Health Insurance Marketplaces: Preparing to assist people with disabilities What do you know? What do you need to know?

Transcription

1 Health Insurance Marketplaces: Preparing to assist people with disabilities What do you know? What do you need to know? August 7, 2013

2 Webinar Overview Webinar Recording & Slides - Q & A - Please submit your questions throughout the webinar via the question box on your webinar dashboard. Questions will be answered following the presentation. Survey - Please complete the short survey at the end of the webinar!

3 Introductions Barbara Kornblau, JD, OTR, FAOTA, Coalition for Disability Health Equity Rachel Patterson, MPA, Association of University Centers on Disabilities Niketa Sheth, MPA, Christopher & Dana Reeve Foundation

4 Health Insurance Marketplaces: Preparing to assist people with disabilities What do you know? What do you need to know? Barbara L. Kornblau, JD, OTR Coalition for Disability Health Equity Florida A&M University

5 Exchanges/Marketplaces New rules were released in early July Enrollment begins October 1, 2013 for people currently uninsured and some others Large employers don t have to participate until 2015 No more PCIPs after December 31 st Must apply by Dec. 7 th to have uninterrupted coverage.

6 Essential Health Benefits ACA included coverage for rehabilitation and habilitation in its essential health benefits (EHB) HHS: states will choose four benchmark plans based on private plans currently in existence in their state. These newly established plans would theoretically include rehabilitation, habilitation, and the other specified essential health benefits. However, most private plans exclude habilitation and this creates a dilemma in the states establishing their plans based on existing plans.

7 Essential Health Benefits Nov 2012, HHS released an EHB proposed rule to address the dilemma. HHS proposed that if a state s base-benchmark plan does not cover habilitation, the state can define the services it will include under habilitative services. HHS proposed to give the states the flexibility to lead the development of habilitation services policy. The essential benefits apply in 2014 to the individual and small employer group insurance coverage that will be sold through the insurance exchanges, and Medicaid plans.

8 marketplace.cms.gov/getofficialresources/training-materials/the-health-insurance-marketplace-101.zip

9 marketplace.cms.gov/getofficialresources/training-materials/the-health-insurance-marketplace-101.zip

10 Bottom Line The lower the premium, the higher the out-ofpocket costs when you need care; The higher the premium, the lower the out-ofpocket costs when you need care. Note: The Marketplace also offers "catastrophic" plans to people under 30 years old and to some people with very low incomes.

11 Alternative Benefit Plans (ABPs) Available to the Medicaid expansion group Benchmark of benchmark equivalent The minimal required benefits (MRB) states can + more ABPs must cover the 10 Essential Health Benefits (EHB) whether the state uses an ABP for Medicaid expansion or coverage of any other groups of individuals Individuals in the new adult eligibility group will receive benefits through an ABP If habilitation is not in the benchmark plan, the state will define habilitative services and devices either in parity with rehabilitative services and devices or as determined by the state and reported to CMS in the ABP template

12 Alternative Benefit Plans (APBs) States must select a coverage option from 4 benchmark options The Standard Blue Cross/Blue Shield Preferred Provider Option offered through the Federal Employees Health Benefit program State employee coverage that is offered and generally available to state employees Commercial HMO with the largest insured commercial, non-medicaid enrollment in the state Secretary-approved coverage, a benefit package the Secretary has determined to provide coverage appropriate to meet the needs of the population

13 Summary of ABPs ABP must cover 10 EHB Preventative care (without cost sharing) Mental health parity So ABP = Benchmark (MRB) + Supplement or Substitute Benefits to cover required benefits (those listed above)

14 Prescription Drugs EHB prescription coverage standard: Provide at least the greater of: 1 drug in every USP category and class; or, Same # drugs in each category and class as EHB benchmark plan. This may be less than what they have now & may be less than Medicare Part D Must include a provision to allow an enrollee to request and gain access to clinically appropriate drugs not covered by the plan

15 Overview-of-Final-Eligibility-and-Enrollment-II-Rule.pdf

16 Medicaid Expansion ACA expands Medicaid coverage for most lowincome adults to 138% of the federal poverty level (FPL) ($15,415 for an individual or $26,344 for a family of three in 2012) Supreme Court left some folks in limbo said Medicaid expansion was optional for states Some states are talking about putting people in Medicaid in the exchanges/marketplaces via premium assistance Establishes rules regarding premium assistance to support enrollment of individuals eligible for Medicaid in health plans in the individual market, including enrollment in QHPs doing business on the Exchanges/Marketplaces

17 Current Status of Medicaid Expansion Decisions as of July 1, 2013 Kaiser Family Foundation #21 #24 #6

18 Kaiser Family Foundation

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20 Health Insurance Exchanges Status for 2014 As of May 10, 2013 Source: GAO analysis of CMS data a Iowa planned to assist with the plan management function, and not the consumer assistance function b On May 10, 2013, CMS indicated it intended Utah would operate a state-based Small Business Health Options Program (SHOP) exchange, but the individual exchange would be an FFE, for which Utah would assist with plan management

21 "Health Policy Brief: Health Insurance Exchanges and State Decisions," Health Affairs, July 18,

22 Coordination Between state departments of insurance, exchanges, state Medicaid agencies, and the federal government and Between Medicaid and exchange/marketplace technology system so consumers can seamlessly enroll in either public or private coverage through the exchange. States that operate their own exchanges collaboration easier to manage within the state States with federally facilitated exchanges greater difficulty establishing the necessary integration between state departments of insurance and Medicaid agencies and the federally facilitated exchange "Health Policy Brief: Health Insurance Exchanges and State Decisions," Health Affairs, July 18, 2013

23 Consumer Assistance - SBE State based exchanges (SBE) responsible for the consumer assistance functions of their exchanges, including establishing a web portal, call center, and navigator program to help people find and enroll in public or private coverage. "Health Policy Brief: Health Insurance Exchanges and State Decisions," Health Affairs, July 18, 2013

24 Consumer Assistance SBE & SPE Can choose to use federal funds to establish in-person assistance programs to supplement their navigator programs, which cannot be fully funded by exchange establishment grants--thus helping to ensure that there will be enough assisters to help people enroll in coverage. "Health Policy Brief: Health Insurance Exchanges and State Decisions," Health Affairs, July 18, 2013

25 Consumer Assistance - FFE Federally facilitated exchange states will have limited assistance since states must rely on a limited federal funding stream for grants to navigators and will not have in-person assistance programs to supplement the work. "Health Policy Brief: Health Insurance Exchanges and State Decisions," Health Affairs, July 18, 2013

26 What kind of assistance will be available through the Marketplace? Fact Sheet: Helping Consumers Apply & Enroll Through the Marketplace

27 Marketplaces/Exchanges Health Navigators Major impact on participation by PWD CMS announced grants RFP for navigator programs 45 CFR (e)(5) and (d) and (e) require Navigators and non-navigator assistance programs to provide meaningful access to people with disabilities Certified application counselors can provide information with reasonable accommodations for those with disabilities through referrals to Navigators, non-navigator assistance personnel, and/or the Exchange call center Federal Register / Vol. 78, No. 137 / Wednesday, July 17, 2013 / Rules and Regulations

28 How are these roles funded? Fact Sheet: Helping Consumers Apply & Enroll Through the Marketplace

29 Required Training & Certification Fact Sheet: Helping Consumers Apply & Enroll Through the Marketplace

30 Misc Provisions Training for navigators will be made public through marketplace.cms.gov Is supposed to cover services to PWD Will require annual continuing education New rules amends meaningful access standards to require that translation services and accessibility aids be provided when necessary or when requested by the consumer.

31 Advanced Premium Tax Credits Eligibility is based on Household income, and family size (at end of year) Income between 100% to 400% of the Federal Poverty Level (FPL) ($23,550 $94,200 for a family of four in 2013) Obtaining qualified health insurance through the Marketplace Ineligibility for government-sponsored coverage, affordable employer-sponsored insurance, or certain other minimum essential coverage

32 "Health Policy Brief: Premium Tax Credits," Health Affairs, August 1,

33 Advanced Premium Tax Credits This tax credit is paid up front directly to the insurer. Advanced each month when premiums are due. The advance payment of the tax credit is based on the consumer s anticipated annual income. This is reconciled at the end of the year with the annual filing of the income tax return when actual income is known. If the family s income (or other circumstances, such as family size) changes from the original estimate for the credit amount, the family gets a refund or repays the excess amount up to $1,500, the maximum amount for their income level (see Exhibit 2).

34 "Health Policy Brief: Premium Tax Credits," Health Affairs, August 1,

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36 State-Level ACA Implementation Rachel Patterson, MPA Association of University Centers on Disabilities

37 State Decisions on Exchanges Benchmark Plan Selection Essential Health Benefits Habilitation Non-discrimination standards

38 State Decisions on Medicaid Expansion Alternative Benefits Package Benchmark plan Essential Health Benefits Habilitation Exemption process

39 UCEDD Involvement: Arkansas

40 UCEDD Involvement: Michigan

41 UCEDD Involvement: Wisconsin

42 We still have work to do

43 Medicaid ABP Exemption Exchange Qualified Health Plan Single Streamlined Application Medicaid Expansion Group Traditional Medicaid Alternative Benefits Package Traditional Medicaid Benefits

44 Consumer Assistance: Navigators Certified Application Counselors (CAC) In-Person Assistance (IPA) Consumer Assistance Programs (CAP)

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47 open enrollment Starts October 1 HealthCare.gov CuidadoDeSalud.gov TTY:

48 Resources for Patients and Organizations Niketa Sheth, MPA Senior Vice President, Quality of Life Christopher & Dana Reeve Foundation

49 Coverage Checklist: Questions to Ask When Choosing a Plan How much can you afford to spend on premiums and out-ofpocket medical expenses? What health care services do you use? Are there specific providers, health care facilities or pharmacies that you prefer? What medications, therapies and equipment will you (and your family) need over the coming year?

50 Sample Coverage Checklist - Paralysis Needs Services Providers Medications DME Paralysis Autonomic Dysreflexia Ulcers Kidney Stones Primary Care Emergency Care Medical and Surgical Stabilization Rehabilitation Physiatrist Rehab Nurse Occupational Therapist Physical Therapist Pain management Bowel control and function Sexual functioning Assistive Technology Beds & Mattress Catheters Driving & Transportation UTI Spasticity Preventive Care Specialty Sustaining Care Speech Language Pathologist Neurologist Respiratory Management Sexual Functioning Aides Surgical Care Outpatient Care Transfer Devices Wheelchairs and Seating

51 Resources for People with Disabilities Government Healthcare.gov DOL.gov VA.gov Disability.gov Medicaid.gov Medicare.gov Advocacy Organizations Christopher & Dana Reeve Paralysis Resource Center Families USA Kaiser Family Foundation American Association of People with Disabilities Association of University Centers on Disabilities The Arc Specific Disability Groups

52 Tips to Communicate on the ACA Know the right questions to ask Educate and engage your audience Timely alerts and updates Webinar Series ACA Micro-Site Social Media Tools Create a feedback mechanism The Time Is Now

53 Q & A Ask a question! - Type your question in the question box on your webinar dashboard. - The moderator will read the question.

54 Learn more about the Friends of NCBDDD! - Thank You Questions about the webinar? - Tory Christensen (tchristensen@aucd.org) Please take a few minutes to complete the survey!