Transcript Access to HIV Drugs Continuum

Federal Health Care Reform: The
Impact on NYS Programs
Buffalo, NY
October 13, 2010
Presented by:
Trilby de Jung
Senior Health Law Attorney
Today’s Agenda
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Overview of PPACA
New coverage options already in effect
Major provisions most relevant to low-income
populations
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Public Program Expansion
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State Exchange & Coordinated Enrollment
Selected service Delivery Reforms
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What we still don’t know - questions/choices
for policy makers
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Overview
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PPACA has a two-fold vision – universal
coverage and cost control.
Most of the provisions we will look at today fall
into the universal coverage bucket.
We will also look at some of the service
delivery reforms that are aimed at controlling
costs.
The reforms in both areas are phased in
gradually – lots of discretion during
implementation (with HHS and the states)
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Universal Coverage?
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2.6 million uninsured in New York
PPACA approach to universal coverage as a
three-legged stool
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Employer coverage (reforms w/out reductions)
Public programs (significant expansion)
Affordable private insurance w/mandate
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New marketplace (> 1 M will be eligible for coverage through
the Exchange)
Tax subsidies (of those in Exchange, 700,000 eligible for tax
subsidies)
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Who is left behind?
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Dramatic expansion of coverage – another
1.2 million will be covered in NY.
But some are left behind
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Undocumented immigrants (400,000)
Eligible but unenrolled in public programs (up to
1 M could remain)
Those qualifying for hardship exemptions
(200,000)
Those paying penalties (190,000)
Between 1.4 and 1.8 million New Yorkers
could remain uninsured
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New Coverage
Options Already in
Effect
High Risk Pools – NY’s Bridge Plan
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Temporary coverage through GHI
Includes pharmacy and vision care with no
deductibles and very low co-pays
For individuals only, no family or dependent
coverage is available
Individuals must have a pre-existing condition, be
uninsured for 6 months, a resident of NYS and
lawfully present (immigration status)
Premiums are standardized: $362 for counties
above the Hudson Valley, $421 for downstate
For more information, www.nybridgeplan.com
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Young Adults Coverage
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PPACA requires insurers to allow young
adults to remain on parents’ policy up to age
26, if no other coverage available
Beginning in 2014, coverage extension is an
option even if other coverage is available
(HHS requirements)
The rule takes effect on all plans or policy
years starting September 23, 2010 or later.
Special 30 day re-enrollment opportunity
must be provided no later than the start of
the new plan/policy year.
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Public Program
Expansion
Medicaid to 133% of FPL by 2014
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New mandatory eligibility category created
Traditional eligibility categories remain
New category is all who are not:
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Age 65 or older
Pregnant
Entitled to or enrolled in benefits under
Medicare Part A
Enrolled under Medicare Part B or
Included in any other mandatory groups
(Sections I – VII of SSA 1902(a)(10)(A)(i)
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Public Program Eligibility in NYS, 2010
Slide courtesy of the United Hospital Fund
Notes: Eligibility for all programs is expressed as a gross income standard. The 2009 Federal Poverty Level (FPL) is $10,830 for an individual and $18,310 for a family of three.
Children with gross family income above 160% FPL are charged an income-related premium in Child Health Plus.
“
“ refers to the federal minimum Medicaid eligibility level under the Patient Protection & Affordable Care Act.
“----” refers to the enacted Family Health Plus eligibility expansion which is contingent upon federal approval .
“No ceiling” refers to the fact that workers with income above Medicaid/Child Health Plus/Family Health Plus levels are eligible for the FHP buy-in although they are not eligible for
state premium subsidies; and small businesses are eligible for the HNY program if at least one third of their employees have income below $40,000 and one lower-income
employee enrolls.
MAGI Budgeting
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New Income test based on Modified
Adjusted Gross Income of 133% FPL
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Flat deduction of 5% takes income up to 138%
MAGI will not apply to the following
groups, absent a waiver (waivers for duals
are explicitly mentioned)
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Those over 65
SSI recipients, SSI-related & foster care kids
Medically needy
MSP enrollees
Those using chronic care services
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MAGI Budgeting
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No asset test
Gross test – no disregards for earned
income, child care
However, certain income will not be
counted (IRS/tax rules)
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Family size is who files taxes together
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Child support
SSI, Survivor’s benefits (see IRS publication 17)
Step-parents & grandparents may be included
MAGI parents must enroll children
MOE provision in effect until 2014
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Alignment is not perfect…
Traditional Eligibility
Categories
New
Eligibility
Group
MAGI
Benchmark Benefits
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Mandatory expansion covers only
“benchmark” benefits for most
Benchmark coverage to include at
least essential health benefits required
of plans in the exchange
Secretary approved benchmark can
include full Medicaid benefits
Thus benchmark is floor not ceiling
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Basic Health Plan Option
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States can create a Basic Health Plan for
newly eligibles up to 200% of FPL
Lawfully present immigrants subject to 5
year bar can participate in the Basic
Health Plan
States will receive 95% of what the
federal government would have paid in
subsidies for enrollees
Currently, no federal contribution for
lawful immigrants in Medicaid – except
pregnant women and children
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State Exchanges
& Coordinated
Enrollment
State Insurance Exchanges
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Exchange will function as a new
marketplace for “qualified health plans”
and the subsidies that help lower costs
How to conceptualize the Exchange?
Only qualified people can buy
products…but can anyone enter?
Because of the new systems, education
and assistance available to users of the
Exchange, we are urging NYS to open the
door to all, even those who will not get
coverage through the Exchange
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State Insurance Exchanges
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Primary purpose of Exchange – facilitate
coverage for individuals and small
businesses
Only qualified individuals can buy
insurance and apply for subsidies
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Residence in state running the Exchange
“Lawfully present” immigration status (no five
year ban)
Subsidies are available up to 400% of FPL
(using MAGI from last tax filing)
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Coordinated Enrollment
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PPACA requires Exchange(s) to also serve as
a portal for applications for public programs
and hardship exemptions
Single application for Exchange, tax subsidy,
Medicaid and Child Health Plus
Applications must have on line, in person, mail
and telephone options
States must screen those ineligible for
Medicaid/CHP for tax subsidy
Data matching through SSA, Treasury &
Homeland Security
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Consumer Education &
Navigational Assistance
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PPACA requires states to create and fund a
Navigator function within their Exchanges.
Duties of Navigators:
 Engage in public education re enrollment
and subsidies
 Provide culturally & linguistically
appropriate materials
 Facilitate enrollment
 Refer for complaints and/or grievances
Also some funding for Consumer Assistance
Programs
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Exchange Communications
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Notification of eligibility for
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Tax subsidy
Other cost sharing
Public Plan
Hardship exemption
Appeal rights when denied
Confirmation of plan choice
Appeals rights for recoveries?
Opportunity to ensure consistent,
consumer friendly tone, culturally and
linguistically appropriate notices
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Maximizing Exchange Potential
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Allow all to benefit from new systems,
improved communications and assistance
of Navigators
Educate people who will be left behind
regarding charity care, Emergency
Medicaid
How about pre-screening for these
programs?
How about education regarding penalties,
reconciliation, recoveries?
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Delivery System
Reforms
Primary Care Investments
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Temporary rate boost to Medicare
levels with 100% federal funding
$9.5 Billion for Community Health
Centers
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Two New Federal Offices
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The Center for Medicare & Medicaid
Innovations
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>$10 B for new patient care and payment
models, includes state flexibility to assume
management of Medicare funds to better
integrate care
Federal Coordinated health Care Office
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Better coordination of coverage & payment
for dual eligibles
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Improvements in Part D
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No less than seven adjustments to
cost-sharing, premiums, enrollment
periods, donut hole calculations (plus
$250 checks!)
Inspector General to do study related
to dual eligibles and comparative drug
costs under Part D and Medicaid
Outreach and assistance funding
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New Home Care Options
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The Balancing Incentive Program – $$
for structural changes to strengthen
community-based long term care
The Community First Choice Option – a
new state plan benefit for ADL services
Stronger HCBS state plan benefit
Spousal Impoverishment protections in
all waiver programs (temporarily)
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Addressing Disparities
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Health programs subject to nondiscrimination provisions of
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Title VI
Age Discrimination Act
Section 504 of the Rehabilitation Act
Data collection by race, ethnicity,
language, gender and disability – to be
reported publicly, and analyzed for
trends
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Policy Choices for
New York
Questions regarding
existing programs
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Will New York maintain FHPlus for parents
and young adults?
Will it create a Basic Health Plan?
Will it maintain its CHP program once the
Exchange is fully functioning?
How will NY ensure coverage for all
immigrant children?
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Questions re Public Program
Enrollment & the Exchange
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How will NY coordinate the enrollment
and eligibility rules and systems for
MAGI and Non-MAGI populations?
Will the Exchange be open to all?
How will else can we provide seamless
transitions between coverage options?
What role will counties play in
eligibility and enrollment?
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For questions or
comments:
Trilby de Jung
[email protected]