Transcript Slide 1

Affordable Care Act
Community Forum
September 2013
Welcome
David Evans
Chief Executive Officer
Affordable Care Act (ACA)
Marketplace 101
Agenda
• Introduction to the ACA and the Health
Insurance Marketplace
• Eligibility
• Application Process
• Coverage
• Affordability
• Responsibility for Coverage
• Key Points to Remember
• Local Resources
www.CentralHealth.net
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What is the ACA?
The Patient Protection and Affordable Care Act,
More commonly known as:
The Affordable Care Act (ACA) is the national
health reform law passed by Congress and signed by the
President in March 2010.
www.CentralHealth.net
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What is the goal of the ACA?
Increase the rate of healthcare coverage for
Americans while addressing overall healthcare
costs.
• Establishing consumer rights and protections
• Increasing insurance options
• Providing assistance for healthcare costs
www.CentralHealth.net
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What is the Health Insurance
Marketplace?
Also known as the “Exchange”, the Health
Insurance Marketplace is a new way to purchase
health insurance.
The “Marketplace” will provide a way for
consumers to:
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Look for and compare health plan options
Complete one application for multiple plans
Determine eligibility for tax credits & cost sharing
subsidies
Enroll in health insurance plan
www.CentralHealth.net
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Who Manages the Marketplace?
Each State can choose to:
• Create and manage their own marketplace
• Partner with the federal government to manage
their marketplace jointly
• Have the federal government manage the
marketplace for their State
www.CentralHealth.net
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Who is Eligible to Participate?
• Individuals and Small Businesses with up to
100 employees can purchase health insurance
through the Marketplace.
Eligibility requirements:
• Must live in the U.S.; within service area
• Must be a U.S. citizen or national, or
• Be lawfully present in U.S.
• Cannot be currently incarcerated
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Application Process
One streamlined process to determine potential
eligibility for:
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Medicaid
Children's Health Insurance Program (CHIP)
Private health insurance offered by Qualified Health
Plans (possible tax credits and cost sharing subsidies)
Can apply:
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On-line
Phone
Mail
In person -receive personal assistance
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Qualified Health Plans
• Private insurance companies certified by the
Marketplace in each respective State, who:
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Have adequate provider networks
Provide Essential Health Benefits
Offer at least one plan at the “Silver” level and
one plan at the “Gold” level
Agree to charge the same premium rates
whether offered through the Marketplace or
outside of the Marketplace
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Coverage: Essential Health Benefits
Qualified Health Plans participating in the Marketplace
will be required to offer benefits that meet a minimum set
of standards called Essential Health Benefits.
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Ambulatory services
Emergency services
Hospitalization
Maternity and newborn care
Mental health and substance use disorder services, including
behavioral health treatment
Prescription drugs
Rehabilitative and habilitative services and devices
Laboratory services
Preventive and wellness services and chronic disease management
Pediatric services, including oral and vision care
www.CentralHealth.net
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Coverage: Plan Levels
Levels of Coverage
Plan Pays on Average
Consumer Pays on
Average*
(In addition to the
monthly premium)
Bronze
60%
40%
Silver
70%
30%
Gold
80%
20%
Platinum
90%
10%
*Based on average cost of an individual under the plan – may not be the same for every enrolled person.
www.CentralHealth.net
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Coverage: Catastrophic Plans
Who is Eligible?
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Young adults under age 30
Those who cannot afford coverage and obtain a
hardship waiver from the Marketplace
What is Catastrophic Coverage?
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Plans with high deductibles and low premiums
Includes coverage of 3 primary care visits and
preventive services at no cost
Protects consumers from high out-of-pocket costs
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Coverage: Enrollment
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Initial Enrollment Period (1st year only):
October 1, 2013 – March 31, 2014
If you enroll:
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Your coverage will begin:
October 1 – December 15
January 1, 2014
December 16 – January 15
February 1, 2014
January 16 – February 15
March 1, 2014
February 16 – March 15
April 1, 2014
March 16 – March 31
May 1, 2014
Beginning October 2014 - Annual Enrollment Period
October 15th – December 7th
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Coverage: Qualifying Events
•
Certain qualifying events will allow individuals to
enroll during the year
Examples of Qualifying Events
Birth/Death
Loss of Minimum Essential
Coverage
Adoption
Gain of a dependent or becoming
a dependent through marriage
Legal separation or divorce
Error in enrollment
Becoming a U.S. citizen, national, Financial change impacting
or lawfully present individual
eligibility for tax credit
Move out of service area
Exceptional circumstances such
as a natural disaster
www.CentralHealth.net
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Affordability: Advanced Premium
Tax Credits
• Advanced Premium Tax Credit is a new kind of
tax credit that can be used to lower monthly
health plan premiums
• Through the Marketplace individuals can apply
for advance payment of this tax credit
• Advance payments will be sent directly to the
insurance company and applied towards
monthly premiums
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Affordability: Advanced Premium
Tax Credits
• Monthly amounts owed by individuals can be
reduced
Example:
• Monthly premium: $300
• Advance payment: $240 a month
• Monthly amount owed by individual: $60
www.CentralHealth.net
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Affordability: Advanced Premium
Tax Credits
• The Marketplace will estimate the amount of
advance payments based on projected income
• Report income changes immediately to avoid
overpayments
• Advance payments will be reconciled at tax time
against the actual Premium Tax Credit amount
individuals are eligible for based upon actual
income
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Affordability: Advanced Premium
Tax Credits
• Option to pay total monthly premiums and claim
tax credit on income tax return
Example:
• Monthly premium: $300
• Projected advance payment: $240 month
• Individual can choose to pay: $300
monthly and receive $2,880 refund
($240 x 12); instead of advance payments
www.CentralHealth.net
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Affordability: Advanced Premium
Tax Credits
Who is Eligible?
• Individuals/Families with household incomes
between 100-400% of Federal Poverty Level
(FPL) who do not have access to public
health benefits or affordable employer
coverage.
• Affordable employer coverage exists as long
as the lowest cost "individual" plan offered by
an employer does not exceed 9.5 % of the
employee's household income
www.CentralHealth.net
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Affordability: Cost-Sharing Subsidies
Cost Sharing Subsidies
• A provision of the ACA requires that individuals with
lower income levels have their cost sharing amounts
reduced
• Health plans will be responsible to pay a greater
share of the covered benefits for qualifying
individuals
Who is Eligible?
• Individuals/Families with household incomes
between 100 - 250% of FPL
• Who enroll in a Silver-Level plan
www.CentralHealth.net
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Affordability: Cost-Sharing Subsidies
• Qualifying subsidies will be automatically
reflected in individual cost sharing amounts
Example:
(Silver Plan)
• Co-pays for households at 250% FPL may
be $10 for Dr. Visit, $7 for prescriptions
• Co-pays for households at 100% FPL may
be $5 for Dr. Visit, $3 for prescriptions
www.CentralHealth.net
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Responsibility for Coverage
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A provision of the ACA requires that all individuals have
health insurance beginning in 2014.
Exceptions may be given for:
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Financial hardships
Religious objections
Qualifying Indian tribes
Those for whom the lowest cost health plan exceeds 8% of their
household income
Those whose income is below the tax filing threshold
Those who do not qualify for an exception and do not
have qualifying coverage will be required to pay an
annual financial penalty.
www.CentralHealth.net
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Responsibility for Coverage:
Penalties
Penalty amounts will be phased in and will gradually
increase from 2014 to 2016
2014
• Penalty is $95/adult
and $47.50/child up
to $285/family; OR
• 1% of income –
whichever is greater
2015
2016 and Beyond
• Penalty is
$325/adult and
$162.50/child up to
$975/family; OR
• Penalty is
$695/adult and
$347.50/child up to
$2,085/family; OR
• 2% of income –
whichever is greater
• 2.5% of income –
whichever is greater
www.CentralHealth.net
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Key Points to Remember
There will be multiple options for health care
coverage –
• Public Programs – Medicare, Medicaid, CHIP
• Health insurance plans offered thru Employers
• Health insurance plans offered outside of the
Marketplace
• Health insurance plans offered by Qualified
Health Plans through the Marketplace
• Tax Credits and Cost-Sharing Subsidies
available through the Marketplace
www.CentralHealth.net
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2013 Federal Poverty Guidelines
Persons in
family/household
100%
250%
400%
1
$11,490
$28,725
$45,960
2
$15,510
$38,775
$62,040
3
$19,530
$48,825
$78,120
4
$23,550
$58,875
$94,200
5
$27,570
$68,925
$110,280
6
$31,590
$78,975
$126,360
7
$35,610
$89,025
$142,440
8
$39,630
$99,075
$158,520
For family units of more than 8 members, add $4,020 for each additional member
Sources: medicaid.gov and FamiliesUSA
www.CentralHealth.net
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Application Assistance Available to General Public
Travis County
Organization
Address
City
Zip Code
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CommUnityCare – North Central
1210 W. Braker Lane
Austin
78758
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CommUnityCare – Pflugerville
15822 Foothill Farms Loop
Pflugerville
78660
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CommUnityCare – Rundberg
825 E. Rundberg, Suite B1
Austin
78753
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CommUnityCare – UT Family Wellness
2901 N. IH-35, Suite 101
Austin
78722
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CommUnityCare – Hancock
1000 E. 41st Street, Suite 925
Austin
78751
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CommUnityCare – Manor
600 W. Carrie-Manor Street
Manor
78653
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CommUnityCare – East Austin
211 Comal Street
Austin
78702
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CommUnityCare – Rosewood-Zaragosa
2802 Webberville Road
Austin
78702
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CommUnityCare – South Austin
2529 S. 1st Street
Austin
78704
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CommUnityCare – UT Children’s Wellness
5301 Ross Road, Suite H
Del Valle
78617
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CommUnityCare – Oak Hill
8656-A Hwy 71 West, Suite C
Austin
78735
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CommUnityCare – William Cannon
6801 S. IH-35, Suite 1-E
Austin
78744
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LoneStar Circle of Care – Seton Northwest
11111 Research Blvd., Suite 230
Austin
78759
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LoneStar Circle of Care – Ben White
1221 W. Ben White Blvd. Suite B200
Austin
78704
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Foundation Communities – North
Highland Mall – 6001 Airport Blvd
Austin
78752
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Foundation Communities – Southwest
2600 W. Stassney Lane
Austin
78745
CommUnityCare – 512.978.9015 ▪ LoneStar Circle of Care – 1.877.800.5722 ▪ Foundation Communities – 2-1-1
www.CentralHealth.net
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Application Assistance to Existing
Client Base
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Central Health Eligibility Services
Seton Community Clinics
Austin Travis County Integral Care
(ATCIC)
People’s Community Clinic
www.CentralHealth.net
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Education and Referrals for Existing
Client Base
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Child Inc./HeadStart Program
Easter Seals
Project Access
WIC Program
SIMS & HAAM Foundations
www.CentralHealth.net
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Additional Services
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Central Health has committed to fund additional
outreach & education efforts
These efforts will:
 Compliment services provided by Enroll
America
 Coordinated culturally competent, community
based approach
 Data driven activities, directed at targeted
populations and underserved areas of county
 Allow for assistance in non-traditional settings
such as schools, community events or even
personal residents
www.CentralHealth.net
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Additional Services
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Central resource for local information &
referrals
United Way for Greater Austin
 Manages the local 2-1-1 Center
 10 County Central Texas region
 Central Health Healthcare
Navigation Center
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www.CentralHealth.net
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United Way 2-1-1 Center
 Available to provide:
 General information and referrals to Health
Insurance Marketplace Call Center
 Information and warm transfers to:
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Each of the local Marketplace resources
Central Health Healthcare Navigation Center
 Prescreen individuals for potentially
eligibility of:
 Medical Access Program (MAP)
 Medicaid
 CHIP/CHIP Perinatal
 Health Insurance Marketplace
www.CentralHealth.net
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Summary
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Coordinated, systematic approach
Prevent confusion & avoid duplication of
efforts
Maximize use of existing resources
Locally:
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Enhanced outreach & education efforts
In person application assistance – general population
Application assistance for existing clients of multiple
organizations
Education & referrals from numerous organizations
Central resource for local information - United Way
2-1-1 Center
www.CentralHealth.net
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Questions?
www.CentralHealth.net
Enrollment and Outreach for
Integral Care
ACA and Integral Care
• Champion for Coverage and Certified
Application Counselor Organization
– Training staff and volunteers to assist with enrollment
• Consumer Benefits Office will enroll eligible
people using Integral Care services
• Additional Open Enrollment for the public
– 1631 East 2nd Street
– 1702 South Lamar, Large Training Rm
– 5225 North Lamar Professional Building
– Dove Springs
Enrollment Information for
People Currently Using Services
• Approximately 1,200 People are Eligible
• Provide Technical Assistance
• Begin October 1st – March 31st
• Currently Recruiting Volunteers for Enrollment
Assistance for the Public (Limited Space)
• Offering Extended Hours
Additional Outreach Efforts
• Working with partner organizations for referrals
to enrollment sites
• Traditional marketing and social media activities
• Online information and resources
• Participation in fairs and community events:
– Binational Health Week fair
– Community Connections Health Fairs
Mental Health & Substance Use
Parity
• Parity means insurance companies can not
discriminate against mental health and
substance use treatment in coverage decisions
• ACA designates mental health coverage as an
essential health benefit
• All plans offered in the Marketplace must offer
coverage and you cannot be denied due to a
preexisting condition
Prevention, Wellness & Chronic
Disease Management
• Essential Health Benefit
• Profound disparity in life expectancy for persons
with serious mental illness:
– Persons with a serious mental illness are more than
twice as likely to smoke cigarettes
– People with major depressive disorder are at higher
risk for cardiovascular disease and stroke
• Includes smoking cessation and other programs
to help people get and stay healthy
Questions?
Q & A Session
Closing Remarks
David Evans
Chief Executive Officer