1 Covered California: California s New Health Insurance Marketplace Amber Kemp, MBA Vice President, Health Care Coverage California Hospital Association
2 Overview California s Uninsured Medi-Cal Expansion Covered California Marketplace In-Person Assistance Program Resources
3 CALIFORNIA S UNINSURED
4 California s Uninsured Before January 1, 2014: 7.1 million uninsured residents under age 65. On January 1, 2014: 2.6 million Californians qualified for subsidies through Covered California, California s Health Benefit Exchange. 2.7 million Californians do not qualify for subsidies but now benefit from guaranteed health coverage under the Affordable Care Act. 1.4 million Californians estimated to be newly eligible for Medi-Cal.
5 Affordable Care Act Provisions to Expand Coverage to the Uninsured Some of the provisions include: Expansion of Medi-Cal income eligibility to individuals and families with incomes up to 138% of the federal poverty level (FPL). Advance premium tax credit subsidies available to individuals and families above 138% and up to 400% of the FPL if they choose to purchase health coverage through a health benefit exchange. The ability for small business to purchase health coverage with or without subsidies through a health benefit exchange.
6 MEDI-CAL EXPANSION
7 Medi-Cal Expansion Enrollment Projections 8.5 million currently enrolled in Medi-Cal 1.4 million newly eligible in in 3 insured Californians will have Medi-Cal after ACA is fully implemented
8 Federal Medical Assistance Percentages (FMAP) Current FMAP is 50% FMAP for Expansion Population 100% - Calendar years % - Calendar year % - Calendar year % - Calendar year % - Calendar year 2020 and thereafter
9 Medi-Cal Enrollment
10 New Medi-Cal Benefits Mental Health Substance Use Disorder Adult Dental
11 Simplified Eligibility & Enrollment Self-Attestation is allowed Access to federal electronic verification hub Modified Adjusted Gross Income test Eliminate asset test Presumptive Eligibility is Expanded
12 Hospital Presumptive Eligibility (HPE) Gateway Program SB x1 (Statutes of 2013) implements the Hospital Presumptive Eligibility (HPE) Gateway Program Qualified Hospitals make presumptive eligibility determinations for: Children up to age 18 Parent-caretaker relatives Pregnant women Former foster care children Newly eligible adults ages 19 through 64 with incomes up to 138% FPL
13 HPE Gateway Program PE determination based on income, household size, and state residency. PE determination conducted in real-time. Self-attested accepted. Full-scope Medi-Cal benefits provided for a period of up to two months from the first day of month in which the PE application was submitted. Hospital must provide individual with application for regular Medi-Cal.
14 HPE Gateway Program Steps to participate: Complete, sign, and return participation agreement to DHCS available at: Complete the HPE Gateway Program training: o Online o Access available after submission of signed agreement
15 COVERED CALIFORNIA MARKETPLACE
16 State Decisions for Creating Health Benefit Exchanges Source: kff.org (May 10, 2013)
17 State-Based Exchanges
18 Covered California Serves Two Markets Individual Purchasers (Individual Exchange) Many people < 400% federal poverty level will be eligible for tax credits (premium subsidies) through Covered California to offset costs of coverage. On a voluntary basis, all legal residents may purchase individual coverage through the Exchange. Small Employers (SHOP Exchange) Small, low-wage firms will be eligible for tax credits to offset employer contributions only if the firm purchases through the Exchange. On a voluntary basis, any small employer may purchase through the Exchange.
19 Covered California Marketplace Income Eligibility and Coverage Options
20 Covered California Marketplace Income Eligibility
21 Covered California s Annual Enrollment Goals By 2015: By 2016: By 2017: Enrollment of up to1.2 million Californians. Enrollment of up to 1.6 million Californians. Enrollment of up to 2 million Californians.
22 Covered California Enrollment
23 Covered California Enrollment
24 Covered California Growth Projections
25 Covered California s Target Segments By Age and FPL
26 Total Three Month Enrollment vs. Base Six Months Projections
27 Total Three Month Enrollment vs. Base Six Months Projections (Age)
28 Total Three Month Enrollment vs. Base Six Months Projections (Ethnicity and Race)
29 Total Three Month Enrollment vs. Base Six Months Projections (Region)
30 Enrollment Amongst Millennials (ages 19-29)
31 Ethnic Mix of Exchange Subsidy Eligible Californians
32 Enrollment Amongst Hispanic/Latinos
33 Open Enrollment Advertising Campaign (October 1 March 31)
34 Reaching California s Diverse Population
35 Outdoor Marketing
36 TV Spots and Videos
37 Direct Mail
38 Key Findings
39 Covered California Health Plans Individual Exchange
40 Covered California Health Plans SHOP Exchange
41 Children s Dental Insurance Plans
42 Essential Health Benefits Ambulatory patient 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
43 Standard Benefit Plan Design All Covered California Health Plans cover the same health care services. Benefit plans have different levels of costsharing with the consumer through copays, deductibles, and coinsurance.
44 Covered California Metal Tiers of Coverage
45 Covered California Metal Tiers of Coverage
46 Covered California Enrollment by Metal Tier
47 Health Plan Pricing Regions
48 New Rules for Equitable Premium Calculation Premium rate is driven by Age Zip code which drives pricing region Benefit plan selected 139% to 400% of Poverty Consumer pays Fair Share percent of income ranging from 2% to 9.5% Premium assistance (in the form of the advance tax credit) paying the balance
49 Pricing Regions with Average Silver-Level Plan Cost
50 Eligibility Requirements for Premium Assistance and Cost-Sharing Reductions Purchase coverage through Covered California; Under 400 percent of the federal poverty level; AND Not eligible for minimum essential coverage (e.g. Medi-Cal, Medicare, or affordable coverage through an employer).
51 Advance Premium Tax Credits Consumers eligible for premium assistance have a choice of how to claim their premium subsidies: In advance: Paid monthly directly to health plan Consumer has risk of overpayment or underpayment if income fluctuates If income changes, consumer is encouraged to timely report changes to Covered California Wait until taxes are filed
52 Cost-Sharing Reductions
53 Cost-Sharing Reductions Individuals must enroll in a Silver-level health plan to receive cost-sharing subsidies. Out-of-pocket costs (including maximum and deductible) become much lower when a Silver-level health plan is enhanced with federal cost-sharing subsidies. How much the plan is enhanced is shown by the number next to the metal tier (e.g. Enhanced Silver 87 ).
54 Catastrophic Coverage Plans Eligibility requirements: Under age 30; or Receive a hardship exemption because lowest-cost Bronze plan is more than 8 percent of MAGI income. Consumers whose health plans have been recently cancelled. Offers the same benefits as the other plans but at a much lower monthly premium and much higher out-of-pocket costs. If selected, individual cannot receive premium assistance of cost-sharing reductions, even if eligible.
55 The Bridge Plan
56 Streamlined Application Process
58 The California Healthcare Eligibility, Enrollment and Retention System (CalHEERS) Online Application Portal
59 COVERED CALIFORNIA IN-PERSON ASSISTANCE PROGRAM
60 California s Uninsured Population is Spread Throughout the State Figure depicts California s subsidy-eligible population by region Source: CalSIM model, version 1.8
61 Covered California In-Person Assistance Program
62 Certified Enrollment Entities
63 Steps for Hospitals to Register as a Certified Enrollment Entity Complete Certified Enrollment Entity Application Submit Certified Enrollment Entity Application to Covered California Complete Certified Enrollment Entity Training
64 CEE Training CEE Training will cover: Covered California overview In-person assistance program overview Certified enrollment entities roles and responsibilities Certified enrollment counselor recruitment, role, services and support Compensation Expectations for monitoring, reporting and quality assurance Collateral materials management Certified enrollment entity agreement
65 Certified Enrollment Counselors
66 Steps for Hospital Staff to Enroll as Certified Enrollment Counselors Complete Certified Enrollment Counselor Disclosure Form Pass Fingerprinting and Criminal Background Check Complete Certified Enrollment Counselor Training Pass Certification Exam Administered by Covered California
67 Certified Enrollment Counselor Training Modules Introduction to ACA, Covered CA, and Health Insurance Certified Enrollment Counselor Role Eligibility and Enrollment for Individuals and Families Eligibility and Enrollment for Small Businesses Covered California Health Plan Options Compliance Standards Privacy and Security Providing Consumer Assistance
68 Application Process
69 Application Pathway Estimates Paper Application Self-Enrolled 10% Paper Application Assister Enrolled 10% Service Center Enrollment 20% Online Self-Enrolled 20% Online Assister Enrolled 40%
70 Enrollment Support Breakout
71 Enrollment Support: Key Metrics
72 Enrollment Dates Initial open enrollment 2015 Enrollment Subsequent Enrollment Medi-Cal Applications October 1, March 31, 2014 November 15, 2014 January 15, 2015 October 15 December 7 each year Accepted year-round
74 CalHEERS Demonstration Webinar User scenario of the Eligibility and Enrollment Process: Set up account, identify household members, personal data, income Verify income, determine subsidy (advanced premium tax credit) Compare and select health plan To view a recording of the webinar, visit
75 Helping Individuals Obtain Health Coverage Guidebook The guidebook includes strategies California hospitals can use to help enroll individuals in health coverage programs under the Affordable Care Act. An electronic version is available at
76 Fact Sheets: Covered California 101 for Hospital Staff Informational fact sheets about the Covered California marketplace and relevant provisions of the ACA Can be used individually or as a package to help educate staff, board members, volunteers and others. Fact sheets are available at
77 Hospital Presumptive Eligibility (HPE) Gateway Program Resources Resources to assist hospitals and their staff in understanding presumptive eligibility under the ACA are available at
78 CHA Portal - Covered California Marketplace Resources Resources to assist hospitals and their staff in understanding California s new health insurance marketplace are available
80 Contact Amber Kemp, MBA Vice President, Health Care Coverage California Hospital Association (916)
81 THANK YOU!