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Pierce County HealthWatch June 26, 2014
Mike Rust, Chief Operating OfficerABC for Rural Health, Inc.100 Polk County Plaza, Suite 180Balsam Lake, WI 54810(715) [email protected]
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ABC for Rural Health, Inc.
A Wisconsin-based nonprofit public interest law firm dedicated to linking children and families, particularly those with special health care needs, to health care benefits and services.
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Patient Protection andAffordable Care Act
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Affordable Care Act
• Open Enrollment – 11/15/2014 – 2/15/2015• SEP’s
– Loss of Minimum Essential Coverage– Changes in life circumstances– Enrollment problems– Exceptional circumstances
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Loss of Minimum Essential Coverage
• MEC is cancelled, involuntarily terminated, or ends before January 2015
• Loss of job is common• Must be involuntary• MEC includes Medicaid and BadgerCare• New coverage must begin on the 1st day of the
month after MEC ended
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Changes in Life Circumstances
• Turning 26• Moving to where the plans are different• Adding a dependent (marriage, birth,
adoption, foster care placement)– In the last 3, new coverage must start the date of
that event, regardless of plan enrollment date
• Divorce or death must also include loss of MEC
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Enrollment Problems
• Unable to enroll• Error, misrepresentation, or inaction of an
official or agent, misconduct, material violation of the contract by a plan
• Individuals who were « in line »• Individuals who were denied Medicaid, but
not notified until after open enrollment
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Exceptional Circumstances
• Losing eligibility for a hardship exemption• Surviving domestic violence (until May 30)• Loss of HIRSP (Until May 1)• Seeking to terminate COBRA (until July 1)• Loss of an individual plan outside of open
enrollment• Service in AmeriCorps, VISTA, NCCC
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Other Examples
• Unexpected hospitalization or temporary cognitive disability
• Natural disaster• Technical error between Marketplace and
plan• Immigration system error• Display of incorrect plan data
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System Appeals
• Whether you’re eligible to buy a Marketplace plan• Whether you can enroll in a Marketplace plan outside the
regular open enrollment period• Whether you’re eligible for lower costs based on your
income• The amount of savings you’re eligible for• Whether you’re eligible for Medicaid or the Children’s
Health Insurance Program (CHIP)• Whether you are eligible for an exemption from the
individual responsibility requirement
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System Appeals
• Send a letter or a Wisconsin appeal form to– Health Insurance Marketplace
465 Industrial Blvd. London, KY 40750-0061
• Wisconsin appeal form location– https://www.healthcare.gov/downloads/market
place-appeal-request-form-a.pdf– Appeals may be expedited. You may ask for
representation. Should be done in 90 days.
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Plan Appeals
• Your insurer must notify you of denials in writing and explain why:
– Within 15 days if you’re seeking prior authorization for a treatment
– Within 30 days for medical services already received
– Within 72 hours for urgent care cases
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Internal Appeals
• Must file internal appeal within 180 days • Appeal must be decided within 30 days if you
have not received the service and 60 days if you have received the service
• Then you may seek external appeal• You may request an expedited appeal for
urgent situations
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OCI RE: Training
• Nonnavigator assisters, including certified application counselors, are required to complete 8 hours of health insurance continuing education training annually.
• Entities must attest to training on an OCI attestation form by October 1 annually
• This guidance does not apply to navigators.
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Required Topics
1. Principles of health insurance2. Wisconsin health insurance laws and regulations3. Public health program law, regulations and
guidance including BadgerCare and Medicare4. Federal Affordable Care Act law, regulations and
guidance5. Privacy and Security Guidelines - Personally
Identifiable Information (PII)
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ACA Discussion
• Provider network issues• Outreach, Education and Enrollment Review • Plans for now and for next open enrollment • Problems• Training and resource needs
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Paul Wellstone and Pete Domenici Mental Health Parity and Addiction
Equity Act of 2008 (MHPAEA)
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MHPAEA Basic Requirement
• A plan may not apply any financial requirement or treatment limitation to mental health or substance use disorder benefits in any classification that is more restrictive than the predominant financial requirement or treatment limitation applied to substantially all medical/surgical benefits in the same classification
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MHPAEA Categories
• Financial requirements – e.g., deductibles, copayments, coinsurance, out-of-pocket maximums
• Treatment limitations – limit benefits based on frequency of treatment, number of visits, days of coverage, days in a waiting period, and “other similar limits on the scope and duration of treatment”. – Quantitative treatment limitation – expressed
numerically, e.g., annual limit of 50 outpatient visits– Nonquantitative treatment limitation – not expressed
numerically but otherwise limits the scope or duration of benefits
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Quantitative
• A particular type of financial requirement or QTL must apply to substantially all (2/3) of med-surg benefits in a classification before it may be applied to MH/SUD benefits.
• If requirement applies to 2/3, then permissible level of that limit is set by predominant level that applies to 50%
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Non-Quantifiable (NQTL’s)
• Any non-numerical limits to scope or duration of treatment (processes, strategies, evidentiary standards or other factors) used in applying an NQTL to MH/SUD benefits must be applied comparably and no more stringently than those are applied to medical-surgical benefits
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Sample NQTL’s
• Medical management standards• Prescription drug formulary designs• Standards for provider admission to a network• Determination of UCR amounts• Requirements to use less costly first• Requirements to complete a course of
treatment
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6 Benefit Classifications
• Inpatient, in-network• Inpatient, out-of-network• Outpatient*, in-network• Outpatient*, out-of-network• Emergency care• Prescription drugs
*May use sub-classifications of office visits vs all other care
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Parity Scope & Timeline
• Applies to both mental health and substance use disorder (MH/SUD) benefits
• Generally effective for plan years after October 3, 2009. Fully effective 1/1/11.
• Interim Final Rules issued February 2, 2010• Final Rules issued November 13, 2013• Final rules apply first plan year after 7/1/14
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General Applicablity
• Covers– Fully insured & self-funded large group plans (>50
employees)– Non-federal government plans over 100 (may
request exemption)– Individual & small group plans sold on and off the
Marketplace
• Increased cost exemption
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Specific Applicability
• Newly eligible in Medicaid expansion states• Incorporated by reference into MA for managed care (state
plan) and CHIP (EPSDT)• Not applicable to Medicare except for outpatient co-pays
(20%)• Church plans exempt unless purchase Marketplace plan or
state-regulated plan• Federal Employee HBP covered• TriCare not covered• Does not supersede more stringent state parity laws (WI –
eg., autism mandate)
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Final Rule Clarifications
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Intermediate Care
• Parity applies to intermediate levels of care received in residential treatment and intensive outpatient settings– Intermediate care for MH/SUD treatment
services must be assigned to the same classification that plans or issuers assign residential treatment for medical-surgical care.
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Transparency
• Upon request of a participant or contracting provider, plan administrators must disclose the criteria for medical necessity.
• Plan documents must be provided within 30 days of a request.
• The reason for any denial of benefits must be made available automatically and free of charge.
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Scope of Services
• Parity requirements for NQTLs are expanded to include restrictions on geographic location, facility type, provider specialty and other criteria that limit the scope or duration of benefits for services (including access to intermediate levels of care, out of state care).
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Provider Rates
• The final rule confirms that provider reimbursement rates are a form of NQTL
• All rate-setting factors must be applied comparably and no more stringently on MH/SUD providers.
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Items
• The final regulations clarify that mental health benefits, medical/surgical benefits and substance use disorder benefits each include benefits for items as well as for services.
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Cumulative Requirements
• Definitions:– Cumulative financial requirements
– e.g., deductibles (excludes lifetime and annual dollar limits)– Cumulative quantitative treatment limitations
– e.g., annual or lifetime day or visit limits
• MH/SUD and medical/surgical benefits must accumulate toward the same, combined deductible (or other cumulative requirement/limit) within a classification– In other words, separate but equal deductibles are not allowed
(even if a plan uses more than one service provider)
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ACA & MHPAEA
• Expands MHPAEA to individual and small group market• Requires coverage of MH/SUD services as one of the
ten essential health benefits• Prohibits annual or lifetime dollar limits on the 10
EHB’s• Preventive services (alcohol misuse screening and
counseling, depression counseling, and tobacco use screening) are free of cost-sharing
• Prohibits certain kinds of discrimination
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ACA Discrimination
• § 300gg–5. Non-discrimination in health care– A group health plan and a health insurance issuer offering group or
individual health insurance coverage shall not discriminate with respect to participation under the plan or coverage against any health care provider who is acting within the scope of that provider’s license or certification under applicable State law. This section shall not require that a group health plan or health insurance issuer contract with any health care provider willing to abide by the terms and conditions for participation established by the plan or issuer. Nothing in this section shall be construed as preventing a group health plan, a health insurance issuer, or the Secretary from establishing varying reimbursement rates based on quality or performance measures.
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Case Example
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MHPAEA & PPACA
• MHPAEA or PPACA solution?– Patients had been seeing QTT’s– Large corporation employers– New plan with major national carrier denied QTT network
access• “Both providers are deemed non-participating, ineligible provider
and at this time claims will process as non-participating, ineligible provider.
• Under ***** policy only licensed practitioners are accepted. Practitioners with a training certificate will not be added. ***** also does not currently recognize the specialty of Advanced Practice Social Worker as a reimbursable provider”
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SPD General Exclusion
– Treatment or services provided by a non-licensed Provider, or that do not require a license to provide: services that consist of supervision by a Provider of a non-licensed person; services performed by a relative of a Member for which, in the absence of any health benefits coverage, no charge would be made; services provided to the Member by a local, state, or federal government agency, or by a public school system or school district, except when the plan’s benefits must be provided by law, services if the Member is not required to pay for them or they are provided to the Member for free
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Internal Guidance for Behavioral Health• The Behavioral Health provider types that we
credential are those licensed by the state. The three digit codes found at the end of the Wisconsin license number are:
• 123 - LCSW (Licensed Clinical Social Worker)• 124 - LMFT (Licensed Marriage and Family Therapist)• 125 - LPC (Licensed Professional Counselor)• 057 - PhD, PsyD, and EdD (Licensed Psychologist)• 020 - MD (Psychiatrist)
• Only licensed practitioners are accepted. Practitioners with a training certificate' will not be added.
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Analysis
• QTT’s are licensed in Wisconsin• The SPD does not restrict licensure with
reference to training or supervision• Restriction here disagrees with the SPD • May also be problem with Parity if there is no
equivalent Internal Guidance for Medical-Surgical Care
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MHPAEA Financial Impact
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Inpatient
• 10% of large plans out of compliance in 2010• Virtually none in 2011• 2009 – 2011 higher copays and deductibles for
MH/SUD decreased rapidly• For mid-sized employers, between 10% & 16%
out of compliance before MHPAEA, and less than 7% after
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Outpatient
• 30% of large plans out of compliance in 2010 • In 2011, fewer plans out of compliance, but
20% retained higher outpatient, in-network copays for MH/SUD benefits
• Between 2009 and 2011, dramatic decline in more restrictive copays & coinsurance
• Before MHPAEA, 50% of mid-size business plans out of compliance. 40% after MHPAEA
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ER & Rx
• In 2010 vast majority of large plans complied with parity in Rx
• 20% higher cost-sharing for MH/SUD ER • By 2011, virtually all plans complied with both
ER & Rx
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MHPAEA Quantitative Impact
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Inpatient
• In 2010 nearly all large plans compliant on MH• 20% more restrictive for SUD• By 2011, no unequal dollar limits & 8%
unequal day limits (both MH and SUD)• 2009 – 2011 dramatic decline in unequal limits• Largest drop in unequal day limits (50% - 10%)
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Outpatient
• 50% of large plans had unequal visit limits for MH/SUD in 2010
• Less than 7% in 2011• 30% unequal dollar limits in 2010• Virtually none in 2011• Mid-sized employers, 81% out of compliance
in 2008. Down to 13% in 2011.
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MHPAEA NQTL Impact
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Non-Quantifiable Treatment Limitations
• In 2010, most plans still used more restrictive NQTLs for MH/SUD
• Most common:– Precertification requirements– Medical necessity criteria– Routine retrospective reviews for MH/SUD– Reimbursement on lower % of UCR
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MAPP
• Medicaid eligibility for disabled individuals – Household income under 250% FPL– Applicant-only assets under $15,000– $0 Premium if applicant income under 150%– Must have one work experience/month for
“something of value” in return
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BadgerCare Plus
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BadgerCare
• NEW Basic Financial Eligibility Limits– Children (defined as up to age 18)
• Up to 306% FPL– Pregnant women
• Up to 306% FPL– Adults
• Up to 100% FPL• Parents may have Medicare• Childless Adults may not have Medicare
– Certain former foster care youth
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Eligible Groups
Graph from Wisconsin Department of Health Services
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MAGI Income
Under MAGI, countable income = taxable income. This includes (but is not limited to): – Taxable Earned Income, – Taxable Net Self-Employment Income, – Unemployment Compensation, – Alimony/Spousal Maintenance, and – Social Security Income.
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Plus
• After arriving at your Adjusted Gross Income, the next step in calculating your MAGI is to add back certain types of income:
– Non-taxable Social Security benefits (Line 20a minus 20b on a Form 1040)
• For Social Security Benefits include disability payments (SSDI), but exclude Supplemental Security Income (SSI),
– Tax-exempt interest (Line 8b on a Form 1040)– Foreign earned income & housing expenses for Americans living
abroad (calculated on a Form 2555)
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MAGI Pre-tax deductions
• The following deductions will be allowed if the payments are taken out of the individual’s paycheck on a pre-tax basis. (Will be on the pay stub)– Health Insurance Premiums – Health Savings Account – Retirement Contributions – Parking & Transit Costs – Child Care Savings Account – Group Life Insurance
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MAGI Tax Deductions
• Tax deductions listed on page 1 of form 1040. – Student Loan Interest (capped at $208/month)– Higher Education Expenses – tuition, school fees, room & board,
supplies, books, etc. (capped at $333)– Self-Employment Tax Deduction– Spousal Support/Alimony (court ordered amount)– Teachers’ Tax-Deductible Expenses (capped at $21/month)– Out-of-pocket Costs for a Job-Related Move– Loss from Sale of Business Property
• Itemized deductions are not allowed.
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New Income Counted by MAGI
– Financial aid, if used for living expenses. – All Tribal per capita payments from gaming
revenue. – AmeriCorps income. – Taxable retirement, pension and annuities. – Interest & dividends. – Lump sum income counted in month received.
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MAGI Exempt Income
• Some common income types that will NOT be counted for BadgerCare Plus eligibility include: – Child Support, – Supplemental Security Income (SSI), – Workers’ Compensation, and – Veterans Benefits.
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Whose Income is Counted?
• In general, everyone in an assistance group will have their income counted.
• In some cases, children and tax dependents’ income will not be counted, if their income is so low that they are not required to file taxes.
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Reminder – “Expect to…”
• For MAGI questions, ACCESS will ask about what individuals are planning to do for the current tax year in which they are applying, not the previous year.
• Example: If applying for benefits in March 2014, ACCESS will ask about the taxes that the individual expects to file in 2015 for income that he or she has in 2014.
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Who is Subject to MAGI Rules?
• BadgerCare Plus Members: – Children, – Parents and caretaker relatives, – Pregnant women, and – Adults with no dependent children.
• Family Planning Only Services (FPOS) members will be subject to MAGI income rules, but always with a group size of one.
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Who is Not Subject to MAGI Rules? MAGI rules do not apply to: • Elderly, blind and disabled groups • Elderly, Blind and Disabled (EBD) Medicaid • Long-Term Care (LTC) Waiver Enrollees • SeniorCare • QMB, SLMB, SLMB+ • MAPP • Well Woman Medicaid • Categorically eligible populations • Former Foster Care Youth
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Backdating BadgerCare
Children determined eligible for BadgerCare Plus can backdate coverage. Backdating is determined by age and income:
• Are eligible for up to the first of the month, 3 calendar months prior to the month of application,
• For any of the months their family income was at or below the threshold
• Under MAGI rules:AGE INCOME
Infants less than 1 year Below 306%FPL
Age 1-5 Below 191% FPL
Ages 6-18 Below 156% FPL
All former foster care youth that meet criteria
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Backdating Rules for Pregnant Women:
• All pregnant women, except those eligible under the BC+ Prenatal program, may have their eligibility backdated to whichever is more recent:– The first of the month in which the pregnancy
began -or-– The first of the month, three months prior to the
month of application.
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Backdating Rules for Family Planning Only Services (FPOS):
• Eligibility for FPOS begins on the first of the month of application, if all non-financial and financial eligibility requirements are met.
• FPOS may be backdated up to three months from the month of application.
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Backdating Rules for Parents & Caretakers
• All non-pregnant, non-disabled parents and caretakers may have their eligibility backdated up to the first of the month, three calendar months prior to the month of application for any of the months in which their family income was at or below 100% FPL
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Backdating Rules for Childless Adults
• Childless adults with assistance group income under 100% FPL will be eligible for backdating for up to the first of the month, three calendar months prior to the month of application.
• However, retroactive coverage cannot begin prior to April 1, 2014.
• As a result, a childless adult could not be eligible for the full three calendar months period of backdating until July 1, 2014.
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BadgerCare PlusCrowd Out Rules
• Affects children based on age relative to household income:– < 1 year old = no effect on eligibility– Age 1 to 6th b-day = check insurance access if income > 191% FPL (185%)– Age 6 to 18th b-day = check insurance access if income > 156% FPL (150%)
• May be denied eligibility if:– Employer contribution is at least 80% of total premium cost; and,
• Are currently enrolled in employer plan, or• Failed to enroll in employer plan offered any time in the last 12 months, or• Have current ability to enroll in coverage that will start within three
months, or• Employer coverage was dropped during previous three months
* “Good Cause” exceptions may apply
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Separated, Divorced, Unmarried Parents
• Only one parent can include the child in the household for purposes of determining income eligibility for Marketplace financial assistance and BadgerCare– Alternating dependent exemptions can cause children to have
to switch coverage from year to year if:• Parents live in different geographic locations not served by
same plan network• One parent has Marketplace coverage and the other has
BC+/Medicaid– Can also cause parents with income near 100% FPL to churn
between Marketplace and BadgerCare
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Location & Access
• Geographic location and network access– Children may be eligible for Marketplace financial
assistance if they do not have meaningful access to the provider network of a parent’s insurance plan even if they technically could be enrolled in coverage that meets minimum essential coverage standards
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COBRA
– In many cases, spouses who previously would have had to rely on former spouse’s continuation coverage will be eligible for Marketplace coverage at lower cost.
– COBRA election is no longer the only option– Forgoing COBRA election does not disqualify individual for
APTC/CSR– COBRA coverage is retroactive from date of notice to
election date– COBRA election deadline is at least 60 days– Election deadline is 30 days for plans governed by Wisconsin
insurance law (e.g. very small group and some church plans)
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Maximizing Coverage
• Commercial insurance coverage does not necessarily preclude using public benefits for ‘wraparound’ coverage.
• Children can use BadgerCare as secondary coverage as long as they are not subject to insurance crowd out rules.
• Adults under 100% FPL are exempt from crowd out rules and can have BadgerCare as secondary coverage on top of any other insurance (except Medicare).
• Crowd out rules do not apply to disability based Medicaid programs
• Medicaid enrolled provider may not balance bill for Medicaid covered services, including copays not covered by other insurance
• Secondary coverage may pay deductible expenses
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MAPP
• Medicaid eligibility for disabled individuals – Household income under 250% FPL– Applicant-only assets under $15,000– $0 Premium if applicant income under 150%– Must have one work experience/month for
“something of value” in return
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One Final Hitch…
• DHS uses the current year’s federal poverty level to determine BadgerCare and Medicaid eligibility
• Until next open enrollment, the Marketplace will use 2013 federal poverty levels to determine eligibility for APTC and CSR
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HealthWatch
