december: aca learning session on exchanges, medicaid, and affordability
DESCRIPTION
Dec. ACA Learning SessionTRANSCRIPT
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
Affordable Care Act
Near Universal Insurance Coverage
Guaranteed Issue &
Insurance Mandate
Improvement Programs
(and grants)
Health Benefit
Exchanges
Expansion of Medicaid
Subsidized commercial
insurance for middle-income
families (market based)
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.
• “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 (R-
Sylvania)
• introduced into the Revised Code the manner in which
the State of Ohio will regulate Navigators under the
Affordable Care Act (ACA)
• 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.
• 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
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
14
Federal Health Care Reform:
Patient Protection and Affordable Care Act (ACA)
0%
100%
200%
300%
400%
500%
Children 0-18 without coverage
Parents Childless Adults Disabled Workers Other Aged, Blind and Disabled
Fed
eral
Po
vert
y Le
vel (
FPL)
Medicaid
Private Insurance
Disabled Ohioans in this income range “spend down” their income to qualify for Medicaid
* The 2012 poverty threshold is $11,170 for an individual and $23,050 for a family of four.
Current Ohio Medicaid Coverage
Woodwork Effect
As a result of the federal mandate on individuals to purchase health
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.
0%
100%
200%
300%
400%
500%
Children 0-18 without coverage
Parents Childless Adults Disabled Workers Other Aged, Blind and Disabled
Fed
eral
Po
vert
y Le
vel (
FPL)
Medicaid
Private Insurance $92,200*
(family of 4)
Disabled Ohioans in this income range “spend down” their income to qualify for Medicaid
$31,809* (family of 4)
Health Benefit Exchange
Optional ACA Medicaid Expansion to 138%
* The 2012 poverty threshold is $11,170 for an individual and $23,050 for a family of four.
Current Ohio Medicaid Eligibility Federal Exchange Eligibility Not Covered by Ohio Medicaid or Federal Exchange
2014 Federal Health Coverage Expansion
Impact of ACA
• Initial Draft Estimates for Eligible but Not Enrolled
17
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
Impact of ACA
• Initial Draft Estimates for New Enrollees
18
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
Behind the Numbers
• Based on the 2008 and 2010 Ohio Health Surveys
• Developed with both of Medicaid’s actuaries (Milliman, previous and Mercer,
current)
• Conservative estimates on take-up rates:
19
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%
20
Next Steps
• Determine how Medicaid will pay for woodwork effect
• Review long-term budget projections
• Decision will most likely be announced in the budget
21
Medicaid of the Future
22
Fragmentation vs. Coordination
Multiple separate providers
Provider-centered care
Reimbursement rewards volume
Lack of comparison data
Outdated information technology
No accountability
Institutional bias
Separate government systems
Complicated categorical eligibility
Rapid cost growth
Accountable medical home
Patient-centered care
Reimbursement rewards value
Price and quality transparency
Electronic information exchange
Performance measures
Continuum of care
Medicare/Medicaid/Exchanges
Streamlined income eligibility
Sustainable growth over time
SOURCE: Adapted from Melanie Bella, State Innovative Programs for Dual Eligibles, NASMD (November 2009)
23
Integrated Care Delivery
for Individuals Enrolled in both
Medicare and Medicaid
24
25
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
26
Stark
Wood
Wayne
Butler
Lorain
Clark
Union
Trumbull
Franklin
Fulton
Portage
Clinton
Lucas
Medina
Warren
Greene
Summit
Madison
Pickaway
Geauga
Clermont
Delaware
Lake
Hamilton
Cuyahoga
Columbiana
Mahoning
Montgomery
Ottawa
Ohio ICDS Regions
Central
Molina
Aetna
NW
Aetna
Buckeye
WC
MolinaBuckeye
SW
Molina
Aetna
NE
United
CareSource
Buckeye
EC
United
CareSource
NEC
UnitedCareSource
ICDS Regions and Demo Counties
Central
EC - East Central
NE - Northeast
NEC- Northeast Central
NW - Northwest
SW - Southwest
WC - West Central
27
Transitioning Children with Special
Needs from Fee-For-Service to
Managed Care
28
Who Will Transition
• 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
29
Health Homes
30
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
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
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
Enrollee’s Share of Premium After Low Income Subsidies
Low Income Annual Premium (after subsidies)
Income as % of FPL
Annual Income
Premium as % of Income
Annual Premium
Monthly
Premium
100% $11,170 2% $223 $19
138% $15,415 3% $462 $39
150% $16,755 4% $670 $56
200% $22,340 6.30% $1,407 $117
250% $27,925 8.05% $2,248 $187
300% $33,510 9.5% $3,183 $265
350% $39,095 9.5% $3,714 $310
400% $44,680 9.5% $4,245 $354
Enrollees’ Share of the Premium
Single Person – CY 2012 FPL
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)
Income as % of FPL
Annual Income
Premium as % of Income
Annual Premium
Monthly
Premium
100% $23,050 2% $461 $38 138% $31,809 3% $954 $80 150% $34,575 4% $1,283 $107 200% $46,100 6.30% $2,904 $242 250% $57,625 8.05% $4,898 $408 300% $69,150 9.5% $6,569 $547 350% $80,675 9.5% $7,664 $639 400% $92,200 9.5% $8,759 $730
Enrollees’ Share of the Premium
Four-Person Family – CY 2012 FPL
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)
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
Out-of-Pocket Spending Limits After Subsidies
Premium plus Cost Sharing (out-of-pocket expenses to health care providers)
Income as % of FPL
Annual Income Annual
Premium
Annual Cost Sharing
Expenses Limit
Maximum Annual
Premium Plus Cost Sharing
Maximum Monthly 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
Enrollees’ Share of the Premium and
Cost Sharing After Subsidies
Single Person – 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)
Single Person Example – CY 2012 FPL
Premium plus Cost Sharing (out-of-pocket expenses to health care providers)
Income as % of FPL
Annual Income Annual
Premium
Annual Cost Sharing
Expenses Limit
Maximum Annual
Premium Plus Cost Sharing
Maximum Monthly Premium Plus Cost Sharing
100% $23,050 $461 $3,993 $4,454 $371
138% $31,809 $954 $3,993 $4,947 $412
150% $34,575 $1,283 $3,993 $5,276 $440
200% $46,100 $2,904 $6,050 $8,954 $746
250% $57,625 $4,898 $6,050 $10,948 $912
300% $69,150 $6,569 $7,986 $12,619 $1,052
350% $80,675 $7,664 $7,986 $15,650 $1,304
400% $92,200 $8,759 $7,986 $16,745 $1,395
Enrollees’ Share of Premium and Out of Pocket Expenses After Subsidies
Four-Person Family – CY 2012 FPL
FPL 100% 200%
Monthly Income
$ 1,921 $ 3,842
Monthly Premium +
Cost Sharing $ 371 $ 746
Premium plus Cost Sharing (out-of-pocket expenses to health care providers)
Four Person Family Example – CY 2012 FPL
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-coverage-
flowchart.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