Health Care Reform: What Is It, How Does It Work, And How Does It Affect Me?

1. Health Care Reform: What Is It, How Does It Work, And How Does It Affect Me? Lake County Department of Social Services 7/17/13 County Logo

2. The Parking Lot Today is an overview of Health Care Reform. We aren’t going into the specifics, just yet. Please submit questions to the parking lot. Parking Lot Q&A Submit your questions & we will post the answers as we get them to the Resources page under Training at \\ss_cardassian\DATA1\Forms\Program Support\resources.mht

3. Presentation Overview • The Basics • What Is Health Care Reform? • The Mechanics • How Does It Work? • What Is My Role As An Eligibility Worker? • The Challenges • How Are We Preparing?

4. Affordable Care Act Basics • Affordable Care Act passed in 2010 • Changes that have already been implemented: • Access for uninsured with pre-existing conditions • Coverage for young adults until 26 on a parent’s plan • Coverage for preventive services such as mammograms and colonoscopies • Two mechanisms for expanding coverage: • Medicaid expansion • Tax-based subsidies through state-based exchanges *The exchange is where individuals and families who buy their own health insurance now or who currently forgo it all together, will be able to go to find affordable coverage.

5. Affordable Care Act Basics

6. Affordable Care Act Basics • Income is determined by a person or a family’s Modified Adjusted Gross Income (MAGI) as determined under federal tax rules and reported via their federal tax filings. • Someone with an income over 400% can still purchase coverage through the Exchange; however, they will not be eligible for any subsidies.

7. Affordable Care Act Basics Medicaid/Medi-Cal Expansion Tax Subsidy Exchange-Based Coverage • Simplifications in program (no asset test, etc.*) • Income & household size calculated differently than CalFresh, CalWORKs • Governed by California Department of Health Care Services *For many MC programs. • Tax credit subsidies for qualified enrollees • Cost-sharing reductions for lowest income • Marketplace for those greater than 400% FPL to purchase unsubsidized coverage • Governed by Covered California - new name for the state’s exchange, created in 2010

8. Affordable Care Act Basics • There will be penalties for individuals who do not have some form of minimum health care coverage. • There will be penalties for companies and businesses who don’t provide any coverage at all and/or affordable coverage. • We won’t be going over the specifics of the penalties today. However, what this means to us is that we will see an increase in people coming to us to sign up for MC and health care insurance to avoid paying these penalties. And, an increase in volume because more people will be eligible to MC due to expanded coverage.

9. Affordable Care Act Basics • Open Enrollment Starts October 1, 2013 • 76 days from today • Coverage Begins January 1, 2014 • 168 days from today

10. Affordable Care Act Mechanics • County system C-IV still in use • Part of the Statewide Automated Welfare System or SAWS. (CalWIN and Leader are also part of SAWS) • New system being built for Exchange and Medi-Cal rules • Known as CalHEERS (California Healthcare Eligibility, Enrollment, and Retention System • Will include online portal, rules engine, and Exchange plan selection. • Pre-Enrollment will start October 1, 2013 • Two systems must be interfaced to work together • Will avoid having staff use two systems • Interface delayed – October 1, 2013 to January 1, 2014 • Delay has customer service and workload implications

11. Affordable Care Act Mechanics The public can apply for Medi-Cal and shop for APTC • At C4Yourself.com • CoveredCA.com • In person in our lobby • By mail (to DSS or Covered California) • By phone through Covered California • By calling any County DSS “No Wrong Door”

12. Affordable Care Act Mechanics:The Players • The customer can go to Covered California (the online market place), enter their information, and get a Medi-Cal determination for some or all members of their household, and purchase health care for others. At Covered California customers can compare plans, use their Advance Premium Tax Credits (APTC), or purchase exchange plans.

13. Affordable Care Act Mechanics:The Players • The customer can come into our office (DSS) and get a Medi-Cal determination and we can help them with plan selections and help them use their Advance Premium Tax Credits (APTC) to purchase health care for some or all of the people in their home. We can also help them with exchange plan selection. *Not everyone will need to know everything by October. There will be a specialized unit in place.

14. Affordable Care Act Mechanics:The Players Community-based Certified Enrollment Counselors are being recruited to enroll individuals; they will be compensated. • In addition, Certified Insurance Agents can enroll individuals into Exchange plans. • Or customers can call Covered California

15. Affordable Care Act Mechanics Warm hand off/not to our county • After case established, transferred to our county • for ongoing case management

16. Affordable Care Act Mechanics Exchange agent will do a “quick sort” to determine whether it is an Exchange or Medi-Cal customer. The agent will use an automated “Smart Calculator” tool available to call center agents in CalHEERS. The quick sort will tentatively consist of questions such as: • How many people in the family? • Are there any children who are seeking coverage? • Is anyone who is pregnant seeking coverage? • Is anyone who is elderly or disabled seeking coverage? • What is the annual income? Tentative questions to sort the call to the county include: • Single childless adult under 138% FPL • Pregnant woman under 200% FPL • Child of an adult who is not applying for coverage and is under 250% FPL • Elderly or disabled

17. Affordable Care Act Mechanics:Operations – Culture Change for All • All doors lead to coverage • Enrollment in all available coverage • First-class customer experience • Coordinated services (horizontal integration) • Example: CalFresh The question is no longer, whether a customer is eligible, but rather, for what is a customer eligible? Human Services Department

18. Affordable Care Act Mechanics:Horizontal Integration • What is it? • Determining customer’s eligibility for other services (CalFresh, CalWORKs) • Big opportunity • Counties are key to this in California • Guidance • Forthcoming from federal government • CalHEERS interface delay • Major factor in why horizontal integration will be difficult in first few months

19. Affordable Care Act Mechanics:Coverage • Standardized Benefits Essential health benefits must be covered by all plans Preventative care covered Mental health and substance abuse covered Pediatric including dental and vision covered Center for Human services, UC Davis Extension (ED.). 2013. Introduction to Health Care Reform. Davis, CA: Center for Human Services, UC Davis extension.

20. Affordable Care Act Mechanics:Coverage Essential Health Benefits Ambulatory patient services Prescription drugs Emergency services Rehabilitative services and devices Hospitalization Laboratory services Maternity and newborn care Preventative and wellness, chronic disease management Mental health and substance use services Pediatric services, including dental and vision Center for Human services, UC Davis Extension (ED.). 2013. Introduction to Health Care Reform. Davis, CA: Center for Human Services, UC Davis extension.

21. Affordable Care Act Mechanics:Coverage ~ The Metal Tiers • Standardized Coverage • Platinum, Gold, Silver Bronze Platinum Plan~insurance pays average 90% of cost of care Gold Plan~insurance pays average 80% of cost of care Silver Plan~insurance pays average 70% of cost of care Bronze Plan~insurance pays average 60% of cost of care • Higher premiums, lower cost sharing • Lower premiums, higher cost sharing • Catastrophic coverage available for up to age 30 Center for Human services, UC Davis Extension (ED.). 2013. Introduction to Health Care Reform. Davis, CA: Center for Human Services, UC Davis extension.

22. Affordable Care Act Mechanics:Coverage ~ Affordable and Expanded • Medicaid expanded to 138% of poverty level, no asset test • Medicaid expansion includes childless adults • Advance Premium Tax Credits (APTC) between 138% and 400% of poverty level • Cost Sharing Reductions (CSR) between 138% and 250% of the poverty level • Income calculated using tax filing household Modified Adjusted Gross Income (MAGI).

23. Affordable Care Act Mechanics:Plan Selection • customers choose the metal tier level of health coverage. • customers can use APTC to reduce their monthly premiums when purchasing health coverage. • customers can participate in Cost Share Reduction. • Cost Share Reduction (CSR) can reduce deductibles, coinsurance or co-payments. Cost Share Reduction is available to households between 100% and 250% of FPL who are enrolled in the silver plan and legal immigrants under 100% FPL who are ineligible for Medicaid.

24. Affordable Care Act Mechanics • Single Streamline Application • There will be a new single, streamline application used for Medi-Cal and Exchange customers. • The MC 210 and MC 231 are being eliminated and the SAWS2 is being modified.

25. Affordable Care Act Mechanics • Income will be verified using ex parte rules. • We will attempt to use information from another program (i.e. CalFresh) whenever possible. • We will use all resources available to us to verify income before asking the customer to provide. • We will have a new tool available for us to use to verify income called the Federal Hub which will interface with all states.

26. Affordable Care Act Mechanics • No asset test for most Medi-Cal programs. (Asset test still needed for LTC, MN, CW linked, Adoption Assistance Program, foster care, and A&D)

27. Affordable Care Act Mechanics:The Role Of Eligibility Worker • Understand new eligibility rules & options • Accept “warm hand offs” from Covered California call center (not applicable in this county) • Provide ongoing case management for all Medi-Cal programs • Enroll customers into all programs for which they are eligible, such as CalWORKs, CalFresh, Medi-Cal, & APTC* (process known as horizontal integration) • Learn new new web based applications: CalHEERS and the Federal HUB *Not everyone will need to know everything by October. There will be a specialized unit in place.

28. Challenges • Outstanding rules from state & federal government • Delayed automation • Working With Information As It Becomes Available But… Failure is NOT an option

29. How Is Our County Preparing? • Communication Health Care Reform Update Postings HCR Planning Team already in place and meeting weekly Webinars/Conference calls attended weekly by HCR Team • Train The Trainer • Training On Systems CalHEERS and Federal HUB training to follow • Training On Procedures Mini-Trainings 1st and 3rd Wednesdays as info becomes available OPA Trainings will focus on HCR as allowed • Staffing Changes to follow • Parking Lot Q&A Submit your questions & we will post the answers as we get them.

31. The question is no longer, whether a client iseligible, but rather, what are they eligible for?