial help
(Income 100-400%
FPL)
Medicaid
Expansion
(income up to
133% FPL)
Pre-2010
options
(employer,
“Old
Medicaid,”
Medicare, etc.)
No help
for people
under
100% FPL*
Insurance
Marketplace with
financial help
(Income 100-400%
FPL)
*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
Same
or
better
•Employer
sponsored
insurance
•Insurance Marketplace
with subsidies for lower
income uninsured
•Medicare
•Foster kids keep
Medicaid up to age 26
•Medicaid
•Health Choice
(CHIP)
•Ryan White/ADAP
•Free preventive services
New
•Medicaid/CHIP: New
rules for counting
income for (“MAGI”) –
based on IRS standards
•Medicare Part D donut
hole keeps closing
Ryan White & ADAP
continue
•There will still be coverage gaps
•Need for wrap-around services that aren’t covered by
insurance
•Undocumented
•Families for whom marketplace insurance is unaffordable
even with subsidies
Coverage gaps:
•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


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

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 100400% FPL

Standardized plans –
◦ Will follow Blue Cross Blue Shield Blue Options plan
◦ Comprehensive drug formulary

Essential Health Benefits
•
•
•
•
•

Ambulatory Services
Hospitalization
Maternity & Newborn Care
Mental Health/Substance
Abuse
Prescription Drugs
Free Preventive Services –
•
•
•
•
•
Emergency Services
Rehabilitative/Habilitative
Lab Services
Preventive & Wellness
Services & Chronic
Disease Management
Pediatric services
◦ Well woman’s exam, mammogram, immunizations, STI
prevention counseling, smoking screening & cessation,
etc.
Provider
networks
Benefits &
utilization
limits
Drug
coverage
Cost
Premium
Cost sharing
reductions
Out of pocket
maximum
• Between 100% and 400% FPL
• Premium cost: 2% - 9.5% of income
• Between 100% & 250% FPL
• Reduced co-pays, deductibles, etc
• 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
100 133 250 400
Under 100 %
FPL – no
subsidy
Over 100% FPL
– help with
premium &
cost sharing
Over 133%
must have
“minimum
essential
coverage”
Under 250% help with
cost sharing
Over 400% can
buy insurance,
but no
financial help
Premium
Tax Credit:
Cost
sharing:
•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
•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%


Online & paper
applications
Website:
◦ Checks eligibility
for Medicaid,
CHIP, insurance
subsidies
◦ Provides plan
comparison
◦ Enrollment online
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
24-hour toll
free call
center
Friends,
family
Website
Consumer
Assistance
Case
managers
Certified
Application
Counselor
Navigators
Insurance
Agents &
Brokers
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
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
Figure out how your
clients will be assisted
•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?
•How will they get trained?
Can your staff assist?
What other
groups/resources exist
in your community?
•How will this work be funded?
•Who else is working on enrollment?
•What are the navigator entities?
Under 100%
FPL
100-133%
FPL
133% FPL –
400% FPL
• Not eligible for subsidy, exempt from mandate
• Unless other resources/assistance, stay on Ryan
White
•Eligible for subsidy, exempt from mandate
•Consider enrollment on case-by-case basis
•Possibility of ADAP assistance with costs (2014)
•Eligible for subsidy
•Subject to mandate
•Guidance expected from HRSA on payer of last resort
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

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/outreachenr
ollment.html
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Duke Legal Project Health Reform Information
site (coming soon)
Hivhealthreform.org
Healthcare.gov
http://kff.org/health-reform/
http://marketplace.cms.gov/