Health Reform and Health Coverage:
Changes Ahead for Kids and Families
Kim VanPeltSt. Luke’s Health Initiatives
September 16, 2013
Coverage Expansion
Employer-based coverage Medicaid
The “Exchange”
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Medicaid Expansion • Over 300,000 Arizonans will benefit
• Provides coverage up to 138% of the federal poverty level (approximately $32,500 for a family of four)
• Supported by the Governor, passed by the Legislature
• Restores the will of the voters
• Approximately 60 percent of voters support restoration or expansion
• Eligibility screening begins in October, coverage begins on January 1, 2014
Improvements to Coverage
• Prevents discrimination in pricing based on pre-existing conditions
• Essential benefits chosen by Arizona allows for coverage of many services
• Those who have self-insured or grandfathered plans will not benefit from essential benefits, elimination of cost-sharing
Essential Benefits
• Emergency services • Hospitalization• Maternity and newborn care• Mental health and substance use disorder services• Prescription drugs;• Rehabilitative and habilitative services and devices • Laboratory services• Preventive and wellness services• Chronic disease management• Pediatric services, including oral and vision care
Essential Benefits
• Arizona picked state employee plan, administered by United Health Care, as benchmark
• www.cms.gov/CCIIO/Resources/Data-Resources/Downloads/arizona-ehb-benchmark-plan.pdf
The Marketplace• Exchange now called the Marketplace
• Arizona deferring to the federal government to run
• Online site for individuals and small businesses to compare and purchase health coverage
• Intended to simplify and structure health insurance choices for individuals, families and small businesses
• Exclusive mechanism for receiving federal subsidies and plans with cost-sharing limits
The Marketplace
• Open enrollment begins October 1
• Open enrollment will occur through the end of March
• 1.3 million Arizonans predicted to eventually receive coverage through the marketplace
The Marketplace
Expected Enrollment by Type
• Individual Exchange: 496,000
• AHCCCS (assuming Medicaid expansion):343,000
Plan Levels of CoverageLevel of Coverage Plan Pays on Average Enrollees Pay on Average
(In addition to the monthly plan premiums)
Bronze 60% 40%
Silver 70% 30%
Gold 80% 20%
Platinum 90% 10%
Catastrophic Plans
• Eligible to adults under 30 years of age
• Also available to those who obtain a hardship waiver from the marketplace
• Includes plans with high deductibles, lower premiums
• Includes coverage or three primary care visits and preventive services
Premium Subsidies
• Tax credit is advanceable or refundable
• Eligibility is based on – Projected household income and family size– 100 – 400% FPL ($23,550 -$94,200 for a family of four in 2013)– Obtaining qualified coverage through the marketplace– Ineligible for government-sponsored coverage, affordable-
sponsored insurance, or certain other minimum essential coverage
• Tax credits available to immigrants who are lawfully present
Cost Sharing Reduction
• Eligibility for reduced cost sharing is based on – Incomes at or below 250% of FPL ($58,875
annually for a family of four in 2013)– Receiving the new premium tax credit– Enrolling in a marketplace silver-level plan– No cost sharing for members of Tribes
Individual Mandate
• Beginning in 2014, most people must have health coverage or pay a fee when you file your tax return
• Some people may qualify for an exemption
Cover Arizona
• Builds off of the successful outreach efforts for the Pre-Existing Conditions Insurance Pool
• More than 300 members
• Two goals:
– Maximize enrollment of individuals and families in the new insurance marketplace and Medicaid
– Identify and assess outreach efforts so that we can build on our successes
Local Action Needed to Ensure Success
• Awareness
• Outreach
• Enrollment Assistance
Enrollment Assistance
• Navigators
• Certified Application Counselors
• Toll Free Hotline
• Brokers
Special Issues for Kids and Families
• Members of the same family may qualify for different programs
• KidsCare II disappears in 2014
• Businesses may begin dropping family coverage
Two Doors
• Health E Arizona Plus
• Marketplace
Timeline• August – Navigator grants awarded
• August – September – Navigators and certified enrollment assisters trained
• October – Determination of which plans will participate in the exchange
• October - Open enrollment in the exchange begins
• October - Media campaign begins, driving people to Healthcare.gov
• January 1, 2014 – Coverage purchased through exchanges takes effect
Need more information
• www.healthcare.gov
• Marketplace Call Center (Consumers) - 24/7 English and Spanish and 150 Languages 1-800-318-2596, 1-855-889-4325 (TTY)
• www.marketplace.cms.gov
• www.coveraz.org
www.slhi.org
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