1 A nonprofit service and advocacy organization © 2013 National Council on Aging Aging Briefing Series Webinar Keeping Pace with the Affordable Care Act: What You and Your Older Clients Need to Know October 29, 2013
Feb 25, 2016
1A nonprofit service and advocacy organization © 2013 National Council on Aging
Aging Briefing Series Webinar
Keeping Pace with the Affordable Care Act:
What You and Your Older Clients Need to Know
October 29, 2013
2A nonprofit service and advocacy organization © 2013 National Council on Aging
What we’ll cover
Background on ACA How the law affects your clients with
Medicare & Medicaid, and those without insurance
Medicaid expansion Health Insurance Exchanges What this means for you and your clients Resources
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Confused? You are not alone
Kaiser Poll: “Six Months Before Marketplace Open Enrollment Begins, Many Americans Remain Unaware of, or Confused about, the ACA”• 7% - Supreme Court overturned it• 12% - Congress repealed it• 23% - Don’t know
• ACA = Obamacare• http://www.cbsnews.com/8301-504784_162-57605754-1039
1705/jimmy-kimmel-on-obamacare-vs-the-affordable-care-act/
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A little background
Affordable Care Act (ACA) signed into law on March 23, 2010
Key components of ACA are designed to: Strengthen consumers’ health care
choices and protections Offer a wide-range of coverage options Make health care affordable and
accessible for all Americans
Many changes, varying effective dates, bigger components in place by 2014
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Supreme Court ruling – What about it?
After health reform law was passed, 26 states filed a lawsuit against:o Individual Mandateo Medicaid Expansion
On June 28, 2012, the Supreme Court:o Upheld that individual mandate
is not unconstitutionalo However, States cannot be
“coerced” (lose current Medicaid funding) into expanding Medicaid
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ACA - Implementation and Challenges ACA – survived the Supreme Court and the
election More legal challenges ahead More political challenges• CLASS Act (provided for national voluntary LTC
insurance program)oNot implemented by AdministrationoRepealed and replaced with LTC Commission
Budget Battles Healthcare.gov website woes
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Medicare & the ACAKey messages from CMS:
Medicare’s open enrollment is not part of the new Health Insurance Marketplace
Medicare open enrollment has not changed. It is from October 15 – December 7
It is against the law for someone who knows that an individual is on Medicare to sell them a Marketplace plan (with the exception of an individual who is employed and covered by small employer health insurance marketplace, SHOP)
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How ACA affects your clients with Medicare
Closes Part D Coverage Gap: • In 2010, began with $250 rebate check• Increasing discounts and plan payments until 2020• Nearly 7.1 million people already saved over $8.3
billion on drugs in coverage gap Starting with the 2012 plan year, moved and
extended annual Part D and Medicare Advantage open enrollment period (Oct 15-Dec 7)
As of 2011, provides new and free preventive benefits under Medicare, including Annual Wellness Visit• To date, 34.1 million beneficiaries took advantage of
one or more free preventive services
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How ACA affects people with Medicare (cont.) Payments:
• No guaranteed Medicare benefits were cut• ACA reduces payments to private (Medicare
Advantage) plans to keep rates for services in line with Original Medicare
• Higher income beneficiaries (making over $85K [individual] or $170K [couple]) pay slightly higher premiums for Part B and D
• Does not reduce payments to doctors, but does slow rate of payment increases to hospitals, nursing home, and other facilities
Imposes penalties for hospital readmissions within 30 days after discharge for certain conditions
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How ACA affects people with Medicare and Medicaid (“duals”)
10.1 million duals in the U.S. ACA testing new models for better care, better
coordination of services (www.innovations.cms.gov)• In 2011, CMS awarded 15 states design contracts up to $1
million to develop integrated service and delivery payment models
• 26 states submitted proposals to align the financing and benefits of the two programs under two models. Several have withdrawn proposals.
• Eight states have signed MOUs with CMS to move forward Give states more flexibility to offer Home and
Community Based Services (HCBS)
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Current state of the states : Demo proposals
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How ACA affects those in need of insurance As of July 2010, establishes Pre-Existing Condition
Insurance Plan (PCIP), helps people that could not get insurance due to pre-existing conditions• Programs ends on 1/1/2014 because of availability of
insurance in marketplaces. Notices being sent to all PCIP enrollees soon.
Allows states option to expand Medicaid to those not traditionally covered beginning as soon as 2010
For 2014, individuals without coverage must obtain health insurance or pay a penalty• Health Insurance Exchanges (Marketplaces) opened
on Oct. 1 to sell plans to these individuals for 2014
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Medicaid Expansion – What’s happening? Will cover many of those not previously eligible:
• Ages 19-64 and • Income under 138% (133% with a 5% disregard) of
federal poverty level (FPL)• No resource test• Does not cover undocumented immigrants
Federal government pays 100% of expansion for 2014-2016; phased down to 90% by 2020
By 2019, Medicaid expansion estimated to cover ~16 million people who otherwise would be uninsured
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Which states chose to expand?
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Health Insurance Marketplaces (Exchanges) – What are they? Marketplaces available both for individuals and
small employers One-stop shopping – single application for
Exchange, Medicaid, and CHIP Affordable options for people with limited income
(tax credits, reduced cost-sharing) Can’t be denied insurance even with pre-existing
conditions (“Guaranteed Issue”)• Premiums can only vary by family size, geographic
location, tobacco use and age, not by health status. Standard offering of health benefits (“Essential
Health Benefits”)
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Subsidies for premiums and cost-sharing There is a tax credit/subsidy to help lower
the premiums for people with low and modest incomes who purchase insurance on the “exchanges.”
Financial assistance to pay premiums is provided to individuals with incomes between 100 to 400% of FPL Amount of tax credit is based on cost of second
lowest cost silver plan in the area where person lives
Financial assistance to pay other cost-sharing to those with income between 100 to 250% of FPL• But only for “silver” level plans
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“Coverage Gap” Question: What happens to individuals who:• Are not currently eligible for Medicaid,• Live in a state that did NOT expand
Medicaid to 138% of poverty,• And whose income is not 100% of FPL
and therefore not eligible for the tax credit/subsidy?
Answer: They may not be eligible for either Medicaid or the subsidy. • Approximately 4.8 million affected
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How are the Exchanges (Marketplaces) run? Exchanges (aka Marketplaces):
• Must be a government agency or non-profit • Must serve both individual and businesses• Can form regional Exchanges, or have multiple
exchanges operating in one state
States can choose from three models: • State-based exchange • State-federal partnership• Federally-facilitated exchange (FFE)
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Exchange models
State-based exchange • State runs its own exchange• May have an Exchange Board to settle on policy decisions
(i.e., model type, benefits package, IT structure, contracts) State-federal partnership
• State works with federal government, likely help with plan management functions such as certifying qualified health plans, oversight, etc.
Federally-facilitated exchange (FFE)• Federal government ensures state has Exchange in place,
will still need help from states • Default model if states did not choose a model by Feb 15,
2013
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Health Exchange Status
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Streamlined, dynamic application process Streamlined application can be used to apply for:
• Insurance through the Individual or SHOP Exchanges• Medicaid• SCHIP• http://www.cms.gov/CCIIO/Resources
Applications can be submitted:• Online via the Exchange Website• Call Center • By Mail• In-Person
Information collected includes:• Baseline information• Income information (for Medicaid or tax credits)• Program specific information
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Marketplace application
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What plans will be available?
Qualified health plan required to offer uniform benefits package
Scope of benefits: 10 “general” essential services
Four levels of coverage: bronze, silver, gold and platinum• Insurer must offer at least one silver & gold
level plan in the Exchange Maximum out of pocket costs for enrollee
for 2014 - $6,350
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Essential Health BenefitsQualified health Plans cover Essential Health
Benefits which include at least these 10 categoriesAmbulatory patient services Prescription drugs
Emergency services Rehabilitative and habilitative services and devices
Hospitalization Laboratory services
Maternity and newborn care Preventive and wellness services and chronic disease management
Mental health and substance abuse disorder services, including behavioral health treatment
Pediatric services, including oral and vision care (oral services may be provided by stand alone plan)
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New Qualified Health Plans - Metals Metal plans – bronze, silver, gold, platinum
Differentiated by the actuarial value - the average amount of insurance expenses that would be paid by the plan.
The higher the actuarial value of the plan, the lower the out of pocket costs for the plan member.
The more the insurer pays out, the higher the premium
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Plan Coverage of Expenses
Bronze Silver Gold Platinum0
10
20
30
40
50
60
70
80
90
100
Plan Coverage of Expenses
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Individual Market Premiums: Why will they change
Prohibition against discrimination against people with pre-existing conditions
Elimination of surcharges based on health status Limiting of premium variation due to age (can
only charge 3 times more for older individuals) Elimination of gender-based rating Minimum essential coverage Premiums will be higher for some, lower for
others Will only be based on age, family size,
geographic location, and smoking status.
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Penalty if don’t get insurance 2014 - $95 per adult ($47.50 per child) or 1% of
family income, whichever is greater• Up to $285 for a family
2015 - $325 per adult ($162.50 per child) or 2% of income, whichever is greater• Up to $975 for a family
2016 and beyond - $695 per adult ($347.50 per child), or 2.5% of income, whichever is greater• Up to $2,085 for a family
No penalty if family income is below the threshold for filing tax return
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Who will help consumers of the Exchanges?
Navigators• Provides public education - objective,
trustworthy• From at least two agencies/organizations
with one being a community-based partner
• Receive grant funding by the Exchange• ~200 Navigators in MD
In-Person Assisters• Only available for state-based and
partnership exchanges, not federal facilitated exchanges
• Must be funding through separate grants• ~300 In-person assisters in MD
Certified Application Counselors
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Key enrollment dates through the Marketplace Initial Open Enrollment Period:
o October 1, 2013 - March 31, 2014o Coverage effective no sooner than January 1, 2014
Annual Open Enrollment Period (starting in 2015)o October 15 – December 7, coverage effective
following January 1
Also, Special Enrollment Periods (SEP) for exceptional situations (see next slide for SEP situations)
Note: Medicaid & CHIP applications can go through the Exchange or through Medicaid offices, and anytime of the year
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Special Enrollment Periods
Special Enrollment Periods (SEPs) outside the initial or annual enrollment period may include:• Loss of minimum essential coverage• Gain or become a dependent• Become a U.S. citizen• Enrollment errors• Plan violates their contract• Gain or lose eligibility for tax credits or cost-sharing
subsidies• Move outside of the Exchange service area• Exceptional circumstance
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Healthcare.gov - Marketplaces
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Maryland Health Connection
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Special considerations for boomers
Many people aged 60-64 will likely be participating in Exchanges, especially if they’ve lost jobs during the recession, retired or are underemployed and lack insurance
Those receiving subsidies likely eligible for other benefits, such as SNAP, LIHEAP, and (once 65) Medicare Savings Programs and Low Income Subsidy
How will they get connected to these other programs?
Do they know when and how to transition to Medicare?
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Medicare & the Marketplace
Most people with Medicare will not benefit from the Marketplace• Marketplace significantly more expensive • No premium or cost-sharing subsidies if have
Medicare However, some people may want to consider their
options:• People under 65 and disabled and waiting for
Medicare• People without guaranteed issue right for Medigap
Marketplace plan does not protect against late-enrollment penalty, so clients need to sign-up for Medicare on time!
Fact sheets available on http://www.ncoa.org/assets/files/pdf/center-for-benefits/medicare-and-marketplace.pdf
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Beware of Scams Higher risk of fraud due to confusion
between the two open enrollments There are no “Obamacare” cards and
no need to replace Medicare card No one should share their Social
Security or Medicare number with anyone who knocks on their door or solicits them uninvited
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General ACA-related resources Health care reform: www.Heathcare.gov, and about
Marketplace: www.marketplace.cms.gov Where states stand on Medicaid expansion:
http://ahlalerts.com/2012/07/03/medicaid-where-each-state-stands-on-the-medicaid-expansion/ (updated regularly) and www.nasuad.org/medicaid_expansion_tracker.html#WA
Affordable Care Act and Health Exchanges status: http://healthreform.kff.org/
Center for Consumer Information and Insurance Oversight (CCIIO): http://cciio.cms.gov/
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Resources for checking facts/myths PolitiFact (Pulitzer Prize winning site that
researches common claims about health care reform): http://www.politifact.com/subjects/health-care/
Fact Check (project of Annenberg Public Policy Center): http://www.factcheck.org/
AARP health reform fact sheets (multiple languages): http://www.aarp.org/health/health-care-reform/health_reform_factsheets/
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Stay in touch
Visit us on the web at: www.CenterforBenefits.org
And for your clients:www.MyMedicareMatters.org
www.BenefitsCheckUp.org
Contact today’s presenter: [email protected]
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Questions/comments
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Use of Out-of-Network Providers for Emergency Care
Many plans will have provider networks which plan members may be required to use for non-emergency care
Insurance plans are prohibited from charging members higher co-payments or coinsurance payments for out-of network emergency services
Insurance plans cannot require members to get prior approval before getting emergency room services from a hospital outside the plan’s network