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+ Connecting Communities to Coverage:
The Affordable Care Act in ILOctober 1, 2013
Connecting Communities to Coverage: The Affordable Care Act in Illinois
About EverThrive Illinois
Formally known as Illinois Maternal and Child Health Coalition
Our Projects and Initiatives: Health Reform Projects School Health Project Immunization Project Health Disparities Project Premature Birth Project Cooking Matters Project
www.ilmaternal.org
@EverThriveIL
#NASWIL
Kathy Waligora, M.S.W
Manager, Health Reform Initiatives
Learning Objectives
Understand the basic provisions of the law likely to impact clients
Get an introduction to the new enrollment systems, including the Marketplace.
Understand the role of social workers in connecting communities to coverage
Gain access to tools and resources which will help you to connect with other enrollment specialists and stakeholders
ACA 101
The Affordable Care Act puts in place comprehensive reforms that: Ensure that all insurance is high quality, Protect consumers from insurance industry practices which
limited access to coverage for many, and Improve access to affordable health coverage.
If you are already insured, the only changes you will see are new benefits, better consumer protections, and more value for every dollar you spend on care. If you like your plan you can keep it and don’t need to do anything differently.
If you are uninsured, new pathways to coverage will make it easier than ever to get covered and stay covered. Financial assistance will be available to guarantee you can pay for coverage and health care.
Key Components
Extended dependent coverage to age 26
No pre-existing condition exclusion for children
Preventive services without cost sharing
CountyCare-the early expansion of Medicaid in Cook County
No lifetime limits on care Small business tax credits No insurance rescissions except
in cases of fraud/intentional misrepresentation
New Marketplace to buy insurance and receive financial help to pay for it
New Medicaid Adult Group available to adults under 138% FPL
Financial Assistance to purchase private insurance
Medicaid available to former foster children up to age 26 at any income level
No pre-existing condition exclusion for adults
All plans must cover Essential Health Benefits
No annual limits on care No gender rating Closing Medicare Part D donut hole Individual and Employer Responsibility
Available Now… 2014 and Beyond…
Connecting Communities to Coverage 2013
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Essential Health Benefits
Individual Responsibility
The individual mandate requires most Americans to purchase health insurance starting January 1, 2014 or pay the shared responsibility payment if they do not comply
People are exempt from the shared responsibility payment if: They would have to spend more than 8% of household income on
the cheapest qualifying health insurance plan even after tax credits and subsidies
Their income falls below the threshold for filing federal income tax
They are undocumented or not a lawfully permanent resident
People already meet this requirement if: They have insurance through an employer or purchase individual
insurance. They have insurance through Medicaid, Medicare, CHIP, Veteran’s
Administration and/or Tricare for active duty and retire military, Indian Health Services
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+Cost & Financial Assistance
Cost of Health Insurance
There are three factors that can determine an individual’s premium: Age
Up to 3x more for older adults Tobacco Use
Up to 1.5 times for tobacco users Where you live
IL recently released premium rates and they were 25% lower than expected and much lower than other states
Limits on Cost Sharing
“First-dollar” (no deductible/cost-sharing) coverage on preventive health
Limit small group health plan deductibles in 2014 to $2,000 for single, or $4,000 for family (adjusted annually)
Limit out-of-pocket amount in 2014 to $6,350 for single and $12,700 for family (adjusted annually)
Maximum out-of-pocket limits are reduced further for individuals and families below 250% FPL
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Financial Assistance
Premium Tax
Credits
•Helps you pay the monthly cost to have a plan
Cost-Sharing
Reductions
•Decrease the charges (e.g., copays, deductibles) you must pay when receiving health care services covered by the plan
Premium Tax Credit
Take It Now! (Advanced) Taking It Later! (Tax Time)
October 2013 – March 2014
• Enroll in health plan on Marketplace
• Choose to take all your credit in advance
– or just part of it
• Enroll in health plan on Marketplace
During 2014 • Pay a lower premium each month in 2014
– and now you are covered
• Pay full premium each month in 2014
– and now you are covered
January 2015 – April 2015
• Get a statement from Marketplace showing how much credit you received in 2014
• File your 2014 taxes, including information about tax credit already taken
• File your 2014 taxes• Either subtract the amount of
tax credit from the taxes you owe – or if you don’t owe anything IRS may give you a refund
IL Submitted Rates (non smoker)
Connecting Communities to Coverage 2013
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The REAL cost of Coverage in Illinois
Kaiser Family Foundation: kff.org
+Access to Coverage
Getting Insurance in 2014
Medicaid Expansion
The ACA expands Medicaid to cover all people under 138% of the federal poverty level Must be US Citizen or
Legal Permanent Resident of 5 years or more to qualify
Coverage begins January 1, 2014
100% federally funded in the first three years, gradually reduces to 90% by 2020
CountyCare: A New Medicaid Program for Cook County Who?
Live in Cook County Be 19-64 years old Have income at or below 133% of the
Federal Poverty Level ($14,856 individual, $20,123 couple – annually)
Be a legal immigrant for five years or more or a US citizen
Have a Social Security number or have applied for one
Access services at Cook County Health and Hospital System locations and some participating federally qualified health centers
It is important to continue enrolling eligible individuals into CountyCare as they can be enrolled and back bill for services BEFORE January 1, 2014
Existing Medicaid Programs
You might not need to wait until January to enroll in Medicaid:1.All Kids covers children under a
certain income regardless of immigration status
2.FamilyCare covers parents of children under 19 under a certain income
3.Moms and Babies covers pregnant women under a certain income regardless of immigration status
4.Medicaid for the Aged, Blind, and Disabled provides coverage for older adults and disabled people under a certain income
Get Connected TODAY1-800-843-6154
1-800-447-6404 TTY
The Marketplace
Enroll between Oct 1- March 31 for private insurance; by Dec 15 for coverage beginning Jan 1, 2014
Enroll year round for Medicaid
Three ways to get connected:1. On the web www.GetCoveredIllinois.gov
2. On the phone 1-866-311-1119
3. In Person Work with a Navigator to get
support and advice
The Marketplace in IL
Connecting Communities to Coverage 2013
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Get Covered Illinois
Healthcare.gov
SHOPIndividual
MarketplaceAssess
Medicaid/CHIP
EligibilityApplication for APTC/C
SR
Eligibility
Determinat
ion for
APTC/CSR
ABE
Application available to state office
State worker Processes
Application
Eligibility Determination
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111111111111111111111111111111111111
1111
If potentially eligible referred to Medicaid/CHIP
111111111111111111111111111111111111
1111
The Marketplace
Open Enrollment Period
Enrollment Date/Period Effective Coverage Begins
Oct. 1 – Dec. 15, 2013 Jan. 1, 2014
1st – 15th of month (Jan. – March)
1st of following month
16th – last day of month(Dec. – March)
1st of second following month
Initial Open Enrollment Ends March 31, 2014
Changes can be made within 30 or 60 days of triggering event (marriage, birth, move) that allows
for a change
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***Those who are eligible for Medicaid can apply for coverage any day of the year!
+Role for Social Workers
The Role for Social Workers
Educate clients on health insurance
Educate clients on the Affordable Care Act
Connect uninsured clients to Assisters
Become a Certified Enrollment Specialist
Connect to larger campaigns to elevate messages or even volunteer to canvass your community, host/participate in phone banks, and support events
Connect with other stakeholders across Illinois, using IHM HelpHub
Education: Barriers 29
Healthcare system
Lack of knowledge/information
Financial
Attitudes and perceptions
Culture
Communication
Professional Bias
Physical and social environment
Physical proximity
Politics and Policy
All insurance plans will have to cover doctor
visits, hospitalizations, maternity care,
emergency room care, and prescriptions.
You might be able to get financial help to pay for a health insurance plan.
If you have a pre-existing condition, insurance
plans cannot deny you coverage.
All insurance plans will have to show the costs and what is covered in simple language with
no fine print.
Key Messages30
One of these = top
message for 89% of
population
Source: Enroll America, November 2012
Certified Application Counselors
Who? Community based organization that wants to help by training your staff to assist people applying for coverage through the Marketplace
What? Help people understand, apply, and enroll for health coverage through the Marketplace. Your organization must agree to make sure that designated individuals complete required training, and that they comply with privacy and security laws, and other program standards.
How? Complete a brief application and access training at: http://marketplace.cms.gov/help-us/cac.html
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Major Campaigns
Get Covered Illinois
BeCovered Illinois
Enroll America-Get Covered America
Many other groups will run campaigns, so
there will be no shortage of graphics, materials, resources,
or ideas.
Connecting Communities to Coverage 2013
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Illinois Health Matters HelpHub
An online community where enrollment and outreach stakeholders in Illinois can share their experiences and get access to resources related to the ACA
To request an invite, email [email protected] with the name of your organization, lead agency (if part of IPC or Navigator grant) and /or details of your ACA involvement.
Resources
Illinois Health Matters
http://www.illinoishealthmatters.org
EverThrive Illinois ACA
http://www.ilmaternal.org/hcr
Kaiser Family Foundation
http://healthreform.kff.org/
www.GetCoveredIllinois.gov
+
Questions?
Kathy Waligora, M.S.W.ManagerHealth Reform InitiativesEverThrive Illinois
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