Affordable Care Act: Impact on People with Disabilities

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1 Affordable Care Act: Impact on People with Disabilities Stephanie Altman, Assistant Director of Healthcare Justice October 2014 About Us: The Shriver Center The Sargent Shriver National Center on Poverty Law provides national leadership in advancing laws and policies that secure justice to improve the lives and opportunities of people living in poverty. We specialize in practical solutions. Through our advocacy, communication, and training programs, we advocate for and serve clients directly, while also building the capacity of the nation s legal aid providers to advance justice and opportunity for their clients Like us on Facebook: Follow us on Twitter: 2 What is the Affordable Care Act? Signed into law on March 23, 2010; major coverage provisions began January 1, States are largely responsible for implementation. Must allow federal law, which establishes a floor not a ceiling for coverage. Makes changes to private health insurance coverage, creates health insurance marketplace for individuals and small businesses to purchase insurance, and expands coverage to low-income individuals through Medicaid. Enacts premium tax credits, small business tax credits and cost-sharing reductions to help individuals and small businesses access more affordable insurance options. Includes consumer protections. Includes individual and employer responsibility provisions. 3 1

2 4 New Ways to Get Covered Under the ACA 1) Health Insurance Marketplaces online marketplaces to compare and purchase insurance for individuals and small businesses under 50 employees. 2) Financial assistance available to many to purchase insurance through the Marketplace. 3) Mdi Medicaid idexpansion to Adl Adults ages up to 138% of the Federal Poverty Level (around $1,342 per month for a single individual). 4) Young adults years old can join, remain, or return to their parent s health plan and up to any age if child has a disability and meets requirements of Illinois Insurance Code. 4 First Stop to Get Covered in Illinois First stop for health coverage in Illinois Screening tool directs consumers to the Health Insurance Marketplace or Medicaid Answers questions on health coverage options Allows consumers to search for in-person assistance near them 5 Income Greater than 138% FPL Income 138% FPL or below 6 2

3 New Household and Income Considerations for Families under the ACA 1. MAGI (Modified Adjusted Gross Income) 2. Tax Filing Status 3. Household Composition/Size Defines whose income to count in determining eligibility and how many people are in a person s family for Medicaid and the Marketplace. See 7 DHS Eligibility and Case Progression Case Progression: ACA Adult to AABD See 0 ACA Adult Group: Eligibility See 2 Medicaid Programs in Illinois Before the ACA Medicaid eligibility is organized by category or population, each of which has different rules for how much income and resources you can have. For the most part, only citizens and qualified immigrants can qualify. Children under age 19 All Kids Parents and caretaker relatives of children up to age 19 FamilyCare Pregnant women Moms & Babies People with Disabilities, Seniors (age 65+) or Blind AABD Medicaid including AABD Spenddown Employed person with a disability, age (HBWD Health Benefits for Workers with Disabilities) 9 3

4 Medicaid Expansion Makes Adults Without Minor Children Eligible for the First Time Age and not eligible for other Medicaid category Citizen or Qualified Non Citizen Under 138% FPL or $1,342 per month for a household h of one. No asset or disability test. New income test called MAGI 10 Examples of ACA Adult Group Parent formerly on FamilyCare when youngest child turns 18. Young adult turning 19 who does not have a disability determination from SSA or receive SSI/SSDI. Parents who have work hours/pay reduced and are no longer eligible for employer insurance or staying home to care for child. Caregivers/Personal Assistants. Medicaid Programs in Illinois After the ACA Adults without minor children ACA Adult Group Former Illinois Foster Children up to age 26 Children under age 19 All Kids Parents and caretaker relatives of children up to age 19 FamilyCare Pregnant women Moms & Babies People with Disabilities, Seniors (age 65+) or Blind AABD Medicaid including AABD Spenddown Employed person with a disability, age HBWD Health Benefits for Workers with Disabilities 12 4

5 ILLINOIS MARKETPLACE FOR INDIVIDUALS 13 HealthCare.gov 14 Eligibility for Marketplace Available to U.S. citizens and lawfully present immigrants (regardless of length of residency in the United States) for subsidized or unsubsidized coverage. Undocumented immigrants completely barred from accessing private insurance on the Marketplace. Can still access free clinics, hospitals & federally qualified health centers, employer coverage, and private health insurance plans sold off of the Marketplace. Can purchase health insurance for someone else in their family such as a dependent spouse or child who is eligible based on their immigration or citizenship status through the Marketplace. 15 5

6 2014 & 2015 Open Enrollment Open Enrollment Oct. 1, 2013 March 31, 2014 (April 15 for those in line ) 2015 Open Enrollment Nov. 15, 2014 Feb. 15, 2015 Auto Renewals December 15, 2014: Consumers who are already on Marketplace plans will be auto renewed for coverage beginning January 1, 2015 Enrollment Date/Period Effective Coverage Begins 1 st 15 th of month 1 st of following month 16 th last day of month 1 st of second following month Qualifying Life Events (such as moving to a new state, marriage, or having a baby) open a Special Enrollment Period (SEP) Complex Cases during 2014 Open Enrollment also can open a SEP. Medicaid is always open! Special Enrollment Periods are called SEP If qualified, means that consumers can enroll in Marketplace any time during the year even outside of open enrollment. Must be triggered by specific life event that causes loss of coverage (Minimum Essential Coverage), a change in family status (for example, marriage or birth of a child) or other designated limited circumstances. Usually gives person 60 days after event to enroll. HealthCare.gov has a screening tool to determine if someone is eligible to enroll in a SEP: Qualified Health Plans (QHP) in IL All insurance plans offered on the Marketplace are called Qualified Health Plans (QHPs) - Certified by the Marketplace - Provides Essential Health Benefits - Follows established limits on Cost Sharing (like deductibles, copayments and out of pocket maximums) - Different plans offered in 13 rating areas In 1 st Open Enrollment: 6 carriers offered 165 QHPs on Illinois Marketplace In 2 nd Open Enrollment: DOI announced 10 carriers applied to offer 504 QHPs 18 6

7 What s Covered? Essential Health Benefits QHPs are divided into 4 Metal Levels (and one non Metal Level) There is also one non-metal level plan on the Marketplace called a Catastrophic Plan 20 HealthCare.gov: Plan Compare 21 7

8 Cost: Two Types of New Financial Assistance Premium Tax Credits Helps people pay the monthly cost (premium) to have a plan Cost- Sharing Reductions Decrease the charges (e.g., copays, deductibles) enrollees must pay when receiving health care services covered by the plan Premium Tax Credit 23 A tax credit reduces the insurance premium an individual (or family) owes, only in Marketplace plans. Premium tax credits are advanceable and refundable. Advanceable tax credit: Credit is sent directly to insurer, individual pays insurer balance of premium. Income change or qualifying events may change premium tax credit. Who Is Eligible for Tax Credits? A US Citizen or Lawfully Present Non Citizen and: Ineligible for minimum essential coverage, such as coverage provided through an employer, Medicaid or Medicare or coverage is unaffordable; Eligible to enroll in a QHP through the Marketplace; Part of a tax filing unit; and either Has household income between 100% and 400% FPL (US Citizens) OR If under the 5 year waiting period for Medicaid, has household income between 0-400% FPL -- although tax credit will be based on an income of 100% FPL even if income is below 100% FPL (Lawfully Present Non Citizen) 24 8

9 Who is eligible for cost-sharing reductions? 25 Qualifies for premium tax credit Must be enrolled in silver plan Household income not over 250% FPL Impact of Marketplace Financial Help on People with Employer Insurance Not intended for those with employer coverage. Provisions in place to prevent those with employer offer buying into Marketplace with financial help. Employer offer of self-only coverage to employee is not more than 9.5 % of the household income. Dependent coverage glitch because affordability determination based solely on employee self-only offer of coverage CONSUMER PROTECTIONS 27 9

10 New Consumer Protections for All* Insurance 1. No pre-existing condition exclusions. 2. Essential Health Benefits must be covered. 3. Preventive services available without cost sharing (more on this later). 4. Holds insurance companies accountable for rate increases. 5. Requires companies to spend at least 80% of premiums on health care or else rebate to consumers. 6. Insurers are not allowed to use information about health status or gender to set premiums. 7. Coverage information in plain language. 8. No rescissions. 9. No lifetime or annual limits on essential health benefits. 10. Marriage equality. *Grandfathered plans and some transitional plans do not have to cover these. 28 Preventive Services 29 Complete listing for adults, women, and children: Three Possible Phases Under the ACA Maintain P MEC Qualify for an Exemption Pay the Penalty 30 Image credit: Jonathan Gruber, Health Care Reform: What It Is, Why It's Necessary, How It Works 10

11 Requirement to Have Health Coverage Everyone is required to have minimum essential coverage (MEC) Those without MEC will pay a shared responsibility payment unless exempt Taxpayer is responsible for dependents Coverage requirement, penalties and most exemptions apply ppy on a monthly basis One day rule: A person has coverage for the month if they have coverage for at least one day in the month A person is eligible for an exemption for the month if they are exempt for at least one day in the month 31 What Counts As MEC? Employer-sponsored coverage, COBRA coverage and retiree coverage All metal level health plans and catastrophic coverage purchased in the individual market (inside or outside the Marketplace) Government Sponsored Coverage, such as: Medicare Part A coverage and Medicare Advantage plans Most Medicaid coverage Children's Health Insurance Program (CHIP) coverage Certain types of veterans health coverage Most types of TRICARE coverage Refugee Medical Assistance Self-funded health coverage offered to students by universities for plan or policy years that begin on or before Dec. 31, 2014 Other coverage recognized by the Secretary of HHS as minimum essential coverage 32 Full What Does Not Count As Minimum Essential Coverage (MEC)? If a consumer does not have MEC, then they do not have comprehensive coverage and they may have to pay a penalty or get an exemption. For example, these limited types of coverage are not comprehensive health insurance and therefore do not meet MEC. Worker's Compensation Stand alone vision or dental plan Accident or Disability policy Short-term duration coverage Medi-Gap policies There are also limited Medicaid and other public programs that may not meet MEC such as Family Planning services. In 2014, the federal government determined that these qualify for Transitional Relief from the penalty

12 Individual Mandate or the Penalty The penalty in 2014 is calculated in one of 2 ways. If the consumer does not maintain MEC, they will pay whichever of these amounts is greater: 1% of yearly household income. (Only the amount of income above the tax filing threshold, $10,150 for an individual, is used to calculate the penalty.) The maximum penalty is the national average premium for a bronze plan, which is $2,448 in 2014 ; OR $95 per person for the year ($47.50 per child under 18). The maximum penalty per family using this method is $285. In 2015, the fee will go up to 2% of annual household income or $325 per adult ($ per child), whichever is greater. It is prorated for number of months without insurance in a year. This calculator can be used to estimate the penalty for a consumer: 34 Exemptions from the Penalty Apply at Marketplace Hardship, including: Life circumstance (e.g., domestic violence) Non ACA-compliant plan cancellation without affordable alternative Member of certain religious sects Eligible for Indian Health Services Claimed on Tax Return Income below tax filing threshold Short coverage gap (< 3 months) Insurance coverage is considered unaffordable (> 8% of household income) Certain noncitizens Gap before effective date of Marketplace coverage Granted at Marketplace OR on Tax Return Indian tribe membership Incarceration Member of a health care sharing ministry 35 ACA Medicaid 451,880 Enrolled in ACA Medicaid (August 2014) Source: Transparency/Pages/AffordableCa reactenrollment.aspx 36 12

13 Over 600,000 enrollees in Illinois 37 Source: Get Covered Illinois, Annual Report. August Helpful ACA Resources Get Covered Illinois Illinois Health Matters: Illinois Health Resources a directory of useful websites, fact sheets, and other resources on a variety of different topics for navigators and other assisters: HelpHub is an online community where ACA enrollment specialists in Illinois can share their experiences helping consumers enroll & ask questions to each other and policy experts. To request an invite, helphub@illinoishealthmatters.org with your name, the name of your organization & details of your ACA involvement. Starting Strong Webinars: Starting Strong is a collaborative of health policy and advocacy groups working together to promote successful implementation of the Affordable Care Act in Illinois. Webinars are held monthly on ACA topics: 38 Questions? Stephanie Altman Stephaniealtman@povertylaw.org Ext