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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.

• • •

“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)

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

• •


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

14


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

17


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

18


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:

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

20


Medicaid of the Future

21


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

23


24


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

25


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

26


Transitioning Children with Special Needs from Fee-For-Service to Managed Care

27


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

28


Health Homes

29


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

30


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


December: ACA Learning Session on Exchanges, Medicaid, and Affordability