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Healthcare Reform Presentation

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  • Individual Mandate:
    Exemptions
    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:
    coverage is unaffordable (excedes 9.5% of household income;
    they do not meet the filing threshold for purposes of income tax filing;
    they are Native Americans;
    they have a short lapse in coverage (less than three months since they had minimum essential coverage);
    they have suffered a hardship;
    they are a dependent; or
    they reside outside of the United States.
    Amount of Penalty
    The ACA specifies that the “applicable dollar amount” of the tax is generally $695, to be phased in and adjusted as follows:
    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.
    Reforming Insurance Rules
    Can’t be denied insurance because of pre-existing health condition, even if you don’t currently have coverage
    Children in effect
    Adults in 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 (in effect)
  • Uninsured Legal Residents. Will discuss undocumented later.
  • 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.
    Show 1-2 examples.
  • (read slide)
  • 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