Authors: Victor Y. Wu, MD, MPH Sarah G. Candler, MD, MPH Nathan Moore, MD Will Godfrey, BsME Mallory L. West, B.A. Kavita K. Patel, MD Winston F.

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1 Let s Ask s Authors: Victor Y. Wu, MD, MPH Sarah G. Candler, MD, MPH Nathan Moore, MD Will Godfrey, BsME Mallory L. West, B.A. Kavita K. Patel, MD Winston F. Wong, MD, MS Ruth M. Parker, MD

2 4 Questions for Every Consumer and Provider About Health Insurance What are my choices for health insurance? 2. How do I get it? 3. How do I use it? 4. How much will it cost me?

3 Let s Get on the Same Page Why Health Insurance? Health Insurance Coverage Better Access (Primary and Specialty Care) Improved Health Outcomes Insured Americans compared to uninsured... are less likely to die from a heart attack have less advanced cancer when diagnosed are less likely to die if they are in a car accident have better control of their diabetes Affordable Care Act Beginning in 2014, most U.S. residents are required to have health coverage or pay a penalty It s the LAW! Individual Mandate in 2014 Patient Protection & Affordable Care Act Source: Institute of Medicine. America s Uninsured Crisis Adapted from Colorado Health Institute, Dec 2012

4 What Are My Choices for Health Insurance?

5 Know Thyself Who Am I? Answers you need to know that determine your options... How old am I? Can I get health insurance through my job? Can I get health insurance through my spouse, parent/legal guardian, or school? Am I a U.S. Citizen or a legal U.S. resident? How much do I make a year and how does it compare to the federal poverty level? What state do I live in? Have I served or am I in the U.S. armed services? Am I pregnant? Do I have one of the following conditions: ESRD, ALS, receive disability, or legally blind?

6 U.S. Health Insurance Structure Private Public Individual Market Employer- Sponsored State Sponsored Federally Sponsored Fullyfunded Self Funded Plans Medicare Individual Market Plans High Risk Individual Plans State regulated Small Group Market Plans Health Insurance Marketplace Begins January 2014 Large Group Market Plans Federally regulated Medicaid S-Chip Federal and State Regulated TRICARE Indian Health Services VA Health System Adapted from Colorado Health Institute, Dec 2012

7 Health Insurance Coverage ( ) National Health Expenditure Data. CMS Jan 2012 Employer Health Benefits 2011 Annual Survey. KFF Sep 2011

8 Medicare Who can enroll? Elderly Covers those individuals > 65 years of age who paid into Medicare, or have a spouse that paid into Medicare while in the workforce + Other special medical populations that Medicare covers People with Disabilities People with ALS People with ESRD People < 65 y.o. who received disability benefits from Social Security > 24 months Automatically enrolled in Part A and Part B People with Amyotrophic Lateral Sclerosis are automatically enrolled in Part A and Part B when they begin receiving SSI disability Some individuals (but not all) who have ESRD are automatically enrolled Those who are eligible receive Part A and B only during specific treatment and recovery periods

9 Medicare What does it cover? Part A Hospital Inpatient hospital care Skilled nursing facility care Hospice and home health care Medicare Advantage Part B Outpatient Outpatient care Home health care Durable medical equipment Some preventive care Part C Medicare Advantage Coverage thru private insurers Covers all of Part A & B, some cover Part D Individuals can pay extra $$ for additional benefits not covered by Medicare Traditional Medicare Optional Enrollment and replaces traditional Medicare Part D Prescription Drug Coverage Covers some cost of prescription meds Provided by private insurers Optional coverage Optional Enrollment

10 Medicaid Who does it cover? (2012) People with low-income and people with disabilities Federal government provides joint funding and some minimum eligibility criteria State sets specific eligibility criteria, provides funding, and administers program Have dependent children Eligible Groups Children Have disabilities Pregnant Low income seniors Financial Requirements Based on individual s income as % of Federal Poverty Level (FPL) Each state sets final eligibility criteria & there is variability state-to-state The federal government does stipulate eligibility minimums for the following... Pregnant women 185% FPL Seniors 100% FPL Children % FPL Children % FPL Enrolled into Medicaid Individuals in eligible groups with income < specified % of FPL State specific information at ww.medicaid.gov Childless adults Most states do not currently cover adults without dependents The ACA sought to expand coverage to childless adults at a minimum level up to 133% FPL Impact of? expansion

11 CHIP (Children s Health Insurance Program) Who gets it? Uninsured Children Public health insurance for children whose family s income is too high to qualify for Medicaid For children up to age 19 Eligibility is set by the state you live in with federal guidelines Currently 46 states and D.C. cover > 200% of FPL Additionally, states can choose to cover pregnant women, lawfully residing children that are not U.S. citizens, or children of state and federal employees How does it work? State administered with joint state and federal funding What does it do? Provides free or lowcost medical insurance as determined by each state Where do I find more info? www. insurekidsnow. gov Photo credit: (Jan 2013)

12 Children s Eligibility for Medicaid/CHIP by Income, January 2013 < 200% FPL (4 states) % FPL (22 states) 250% or higher FPL (25 states, including DC) NOTE: The federal poverty line (FPL) for a family of three in 2012 is $19,090 per year. OK has a premium assistance program for select children up to 200% of the FPL. AZ s CHIP program is currently closed to new enrollment. SOURCE: Based on the results of a national survey conducted by the Kaiser Commission on Medicaid and the Uninsured and the Georgetown University Center for Children and Families, 2012.

13 Medicaid Eligibility Expansion Who s doing it? (March 2013) For more information visit: Advisory Board Committee. March 2013

14 VA Health Benefits Who gets it? VA Health Benefits are NOT a health insurance plan What benefits does it cover? VA provides different medical benefits for veterans based on their eligibility Benefits can vary yearly based on federal funding Some benefits & services (e.g. mental health, crisis lines) are provided to all vets regardless of eligibility, as well as families of vets and providers Am I eligible? Each veteran has unique eligibility factors based on service, injuries & illnesses, and income Where, when, and how long you served impacts eligibility In general, minimum duty requirements is > 24 continuous months (w/ exceptions) Medical conditions connected to your service impact your benefits & how much you pay What else impacts my options? Consider your personal options for alternative insurance VA health system will charge private insurance for uncovered services Spouses and dependents are generally not covered ALL Veterans should apply through the VA to determine VA Benefits eligibility!

15 Tricare and IHS Who are these for? Tricare Health benefit program for all uniformed services (Army, Navy, Marine Corps, Air Force, Coast Guard, Public Health Service, and the National Oceanic and Atmospheric Administration) Eligibility criteria targeted for active duty service members and their spouses/unmarried children, uniformed service retirees and their families, medal of honor recipients and their families, families of those who lost their spouse during active duty, and reservists activated for more than 30 consecutive days Indian Health Services Provides medical services to Native Americans who are members of a Federally recognized Tribe IHS is a healthcare system that provides primary care and inpatient services to its members IHS is not an insurance or benefits program IHS also contracts with non-ihs providers to provide necessary services that direct IHS providers may not be able to provide

16 U.S. Health Insurance Structure Private Public Individual Market Employer- Sponsored State Sponsored Federally Sponsored Fullyfunded Self Funded Plans Medicare Individual Market Plans High Risk Individual Plans State regulated Small Group Market Plans Health Insurance Marketplace Begins January 2014 Large Group Market Plans Federally regulated Medicaid S-Chip Federal and State Regulated TRICARE Indian Health Services VA Health System Adapted from Colorado Health Institute, Dec 2012

17 Employer-Sponsored Insurance (ESI) What does my job offer? Employers are not required to offer Employer-Sponsored Insurance (ESI) but those that do have different options they can offer you: Companies with fully Insured plans pay a fixed premium to an insurance company to cover each employee s healthcare expenses. The insurance company then pays cost of the actual healthcare expenses used Companies with self-funded plans pay the healthcare expenses of their employees in addition to paying administration fees and stop-loss premiums to an insurance carrier to administer the plan Less likely to be offered to: Employees of small firms Part-time workers Low-wage workers Newly hired workers (often have waiting periods) Dependents Retirees Self Funded Plans Do not have to follow individual state health insurance regulations Do fall under federal regulations and new guidelines of ACA Fully Funded Plans Must comply with state regulations which include minimum required health benefits and coverage HMO POS PPO High-deductible Health Plans HSA/FSA

18 Health Insurance Marketplaces What is it? If you are not eligible for public or employer-sponsored insurance... A state health insurance marketplace is a central location where to shop for health insurance plans. The marketplace will provide information on cost and quality. You will fill out a simple application to determine your insurance options and tax credits. Like a or for health insurance! US citizens and legal immigrants who are not offered ESI or cannot afford the ESI offered by their employer Marketplaces aim to be consumer friendly, efficient, streamlined, and transparent! Businesses with fewer than 100 employees or for those who are self-employed Adapted from Colorado Health Institute, Dec 2012

19 Health Insurance Marketplaces How will it help me with my options? Insurance Plan 1 Insurance Plan 2 Insurance Plan 3 Insurance Plan 4 Insurance Plan 5 You can use your state s marketplaces to Compare available plans from different insurance companies on price, quality, and benefits 2. Select between different insurance plan levels (called tiers ) that best fit your health needs 3. Fill out simple application that will show your insurance options on the marketplace as well as other options you may be eligible for (ex. Medicaid or CHIP) 4. Use an online calculator to determine how much a plan will cost you

20 The ACA and Your Insurance Plan How does the new law affect your options? New Health Insurance Marketplace Plans (available Oct 2013) New Group & ESI Private Health Insurance Plans (created after 2011) Existing Group & ESI plans (before 2010) Existing individual plans (before 2010) Bans lifetime limits on benefits Extends coverage to young adults < 26 y.o. on parent or legal guardian s plan Limits administrative costs and profits for insurance companies Limit on waiting periods for coverage & bans recissions Cannot be denied coverage based on pre-existing conditions Bans annual limits on benefits Free recommended preventive care coverage Limit on out-of-pocket costs Mandates essential health benefits coverage

21 What if I don t qualify for any of these options? Individuals at risk for remaining uninsured include: Undocumented immigrants not eligible for the marketplaces Financially poor individuals and vulnerable populations who cannot afford subsidized coverage or were unable to use marketplace to get insurance Options to consider: Local Subsidized care health care providers and hospitals will sometimes offer discounts and financial assistance Community Health Centers federally run health centers that provide primary and preventive health care with payments based on sliding scale of your income Free Health Clinics local non-profit organizations that provide free charity care and some preventive health services Emergency Room services anyone seeking treatment through an Emergency Room is guaranteed emergent care

22 Kaiser Family Foundation and JAMA 2013

23 Resources Kaiser Family Foundation: Health Reform: Seven Things You Need to Know Now, Consumer Reports df/ncqa/the_affordable_care_act- You_and_Your_Family.pdf

24 Let s Ask 4 Project Team Project Team (Faculty Leads) Victor Wu, MD, MPH; Chief Medical Resident, Grady Mem. Hosp, Emory Univ SOM Sarah Candler, MD, MPH; Medical Student Class of 13, Emory University SOM Nathan Moore, MD; Medical Student Class of 13, Washington Univ. SOM Will Godfrey, BsME.; Research Assistant, Emory Univ. SOM Mallory West, B.A.; Research Assistant, The Brookings Institute Ruth Parker, MD; Professor of Medicine. Peds. & Public Hlth. Emory Univ. SOM Kavita Patel, MD; Economic Studies, The Brookings Institute Winston Wong, MD, MS; Dir. Disparities Improv. & Qual. Initiative, Kaiser Permanente Kara Jacobson, MPH; Sr. Rsch. Assoc. Faculty, Rollins Sch. of Public Hlth, Emory Univ. National Advisory Board Sue Birch, MBA, RN; Exec. Director, Colorado Health Care Policy and Financing Lyla Hernandez, MPH; Board on Population Health and Public Health Practice, IOM Rose Martinez, ScD; Board on Population Health and Public Health Practice, IOM Bernie Rosoff, MD, MACP; North Shore-Long Island Jewish Health System Scott Ratzan, MD, MPA; VP Global Corp. Affairs, Anheuser-Busch InBev Paul Schyve, MD; Sr. Advisor Healthcare Improvement, the Joint Commission