PresentersMarc J. Smith

Mary-Michal Rawling

The Affordable Care Act (ACA)

Starting in January 1, 2014

it will be Required that most U.S. citizens and legal residents obtain and maintain healthcare coverage for themselves and their dependents, or pay a penalty

Expands access to affordable health coverage by creating a new way to purchase coverage through affordable health insurance “Exchanges,” Covered California

Expands the current Medi-Cal program to provide opportunities for more individuals to be eligible

Simplifies the Medi-Cal process for easy enrollment and renewal

Essential Health Benefits

In order for health insurance to meet the ACA requirements, the plan must include

Minimum Essential Coverage

Programs identified to meet the Minimum Essential Coverage requirement include:

An eligible employer-sponsored plan

An individual policy (Obtained through or outside Covered CA)

A government plan (Medicare, Medi-Cal, TRICARE, VA)

Essential Health BenefitsEssential health benefits included in every plan:Ambulatory patient servicesEmergency servicesHospitalizationMaternity and newborn careMental health and substance use disorder

services, including behavioral health treatmentPrescription drugsRehabilitative and habilitative services and devicesLaboratory servicesPreventive and wellness services and chronic disease

managementPediatric services

What types of coverage will be available January 2014?

Modified Adjusted Gross Income (MAGI) Medi-Cal aka Medi-Cal expansion

Non-MAGI Medi-Cal- Refers to currently eligible Medi-Cal by 2013 standards

Subsidized Covered California CoverageAdvanced Premium Tax Credit

Cost Sharing Reduction

Individual Covered California plan without a subsidy

Employer coverage

Indigent health services

MAGI/Medi-Cal Expansion

MAGI is a new methodology that standardizes how income and

household composition is calculated to determine Medi-Cal eligibility starting in January 2014.

It is based on tax definitions of income developed by the IRS

MAGI Description

Adults Non-Disabled Individuals between 19 and 64 years of age

Parents Parents and other caretaker relatives with a dependent child

Children Infants and children under age 19, includes Children’s Health Insurance Program (CHIP) also known as the Percentage Program and Targeted Low Income Programs

Pregnant Women Pregnant and post-partum women

Paths to Eligibility

Path 1

Path 2

Path 3

At or below 138% of the Federal Poverty Level

Medi-Cal

Between 139% and 250% FPL

Between 251% and 400% FPL

Over 400% FPL

Eligible for a Covered California Health Plan

with premium assistance and

improved benefits

Eligible for a Covered California Health Plan

with premium assistance but NOT

with improved benefits

Eligible for a Covered California

Health Plan

Covered California

California’s Health Benefit Exchange

Assists customers in choosing a health plan and providers at the best value

Standardized co-pays and deductibles

Offers name-brand health insurance policies

Premium subsidies available to persons without other coverage up to 400% of Federal Poverty Level (FPL)

Cost sharing reductions (co-pays, deductibles) for persons up to 250% FPL

Four “Metal” benefit plans

Enrollment Periods

Apply NOW!Open Enrollment- Now through March 31, 2014

Customers must apply for benefits during open enrollment to be eligible for coverage through Covered California (unless there is a qualifying life event)

Special Enrollment (Must enroll within 60 days of occurrence)

Available when a Customer has a Life Change that impacts eligibility such as:

Loss of health coverage

Marriage or divorce

Pregnancy or birth of child

Moving to a new state

Newly eligible

Change of address that impacts plan selection

Released from incarceration

Medi-Cal applications accepted year-round

Advanced Premium Tax Credit (APTC)

Individuals who are not eligible for Medi-Cal will have the ability to qualify for Advanced Premium Tax Credit to subsidize the purchasing of health coverage.

This program will be available for individuals with incomes between 138%-400% of the Federal Poverty Level (FPL)

Plans will vary in cost depending on which “metal” benefit plan the customer selects (Bronze, Silver, Gold, Platinum)

Cost Sharing Reductions (CSR)

A benefit that reduces the out-of-pocket charges an enrollee must pay for medical care covered by the plan

Income must be under 250% FPL to be eligible

Only Customers enrolled in the Silver Plan are eligible

Metal Benefit Plans

Bronze: lower premiums, higher co-pays, covers 60% Silver Gold Platinum: higher premiums, lower co-pays, covers 90%

60% 70% 80% 90%

40% 30% 20% 10%

Bronze Silver Gold Platinum

Plan Pays You Pay

What are the costs?

Costs are based on your income, household size, age and where you live

Refer to a Certified Enrollment Counselor to see your options (A CEC cannot charge to enroll you)

Medi-Cal generally at no cost

How are rates determined?

Rates are based on:

Age

ZIP code

Household size & income

Health plan and benefit level selected

Rates are not based on:

Health status

Gender

Pre-existing conditions

Tobacco usage

Penalties for Not Having Health Coverage

What do I need to apply?

Information you will need to know

How do I apply?Covered CA “No Wrong Door” approach

There is ONE application to complete when applying for Covered California’s health insurance plans OR Medi-Cal.

Four service options…

Medi-Cal Expansion

Beginning Jan. 1, 2014

Medi-Cal to 138% Federal Poverty Level (FPL)

No linkage required (e.g. minor child)

No asset test for most Medi-Cal patients

Added mental health and substance use disorder benefits– also in private plans

If denied under current Medi-cal rules (pre-January 2014) but if eligible under the expansion then individual is Pre-enrolled for coverage under Merced County that will begin Jan 1st, 2014

Expanded Medi-Cal Eligibility

Eligibility Requirements

Starting January 1, 2014 any individual who meets the following requirements will be eligible for Medi-Cal:

Residency

Citizenship/Immigration status

Number of persons in the household

Social Security Number

Income- At or below 138% FPL

Transition of Medical Assistance Program (MAP)

Most MAP patients will go on Medi-Cal; others to be referred to Covered California

Applications transitioned to HSA from Public Health

These patients will need to establish care with a Primary Care Medical Home

Regional Call Centers

Open 6 days a week Calls from Merced County residents will be transferred

from Covered California to the Regional Call Center in Merced (they will also support residents of Mariposa, Madera, Inyo, Mono, Alpine, Amador, Calaveras, Tuolumne)

The Covered CA Service Center Representative will ask the Customer for the minimum information necessary

Any appropriate cases will be immediately transferred to the County of residence along with delegation of client application processing

Note: Interpretation Services are available for more than 300 languages at the Covered CA Service Center. The Regional Call Center will continue to use the Language Line as needed.

http://kff.org/health-reform/video/youtoons-obamacare-video/

Kaiser Family Foundation

The Youtoons: Get Ready for Obamacare

Key Enrollment Messages

1. Stay healthy with free regular wellness checkups2. You now have access to affordable medical coverage

3. Medical coverage provides me with peace of mind and

financial security

4. For my family’s future I have to provide them with health insurance

5. People without children are now newly eligible for

Medi-cal insurance

1. Free regular wellness checkups

All new health plans must cover preventive care and medical screenings.

Insurers cannot charge copayments, coinsurance or deductibles for such services.

You may be eligible for free preventive screening, like blood pressure and cholesterol test, mammograms, colonoscopies, cancer screenings and more. This includes coverage for vaccines and new preventive services for women.

2. Access to affordable medical coverage

Covered California will give you more choice and control over your health coverage.

Shop for health insurance online, in person, by mail or by phone.

Consumers with low to moderate income may qualify for federal financial assistance.

3. Peace of mind and financial security

Having health insurance is important to your health and financial security.

You can look forward to the peace of mind, safety, and stability that Covered California health plans will provide.

Hopefully you never need to use your health insurance, but it’s good to know you have coverage in case something happens.

4. For my family’s future I have to provide them with health insurance

Take pride in protecting what’s most important to you: your family.

Good health:

Allows children not to miss school

Permits adults to work on a consistent basis to support their family

Cost of a health plan vs. cost of emergency care

5. People without children are now newly eligible for Medi-Cal insurance

The affordable Care Act simplified the requirements for Medi-Cal eligibility and expanded the eligible population to include adults with no dependents

Let’s spin the wheel for

prizes!!!

Our Challenge

Getting all eligible patients covered

Common Excuses for Not Obtaining Insurance “I just want to think about it”

Health care is an important decision for your family that requires careful planning, however, enrollment into Covered California plans is only open until March, 31st 2014 and penalties will be assessed starting next year for those with no coverage

“I never get sick or will pay for care if I need it”

Having health insurance will provide you peace of mind, just in case you need it.

“ I know my family should have coverage, but insurance is too expensive” Covered California allows you to compare coverage options based on price, benefits, quality, and other

features important to you. You can choose the combination of price and benefits that fits your budget and meets your needs.

“We do not want anything to do with Medi-Cal” Expanded coverage under Medi-Cal means that doctors will get paid more for their services and will be

accepting more Medi-Cal patients, thereby, giving them more doctors to choose from You are not required to enroll in Medi-Cal; there are several options for private plans under the Covered

California exchange

“I want my choice of doctors” You have the right to choose the doctor you want from your health plan’s provider network.

Merced Co. Population Characteristics

Merced is home to 256,000 residents

A majority of residents are Latino (54%) and 32% are White (Asian - 7%, Black - 3.5%, Other - 3.5%)

84% of Merced residents are citizens, including 96% of children <18

38% of all residents have income below 150% FPL, including 48% of children <18

Only 40% of Merced residents have private insurance (individual or employer-sponsored)

Source: 2007-2011 American Community Survey 5-Year Estimates, US Census Bureau

Who are the uninsured in Merced? 51,700 Merced residents are uninsured (19.8%)

9 out of 10 uninsured are adults 18-64 Uninsured adults 18-64 (44,000), uninsured children <18 (6,000)

More than 9 in 10 uninsured fall below 400% FPL 43% of the uninsured have income <138% FPL and 90% have

income below 400% FPL

One-third of the uninsured are Non-Citizens (17,500)

Source: 2009-2011 American Community Survey 3-Year Estimates, US Census Bureau

Who are the uninsured in Merced?

3 out of 4 uninsured residents are Latino, despite representing 54% of the population (34,000 uninsured Latinos)

What programs will the uninsured be eligible for after the 2014 coverage expansion?

Close to 30,000 uninsured are almost certainly eligible for Medi-Cal or Covered California subsidies

7,000 – 10,000 of the 17,500 uninsured non-citizens may be eligible for Medi-Cal or Covered California enrollment

8,500 – 11,500 uninsured residents are likely to remain ineligible for any coverage programs following coverage expansion

ACA Coverage Eligibility Estimate

Medi-Cal 14,800

Covered CA - Subsidy 14,900

Covered CA – No Subsidy 3,500

Non-Citizen Covered CA or Medi-Cal 7,000 – 10,000

Remaining Uninsured Ineligible 8,500 – 11,500

What programs will the uninsured be eligible for after the 2014 coverage expansion?

Close to 30,000 uninsured are almost certainly eligible for Medi-Cal or Covered California subsidies Source: Rounded estimates using the 2009-2011 American Community Survey data

Source: Rounded estimates using the 2009-2011 American Community Survey data

What programs will the uninsured be eligible for after the 2014 coverage expansion?

Of the 17,500 uninsured non-citizens (does not include undocumented), between 7,000 – 10,000 may be eligible for Medi-Cal or Covered California enrollment

Source: Rounded estimates using the 2009-2011 American Community Survey data

Current Patterns/Mindset that will be barriers to enrollment

Using the Emergency Room (ER) for primary care

Low income residents opting to pay reduced cost (sliding fee scale) instead of getting coverage

These patterns typically result in:

Lower use of preventive services

Delay of needed care which causes needless pain, suffering, disability, or worse

Much higher overall health care expenditures

Outreach and Enrollment Efforts

Planning to be Certified Enrollment Counselors/Educators

Human Services Agency (mostly Medi-Cal)

Federally Qualified Health Centers

Castle Family Health Centers

Golden Valley Health Centers

Livingston Medical Group

Community Based Organizations (CBO)

Certified Insurance Agents

Outreach and Enrollment Efforts

Monthly Health Care Consortium meetings

Health Care Fact Sheet

Wallet Size Card

Community outreach material at :

http://www.co.merced.ca.us/index.aspx?NID=2000

www.coveredca.com

http://getcoveredca.com/toolkit/

http://www.allinforhealth.org/

Community Resources for Coverage Assistance:

Covered California

1-888-975-1142

Golden Valley Health Centers

1-866-682-4842

See Community Resource Handout for more details

Questions?