1. Health Insurance, the
Affordable Care Act, and
Homelessness
AUGUST 14, 2016
ALEX BONTE, GMHC
COVERED CA CERTIFIED ENROLLMENT COUNSELOR

2. Overview – Starting with the big picture
What do you want to learn about today?
Session overview
Why have health insurance at all?
Stakeholders in healthcare delivery
Medicare and Medicaid
The Affordable Care Act
What’s available to persons affected by
homelessness
The Berkeley Free Clinic
Common understandings
Feel free to move me along if I get stuck in
details
Shout out for words you don’t know if
needed
Ask all the questions

3. Why even health insurance?

4. Why even health insurance?

5. Why even health insurance?
Distribution of risk
Any ideas how to most broadly distribute risk?

6. Stakeholders in healthcare delivery
Patients
PayersPaymentProviders

7. Stakeholders in healthcare delivery
Patients
PayersPaymentProviders
What happens when a patient
can’t afford a premium?

8. Medicare and Medicaid
MEDICARE
A federal program that provides health
coverage to individuals 65 and over or for
certain chronic conditions
No income requirements
Has parts A, B, C, and D but will not be covered
today
MEDICAID
Joint state and federal program for low-
income individuals
◦ Federal government provides most of the
money, state governments can decide what to
do with it
Income requirements based on the federal
poverty level
Relevant for most homeless clients, and has a
more complicated application process, so also
most relevant for community health workers

9. Medicare and Medicaid
MEDI-CAL
Medi-Cal is California’s Medicaid program
◦ Jointly funded by the state and federal governments, but managed by the state government
◦ Benefits are more specifically managed by the county the patient lives in
◦ A no-cost health plan for the patient – no premium, no deductible, no out of pocket costs
◦ Can apply online, over the phone, in person, or by mail

10. The Affordable Care Act
Not a health insurance plan
Was a legislative milestone for the entire
country, not just Obama
Much broader effects than just on
insurance companies
Don’t buy into the polarizing overtones
That being said, the law probably could
have been more accurately titled the
Affordable “Coverage” Act, but can’t win
‘em all.

11. The Affordable Care Act
SO MANY THINGS
Things most relevant for us:
Guaranteed issue – Insurance providers can
no longer refuse to sell coverage to someone
based on a pre-existing condition
◦ Good news for homeless clients who often have
one or more health conditions
Insurers must sell coverage to individuals, on
the individual marketplace (Covered California
in California)
◦ Based on income level (up to 400% of the FPL),
the federal government provides subsidies to
help pay premiums for individuals and families
who buy coverage on the marketplace
Expanded Medicaid eligibility
(remember it’s “Medi-Cal” in
California)
◦ Income levels up to 138% of the FPL
◦ Granted childless adults the ability to apply for
Medicaid coverage
◦ This is huge for homeless clients – childless adults before
the ACA had much fewer options than they do today
◦ Federal government pays 100% the cost of the
expansion for states, tapering down to 90% by
2020

12. Healthcare and Homelessness
Medi-Cal Eligibility
◦ Those making no income
◦ Any single person making under 138% of the FPL
(about $16,000)
◦ Must be residents of California
Challenges faced by individuals facing
homelessness
◦ Verification of residency
◦ Can be supplied by an affidavit, if they do not have a
government-issued ID or address.
◦ Access to the internet, computers, application
resources
◦ Education/literacy barriers
◦ Healthcare literacy – knowing how to access
care, where doctors are, what makes sense to go
in for
◦ The gap between access to coverage and access
to care
◦ What else?

13. Healthcare and Homelessness
Applying for Medi-Cal
“No wrong door” policy
◦ Applications via any means are all legitimate
avenues to coverage:
◦ In person at a county social services office
◦ Medi-Cal Center
Enterprise Office
8477 Enterprise Way
Oakland CA 94621
510-777-2300
◦ In person with a Certified Enrollment Counselor (BFC)
◦ Online at coveredca.com
◦ By mail
◦ In coordination with application for CalFresh (food
stamps/SNAP)
◦ Can apply at any time – do NOT have to wait for
open enrollment
Necessary Documenation
◦ Income
◦ Via paystubs or bank statements or tax return
◦ Or, if no income, can sign an affidavit (BFC has template if
needed)
◦ Residency
◦ If no address, can use a California ID or Driver License
◦ “Or an applicant may provide a written statement indicating
that they are a resident of the state, do not have a fixed
address and cannot provide any of the other documents.”
◦ “A declaration by the individual under penalty of perjury
that he or she intends to reside in this state and does not
have a fixed address and cannot provide any of the
documents listed above.”

14. Healthcare and Homelessness
What happens after enrollment?
Choosing a managed care plan
◦ Within 60 days, the enrollee has to select a
“managed care plan”
◦ This is essentially a health insurance company that accepts
payment from Medi-Cal
◦ During the time when the enrollee has not selected a plan, they
are on fee-for-service Medi-Cal. Meaning they can access
services from any provider that will accept straight Medi-Cal, of
which there are very few. But public health clinics should, as well
as public hospital emergency rooms
◦ A plan and primary care provider will be selected
for them after 60 days.
◦ It’s all county-specific. The plans you can get in
Alameda County are not necessarily the same as
those you can get in San Francisco County
◦ Remember the gap between coverage and care
◦ Choosing a plan wisely requires a lot of knowledge
After choosing a managed care plan, the
enrollee accesses healthcare similar to most
patients covered by a large insurance provider
◦ This then begins a completely separate set of
necessary education about much of the above –
how payments happen, what in-network and out-
of-network providers are, where a patient can
access care, what cost they may be responsible for,
on and on
Getting coverage is far from the end of the
story, but it is absolutely the necessary
beginning.

15. Healthcare and Homelessness
What if a client doesn’t qualify for Medi-Cal?
The individual marketplace, Covered
California
◦ For people who make more than 138% of the
FPL, they will have to purchase individual
coverage on CoveredCA.com
◦ Covered CA makes this eligibility determination during the
application process – the Medi Cal and Individual Coverage
applications are the same
◦ The client receives federal subsidies that go
directly to the insurer to reduce the cost of
premiums
◦ More subsidies for lower incomes
After choosing a plan, the enrollee accesses
healthcare based on which insurer they’ve
chosen
◦ This then begins a completely separate set of
necessary education about much of the above –
how payments happen, what in-network and
out-of-network providers are, where a patient
can access care, what cost they may be
responsible for, on and on
Getting coverage is far from the end of the
story, but it is absolutely the necessary
beginning.

16. The Berkeley Free Clinic
A Certified Enrollment Entity
◦ We have a team of trained Certified Enrollment
Counselors who help people acquire health
coverage
◦ The actual application process is relatively short
and simple, but we spend much of our time on
client education about insurance and accessing
medical services
◦ We have received grant money, but are prohibited
from accepting any sort of compensation from
enrollees or insurance companies
◦ We ask every client about their insurance status
◦ cec@berkeleyfreeclinic.org
◦ Can send questions, contact information for a referral
◦ We may have open hours during open enrollment, but have not
yet decided
Too late this year to train as a CEC but if you’re
interested, reach out next August or September
when we might be doing another training
Sustainability depends on continued funding, but
we did decide to train outside community
members who were interested

17. Wrap-up
INSURANCE IS IMPORTANT!
People with health insurance have demonstrably better health outcomes, and reduce systemic costs
by having ongoing care. Medi-Cal is not perfect coverage by any means, but some coverage is always
better than none.
DON’T BLAME VICTIMS OF HOMELESSNESS
Probably goes without saying, but remember that even after someone gets insurance, without proper
guidance and education, they may just continue to go to the ER frequently like they’re used to. This is
not the fault of the patient, but a failing of our healthcare system to provide adequate, easily-
accessed basic healthcare services as a regular part of every person’s life.
VOTE
Learn what you can about health insurance and healthcare delivery and be an informed voter!
Healthcare reform directly impacts people’s physical health – people like you and the clients you
serve.

18. Resources
•Let’s Get Everyone Covered! Medi-Cal Eligibility and Enrollment Tips for Provers of Homeless
Assistance and Supportive Housing
• http://www.hcd.ca.gov/letsgeteveryonecovered.pdf
• Seriously read this entire document
•http://usich.gov/usich_resources/fact_sheets/ACA/
•http://usich.gov/issue/affordable_care_act1/
•Understanding and Improving the US Healthcare System, University of Michigan free online course
• https://class.coursera.org/ushealthcare-002/wiki/unit1
•Khan Academy Health Care System Course
• https://www.khanacademy.org/science/health-and-medicine/health-care-system
•Everything on Wikipedia.