The Health Insurance Exchange: Key Issues for Native Americans. Sireesha Manne & Kelsey McCowan Heilman, NM Center on Law and Poverty June 27, 2013

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1 The Health Insurance Exchange: Key Issues for Native Americans Sireesha Manne & Kelsey McCowan Heilman, NM Center on Law and Poverty June 27, 2013

2 What We ll Cover Today Exchange Basics What Is the Exchange? Benefits of Coverage What Does It Cost? What Benefits Are Covered? How & When Do You Enroll? Key Issues for Native Communities Consultation Network of Providers Affordable Coverage Protections for Native Americans Who Is Native American?

3 Exchange Basics

4 What if You Don t Have Coverage? & Your income is too high for Medicaid Your job doesn t have Health Benefits, or... Your job has Health Benefits but it is too expensive

5 How Do You Buy Insurance? Lovelace Molina

6 What is the Exchange? NM Health Insurance Exchange Blue Cross Blue Shield Molina NM Health Connections Presbyterian UnitedHealth Insurance Exchange You are in control!

7 The Exchange: A Marketplace Image reprinted with permission from Edward Mullen Studio, February 2012,

8 Comparing Apples to Apples Plain language descriptions Cost calculator Networks of doctors & clinics Essential Health Benefits

9 Companies Compete for Your Business $500! $300! $200! $400!

10 Who Can Use the Exchange? INDIVIDUALS Not qualified for Medicaid Not qualified for job-based coverage Most will get financial help for Exchange SMALL BUSINESS - SHOP Less than 100 employees Financial help if under 25 employees REMINDER: There is no mandate to get insurance No tax penalties for Native American individuals or small business under 50 employees.

11 Benefits of Coverage Choice of Providers You can go to any Indian health provider and the health plan pays (whether or not in network. Invests in Indian Health System No Gaps in Healthcare Financial Security

12 Essential Health Benefits Ambulatory (walk-in) patient services Emergency services Hospitalization Maternity/newborn care Mental health, substance abuse & behavioral health Prescription drugs Rehabilitative & habilitative services Laboratory services Preventive/wellness services Pediatric services, including oral & vision care Other benefits (like adult dental) will require purchase of additional coverage.

13 What Does It Cost? With financial help, health insurance may be LOW COST or even FREE!

14 Two Types of Insurance Costs: Premiums Monthly payment to insurance company Cost-Sharing Copays & Deductibles when you get care

15 Exchange Plans Ranked by Costs Premiums Cost- Sharing The federal government will help with both costs

16 #1: Financial help for premiums People with incomes under 400% of poverty level get financial help to lower monthly premium costs. Household Size Income Under 400% FPL 1 person $45,960 2 people $62,040 3 people $78,120 4 people $94,200 5 people $110,280 6 people $126,360 Premium tax credits are: Advanceable: You don t have to wait to the end of the year Refundable: You get the full value of the tax credit no matter how much you owe (or don t owe) in taxes

17 Tax credits can be used to buy any type of plan on the Exchange Most expensive premiums Tax Credit Amount (based on Silver Plan) Least expensive premiums BRONZE plans may be very low cost or free.

18 #2: Financial help for cost-sharing NO cost-sharing for Native Americans with incomes under 300% of poverty level, and NO cost-sharing for services from Indian health providers regardless of income. Household Size Income Under 300% FPL 1 person $34,470 2 people $46,530 3 people $58,590 4 people $70,650 5 people $82,710 6 people $94,770 This means a BRONZE plan could be very low cost or totally free for many Native Americans.

19 Sample Family: 250% FPL $59,000 annual income; 2 working parents earning about $14/hour each Premiums with Tax Credit Cost-Sharing Non-Native Family Cost-Sharing Native Family Platinum Plan $700/ Month Low NONE Silver Plan $400/ Month Medium to High NONE Bronze Plan $200/ Month High NONE

20 Sample Family: 150% FPL $35,000 annual income; 2 working parents earning about $8/hour each Premiums with Tax Credits Cost-Sharing Non-Native Family Cost-Sharing Native Family Platinum Plan $300/ Month Low NONE Silver Plan $100/ Month Low NONE Bronze Plan $0 High NONE

21 Exchange: How to Enroll Online By phone Native American Service Center By mail By fax In person assisters

22 Exchange: When to Enroll Native Americans can enroll during any month of the year Most other people must enroll in open enrollment period: October 1, 2013 to March 31, 2014.

23 Key Issues 1. Native American consultation 2. Provider Networks 3. Affordable Coverage 4. Monitor Protections for Native Americans 5. Who Is Native American? Also: Outreach and enrollment (later today)

24 Exchange: Key Issues for Native Communities

25 NM Health Insurance Exchange (NMHIX) Legislation enacted in 2013 Exchange Board has 13 members In first year, hybrid model: Individual Exchange run by federal government Small business Exchange run by state Consumer assistance and outreach run by state Several Native American-specific provisions

26 Issue #1: Native American Consultation Exchange must have under federal & state law: Tribal consultation (regular and ongoing) Board representation of Native Americans Native American advisory committee Native American liaison Native American Service Center Key Action: Make recommendations/nominations for advisory committee, liaison and Service Center. Timeframe: Starting now. Letters soliciting nominations for advisory committee and liaison positions expected to post as soon as July. Native American Service Center decisions to be made later.

27 Issue #2: Provider Networks HEALTH PLAN Timely Payments Care Coordination Key Action: Contact health plans to ensure Indian health providers are in network. If there are gaps, ask Superintendent for stronger certification criteria. Timeframe: Now. Decisions about qualified health plans made in June.

28 Issue #3: Affordable Coverage Tribes, tribal organizations, and Urban Indian organization can pay members share of premiums Key Actions: Advocate with feds to facilitate payment of premiums Education with community members about Bronze plan value Timeframe: Now for federal advocacy; monitoring starts in October

29 Issue #4: Protections for Native Americans Protections Include: No tax penalties No copays or deductibles if under 300% poverty level No copays or deductibles if at Indian health facility Year-round open enrollment Key Actions: Monitor federal Exchange, and state s Exchange and policies. Push for maximum flexibility (expansive enrollment periods) Timeframe: July-August (state s Exchange may develop plan of operation); October 1, 2013 and onwards (federal Exchange monitoring)

30 Issue #5: Who Is Native American? 1. Exchange (Cost-Sharing & Enrollment Periods) Member of Indian tribe - prove through document issued by federally recognized tribe (ex: tribal enrollment card or CIB) 2. Tax Penalty Exemption *NEW - Member of Indian tribe or eligible for services through an Indian healthcare provider or eligible for I.H.S. services (broad definition) Key Actions: Clarify process for proving status. Monitor ease of getting protections. Help members get documents. Timeframe: Now. The federal government is setting up Exchange.

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