January 2014 CO Coalition for Elder Rights & Abuse Prevention

January 2014

CO

Coalition for Elder Rights & Abuse Prevention

Presentation Outline

Overview of the Affordable Care Act

The Marketplace/Connect for Health Colorado

Medicare and the ACA

What is the Affordable Care Act (ACA)

Refers to the

federal laws and regulations contained in the Patient Protection and Affordable Care Act and the subsequent Health Care and Education Reconciliation Act have come to be called the Affordable Care Act (ACA).

The main goal of the ACA is to provide insurance coverage, both public and private, to reduce the number of Americans

who

are uninsured.

Key Features of the ACA

New Consumer Rights and Protections

Individual Mandate/Shared Responsibility

Affordable

Health Insurance

Marketplace

Strengthening Medicare

Medicaid

Expansion

New Consumer Rights and Protections

Stops

insurance companies from dropping

coverage

Adds

more preventive

care

Extends

coverage for young

adults

Stops

insurance companies from denying coverage because of pre-existing

conditions

Bans

lifetime

limits

Shared Responsibility/The Individual Mandate

Important Points:

Starting

in 2014, individuals must either have health care coverage, an exemption from coverage, or pay a penalty on their tax return for not having insurance.

Only health plans with

minimum essential coverage

will fulfill the mandate.

Some populations are exempt from the mandate.

Penalties for Not Having Health Coverage

The penalty in 2014 is calculated one of

two

ways.

You’ll

pay whichever of these amounts is

higher.

The fee increases every year

.

2014:

1

% of your yearly household

income

or $95

per person for the year ($47.50 per child under 18

).

2015:

2

% of income or $325 per person.

2016 and later:

2.5

% of income or $695 per person.

After:

Adjusted

for inflation.

If you’re uninsured for just part of the year, 1/12 of the yearly penalty applies to each month you’re uninsured.

If

you’re uninsured for less than 3 months, you don’t have a make a payment.

Minimum Essential Coverage

Ambulatory patient services

Emergency Services

Hospitalization

Maternity/newborn care

Mental health/substance abuse

Minimum Essential Coverage, cont.

Prescription drugs

Rehab/

habilitative

services and devices

Laboratory services

Preventive and wellness care/chronic disease management

Pediatric services, including oral and vision care

Plans that Meet the Individual Mandate

Any Connect for Health Colorado Marketplace plan, or any individual insurance plan that you may already have

Any employer plan (including COBRA) with or without "grandfathered" status, including retiree plans

Medicare

Medicaid

Child Health Plan Plus (CHP+)

TRICARE (for veterans and veteran families)

Veterans health care programs

Peace Corps volunteer plans

Other plans may qualify: ask your health coverage

provider

Exceptions to the Individual Mandate

U

ninsured

for less than 3 months of the year

The lowest-priced coverage available to you would cost more than 8% of your household income

You don’t have to file a tax return because your income is too low (Learn about the filing limit.)

You’re a member of a federally recognized tribe or eligible for services through an Indian Health Services provider

You’re a member of a recognized health care sharing ministry

Exceptions, cont.

You’re a member of a recognized religious sect with religious objections to insurance, including Social Security and Medicare

You’re incarcerated, and not awaiting the disposition of charges against you

You’re not lawfully present in the U.S.

Hardship Exemptions. (Examples include: Homeless, eviction, death in immediate family, bankruptcy filing and others)

Hardship Exemptions

If

you have any of the circumstances below that affect your ability to purchase health insurance coverage, you may qualify for a “hardship” exemption:

You were homeless.

You were evicted in the past 6 months or were facing eviction or foreclosure.

You received a shut-off notice from a utility company.

You recently experienced domestic violence.

You recently experienced the death of a close family member.

You experienced a fire, flood, or other natural or human-caused disaster that caused substantial damage to your property.

You filed for bankruptcy in the last 6 months.

You

had medical expenses you couldn’t pay in the last 24 months.

You experienced unexpected increases in necessary expenses due to caring for an ill, disabled, or aging family member.

You expect to claim a child as a tax dependent who’s been denied coverage in Medicaid and CHIP, and another person is required by court order to give medical support to the child. In this case, you do not have

to

pay the penalty for the child.

As a result of an eligibility appeals decision, you’re eligible for enrollment in a qualified health plan (QHP) through the Marketplace, lower costs on your monthly premiums, or cost-sharing reductions for a time period when you weren’t enrolled in a QHP through the Marketplace.

You were determined ineligible for Medicaid because your state didn’t expand eligibility for Medicaid under the Affordable Care Act.

Your individual insurance plan was cancelled and you believe other Marketplace plans are unaffordable.

ACA Key Takeaways

New consumer rights and protections

Shared Responsibility/Individual Mandate

New Health Insurance Marketplace

Medicare Improvements

Medicaid Expansion

The Marketplace/Connect for Health Colorado

What is Connect for Health Colorado?

Colorado’s state health insurance marketplace

Browse, compare, and purchase plans online

Only way to access the federally subsidized discounts.

Key Features of Connect for Health Colorado

Apply online, on paper, in-person or on the

phone

Determine Medicaid Eligibility

Apply for financial assistance

Shop and Compare Health Plans

Purchase and Manage Your Plan Online

Application Process

Paper

Phone

Online

In-Person

Medicaid Determination

In order to be eligible to purchase a plan the Marketplace, customers must first be determined ineligible for Medicaid. Currently, the Medicaid determination must be completed on PEAK.

Application Flow Chart

Connect

for Health Colorado

Eligible

Purchase Plan

Medicaid Application

PEAK

Manage Coverage on Connect for Health Colorado

Apply for Financial Assistance

Manage Coverage on PEAK

Shop for Health Plan

Ineligible

Shop and Compare Plans

Comparison

Shopping

Metal Tiers

Carriers

Comparison Shopping

All plans offer minimal benefits

Beyond minimal coverage, benefits may differ from plan to plan.

Health

Plans are

also divided

in four categories or “metal tiers”, based on

actuarial

value.

Actuarial Value

Actuarial value

= the average percentage of the

health

care expenses the

carrier expects to

pay. A health plan’s members pay the remaining expenses in the form of cost sharing like deductibles, copays, and coinsurance

.

*The

percentage does not reflect non-covered

expenses.

*Premiums are not calculated into actuarial value.

*

Higher premiums tend to accompany higher actuarial values.

Metal Tiers

Bronze-tier

health plans have a value of 60

percent

Silver-tier health

plans have a value of 70

percent

Gold-tier health

plans have a value of 80

percent

Platinum-tier

health plans have a value of 90 percent

Medical Plans

Access

Health Colorado

Anthem Blue Cross and Blue Shield / HMO Colorado

Cigna

Colorado Choice Health Plans

Colorado

HealthOP

Denver Health Medical Plan

Humana

Kaiser Permanente

Rocky Mountain Health Plans

UnitedHealthcare

Dental Plans

Anthem

Blue Cross and Blue Shield / HMO Colorado

BEST Life and Health Insurance Company

Cigna

Delta Dental of Colorado

Dentegra

Insurance Company

Premier Access Dental and Vision

Apply for Financial Assistance

Two types of financial assistance available to offset costs of plans purchased on the Marketplace:

Advance Premium Tax Credits (

APTC)

Cost-sharing Reductions (CSR)

Advance Premium Tax Credit (APTC)

Tax credit available to lower the cost of health insurance premiums.

Available to individuals and families with incomes between 100% and 400% of the federal poverty line.

Available only for plans purchased on the Marketplace.

Available to citizens and lawfully present residents.

APTC, cont.

Two choices for how to receive the APTC:

Applied directly to your premium cost through the carrier.

Received as a tax rebate at the end of the year.

Discrepancies in your APTC due to differences between predicted (as reported on the financial application) and actual income will be reconciled by the IRS at the end of the year.

Cost Sharing Reductions (CSR)

A

federal benefit that reduces the out-of-pocket charges

for health plan (co-pays, deductibles, and co-insurance).

Three

levels of cost-sharing reductions based on

income.

Available to individuals with income up to 250% of the federal poverty line.

Available to citizens and lawfully present residents.

Must purchase a Silver-tier plan to receive the benefit.

How the CSR is Provided

Federal

government pays the health insurer

upfront.

Enrollee

cost sharing charges are automatically reduced when an eligible person or family enrolls in a silver plan

.

People

do not have to keep track of their spending or get

reimbursed.

Not

provided as a tax

credit.

Not

“reconciled” at the end of the

year.

Marketplace: Key Takeaways

Connect for Health Colorado is the State of Colorado’s new Health Insurance Marketplace

You can browse, compare, and purchase a plan online.

You can also apply on paper, over the phone, or in person.

Purchasing on the Marketplace is the only way to access federally subsides discounts on health coverage.

Medicare and the ACA: Important Changes

Closes the “Doughnut Hole”

Improves Access to Primary Care

Changes to Medicare Advantage Plan

Changes to Premiums based on Income

Crackdowns on Fraud

Closes the “Doughnut Hole”

The “doughnut hole” is a gap in coverage in Medicare Part D Drug costs. Here’s how it works:

You

pay out-of-pocket for monthly Part D premiums all year.

You

pay 100% of your drug costs until you reach the $310 deductible amount.

After

reaching the deductible, you pay 25% of the cost of your drugs, while the Part D plan pays the rest, until the total you and your plan spend on your drugs reaches $2,800.

Once

you reach this limit, you have hit the coverage gap referred to as the “donut hole,” and you are now responsible for the full cost of your drugs until the total you have spent for your drugs reaches the yearly out-of-pocket spending limit of $4,550.

After

this yearly spending limit, you are only responsible for a small amount of the cost, usually 5% of the cost of your drugs.

“Doughnut Hole,” cont.

Under the ACA, if

you reach the Medicare Part D coverage gap, you can get discounts on your prescription drugs. The discounts will gradually increase until the coverage gap disappears in 2020.

2014

:

52.5

% discount on

brand-name; 28

% discount on generic drugs.

2015:

55

% discount on

brand-name; 35

% discount on generic drugs

.

2016:

55

% discount on

brand-name; 42

% discount on generic drugs.

2017:

60

% discount on

brand-name; 49

% discount on generic drugs.

2018:

65

% discount on

brand-name; 56

% discount on generic drugs.

2019:

70

% discount on

brand-name; 63

% discount on generic drugs.

2020:

The Medicare Part D coverage gap is completely closed.

Improves Access to Primary Care

Gives

incentives to

physicians and

nurses who provide

primary care

in areas with doctor shortages

.

Gives primary care providers who treat people with Medicare bonus payments for providing quality care.

Changes to Medicare Advantage Plan

New rating system.

Plans that rate at least four out of five stars will receive bonus payments for providing better quality care. You can review your plan’s rating on Medicare’s website

www.medicare.gov/find-a-plan.

Plans must use some of the bonus payments they receive for extra benefits and rebates to people participating in Medicare Advantage plans.

Plans must now limit how much they spend each year on administrative costs. For each dollar received in premiums, Medicare Advantage plans must spend at least 85 cents on care.

Changes to Premiums based on Income

In 2010, beneficiaries filing singly

became subject

to increased premiums if their MAGI is over $85,000; married beneficiaries filing joint returns are subject to increased premiums if their MAGI is over $170,000

.

  In 2010, about 5 percent of Medicare beneficiaries pay the higher income-related premium

.

Since 2011,

i

ncome-related

premiums now also apply to those

who have

Part D prescription drug coverage. The

income levels

are the same as for Part B.

These

income

levels will

stay the same until

2020, not increasing for inflation, which means that more individuals will be subject to the premium increase at a faster rate until that time.

Crackdowns on Medicare Fraud

Medicare fraud results in higher health care costs for everyone. Eliminating fraud cuts costs for families, businesses, and the federal government. It also increases the quality of services for those who need care.

Examples of Medicare

Fraud include:

A healthcare provider bills Medicare for services you never received.

A supplier bills Medicare for equipment you never got.

Someone uses your Medicare card to get medical care, supplies, or equipment.

A company offers a Medicare drug plan that has not been approved by Medicare.

A company uses false information to mislead you into joining a Medicare plan.

ACA Fraud-Reduction Provisions

Tough new rules and sentences for criminals: The law increases federal sentencing guidelines for health care fraud by 20-50% for crimes with over $1 million in losses.

Enhanced screening: Providers and suppliers who may pose a higher risk of fraud or abuse are now required to undergo more scrutiny, including license checks and site visits. 

State-of-the-art technology: To target resources to highly suspect behaviors, the Center for Medicare & Medicaid Services now uses advanced predictive modeling technology. 

New resources: The law provides an additional $350 million over 10 years to boost anti-fraud efforts.

These provisions have recovered over $10.7 billion since 2010.

Medicare: Key Takeaways

Closes the “Doughnut Hole”

Increases access to Primary Care

Changes to Medicare Advantage

Changes to premiums based on income

Crackdowns on Fraud

On to

Medicaid and Peak…