Enrollment Amy Killelea, JD NASTAD HRSA/HAB Grantee Webinar May - PowerPoint PPT Presentation

ADAP and Health Reform: Conducting Outreach and Enrollment Amy Killelea, JD NASTAD HRSA/HAB Grantee Webinar May 29, 2013

Presentation Overview  Part 1: Nuts and Bolts of ACA Eligibility and Enrollment  Part 2: ACA Outreach and Enrollment Training and Funding Opportunities and How HIV/AIDS Programs Can Be Involved  Part 3: Case Study – Massachusetts HIV Drug Assistance Program (Craig Wells)  Questions

Part 1: Nuts and Bolts of ACA Eligibility and Enrollment

Navigating the Marketplace Web Portal Exchange/Marketplace Portal Medicaid (people w/income up to 138% FPL) Qualified Health Plan (QHP) Federal Subsidies for Private Insurance: • Premium Tax Credits (people w/income 100-400% FPL) Federal Data Services Hub • SSN verification via SSA • Cost-sharing reductions (people • Citizenship and immigration status via DHS w/income 100-250% FPL) • Incarceration verification via SSA • Title II benefits information via SSA • MAGI income from IRS

Calculating Income Eligibility: MAGI  What is MAGI? – Income eligibility for Medicaid expansion and private insurance subsidies will be determined using Modified Adjusted Gross Income – MAGI is based on IRS definition of income:  No asset tests or income disregards  Adjusted Gross Income minus certain income (e.g., alimony and business expenses)  Household = tax filing unit (individual and anyone the individual can claim as tax dependent) – MAGI may be different from ADAP definition of income NOTE: only U.S. Citizens and lawfully present immigrants eligible for marketplace coverage

MAGI in Action: Streamlined Application

Navigating the Marketplace Web Portal: Premium Tax Credits  Advance Premium Tax Credits for people with income between 100 and 400% FPL – Tax credit = difference between benchmark premium and taxpayer ’ s expected contribution  Expected contribution based on annual income and increases from 2% of income to 9.5% as income increases  Based on end-of-year tax filings and paid in advance directly to plans (member responsible for overpayment) Income Second Lowest Individual Federal Premium (individual) Cost Silver Level Minimum Tax Credit Plan Premium Contribution Annual Monthly Annual Monthly Annual Monthly Annual Monthly (Michael) $17,235 $1,436.25 $4,500 $375 $689.40 $57.45 $3,810.60 $317.55 150% FPL (Michelle) $34,470 $2,872.50 $4,500 $375 $3,274.65 $272.89 $1,225.35 $102.11 300% FPL

Navigating the Marketplace Web Portal: Cost Sharing Reductions  Cost-sharing reductions (CSR) for people with income between 100 and 250% FPL – Increases actuarial value to reduce member contribution – Only available if person enrolls in a SILVER LEVEL plan Household AV Level AV Reduced OOP Plan Designs Income (Silver Level Requirement Maximum Plans) w/CSR 100-150% FPL 70% 94% ~$2,100 Deductible Copays Coinsurance 150-200% FPL 70% 87% ~$2,100 Deductible Copays Coinsurance 200-250% FPL 70% 73% ~$3,200 Deductible Copays Coinsurance

When Does Coverage Start? Medicaid QHP Through Exchange/Marketplace Eligibility determination “ promptly and without undue 90 day eligibility determination delay ” Continuous enrollment Open enrollment during specified times (with special enrollment available for a set of specific circumstances) Retroactive coverage up to 3 Coverage begins: • If the plan selection is received by the months prior to the date of application exchange/marketplace on or before December 15, 2013, coverage begins January 1, 2014. • If the plan selection is between the 1 st and 15 th day of any subsequent month during open enrollment period, coverage begins the first day of the following month. • If the plan selection is received between the 16 th and last day of the month, coverage begins the first day of the second following month.

How Will Clients Enroll in the Right Plan? Plan Analysis  Prescription drug formulary • Must be comparable to ADAP for ADAP to help with insurance purchasing  Scope of benefits covered • Limits on services (including prior authorization)  Availability/amount of premium tax credits and cost sharing reductions  Cost-sharing design  Provider networks Cost-Effectiveness Analysis  Is the cost of client premiums and co-pays LESS than the cost of providing full-pay drug coverage (aggregate)

Part 2: ACA Outreach and Enrollment Training and Funding Opportunities and How HIV/AIDS Programs Can Be Involved

ACA Outreach and Enrollment Programs and Resources Certified Application Counselors Community Insurance Health Assisters Centers Consumer Patient outreach Enroll Navigator and America Program enrollment  Has the state HIV/AIDS program applied for a Patient Navigator or assister grant?  How is the health department supporting consortia of HIV/AIDS providers to apply for Patient Navigator or assister grants?

Role of Case Managers  Where do case managers fit in outreach and enrollment? – Some states are already using medical case managers to work with clients on insurance benefits counseling and enrollment – Other states are carving out “ insurance benefits counseling ” from case management and developing new positions – All case managers need general training and information on ACA coverage and enrollment to be able to direct clients to appropriate resources

Part 3: The Massachusetts HIV Drug Assistance Program (HDAP) and Navigating Health Insurance post-Health Care Reform in Massachusetts Craig Wells, MSL HDAP Program Director Community Research Initiative of New England

Massachusetts HIV Drug Assistance Program (HDAP) • Three program components: • Full-pay (reimbursement to retail pharmacies for drug costs) • Co-pay (covers co-pay portion of drug costs not covered by insurance) • CHII (Comprehensive Health Insurance Initiative) pays health insurance premiums, including non- group, COBRA, employment-based, MassHealth (Medicaid), and Commonwealth Care/Choice

HDAP/CHII profile • Eligibility: individuals with a gross annual income up to 500% FPL • HDAP is administered for the Massachusetts Department of Public Health by Community Research Initiative of New England (CRI) • HDAP, combined with expanded Medicaid, enables Massachusetts to maintain a high level of treatment access for persons with HIV/AIDS

Comprehensive Health Insurance Initiative (CHII) CHII helps cover the costs of health insurance through assistance with payment of: • Non-group/small group premiums • Employee premium deductions • Self-employed insurance premiums • COBRA payments • Medicaid/MassHealth premiums

Comprehensive Health Insurance Initiative (CHII) • Originally created in 1999 under the HRSA insurance continuation policy as a pilot program designed to assist HIV+ consumers in obtaining/maintaining health insurance to cover the cost of drug treatment while increasing access to comprehensive care • Enrollment voluntary until 2005, when, as cost- savings measure, HDAP required all eligible program enrollees to obtain health insurance coverage

CHII Limitations • CHII cannot make direct payments to clients • CHII does not cover out-of-pocket costs, such as co- pays and deductibles, for: ▪ office visits and outpatient services ▪ prescription drugs not covered by HDAP or client ’ s insurance company ▪ inpatient service, ambulatory care or surgical procedures ▪ emergency room visits

CHII Requirements • Each HDAP client enrolled in CHII must:  Contact his/her health insurance company directly – HDAP staff are unable to contact the insurance company on behalf of client due to insurance/HIPAA regulations  Recertify for HDAP/CHII every 6 months  Re-apply to Medicaid every 12 months  Forward recent health insurance bills to HDAP staff  Inform HDAP/CHII staff of any changes in insurance premium (i.e. increase/decrease in premium amount)

Massachusetts Health Care Reform • Signed into law April, 2006 • Features:  Innovative merger of small and individual insurance markets  Attempt to improve quality and control costs  Completely subsidized, comprehensive health insurance for residents earning up to 150% FPL  Substantial premium subsidies to residents earning 150%- 300% FPL  Reformed non-group/small group insurance markets to lower the cost and offer more choices for residents purchasing non-subsidized plans

Massachusetts Health Care Reform • Features (continued):  Mandate for individuals to purchase coverage  New responsibilities for employers to ensure access for their workers (employers with at least 11+ FTE ’ s)  Qualified aliens (i.e. “ aliens with special status, ” “ documented immigrants, ” or “ legal immigrants ” ) are eligible  On-line portal for enrollment ( “ The Connector ” ) in subsidized and non-subsidized plans  Educational and outreach initiatives on enrollment, plan options

Massachusetts Health Care Reform • Subsidized insurance (clients w/incomes <300% FPL): Commonwealth Care  No deductibles  Co-payments for some services  Eligibility determination concurrent with Medicaid eligibility determination  Income level determines tier level/co-pay amounts