New Mexico Health Care Reform May 28, 2013 Paige Duhamel, Esq. Southwest Women ’ s Law Center
What Does the Affordable Care Act Do? • New Law ( “ Obamacare ” ) – Hold insurance companies more accountable – Lower health care costs – Guarantee more health care choices – Enhance quality of care – Through: • Expanding Medicaid to new populations • Creates insurance marketplaces called Exchanges • Reforms the private insurance market • All by January 1, 2014 (October 1, 2013)
How Do We Get to 2014? • 1. Insurance Coverage – Gain coverage under Medicaid Expansion, purchase insurance through the Exchange, or acquire insurance through another, as yet to be determined basic health care option. • 2. Insurance Reforms – Consumer Protections (e.g. – no pre-existing conditions exclusions) • 3. Personal Responsibility – Individual Mandate (But wait! Native American Exception)
Medicaid Expansion • Governor agreed to expand New Mexico ’ s Medicaid program in 2014. – Yay! • Medicaid Expansion will make approximately 160,000 new New Mexicans eligible for Medicaid coverage. • Adults, age 19-64 with incomes below 138% of the federal poverty level, will become eligible. • Including single adults and working adults.
Medicaid Expansion • Newly Eligible Medicaid Populations – Adults, age 19-64 with incomes below 138% of the federal poverty level. Single Adult Family of Four $15,000 in annual income $32,000 in annual income or less or less
Medicaid Expansion • Newly Eligible Medicaid Populations
Medicaid Expansion • Monthly eligibility income levels –
Medicaid Expansion • State Coverage Insurance (SCI) – If you or someone you know has State Coverage Insurance (SCI) this program will end in 2013. – Don ’ t worry! Many individuals currently on SCI will now qualify for Medicaid or substantial financial assistance to purchase private health insurance coverage through the Exchange (and you can ’ t be denied if you have a pre-existing condition).
What is an Insurance Exchange? • The Affordable Care Act creates health insurance marketplaces called “ Exchanges ” where individuals: – can purchase insurance – qualify for premium subsidies to make health care coverage more affordable – Offer plans that have standardized benefits options called “ Qualified Health Plans. ”
What is an Insurance Exchange? • The Idea Behind Exchanges – – By pooling people together, and creating economies of scale, Exchanges create more buying power. – Exchanges leverage that buying power to • Reduce transaction costs • Increasing transparency • Create more efficient and competitive markets for individuals and small employers. – Historically, the individual and small group health insurance markets have suffered from adverse selection and high administrative costs, resulting in low value for consumers.
Who Gets Insurance Through Exchange? • Who gets covered? – Individuals and families who make more than 133% and 400% of the federal poverty level in annual income will be able to purchase insurance through the Exchange and receive premium subsidies. – Individuals above 400% FPL who do not receive coverage through their employers, and who do not qualify for subsidies. – Ultimately, about 400,000 New Mexicans. • Single Adult Individual Family of Four • $44,000 in annual income or $89,000 in annual income or Family less less
Exchange Eligibility • Monthly eligibility income levels –
Insurance Coverage Offered Through Exchange • Exchange must offer “ Qualified Health Plans. ” – A qualified health plan (QHP) is a plan that is certified by and offered through the Exchange: • Essential health benefits • Fully insured plans only • Accreditation on clinical quality measures • No pre-existing coverage exclusions for all ages • No annual limits on essential health benefits • No lifetime dollar benefits on essential health benefits • Minimum levels of coverage ( no cost-sharing for preventative services)
Insurance Coverage Offered Through Exchange • Essential health benefits – Ambulatory patient services – Emergency services – Hospitalization – Laboratory services – Maternity and newborn care – Mental health and substance use disorder services, including behavioral health treatment – Prescription drug coverage – Rehabilitive and habilitative services and devices – Preventative and wellness services, and chronic disease management – Pediatric services, including oral and vision care.
Consumer Protections • Insurance Reforms and Regulations – The Affordable Care Act contains many consumer protections that have been designed to preserve the continuity of doctors ’ care of patients and patients ’ access to health care services, without arbitrary limitations.
Individual Mandate • Most individuals who can afford it will be required to obtain basic health insurance coverage or pay a fee to help offset the costs of caring for uninsured Americans. • If coverage is not available to an individual, he or she will be eligible for an exemption. • American Indians are automatically exempt – AI ’ s are not required to obtain health insurance coverage.
Employer Responsibility • Employers Have Responsibility to Offer Coverage – Employers with more than 50 full-time employees are required to offer minimum essential health coverage. – Employers who do not comply and whose employees are forced to seek a subsidy for health care coverage will be penalized. – TRIBES ARE NOT EXEMPT FROM EMPLOYER COVERAGE REQUIREMENT. – Tax credits available to small businesses that provide employees coverage.
Consumer Enrollment • Ways an Exchange will help consumers enroll in insurance coverage: – Must provide • A consumer-friendly website. • A toll-free hotline • A Navigator Program (state and federally mandated) – Can provide additional enrollment assistance options • An in-person assister program • Brokers and insurance agents • Health care providers
What Are Navigators? • Navigators are entities that will assist consumers and small employers with enrollment in the Exchange. – Conduct public education activities to raise awareness of the Exchange – Help people enroll in and apply for insurance coverage through the Exchange – Must provide culturally and linguistically sensitive services – Offer referrals to ombudsman programs to assist in conflict dispute resolution. – Funded by the state – NO FUNDING ALLOCATED IN NM IN 2014.
Who can be a Navigator? • Navigators must come from two categories of organizations, one of which must be consumer- oriented non-profit. – Navigator entities can include: • Tribes • State or local human services agencies • Other public or private entities that are capable of carrying out the required duties and providing information that is fair, impartial, culturally sensitive, and accurate. • Insurance carriers CANNOT be Navigators.
Navigators and Medicaid • What are Navigators ’ relationship to Medicaid? – Training requirements mandate that Navigators must be trained in Medicaid/other affordability programs eligibility. – Duties do not require Navigators to include Medicaid enrollment. – Only duty is to refer individuals to Medicaid and other affordability programs where appropriate. – Application will screen for both Medicaid and Exchange.
Who Are In-Person Assisters? • Surge workers – Perform similar functions in enrollment assistance as Navigators. – Intent is to supplement the Navigator program in its first year – Help enroll large numbers of individuals newly eligible for coverage – Proposed regulations - must meet same federal conflict of interest standards as Navigators, plus additional federal standards
Difference Between In-Person Assisters and Navigators In-Person Assisters Navigators Salaries federally funded Salaries state funded Temporary program – Surge workers to Permanent program/workforce address high-volume enrollment needs Paid through contract, direct hiring, or Paid for by grant-award program grants, at state ’ s discretion NM has applied for some federal funding No funding currently allocated
Assisters and Medicaid • What are Assisters ’ relationship to Medicaid? – Training requirements mandate that Assisters must be trained in Medicaid/other affordability programs eligibility. – Duties require Assisters to discuss full range of insurance affordability programs, including Medicaid, with consumers, and direct individuals to enrollment resources. – Application will screen for both Medicaid and Exchange.
What Are Certified Application Counselors? – Two different kinds of Certified Application Counselors (CAC) • Exchange CAC - mandatory • Medicaid CAC – by option of state
What Are Certified Application Counselors? • Exchange CAC ’ s – Mandatory state program – Exchange must provide training and certification to Exchange and Medicaid-designated organizations for staff and volunteers. – Intention is to have a training and certification program for staff employed by FQHC ’ s, hospitals, and other agencies that have staff that work with consumers on coverage issues.
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