Public & Private Health Insurance Coverage & Community Health Centers

1. Public & Private Health Insurance Coverage & Community Health Centers The Affordable Care Act, BadgerCare, and Community Health Centers A primer for AmeriCorps members

5. What do you know about the Affordable Care Act?

6. What was the ACA intended to do? Solutions in the ACA • Mandatory health insurance • Individual Marketplace • Elimination of caps • MA Expansion • Guaranteed Issue Problems • 18 – 20% uninsured rate • Affordability • Jobs • Already sick • 70 million Americans in medical debt

7. In Short… The Patient Protection and Affordable Care Act

8. Patient Protection… AKA Health Insurance Reforms • Allows young adults to stay on parents’ policies until they are 26 • Eliminates lifetime limits • Phases out annual limits (gone in 2014) • Many preventive care services must be offered without co-pay or deductible • 80% of your premium most go to care (MLR) • Minimum Essential Benefits • No denials for pre-existing conditions!

9. …and Affordable Care Act! • Individual Marketplace • Subsidies for low-income individuals • Tiers of coverage • New Funding for Community Health Center expansion • Hooray! • Medicaid Expansion • State choice

10. ACA Creates New Marketplaces Avenues to Health Insurance TRICARE Military Providers Doctors Specialists Hospitals Clinics Rx Drugs Etc. Exempt Government Coverage VA Some Veterans Uninsured Medicare Seniors and SSDI Insured Products HMOs PPOs FFS Etc. Insured Medicaid < 100% of FPL, EBD, SSI, Pregnant Women & Children Individuals and Self-Employed Individual Marketplace Private Coverage SHOP Marketplace Small Groups 1-50 FTEs Self-Insured Employer Large Groups 50+ FTEs Credit: Community Advocates Public Policy Institute

12. 1. Create an account

13. 2. Apply JOE’S SUPER AWESOME HEALTH PLAN Premium: $300 WITH ATPC: Now is $76 Co-Pay: $20 PCP WITH CSR: Now is $0 OR

14. 3. Pick a Plan • Which Qualified Health Plan? • Which Metal Tier? • How much can I afford with or without advance premium tax credits and cost-sharing reductions? • Is my current doctor in network? • Are my specific medications covered?

15. Credit: Center for Budget and Policy Priorities

16. Qualified Health Plans in Wisconsin The individual plans sold by health insurance companies on the Marketplace are known as “Qualified Health Plans” The Wisconsin Office of the Commissioner of Insurance lists QHPs by county and plan year on their website.

17. OCI Map of Comprehensive Health Insurers - Individual Market

18. Metal Tiers Plans sold on the Health Insurance Marketplace are divided into four metal tiers, and some offer catastrophic coverage.

19. Cost Sharing Subsidies Individuals with lower incomes can receive discounts on their deductibles and co-pays when they enroll in a silver plan. They further stretch the value of one’s health insurance. These do not need to be reconciled.

20. Premium Tax Credits (PTC) The ACA created a federal tax credit that helps people purchase health insurance in health insurance marketplaces (also known as exchanges). The “premium tax credit” is available immediately upon enrollment in an insurance plan so that families can receive help when they need it rather than having to wait until they file taxes. People can choose to have payments of the premium tax credit go directly to insurers to pay a share of their monthly health insurance premiums charged or wait until they file taxes to claim them.

22. Wisconsinites Plan Selections by Metal Level, Plan Year 2019

24. An Example

25. 4. Enroll! In order to start receiving benefits, you must enroll in that plan and begin making premium payments.

26. Benefits, explained

27. Benefits, explained

28. 5. Effectuate & Use Your Coverage!

29. Individual Mandate Starting with the 2019 plan year, the Shared Responsibility Payment no longer applies

30. When Can You Enroll? Marketplace Open EnrollmentNovember 1-Dececmber 15, 2019* BadgerCare & Medicaid Year Round! *Marketplace Special Enrollment Period is Year Round

31. What is a Special Enrollment Period? • If a person or family experiences a qualifying life event or in certain other circumstances related to the enrollment process, they may be eligible for a Special Enrollment Period (SEP) • This SEP will allow them to enroll in health insurance coverage through the Health Insurance Marketplace outside of a open enrollment period. The individual or family will typically have 60 days from the qualifying life event or approval of their SEP request to enroll in new Marketplace coverage

32. Special Enrollment Periods • Marriage • Marriage with Dependent Gained • Divorce (if loss of MEC) • Death (if loss of MEC) • Birth • Adoption • Placement for Adoption • Foster Care Placement • Permanent Move to New Service Area • Becoming Lawfully Present • Gaining AI status • Income change resulting in change in APTC eligibility (if enrolled) • Release from Prison • Involuntary loss of ESI • Loss of Dependent Status • Expiration of COBRA • Individual plan non-renewal outside of open enrollment • Errors, mis-representation or inaction by enrollment assister • QHP misrepresentation or contract violation • Technical problems • Immigration status error • Website display error • Unresolved casework • Medicaid/Marketplace transfer issues • Natural Disaster • Serious Medical Condition • Victims of Domestic Violence • Loss of Hardship exemption http://www.healthreformbeyondthebasics.org/wp-content/uploads/2015/06/SEP-Reference-Chart.pdf

33. What doesn’t trigger a SEP? • Voluntarily dropping other coverage • Loss of eligibility for coverage when one was not actually enrolled in it • Being determined newly eligible for subsidies if you aren’t currently enrolled in a QHP • Income change (unless your income moves above 100% FPL) • Being terminated from coverage due to non-payment of premiums. • Divorce or death of a family member without it resulting in a loss of coverage.

34. A Guide to Special Enrollment Period Triggers and Timing

35. Who Can Help Me? The State and Federal Government train and certify individuals who can help you apply for health insurance through the Marketplace: • Certified Application Counselors • Navigators • Non-Navigator Enrollment Assisters • Agents & Brokers Find them here: www.enrollwi.org www.localhelp.healthcare.gov

36. How many Wisconsinites have Marketplace coverage?

37. What do you know about BadgerCare?

38. BadgerCare Basics BadgerCare is the name for Wisconsin’s Medicaid program which offers health coverage to individuals with low-incomes. 400%FPL 300%FPL 306%FPL 200%FPL 100%FPL 50%FPL

41. Section 1115 Waivers: What is an 1115 Waiver? Section 1115 of the Social Security Act gives the Secretary of Health and Human Services authority to approve experimental, pilot, or demonstration projects that promote the objectives of the Medicaid and Children’s Health Insurance Program (CHIP) programs. Under this authority, the Secretary may waive certain provisions of the Medicaid law to give states additional flexibility to design and improve their programs.

42. *DHS Reforms BadgerCare Plus for Childless Adults* Population Covered: Non-pregnant adults without children (19-64) who make less than 100 percent of FPL. • Premiums • Cost Sharing • Work Requirements and Time Limits • Health Risk Assessment • Comprehensive substance use disorder residential treatment was added for all enrolled in BC+ or Medicaid.

43. BadgerCare 2013: Pre ACA % FPL: 0% 133% 150% 200% 100% 300% No cost-sharing With a premium No cost-sharing With a premium Health Insurance Exchanges for Individuals and Small Groups With a premium No cost-sharing No cost-sharing

44. BadgerCare 2014: Post ACA % FPL: 0% 133% 150% 200% 100% 306% No cost-sharing With a premium Deductible Deductible No cost-sharing With a premium No cost-sharing Marketplace Coverage – APTCs & CSRs No cost-sharing Marketplace Coverage – APTCs & CSRs

45. BadgerCare: November 1, 2019 % FPL: 0% 133% 150% 200% 50% 100% 306% $8* Marketplace Coverage – APTCs & CSRs $4 No cost-sharing No cost-sharing

46. What Does BadgerCare Cover? • Case management services • Chiropractic services • Dental services • Family planning services and supplies • HealthCheck (Early and Periodic Screening, Diagnosis and Treatment) for people under 21 years of age. • Some Home and community-based services • Home health services or nursing services if a home health agency is unavailable • Hospice care • Inpatient hospital services other than services in an institution for mental disease • Inpatient hospital, skilled nursing facility, and intermediate care facility services for patients in institutions for mental disease who are: • Under 21 years of age • Under 22 years of age and was getting services when you turned 21 years of age • 65 years of age or older • Intermediate care facility services, other than services at an institution for mental disease • Laboratory and X-ray services • Medical supplies and equipment • Mental health and medical day treatment • Mental health and psychosocial rehabilitative services, including case management services, provided by staff of a certified community support program • Nurse midwife services • Nursing services, including services performed by a nurse practitioner • Optometric/optical services, including eye glasses • Outpatient hospital services • Personal care services • Physical and occupational therapy • Physician services • Podiatry services • Prenatal care coordination for women with high-risk pregnancies • Prescription drugs and over-the-counter drugs • Respiratory care services for ventilator-dependent individuals • Rural health clinic services • Skilled nursing home services other than in an institution for mental disease • Smoking cessation treatment • Speech, hearing, and language disorder services • Substance abuse (alcohol and other drug abuse) services • Transportation to obtain medical care • Tuberculosis (TB) services

47. When Can You Enroll?

48. How Can I Enroll?

49. Who Can Help Me? The Wisconsin Income Maintenance Consortia are responsible for processing BadgerCare, FoodShare and Medicaid Applications. Income Maintenance staff are the only individuals who can make an eligibility determination, however anyone can help an individual to apply.

50. Manage benefits on the go!