Healthcare Reform Presentation
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  • Individual Mandate: <br /> Exemptions <br /> There are also several exemptions to the individual mandate. Persons who are applicable individuals will still be exempt from the penalty of the individual mandate if: <br /> coverage is unaffordable (excedes 9.5% of household income; <br /> they do not meet the filing threshold for purposes of income tax filing; <br /> they are Native Americans; <br /> they have a short lapse in coverage (less than three months since they had minimum essential coverage); <br /> they have suffered a hardship; <br /> they are a dependent; or <br /> they reside outside of the United States. <br /> Amount of Penalty <br /> The ACA specifies that the “applicable dollar amount” of the tax is generally $695, to be phased in and adjusted as follows: <br /> As you can see from this chart, the penalty tax starts as a nominal tax in 2014, and by 2016 it is much more significant. <br /> Reforming Insurance Rules <br /> Can’t be denied insurance because of pre-existing health condition, even if you don’t currently have coverage <br /> Children in effect <br /> Adults in 2014 <br /> Health plans cannot drop people from coverage when they get sick (in effect) <br /> No lifetime limits on coverage (in effect) <br /> No annual limits on coverage (2014) <br /> Allows young adults to stay on their parents’ health care plan until age 26 (in effect) <br />
  • Uninsured Legal Residents. Will discuss undocumented later. <br />
  • You can go to the Covered California website and see how much things like co-payments cost under the plan, and how you pay on a sliding scale,a nd how your deductible can be affected by your income as well. <br /> Show 1-2 examples. <br />
  • (read slide) <br />

Healthcare Reform Presentation Presentation Transcript

  • 1. What Do You Need to Know about Health Care Reform? Anne Donnelly, Project Inform Courtney Mulhern-Pearson, San Francisco AIDS Foundation
  • 2. Presentation Outline • Part 1: What does Health Care Reform Do? • Part 2: What’s Up in California?
  • 3. HCR is Vital For People with HIV: Status Quo = Access to Care Crisis Few on employer insurance; 17% PLWH compared to 54% general population
  • 4. What Does Health Care Reform Do? US (Federal) CA (State) Individual Mandate US citizens and legal residents must maintain health coverage or face a tax penalty unless exempted. CA residents must obtain healthcare coverage in 2014 or face a tax penalty, unless exempted. Expanded Coverage: Focus on the Uninsured State option to expand Medicaid Medi-Cal expansion < 138% FPL; Insurance Marketplace in all states – federal or state run Covered California (California’s state run marketplace) > 138% FPL Affordability Subsidies for lower income people – in marketplace; Exemptions for hardships, Out of pocket caps on coverage – for all Same in California Reforms Private Insurance: Creates New Protections Eliminates denials and increased premiums for pre-existing conditions; no annual or lifetime limits on coverage Same in California Strengthens medical work force; Improves Care Coordination Strengthens medical work force; Improves Care Coordination Other 4
  • 5. Makes Comprehensive Insurance a Right ACA Essential Health Benefits • • • • • • • • • • Ambulatory services Emergency services Hospitalization Maternity/newborn care Mental health and substance use disorder services – to parity Prescription drugs Rehabilitative and habilitative services Laboratory services Preventive and wellness services and chronic disease management Pediatric services * Vision and dental remain a gap In California “Benchmark” Plan for Covered CA: Kaiser Small Group Employer Plan “Alternative Benefits Package” Basically the same as traditional Medi-Cal 5
  • 6. Strengthens Prevention: Some Examples • STI prevention counseling (high risk adults only; sexually active adolescents) • HPV vaccination (all women) • Syphilis screening (high risk adults and pregnant women) • HIV screening ( everyone age 15-65) • Hepatitis C screening (for high risk adults) • Hepatitis B Screening (pregnant women) • Chlamydia screening (young & high risk women) • Gonorrhea screening (high risk and pregnant women) • Gonorrhea preventive Rx (all newborns) • HPV DNA testing (30+ women) • Tobacco cessation counseling CDC. HIV Surveillance Supplemental Report. U.S. Department of Health & Human Services, 2012, Vol. 17, No. 4 CDC. HIV Cost-Effectiveness. U.S. Department of Health and Human Services, 2012 -13 6
  • 7. Reforms Private Insurance • Can’t be denied insurance because of pre-existing health condition, even if you don’t currently have coverage (2014) • Health plans cannot drop people from coverage when they get sick (in effect) • No lifetime limits on coverage (in effect) • No annual limits on coverage (2014) • Allows young adults to stay on their parents’ health care plan until age 26
  • 8. Expands Coverage Estimated 32 Million will gain coverage by 2019 Medicaid Income Under 138% FPL Marketplace Income above 138% FPL
  • 9. Expanding and Improving Medicaid (State Option) • Everyone at or below 138% FPL (about $16,000 annually ) regardless of disability status • Removes asset test • Provides essential health benefits (EHB) • Allows for standard covered preventive services – State option for cost sharing • Increases primary care reimbursement for 2013/2014 • Provides option for a medical home
  • 10. Private Insurance Marketplaces • All states will have a Marketplace • – Either state run or federally run Marketplaces must provide assistance with coverage – Assisters, Enrollment Counselors, Navigators • Assistance with costs • • Out-of-pocket subsidies for those between 100 – 250% FPL ( ~29K for an individual) Premium tax credits for those between 100-400% FPL ( ~$46K for an individual)
  • 11. Who’s Left Out? Undocumented immigrants left out: •Barred from Marketplace plans •Not eligible for non-emergency Medicaid •Eligible for restricted “emergency” Medicaid •Eligible for services through community health centers and/or safety-net providers Legally present immigrants: •5 year waiting period for Medicaid services continues •Can purchase with subsidies in Marketplace
  • 12. Who Provides HIV Care in the Future? Individuals with income up to 138% FPL – State Option Eligible for Medicaid based on income alone (Ryan White still needed to fill in gaps not covered by Medicaid) Individuals with incomes above 138% FPL Eligible to buy in Marketplace Income between 100% and 250% FPL Eligible for premium tax credits and costsharing subsidies Income between 250% FPL and 400% FPL Eligible for premium tax credits (Ryan White still needed to fill gaps ) Individuals with unmet care and treatment Ryan White Program still a safety net for: needs insured people with unmet need and gaps in services legal immigrants not eligible for Medicaid, and undocumented immigrants
  • 13. The Challenge for People with HIV and their Providers • Medicaid expansion not in every state • Ryan White program (RW) – patient centered comprehensive HIV care – providers funded by grants • Ryan White: Payer of last resort • HCR expanded coverage means transitions – PWH: Transitions to new plans, providers, pharmacies • Once in new coverage, may need continued access to some RW services – HIV Providers – to new payers • Once in new plans they may not cover all services – continued RW funding
  • 14. PART 2: WHAT’S UP CALIFORNIA?
  • 15. “A Bridge to Health Care Reform” July 2011 • Low Income Health Program (LIHP) Partial and temporary county – based Medicaid expansion: called SF Path in San Francisco – Ends December 31, 2013 – SF Path eligibility has recently changed from 25% to 133% FPL • Medi-Cal managed care expansion: moved most from fee-forservice into Medi-Cal managed care plans – Must get care in your managed care “network”
  • 16. What Will Health Care Reform Bring in CA in 2014? • People with employer coverage, Medicare and traditional Medi-Cal will see few changes – Employers could extend coverage to more full time employees – Insurance reforms apply to employer coverage – Small employers will have some tax credits and access to the Marketplace – All covered people, including Medi-Cal and Medicare, will have access to certain free preventative services – Medicare recipients will get more help with prescription drugs • Medi-Cal (California’s Medicaid program) expansion • A state run Marketplace - Covered California
  • 17. How to enroll • You should be able to enroll in Medi-Cal and Covered California at the same location – Not clear yet which enrollment locations will have HIV expertise – Several HIV clinics will assist but have not yet been certified • Medi-Cal – – – – Can enroll in Medi-Cal at any time during the year If eligible, you need to enroll Important to choose your provider and your “network” Will have to do provider choice on paper form
  • 18. How to enroll • Covered California – Open enrollment October, 2013 - March 31, 2014 – If eligible, you should consider enrollment – Advising people to wait until more details and assistance are available • Covered California website doesn’t yet have adequate information to make informed decisions – No information on provider networks – No formulary information • Currently very few helpers have been certified
  • 19. A closer look at Covered California • Five plans offered in San Francisco – Anthem – Exclusive Provider Organization (EPO) – Blue Shield – Preferred Provider Organization (PPO) – Chinese Community Health Plan – Health Maintenance Organization (HMO) – Kaiser Permanente (HMO) – Health Net (PPO)
  • 20. Plans available at four different “tiers” or cost levels
  • 21. Covered California – Cost Assistance Available Two kinds of cost assistance available: 1. Cost sharing subsidies • For people between 100% and 250% FPL (about $16,000 annually) • must take a Silver plan to receive help with out of pocket costs 1. Premium tax credits • For people between 100% and 400% FPL (about $46,000 annually)
  • 22. Remember! Remember! • The income figure we use to calculate extra help is based on MAGI but must consider PROJECTED INCOME FOR 2014. • If you underestimate this figure now, you may end up owing money back to the Federal government when you report 2014 taxes (in 2015.)
  • 23. Additional cost assistance for people with HIV • Premium help: – State Office of AIDS is planning to assist with premium costs in Covered California – Program is call Office of AIDS Health Insurance Premium Payment Program • Eligibility is the same as ADAP • Cost sharing for prescription drugs – Pay co-pays etc. for ADAP drugs only • Currently no assistance available for other out of pocket costs including primary medical co-pays or lab co-pays
  • 24. Transitions for people with HIV/AIDS • Transitions for uninsured people with HIV, if eligible: – From SF Path to Medi-Cal expansion (mandatory movement) • Administrative move; will receive letter notice from DHCS; should ensure that you get the providers you want – From Ryan White to Medi-Cal expansion (mandatory movement) • Will happen with Ryan White recertification; ensure that you choose the providers you want; believe you will need to see someone at your clinic for help – From Ryan White to Covered California (not mandatory but RW doesn’t meet individual mandate) • Complex choices, open enrollment until March 31, 2014 • From PCIP to Covered California – Mandatory in order to maintain coverage, PCIP ends December 31, 2013
  • 25. What do you need to know before you make any decisions • Big and complex change – Don’t go it alone! • Read and keep all documents that are sent to you regarding your health care • Reach out for help – – – – Your current provider HIV experienced benefits counselor Tax consultant A certified enrollment counselor • But know that they may not have HIV specific information
  • 26. Some important considerations – Covered California • You don’t need to sign up for Covered California immediately – Must sign up for Covered California by December 15 th if you need your coverage to start on January 1, 2014 – Must sign up prior to February 15, 2014, in order to avoid the individual mandate tax penalty • Do your homework in order to make sure you pick the best plan for you – If you want to stay with your provider check with them to see what plans they are contracted with – If possible, see an HIV experienced benefits counselor to understand how your plan will work with OA-HIPP/ADAP • Don’t expect the Covered California enrollment counselors to understand HIV programs • Ask for a bridge supply of medications from your provider before you transition to Medi-Cal
  • 27. Some Important Considerations – Medi-Cal • Make sure you don’t get defaulted into a plan – choose a plan • Consider which plan includes your provider as well as which networks are available (hospitals, etc.) • Make sure to sign up with a paper application if you want to choose your provider • Medi-Cal has consumer protections available – if you have problems with coverage you should seek help to exercise those rights • Ask for a bridge supply of medications from your provider before you transition to Medi-Cal
  • 28. Resources  State HCR Information -www.statereforum.org  Enroll America www.enrollamerica.org  Center for Budget and Policy Priorities - www.cbpp.org  Treatment Access Expansion Project – www.taepusa.org  Kaiser Family Foundation – www.kff.org  Families USA – www.familiesusa.org  National Health Law Program – www.nhelp.org  NASTAD – www.nastad.org  Health Resources and Services Administration – www.habhrsa.gov
  • 29. CA Resources  Covered California – www.coveredca.com  Health Access - www.health-access.org  Western Center on Law and Poverty – www.wclp.org  National Senior Citizens Law Center – www.nsclc.org  Health Consumer Alliance – www.healthconsumer.org
  • 30. Contact Anne Donnelly, Project Inform 415.558.8669x208 adonnelly@projectinform.org Courtney Mulhern-Pearson, San Francisco AIDS Foundation 415.487-8008 cpearson@sfaf.org San Francisco HIV Health Care Reform Task Force sfhivhealthreform@gmail.com