Affordable Care Act (ACA) Learning Sessions for Social Sector Leaders & Community Advocates December 5, 2012 Coordinated by Access HealthColumbus Community Advisory Committee Purpose Spread knowledge of federal health care reform in non-profit organizations to improve their ability to serve clients during the implementation of the Accountable Care Act (ACA). Today’s Objectives 1. Provide an update on Health Benefit Exchanges (HBE) 2. Improve knowledge on: • Medicaid Ohio expansion possibilities • ACA cost and affordability for health benefits through the HBE 3. Obtain input on shaping future Learning Sessions
Expansion of Medicaid
Health Benefit Exchanges
Near Universal Insurance Coverage
Affordable Care Act
Improvement Programs (and grants)
Subsidized commercial insurance for middle-income families (market based) Guaranteed Issue & Insurance Mandate
11/16/12 – Ohio submitted intent for federal Health Benefit Exchange
Early 2013 – Ohio’s budget process will include the governor’s recommendation on Medicaid expansion for Ohio June 2013 – State will finalize budget with Medicaid expansion decision Fall 2013 – People begin to enroll through Health Benefit Exchanges January 2014 -• Permanent insurance reforms take effect • Low income subsidies start • Coverage through exchanges becomes effective • Mandates take effect o Individual Mandate o Employer Mandate
Health Insurance Exchanges
Exchanges were upheld by the Supreme Court. – – –
Each state shall establish a qualified Exchange by January 1, 2014. If a state chooses not to operate an exchange, the federal government will do so. People will begin enrolling through exchanges in the fall of 2013.
Health Benefit Exchange Options
1.
An state built Health Benefit Exchange
2.
A federally facilitated Health Benefit Exchange
3.
A hybrid/partnership Health Benefit Exchange - Some features of each
Ohio’s Health Benefit Exchange decision, November 16, 2012 Governor John Kasich sent a letter to the director of Centers for Medicare and Medicaid Services Center for Consumer Information and Insurance Oversight to indicate Ohio’s Health Benefit Exchange decision under the Affordable Care Act.
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• • •
“At this point, based on the information we have, states do not have any flexibility to build and manage exchanges in ways that respond to unique needs of their citizens or markets.” “Ohio will not operate a federally-mandated exchange but instead will exercise its right under the law to leave that to the federal government;” “Ohio will … retain the right to regulate the state’s insurance industry…” Ohio will retain the right to determine Medicaid and CHIP eligibility for its citizens Ohio reserves right to amend its intentions should HHS announce changes, etc.
Key Exchange Functions in a Federally–facilitated Exchange (FFE) - Objectives
Objectives of the FFE:
Positive consumer experience
Attractive and viable market for insurers
Working quickly and effectively with States
Reducing administrative and operational burdens on all exchange participants
From: General Guidance on FFEs, issued by Health and Human Services, May 16, 2012
Key Exchange Functions in a Federally–facilitated Exchange (FFE) - Activities
Health and Human Services activities for FFE: • Developing a unified FFE infrastructure
• Will look to States, consumers, issuers, health care providers, employers, and other local stakeholders to provide input in each state • Early 2013- Qualified Health Plan Issuer applications will be released
• Summer 2013- Agreements with Qualified Health Plan Issuers will be completed • October 1, 2013- Open enrollment on exchanges for the 2014 coverage year will begin From: General Guidance on FFEs, issued by Health and Human Services, May 16, 2012
Medicaid Expansion, Ohio possibilities On June 28, 2012, the United States Supreme Court issued an opinion upholding the constitutionality of the ACA, with the exception of one provision.
States now can decide not to expand their Medicaid programs without losing all federal Medicaid funding.
Source: Supreme Court Policy Brief, Health Policy Institute of Ohio, July 2012, http://bit.ly/SjDBca
Health Benefit Exchange Navigators – Pending House Bill 613 •
Sponsored by Representative Barbara Sears (RSylvania)
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introduced into the Revised Code the manner in which the State of Ohio will regulate Navigators under the Affordable Care Act (ACA)
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HB 613 establishes separate certification requirements for Navigators and Insurance Agents with Ohio Department of Insurance in charge of both
Health Benefit Exchange Navigators – Pending House Bill 613 •
Under HB 613, a Navigator would not be permitted to sell, solicit or negotiate health insurance.
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The bill would prevent Navigators from enrolling an individual or employee in a health insurance plan. The bill is scheduled for a possible vote in the House Health and Aging Committee on December 5, 2012. Concerns include: prematurely establishing Navigator rules, limiting Navigator assistance, lacks protections around cultural and linguistic appropriateness and disability accessibility
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Federal Health Care Reform:
Patient Protection and Affordable Care Act (ACA)
Individual mandate to purchase health insurance Insurance market reforms: limit pre-existing conditions, guaranteed issue, community rating Health benefit exchange: provide individuals with income between 100% and 400% of poverty a sliding-scale federal subsidy to purchase private insurance Expand Medicaid to everyone below 138% of poverty The Supreme Court upheld all provisions of the ACA but made the Medicaid expansion optional for states
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Current Ohio Medicaid Coverage 500%
Woodwork Effect
Private As a resultInsurance of the federal mandate on individuals to purchase health Federal Poverty Level (FPL)
400%
insurance, an estimated 320,000 Ohioans who are currently eligible for Medicaid but not enrolled are expected to enroll in January 2014, at an estimated two-year State cost of $700 million.
300%
Disabled Ohioans in this income range “spend down� their income to qualify for Medicaid
200% 100%
Medicaid 0% Children 0-18 without coverage
Parents
Childless Adults
Disabled Workers Other Aged, Blind and Disabled
* The 2012 poverty threshold is $11,170 for an individual and $23,050 for a family of four.
2014 Federal Health Coverage Expansion 500%
Private Insurance Federal Poverty Level (FPL)
400%
$92,200* (family of 4)
Health Benefit Exchange 300%
Disabled Ohioans in this income range “spend down� their income to qualify for Medicaid
200% Optional ACA Medicaid Expansion to 138%
$31,809* (family of 4)
100%
Medicaid 0% Children 0-18 without coverage Current Ohio Medicaid Eligibility
Parents
Childless Adults
Federal Exchange Eligibility
Disabled Workers Other Aged, Blind and Disabled Not Covered by Ohio Medicaid or Federal Exchange
* The 2012 poverty threshold is $11,170 for an individual and $23,050 for a family of four.
Impact of ACA • Initial Draft Estimates for Eligible but Not Enrolled Calendar Year
People
State $ (millions)
Federal $ (millions)
Total $ (millions)
2014
319,000
$369
$978
$1,347
2015
392,500
$571
$1,027
$1,598
2016
432,500
$613
$1,165
$1,778
2017
437,000
$644
$1,224
$1,868
2018
440,500
$676
$1,284
$1,959
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Impact of ACA • Initial Draft Estimates for New Enrollees Calendar Year
People
State $ (millions)
Federal $ (millions)
Total $ (millions)
2014
597,500
$0
$3,027
$3,027
2015
663,000
$0
$3,523
$3,523
2016
699,500
$0
$3,863
$3,863
2017
706,500
$203
$3,854
$4,057
2018
714,000
$256
$4,008
$4,264
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Behind the Numbers •
Based on the 2008 and 2010 Ohio Health Surveys
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Developed with both of Medicaid’s actuaries (Milliman, previous and Mercer, current)
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Conservative estimates on take-up rates:
Newly Eligible
Subtotal ‐ Previously Insured…………………………………………….
38%
Subtotal ‐ Previously Uninsured…………………………………………
63%
Currently Eligible and Not Enrolled ‐ Nonelderly Non Medicare Subtotal ‐ Other Insurance……………………………………………….
21%
Subtotal ‐ Uninsured………………………………………………………
42%
Currently Eligible and Not Enrolled ‐ Elderly and Medicare…………
12% 19
Next Steps • Determine how Medicaid will pay for woodwork effect • Review long-term budget projections • Decision will most likely be announced in the budget
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Medicaid of the Future
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Fragmentation
vs.
Coordination
Multiple separate providers
Accountable medical home
Provider-centered care
Patient-centered care
Reimbursement rewards volume
Reimbursement rewards value
Lack of comparison data
Price and quality transparency
Outdated information technology
Electronic information exchange
No accountability
Performance measures
Institutional bias
Continuum of care
Separate government systems
Medicare/Medicaid/Exchanges
Complicated categorical eligibility
Streamlined income eligibility
Rapid cost growth
Sustainable growth over time
SOURCE: Adapted from Melanie Bella, State Innovative Programs for Dual Eligibles, NASMD (November 2009) 22
Integrated Care Delivery for Individuals Enrolled in both Medicare and Medicaid
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The Vision for Better Care Coordination • The vision is to create a person-centered care management approach – not a provider, program, or payer approach • Services are integrated for all physical, behavioral, long-term care, and social needs • Services are provided in the setting of choice • Easy to navigate for consumers and providers • Transition seamlessly among settings as needs change • Link payment to person-centered performance outcomes
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Ohio ICDS Regions NE Ottawa
NW Aetna Buckeye
Lake
United CareSource Buckeye
Lucas
Fulton
Geauga
NEC United CareSource
Cuyahoga Wood
Trumbull
Lorain
Medina
Summit
Portage Mahoning
Wayne
Stark
Columbiana
EC United CareSource Union
Delaware
WC
Central
Molina Buckeye
Franklin Clark
Madison
Molina Aetna
Montgomery Greene Pickaway
Butler
Warren
Clinton
SW
Hamilton
Molina Clermont Aetna
ICDS Regions and Demo Counties
NEC- Northeast Central
Central
NW - Northwest
EC - East Central
SW - Southwest
NE - Northeast
WC - West Central
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Transitioning Children with Special Needs from Fee-For-Service to Managed Care
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Who Will Transition •
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All children with special needs that are currently in the Medicaid fee-for-service program The exceptions are children with certain conditions • Cystic Fibrosis • Hemophilia • Cancer
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Health Homes
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Medicaid Health Homes • Goal is to ensure that people are getting the physical health services they need • Where is a person most likely to receive physical health services? • Medicaid Health Homes for people with Serious and Persistent Mental Illness were launched in October
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Q&A Health Benefits Exchanges & Medicaid Expansion possibilities
ACA Costs & Affordability for Individuals and Families
2014 Coverage Reform Overview •
In 2014, the following insurance market reforms take effect: – – – – – –
Guaranteed issuance of coverage Coverage must include essential benefits No pre-existing condition exclusions Plans can have deductibles, copayments and cost sharing requirements subject to limits. Premium vary only by age and smoking (3 to 1) Low income subsidies
Low Income Subsidies
Premium Subsidies –
Premium is the amount you pay to buy insurance coverage
Cost sharing subsidies –
Cost sharing is the out-of-pocket expenses you pay to health care providers as your share of the cost when you have insurance, because of deductibles, copays and co-insurance
Low Income Premium Subsidies
Beginning in 2014, low income premium subsidies are: – – – –
available up to 400% FPL to reduce the cost of buying coverage; only available for coverage on an exchange; determined on a sliding scale, based on income. based on premium for a benchmark plan, allowing individuals to buy more expensive coverage and pay the difference.
Low Income Premium Subsidies Enrollee’s Share of Premium After Low Income Subsidies Income
Premium No More Than % of Income
Up to 133% FPL
2% of income
133 – 150% FPL
3 – 4% of income
150 – 200% FPL
4 – 6.3% of income
200 – 250% FPL
6.3 – 8.05% of income
250 – 300% FPL
8.05 – 9.5% of income
350 – 400% FPL
9.5% of income
Low Income Annual Premium (after subsidies)
Enrollees’ Share of the Premium Single Person – CY 2012 FPL Income as % of FPL
Annual Income
Premium as % of Income
Annual Premium
Monthly Premium
100% 138% 150% 200% 250% 300% 350% 400%
$11,170 $15,415 $16,755 $22,340 $27,925 $33,510 $39,095 $44,680
2% 3% 4% 6.30% 8.05% 9.5% 9.5% 9.5%
$223 $462 $670 $1,407 $2,248 $3,183 $3,714 $4,245
$19 $39 $56 $117 $187 $265 $310 $354
Low Income Annual Premium (after subsidies)
Single Person Example – CY 2012 FPL FPL
100%
200%
Monthly Income
$ 931
$ 1,862
Monthly Premium *
$ 19
$ 117
* Does not include Cost Sharing portion of medical expenses
Low Income Annual Premium (after subsidies)
Enrollees’ Share of the Premium Four-Person Family – CY 2012 FPL Income as % of FPL 100% 138% 150% 200% 250% 300% 350% 400%
Annual Income $23,050 $31,809 $34,575 $46,100 $57,625 $69,150 $80,675 $92,200
Premium as % of Income 2% 3% 4% 6.30% 8.05% 9.5% 9.5% 9.5%
Annual Premium $461 $954 $1,283 $2,904 $4,898 $6,569 $7,664 $8,759
Monthly Premium $38 $80 $107 $242 $408 $547 $639 $730
Low Income Annual Premium (after subsidies)
Four-Person Family Example – CY 2012 FPL FPL
100%
200%
Monthly Income
$ 1,921
$ 3,842
Monthly Premium *
$ 38
$ 242
* Does not include Cost Sharing portion of medical expenses
Low Income Cost Sharing Subsidies
Cost sharing is the out-of-pocket expenses you pay to health care providers when you have insurance, because of deductibles, copays and co-insurance.
Most policies currently have out-of-pocket spending limits, which require the insurance company to pay 100% once you reach the spending limit. In most policies, the current out-of-pocket limits are $6,050 for individuals and $12,200 for families.
Low Income Cost Sharing Subsidies
Beginning in 2014, low income cost sharing subsidies are: – – –
available up to 400% FPL to reduce out-of pocket spending by reducing out-of-pocket limits; only available for coverage bought through an exchange; and determined on a sliding scale, based on income.
Cost Sharing (out-of-pocket expenses to health care providers) Out-of-Pocket Spending Limits After Subsidies Income
Out-of-Pocket Limits (based on 2012 limits)
100 – 200% FPL
$1,997/individual; $3,993/family
200 – 300% FPL
$3,025/individual; $6,050/family
300 – 400% FPL
$3,993/individual; $7,986/family
Above 400% FPL
$6,050/individual; $12,100/family
Premium plus Cost Sharing (out-of-pocket expenses to health care providers) Enrollees’ Share of the Premium and Cost Sharing After Subsidies Single Person – CY 2012 FPL Annual Income
Annual Premium
Annual Cost Sharing Expenses Limit
Maximum Annual Premium Plus Cost Sharing
100%
$11,170
$223
$1,997
$2,220
$185
138%
$15,415
$462
$1,997
$2,459
$205
150%
$16,755
$670
$1,997
$2,667
$222
200%
$22,340
$1,407
$3,025
$4,432
$369
250%
$27,925
$2,248
$3,025
$5,273
$439
300%
$33,510
$3,183
$3,993
$7,176
$598
350%
$39,095
$3,714
$3,993
$7,707
$642
400%
$44,680
$4,245
$3,993
$8,238
$687
Income as % of FPL
Maximum Monthly Premium Plus Cost Sharing
Premium plus Cost Sharing (out-of-pocket expenses to health care providers) Single Person Example – CY 2012 FPL FPL
100%
200%
Monthly Income
$ 931
$ 1,862
Monthly Premium + Cost Sharing
$ 185
$ 369
Premium plus Cost Sharing (out-of-pocket expenses to health care providers) Enrollees’ Share of Premium and Out of Pocket Expenses After Subsidies Four-Person Family – CY 2012 FPL Income as % of FPL
100% 138% 150% 200% 250% 300% 350% 400%
Annual Income
Annual Premium
Annual Cost Sharing Expenses Limit
Maximum Annual Premium Plus Cost Sharing
$23,050 $31,809 $34,575 $46,100 $57,625 $69,150 $80,675 $92,200
$461 $954 $1,283 $2,904 $4,898 $6,569 $7,664 $8,759
$3,993 $3,993 $3,993 $6,050 $6,050 $7,986 $7,986 $7,986
$4,454 $4,947 $5,276 $8,954 $10,948 $12,619 $15,650 $16,745
Maximum Monthly Premium Plus Cost Sharing
$371 $412 $440 $746 $912 $1,052 $1,304 $1,395
Premium plus Cost Sharing (out-of-pocket expenses to health care providers) Four Person Family Example – CY 2012 FPL FPL
100%
200%
Monthly Income
$ 1,921
$ 3,842
Monthly Premium + Cost Sharing
$ 371
$ 746
Q&A ACA Costs & Affordability
Feedback Future Learning Sessions Please fill in your Green handout
Want to learn more about the Affordable Care Act? We will send you links to the slides and these sources:
http://healthreform.kff.org/timeline.aspx?source=QL http://healthreform.kff.org/the-basics/Requirement-to-buy-coverageflowchart.aspx http://healthreform.kff.org/the-basics/employer-penalty-flowchart.aspx http://www.governor.ohio.gov/Portals/0/pdf/11.16.12%20Letter%20to%20HHS.pd f http://cciio.cms.gov/resources/files/FFE_Guidance_FINAL_VERSION_051612.pdf http://healthreform.kff.org/subsidycalculator.aspx http://uhcanohio.org/content/health-care-reform-0