Aging Briefing Series Webinar

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


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



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Begins, Many Americans Remain Unaware of, or Confused about, the ACA”• 7% - Supreme Court overturned it• 12% - Congress repealed it• 23% - Don’t know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/

http://www.cbsnews.com/8301-504784_162-57605754-10391705/jimmy-kimmel-on-obamacare-vs-the-affordable-care-act/




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


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


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


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)


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


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


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)

http://www.innovations.cms.gov/


Current state of the states : Demo proposals


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


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


Which states chose to expand?


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”)


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


“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


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)


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


Health Exchange Status


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


Marketplace application


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


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)


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


Plan Coverage of Expenses

Bronze Silver Gold Platinum0

10

20

30

40

50

60

70

80

90

100

Plan Coverage of Expenses


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.


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


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


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


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


Healthcare.gov - Marketplaces


Maryland Health Connection


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?


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

http://www.ncoa.org/assets/files/pdf/center-for-benefits/medicare-and-marketplace.pdf





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


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/

http://www.heathcare.gov/

http://www.marketplace.cms.gov/

http://ahlalerts.com/2012/07/03/medicaid-where-each-state-stands-on-the-medicaid-expansion/



http://www.nasuad.org/medicaid_expansion_tracker.html

http://healthreform.kff.org/

http://cciio.cms.gov/


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/

http://www.politifact.com/subjects/health-care/

http://www.factcheck.org/

http://www.factcheck.org/

http://www.aarp.org/health/health-care-reform/health_reform_factsheets/




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]

http://www.centerforbenefits.org/

http://www.mymedicarematters.org/

http://www.benefitscheckup.org/

mailto:[email protected]


Questions/comments


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

Documents

Aging Briefing Series Webinar