The Affordable Care Act and People with Disabilities

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1 The Affordable Care Act and People with Disabilities The Arc of Texas envisions a world where people with disabilities are included in their communities and neighborhoods and where quality supports and services respond to their needs and personal choices.

2 Before The ACA Webinar Overview Ways the Affordable Care Act Helps People with Disabilities Reforms Health Insurance Practices Expands and Improves Long Term Services & Supports Expands Access to Health Insurance Coverage Expands Access to Prevention Services and Other Improvements What s Next

3 Why does The Arc support the Implementation of the Affordable Care Act? The Arc of the US has long support ed expanding Medicaid to cover more low income individuals and expanding private health insurance options. The law contains significant nondiscrimination provi sions and improvements to the Medicaid long term services and support system that are critical to meeting the needs of people with I/DD. For too long, insurance companies have been able to charge people higher rates because of their health conditions, deny insurance coverage of people with I/ DD, and limit coverage of needed health care treatments, services and supports. The Arc of the US s ACA info page:

4 Before The ACA Most people with significant disabilities get access to health care from Medicare and Medicaid. Medicaid has robust benefits but poor provider access. Commercial health insurance charges more to people with disabilities and other pre-existing conditions. Commercial insurance frequently will not cover services people with disabilities need.

5 Patient Protection and Affordable Care Act of 2010 Signed into law on March 23rd, 2010

6 ACA Basics For the first time: a system making comprehensive care available to all* Americans, at a cost more people can afford. For the first time: the health insurance marketplace requires insurers to compete based on good care and customer service, and not by avoiding covering people or denying them care they need. The ACA lays a foundation for medical practice reforms based on effective health care, not just rewarding volume; this is ESSENTIAL to cost control and long-term deficit reduction. * Lawfully present in U.S.

7 4 Ways the Affordable Care Act Helps People with Disabilities: 1. Reforms Health Insurance Practices 2. Expands and Improves Long Term Services and Supports 3. Expands Access to Health Coverage 4. Expands Access to Prevention Services and Other Improvements

8 1. Reforms Health Insurance Practices Eliminates pre-existing condition exclusions Bans annual and lifetime limits Ends insurance companies retroactively denying coverage Improves the appeals process when a person is denied coverage of a treatment or service Requires that at least 80% of health insurance premium dollars are paying for health care Helps states to limit unfair increases in insurance rates Prohibits considering health status in calculating premiums (starting in 2014) Requires guaranteed issue and renewals of insurance plans (starting in 2014) Prohibits discrimination based on health status (starting in 2014)

9 No Pre-existing Conditions As of 2010: children (ages 0-18) can not be denied coverage based on pre-existing conditions. Starting in 2014: No one can be denied insurance due to pre-existing conditions. Starting in 2014: No one can be charged more because of health history or condition. Only 3 things lead to higher premiums: age, tobacco use, and geography.

10 No Lifetime or Annual Caps The use of lifetime limits in health plans and insurance policies is prohibited. A lifetime limit is the total amount of money that a health insurance company will pay for health care over the lifetime of a policy. An annual limit is the total amount of money that a health insurance company will cover in one calendar year. Annual limits are being phased out and will end in 2014.

11 Regulating Insurers The 80/20 Rule: Insurers have to spend 80% of your premiums on your health care, only 20% can go to overhead and profits. Because of this, millions of Texans got $167 million in rebates during 2012 ($187 avg check).

12 Individual Mandate Individual Mandate: If you don t have good, affordable coverage through your job, Medicaid/CHIP, or Medicare, you must purchase insurance for yourself, or pay a tax. Exemptions: If it costs more than 8% of your house-hold income, you are exempt pay no penalty. People are also exempt if their income is below tax filing limit, or if they are uninsured because our state fails to expand Medicaid. Provides cost-sharing and premium credits: The law provides costsharing subsidies to eligible low and middle income individuals and families. Why encourage healthy folks to sign up? It lowers the average cost for all, saves money thru prevention. We will all need care at some point and when someone doesn t have coverage we all pay for it in higher premiums and taxes.

13 The ACA s Individual Mandate to Have Insurance in 2014 You d be eligible for Medicaid, if Texas chose to expand

14 2. Expands and Improves Long Term Services & Supports Establishes the Community First Choice for states to cover comprehensive community attendant services under the state s Medicaid optional service plan Reduces Medicaid s institutional bias by creating new financial incentives for states to rebalance their services from more costly institutional settings toward home and community based services Extends Money Follow the Person Demonstration program that provides additional federal payments to help people transition from more costly institutions to home and community based services

15 Community First Choice (CFC) State Option Through the CFC Option, states may choose to provide home and community-based attendant services and supports as part of their state Medicaid plan. States that choose the option will receive a 6% increase in their Federal Medical Assistance Percentages ( FMAP) (the portion of state Medicaid costs the federal government covers) for the CFC services. CFC services are for people of any age with any type of disability who would have to go to an institution if they did not receive the services

16 Community First Choice (CFC) State Option If a state takes up the CFC Option, the state must provide home and community-based attendant services and supports to anyone who qualifies. Since this is not a waiver program, the state cannot set limits on the number of people served as long their disability meets the state s eligibility criteria for institutional services. Texas is planning to apply for CFC and nearly 12,000 Texans are projected to get these services in with the implementation of this option.

17 Balancing Incentive Program (BIP) BIP is a $3 billion grant program that encourages states to rebalance their Medicaid long term services spending away from institutional care and toward home and communitybased services and supports. States that spent less than 50% of their total Medicaid long term services dollars on non-institutional services in Fiscal Year 2009 may participate in the program. States, like Texas, that spend between 25% and 50% of their Medicaid long term care budget on home and communitybased services are eligible for a 2% FMAP increase (2% increase in the portion of state Medicaid costs the federal government covers) for new or expanded home and community-based services.

18 Balancing Incentive Program (BIP) The BIP provisions of ACA require states to: Provide conflict-free case management services (the case manager may not be the provider of community-based services); Use a standard assessment instrument for individuals across the state who may be eligible for leaving an institution and receiving home and community-based services; and Create a system that has no wrong door (people can obtain all necessary information and apply for the services in one place). Texas hope to save up almost $220 million in state funds as a result of the BIP program.

19 Money Follows the Person (MFP) Initially created by Deficit Reduction Act of Federal government pays 100% of the costs of community services for first 12 months after someone leaves an institution. Texas has been a leader in the MFP program and has transitioned almost 20,000 Texans from institutions into the community using MFP; Nationally, approximately 97% of MFP participants who leave an institution stay in the community. The ACA re-authorized MFP until 2016 and changed eligibility requirements to make it available to those who ve been in an institution only 3 months, instead of 6 months.

20 Medicaid and Medicare Improvements The ACA : Gives states the option to expand Medicaid eligibility to childless adults with incomes up to 133% of the federal poverty level. Federal government pays 100% of the cost until 2016 (phases down to 90% in 2020). Creates an option to provide health homes for Medicaid enrollees with chronic conditions. Health homes are intended to be person-centered systems of care that integrate primary, acute, behavioral health, and long term services. Allows a free annual Medicare well visit with assessments and individualized prevention plan. Eliminates Medicare Part D (drug coverage) co-pays for persons who are dually eligible for Medicaid and Medicare, and receiving Medicaid waiver services. Allows states in partnership with the federal government to try new models of care to provide better health care at lower costs to people with complex health care needs who are eligible for both Medicare and Medicaid.

21 3. Expands Access to Health Insurance Coverage Established temporary high risk pools to cover those who are currently uninsured (until 2014) Allows coverage for dependents until age 26 Creates private health insurance exchanges for individuals and small employers to purchase insurance (starting in 2014) Provides significant subsidies to assist low income individuals to purchase coverage in the exchanges and tax credits to help small employers provide insurance to their employees Includes coverage of dental and vision care for children in health insurance plans sold in the exchanges Includes essential health benefits in all plans including: mental health services, rehabilitative and habilitative services and devices, and other critical disability services in the health plans sold in the exchanges

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23 Marketplaces The ACA establishes Health Insurance Marketplaces (formerly known as the Exchanges) Allows individuals to compare private insurance plans based on price, benefits, quality, and other features. Most people will get a break on costs. No wrong door with Medicaid and CHIP. Open enrollment started October 1, 2013, and coverage is effective beginning on January 1, 2014.

24 What is an Essential Health Benefit? The ACA requires all qualified health plans to offer at least these essential 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; and, pediatric services, including oral and vision care.

25 Metal Levels

26 In-Person Enrollment Assistance in Agents/Brokers The ACA Navigators Certified Application Counselors Safety Net Providers Go to Healthcare.gov or Call: TTY:

27 Medicaid Expansion

28 In states that do not expand Medicaid, there will be large gaps in coverage, leaving millions of low-income adults with no affordable options. NOTE: Applies to states that do not expand Medicaid. The current median state Medicaid eligibility limit for parents is 48% FPL in the 21 states that are not moving forward with the Medicaid expansion at this time.

29 4. Expands Access to Prevention Services and Other Improvements The ACA eliminates co-pays for critical prevention services; Creates the Prevention and Public Health Fund to greatly expand wellness, disease prevention, and other public health priorities; Increases opportunities for training of health care providers (including dentists) on the needs of persons with developmental and other disabilities; Improves data collection on health care access for people with disabilities; and Requires the establishment of criteria for accessible medical diagnostic equipment.

30 The ACA 2014 and Beyond YOU Have a Voice! Go to: to find out who your representative is and speak out.

31 Contact The Arc of Texas Jeff Miller, Director of Governmental Affairs Rona Statman, Director of Family Services. Ginger Mayeaux, Advocacy Specialist