Medicaid, CHIP, The Affordable Care Act (ACA) and Children in Out of Home. The Catalyst Center: Who are we?

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1 Medicaid, CHIP, The Affordable Care Act (ACA) and Children in Out of Home Placement May 7, 2012 Carol Tobias Boston University School of Public Health The Catalyst Center: Who are we? A Cooperative Agreement with the Maternal and Child Health Bureau of HRSA A National Center dedicated to the MCHB outcome measure: all children and youth with special health care needs have access to adequate health insurance coverage and financing for their care Located at the Health and Disability Working Group at the BUSPH 1

2 What we do: Conduct policy research Create resources Provide technical assistance Connect those interested in working together A Tutorial on the Basics of Medicaid and CHIP g Medicaid as a second language: A Slightly Irreverent Guide to Common Medicaid Terms, Acronyms and Abbreviations 2

3 Medicaid and CHIP Medicaid Title XIX of the SSA Categorical eligibility and very low income Mandated benefits and optional benefits Jointly funded by states and federal gov t. No cap on enrollment or federal dollars CHIP Title XXI of the SSA No categorical eligibility, less low income Mandated benefits only if administered as part of Medicaid Jointly funded by states and federal gov t. Enrollment may be capped, federal $$ are capped State Plans for Medicaid and CHIP Program administration Provider payments Eligibility criteria and levels Quality control Scope, duration, amount of covered services 3

4 What s different from one state to the next? Eligibility levels (income limits) Medicaid income limit for children >6 is 100% of FPL in most states CHIP incomes range from 175%- 350% of the FPL. Benefits Variation in optional services Variation in scope of coverage Administration Service authorization rules Who provides care Managed care Even more differences with CHIP CHIP can be operated exactly the same way as Medicaid (Medicaid expansion) CHIP can be operated as a separate program CHIP can be operated BOTH ways in a single state. 4

5 EPSDT a Key Difference Early Periodic Screening, Diagnosis and Treatment Medicaid programs are bound by these rules CHIP programs are NOT, unless they are operated as Medicaid expansion programs Medicaid and CHIP webinars tutorial-webinart»may 16»June 21»July 18»September 19 5

6 What do children need from health care reform? Coverage that is: Universal and continuous Adequate Affordable Universal and continuous coverage Section 2004 of the Affordable Care Act Medicaid coverage for former foster care children up to age 26 Effective January, 2014 Transition plans for children aging out of foster care and independent living Must include a power of attorney if child is unable to participate in decisions or does not have/want a relative to do so 6

7 Elimination of pre-existing conditions clauses For children <age 19 now, for all in 2014 Offers promise of extending coverage to 20,000 children denied policies in 2008 And another 18,000 children offered policies that exclude the condition in 2008 Makes it difficult/impossible for states to obtain child-only policies due to cancellation of products Public Coverage Extended Medicaid coverage for everyone up to 133% FPL CHIP reauthorized through 2019 and funded through 2015 No wrong door single application for all programs 7

8 Eligibility simplification: MAGI A single income eligibility formula for all states Applies to Medicaid, CHIP, and subsidies under the Exchanges No more variation by state Eases transitions across programs Maintenance of Effort Applies to Medicaid and CHIP States must maintain income eligibility criteria for public programs No increase in premiums or enrollment fees 8

9 Adequate Coverage Essential Benefits Effective Jan, 2014 plans offered through the Exchanges (and some outside plans) must provide these benefits: Habilitative therapies: physical, occupational, speech/language Prescription medications Durable medical equipment Consumable supplies: diapers, wipes, hearing aid batteries disposable dressings, etc. Eye glasses, hearing aids Mental health services Dental care 9

10 Other Provisions in the ACA Hospice benefit for children allows both curative and palliative care Home visiting program (includes foster families) Health homes for specific conditions including serious mental illness and substance abuse Increase in Medicaid rates for primary care services to match the Medicare rate. Affordable Coverage 10

11 Components of affordability Scope of covered services Cost of insurance premiums Cost and number of co-payments Cost of coinsurance Amount of the deductible Subsidies and Tax Credits Premium tax credits, on a sliding scale, for families with incomes up to 400% of the FPL. Cost-sharing subsidies for families up to 250% of the FPL Available when purchasing silver category of coverage in Exchanges 11

12 Other affordability provisions Cost-sharing subsidies* Out of Pocket Limits* Family Income Average Proportion of Expenses Paid by the Plan Family Income Out of Pocket Limit Up to 150% FPL $3, % FPL $3,927 Up to 150% FPL 94% % FPL 87% % FPL 73% % FPL $5, % FPL $5, % FPL $7,973 Everyone $11,900 *Not applicable to grandfathered or selfinsured plans Figuring it Out Exchanges will provide calculators to help families figure out the cost of coverage. Will help to compare both the benefits and cost of coverage Exchanges also provide a website for comparing plan benefits and costs 12

13 Affordable or not? Most CSHCN receive coverage in grandfathered d or self-insured plans Cost-sharing limits not applicable Lower income families still face high expenses unless really low income In spite of all the changes, the more you use services, the more you will pay Summary There are several major improvements in universal and continuous coverage through ACA. Still major gaps in coverage adequacy Affordability? 13