Health Insurance for Thalassemia and the Affordable Care Act

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Health Insurance Update/Affordable Care Act:
Wendy Murphy, LCSW
January 18, 2014
Thalassemia Patient and Family Conference
Northern California Comprehensive Thalassemia Center
Children's Hospital Oakland

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Health Insurance for Thalassemia and the Affordable Care Act

  1. 1. Wendy Hyde Murphy, LCSW Medical Social Worker Thalassemia Department Children’s Hospital & Research Center Oakland COVERED CALIFORNIA
  2. 2. OVERVIEW • Establishment of Covered CA • Important Legislation • Essential Benefits & Plans • Affordable Coverage & Income Guidelines • How to Enroll & Timeline • Implementation Concerns
  3. 3. COVERED CALIFORNIA • First state in the nation • Diversity and complexity • Cut the # of uninsured by up to 2/3
  4. 4. MISSION • Increase insured Californians • Improve health care quality • Lower costs • Reduce health disparities • Choice and value
  5. 5. ESSENTIAL BENEFITS • Ambulatory • Emergency services • Hospitalization • Maternity & Newborn Care • Mental Health & Substance Use Disorder Services
  6. 6. ESSENTIAL BENEFITS • Prescription Drugs • Rehabilitative Services & Devices • Lab Services • Preventive Services as well as chronic disease management • Pediatric services
  7. 7. CALIFORNIA LEGISLATION Since the passage of ACA, California has enacted over 20 pieces of legislation. • Prevents insurers from denying or discriminating for pre- existing conditions (AB1x2 - Pan; SB1x2 - Hernandez, 2013) 1. cannot refuse to cover or charge 2. premium costs based only on age, zip code, household size and benefit plan.
  8. 8. LEGISLATION Expands Medi-cal (California’s Medicaid program) to all legal residents up to 138% of the poverty level, including adults without children. (AB1x1-Perez; SB1x1-Hernandez) Bridge Plan which allows those in Medi-cal to stay in the managed care plan as their incomes fluctuate and then qualify them for Covered CA. (AB1x3-Hernandez)
  9. 9. INSURANCE PLANS IN CALIFORNIA • Anthem Blue Cross of California • Blue Shield of California • Chinese Community Health Plan • Contra Costa Health Services • Health Net • Kaiser Permanente • L.A. Care Health Plan • Molina Healthcare • Sharp HealthCare • Valley Health Plan • Western Health Advantage
  10. 10. INSURANCE PLANS – COUNTY SPECIFIC Each county has selected 3-6 insurance companies to choose from. Alameda County • Anthem PPO • Blue Shield EPO • Kaiser HMO
  11. 11. METALLIC TIERS Bronze Silver Gold Platinum 60% 70% 80% 90% Speciality Care Co-pay $70 $65 $50 $40 Lab Testing Co-pay 30% $45 $30 $20 Medication Co-pay $19 or less $19 or less $19 or less $5 or less Annual Out-of-Pocket $6,350 Ind $12,700 Family $6,350 Ind $12,700 Family $6,350 Ind $12,700 Family $4,000 Ind $8,000 Family
  12. 12. Plan Bronze Silver Platinum Blue Shield PPO $215 $257 $351 Contra Costa Health Plan HMO $237 $276 $352 Health Net PPO $249 $284 $364 AVERAGE MONTHLY PREMIUMS (25 YEAR OLD – CONTRA COSTA)
  13. 13. AFFORDABLE COVERAGE Premium Assistance (federal subsidy) - reduces cost of premium Cost-sharing Assistance - reduces cost for copays and deductibles.
  14. 14. INDIVIDUAL SUBSIDIZED SILVER PLAN Income Level - Based on Federal Poverty Level 138% 150% 250% 400% Monthly Premium $19 $57 $193 $364 Deductible None $500 $1,500 $2,000 Generic Medication Copay $3 $5 $19 $19 Max Out-of-Pocket $2,250 $2,250 $5,200 $6,350
  15. 15. MEDI-CAL EXPANSION  Medi-cal no-cost health insurance for people with disabilities and annual incomes less than: • $15,856 for individuals • $32,499 for family of four  Allows coverage for parents who would have lost coverage under current rules if their income slightly exceeds the federal poverty level.
  16. 16. INCOME LEVELS AND ASSISTANCE (BASED ON % OF FEDERAL POVERTY LEVEL) Number of People in Household If Your Income is LESS THAN If Your Income is BETWEEN 1 $15,857 $15,857 - $45,960 2 $21,404 $21,404 - $62,040 3 $26,952 $26,952 - $78,120 4 $32,500 $32,500 - $94,200 You may qualify for: Medi-cal Premium assistance through Covered California
  17. 17. HOW TO ENROLL • Online: CoveredCA.com • By phone: Call Covered California at 1-800-300-1506 (TTY: 1- 888-889-4500) M - F 8 a.m. to 8 p.m. & Sat 8 a.m. to 6 p.m. • Fax or Mail application: Fax 1-888-329-3700 or Mail: Covered California P.O. Box 989725 West Sacramento, CA 95798-9725 • In person: Connect with trained Enrollment Counselors
  18. 18. OPEN ENROLLMENT Initial open enrollment  October 1, 2013 – March 31, 2014 Subsequent enrollment  October – December each year Special circumstance  60 days within a certain life-changing event, such as a divorce or the birth of a child  Medi-Cal applications accepted year-round
  19. 19. LANGUAGE ASSISTANCE • Arabic • Armenian • Chinese • Farsi • Filipino • Hmong • Khmer • Korean • Lao • Russian • Spanish • Vietnamese
  20. 20. SHOP & COMPARE TOOL  Household Information - • # of people in the household • Income • ZIP Code  Enrollee Information - • AGE of each adult • Number of dependents age 18 or under: 0 1 2 3 +
  21. 21. Silver Plan Level Blue Shield EPO Anthem PPO Kaiser HMO Rate $759 $848 $867 Premium Assistance $568 $568 $568 Monthly Cost $186 $280 $299 ALAMEDA COUNTY – FAMILY OF 4 $50,000 INCOME LEVEL
  22. 22. PENALTIES  ACA requires that most adults have public or private health insurance by January 2014. Fine increases over 3 years: • Fines 1% of yearly income or $95 per person whichever is greater. • By 2016, fines will increase to 2.5% of income or $695 per person, whichever is greater.
  23. 23. EXEMPTION FROM PENALTIES • Affordability Exemption – if the insurance plan will cost more than 8 percent of household income. • Hardship Exemption - such as homelessness, bankruptcy, domestic violence, large medical debts, utility shutoff notice or death in the family. • Policy Cancellation – if your individual insurance policy is cancelled.
  24. 24. EXCLUSIONS FROM COVERED CA • Currently receiving affordable health insurance through an employer or public program • Medicare or you qualify for Medicare • Undocumented residents (HealthPAC or Restricted Medi-cal, GHPP & CCS)
  25. 25. SPECIAL INSURANCE PROGRAMS  For patients with Thalassemia: • GHPP (Genetically Handicapped Persons Program) • CCS (California Children’s Services)
  26. 26. CONCLUSION • Compare plan options, Obtain subsidized assistance and Enroll • “No Wrong Door” Approach • Concerns?  Will there be enough Medi-cal providers  Bridge Plan – will it work as proposed
  27. 27. • Covered California – www.coveredca.com • Health Care Consumer Advocacy – www.health-access.org • Health Consumer Alliance – www.healthconsumer.org • Genetically Handicapped Persons Program – www.dhcs.ca.gov/services/ghpp • California Children’s Services – www.dhcs.ca.gov/services/ccs RESOURCES

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