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The Affordable Care Act Made Simple Understandable By Congress

The Affordable Care Act Made Simple Understandable By Congress. M E D I C A R E. The ACA is 906 pages long: Many parts are already in effect. We will talk about: Medicaid changes Private insurance market changes. No pre-existing condition exclusions Guaranteed issue

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The Affordable Care Act Made Simple Understandable By Congress

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  1. The Affordable Care Act Made Simple Understandable By Congress

  2. M E D I C A R E

  3. The ACA is 906 pages long: • Many parts are already in effect. • We will talk about: • Medicaid changes • Private insurance market changes

  4. No pre-existing condition exclusions • Guaranteed issue • Premiums can’t be based on health status, but can charge more for smokers! • Plans offered on exchanges must include MH/SA benefits at parity

  5. Allows expansion of Medicaid to 133% FPL with enhanced federal funding. • Allows Medicaid to cover non-disabled adults without dependent children. • Along with formation of exchanges can reduce the uninsured by more than half.

  6. In Mass. 20-30% of patients seeking acute MH/SA services are uninsured (in a state where 97% of population as a whole is insured). • In Mass., half of patients with MH and SUD conditions in focus groups were avoidably disenrolled at least once from their health insurance in the past year. Substance Abuse and Mental Health Services Administration. Enrollment and Disenrollment in Subsidized Health Insurance: Lessons Learned in Massachusetts. November 2011

  7. Unfamiliarity with health insurance and its value • Lack of awareness that they are eligible • Cost concerns (premiums, co-pays and deductibles) • Distrust of government programs • Lack of decision-making skills • Churn • Uncovered services; exclusion for preexisting conditions • Individuals with SUD new to health care system • Complicated enrollment process

  8. Educate!

  9. I am on Medicaid now; will my eligibility change? Answer: If your income is more than 100% of the FPL and you are not on Medicaid due to a disability you may lose your Medicaid. If you are on SSI or SSDI your Medicaid eligibility will not change.

  10. Terminology Check: FPL, or the federal poverty level, is the poverty threshold used by government entities for administrative purposes, such as eligibility for programs. It is based on annual cash income. Loosely, how much an individual or family requires to meet their basic needs.

  11. Examples of FPL: One person: 100% = $11,490 133% = 15,282 Family of four: 100% = 23,550 133% = 31,322

  12. I don’t have Medicaid now but have heard about the expansion. Will I now be able to get Medicaid? Answer: If you are an adult without dependent children and under 100% of the FPL you may now become eligible for Medicaid.

  13. The original law required states to cover everyone up to 133% of the federal poverty level under Medicaid: • $15,282 for an individual • $31,322 for a family of four

  14. However, a Supreme Court ruling said that the federal government could not require this. So states could decide whether to expand or not, although there was a big “carrot”: 100% federal financing for 3 years reduced to 90% eventually.

  15. Wisconsin’s plan: • Cover everyone up to 100% FPL under Medicaid ($11,490 for one person) • Most people over 100% FPL get services through the exchanges. • People on Medicaid due to a disability (SSI or SSDI) remain on Medicaid.

  16. If I stay on Medicaid will my benefits change? Answer: Benefits should not change for those people on SSI/SSDI

  17. Those people under 100% FPL who become newly eligible will have the standard Medicaid benefit: • This is much better than those on the current “CORE” plan.

  18. I heard that there are also changes to the MAPP program. Is that true? Answer: Not now. There was a proposal in the State budget but it was not approved.

  19. Terminology Check: MAPP, or the Medical Assistance Purchase Plan, was designed to reduce disincentives for people on Medicaid to return to work by allowing them to “buy in” to the program.

  20. Will things change if I am on Medicare? Answer: The ACA did not change Medicare eligibility or benefits (except for Part D), although it made some changes to the way providers are paid. If you are on Medicare you may not be able to buy plans on the exchanges and will not be eligible for subsidies on the exchanges if you do.

  21. Will things change if I am on HIRSP? Answer: Yes. The Health Insurance Risk Sharing Program, which is for individuals who have been unable to obtain insurance due to pre-existing conditions, will seek to exist. People will need to either get insurance through Medicaid or through the exchanges.

  22. I am receiving some services now through my county. Will I be able to continue to do so? Answer: Every county makes their own decisions about this so it will depend upon your county.

  23. Changes in both state and federal law will impact the ability of counties to obtain Medicaid reimbursement: • They will be able to gain new reimbursement for the new Medicaid eligibles. • They may lose reimbursement they were receiving for people on MA above 100% FPL.

  24. They may gain additional state financing for mental health services through the Governor’s budget proposal. • They may gain reimbursement for some services through the exchanges.

  25. So what are these exchanges? Answer: The exchanges are a place where individuals can buy insurance and be part of a larger pool of purchasers.

  26. Right now you would have a hard time buying affordable insurance as an individual, especially if you have a disability. -Plans offered in the marketplace cannot refuse you due to a pre-existing condition.

  27. Terminology Check: The federal “exchanges” are also being referred to as the “Marketplace” healthcare.gov

  28. So if I have to use the new marketplace will I still be able to get mental health services? Answer: Yes

  29. The ACA requires all plans on the marketplace to offer certain essential health benefits; one of these is mental health and substance abuse treatment. • Wisconsin’s benchmark plan includes mandated services required in statutes.

  30. The ACA also requires all plans on the marketplace to offer mental health and substance abuse services at parity: • That means that things like visit limits and copays cannot be more restrictive than for other medical services.

  31. We expect the plans offered on Wisconsin’s marketplace to include all of the following: • Inpatient services • Outpatient services • Transitional treatment services • Medications

  32. Transitional treatment services include: • Day Treatment/partial hospitalization • Community Support Programs • Crisis intervention • Residential treatment for AODA

  33. While we know that medications must be made available we do not know at this point how extensive a formulary the exchange plans will provide: • It may be that you will need some type of authorization to continue on a current medication or be asked to switch to a different medication.

  34. Terminology Check: A formulary is a listing of the medications that are offered through a given health plan. A formulary can be “open”, which means it offers any FDA approved drugs, or “closed” which means it offers only certain drugs.

  35. How much will it cost me to buy insurance on the exchange? Answer: we don’t know the answer to this yet.

  36. The exchanges will offer plans at four different levels. Each level will have different estimated out of pocket costs. -the plans with the lowest estimated out of pocket costs will have the highest premiums. • Platinum, Gold, Silver, Bronze.

  37. The ACA says that out of pocket costs for a single person cannot exceed $6250. • However, out of pocket maximums vary by “metal” level. • For silver plan this maximum is $2250.

  38. Subsidies will be available for people between 100% and 400% of the FPL: 400% = $43,320 for single person $88,200 for a family of 4 • Subsidies ensure you don’t pay more than a given % of income for premium.

  39. Individuals eligible for the subsidy, also known as the federal premium tax credit, cannot pay more than the following premium amounts (silver plan): 100% FPL: $19.00/month 200% FPL: $117.00/month

  40. There are also cost-sharing reductions if your income is between 100 & 250% of FPL. • Only apply for “silver” plans.

  41. Benefit Calculator: http://healthreform.kff.org/subsidycalculator.aspx Or search: Kaiser Family Foundation Provides information on your options based on your income and family size.

  42. Catastrophic Plans: • Under 30 years old • Not eligible for subsidies • No other affordable options • Must pay $6350 out of pocket

  43. Can I get insurance someplace other than the marketplace? Answer: Yes, there will be other plans available in a “private” exchange or directly from insurers, as now.

  44. Plans in the private exchange may be less expensive but: -they will not be required to have all the essential health benefits. -they will not be eligible for premium subsidies.

  45. I heard I might have to pay a penalty if I don’t buy insurance. Is this true, and if so how much is it? Answer: yes, there is a penalty for people who don’t purchase insurance.

  46. This will not apply if you are on Medicaid or Medicare. People will be required to report to the IRS whether or not they have insurance.

  47. You will not have to pay a penalty if: -Your income is below 133% FPL and the state does not make you eligible for Medicaid. -Your household income is below the minimum requirement for filing a tax return: $9350 for an individual. -You can’t afford coverage because the minimum premium exceeds 8% of household income.

  48. Hardships • Homelessness • Eviction • Domestic violence • Death of close family member • Disasters damaged individual’s property Must file an application and make request at that time.

  49. Penalties: 2014: Greater of $95 or 1% of income 2015: “ “ $325 or 2% of income 2016: “ “ $695 or 2.5% 2017- : adjusted for inflation Paid as part of taxes.

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