Aging Briefing Series Webinar

1. Aging Briefing Series Webinar October 29, 2013 Keeping Pace with the Affordable Care Act: What You and Your Older Clients Need to Know

2. What we’ll cover • Background on ACA • How the law affects your clients with Medicare & Medicaid, and those without insurance • Medicaid expansion • Health Insurance Exchanges • What this means for you and your clients • Resources

4. Confused? You are not alone • Kaiser Poll: “Six Months Before Marketplace Open Enrollment Begins, Many Americans Remain Unaware of, or Confused about, the ACA” • 7% - Supreme Court overturned it • 12% - Congress repealed it • 23% - Don’t know • ACA = Obamacare • http://www.cbsnews.com/8301-504784_162-57605754-10391705/jimmy-kimmel-on-obamacare-vs-the-affordable-care-act/

5. A little background • Affordable Care Act (ACA) signed into law on March 23, 2010 • Key components of ACA are designed to: • Strengthen consumers’ health care choices and protections • Offer a wide-range of coverage options • Make health care affordable and accessible for all Americans • Many changes, varying effective dates, bigger components in place by 2014

6. Supreme Court ruling – What about it? • After health reform law was passed, 26 states filed a lawsuit against: • Individual Mandate • Medicaid Expansion • On June 28, 2012, the Supreme Court: • Upheld that individual mandate is not unconstitutional • However, States cannot be “coerced” (lose current Medicaid funding) into expanding Medicaid

7. ACA - Implementation and Challenges • ACA – survived the Supreme Court and the election • More legal challenges ahead • More political challenges • CLASS Act (provided for national voluntary LTC insurance program) • Not implemented by Administration • Repealed and replaced with LTC Commission • Budget Battles • Healthcare.gov website woes

8. Medicare & the ACA Key messages from CMS: • Medicare’s open enrollment is not part of the new Health Insurance Marketplace • Medicare open enrollment has not changed. It is from October 15 – December 7 • It is against the law for someone who knows that an individual is on Medicare to sell them a Marketplace plan (with the exception of an individual who is employed and covered by small employer health insurance marketplace, SHOP)

9. How ACA affects your clients with Medicare • Closes Part D Coverage Gap: • In 2010, began with $250 rebate check • Increasing discounts and plan payments until 2020 • Nearly 7.1 million people already saved over $8.3 billion on drugs in coverage gap • Starting with the 2012 plan year, moved and extended annual Part D and Medicare Advantage open enrollment period (Oct 15-Dec 7) • As of 2011, provides new and free preventive benefits under Medicare, including Annual Wellness Visit • To date, 34.1 million beneficiaries took advantage of one or more free preventive services

10. How ACA affects people with Medicare (cont.) • Payments: • No guaranteed Medicare benefits were cut • ACA reduces payments to private (Medicare Advantage) plans to keep rates for services in line with Original Medicare • Higher income beneficiaries (making over $85K [individual] or $170K [couple]) pay slightly higher premiums for Part B and D • Does not reduce payments to doctors, but does slow rate of payment increases to hospitals, nursing home, and other facilities • Imposes penalties for hospital readmissions within 30 days after discharge for certain conditions

11. How ACA affects people with Medicare and Medicaid (“duals”) • 10.1 million duals in the U.S. • ACA testing new models for better care, better coordination of services (www.innovations.cms.gov) • In 2011, CMS awarded 15 states design contracts up to $1 million to develop integrated service and delivery payment models • 26 states submitted proposals to align the financing and benefits of the two programs under two models. Several have withdrawn proposals. • Eight states have signed MOUs with CMS to move forward • Give states more flexibility to offer Home and Community Based Services (HCBS)

12. Current state of the states : Demo proposals

13. How ACA affects those in need of insurance • As of July 2010, establishes Pre-Existing Condition Insurance Plan (PCIP), helps people that could not get insurance due to pre-existing conditions • Programs ends on 1/1/2014 because of availability of insurance in marketplaces. Notices being sent to all PCIP enrollees soon. • Allows states option to expand Medicaid to those not traditionally covered beginning as soon as 2010 • For 2014, individuals without coverage must obtain health insurance or pay a penalty • Health Insurance Exchanges (Marketplaces) opened on Oct. 1 to sell plans to these individuals for 2014

14. Medicaid Expansion – What’s happening? • Will cover many of those not previously eligible: • Ages 19-64 and • Income under 138% (133% with a 5% disregard) of federal poverty level (FPL) • No resource test • Does not cover undocumented immigrants • Federal government pays 100% of expansion for 2014-2016; phased down to 90% by 2020 • By 2019, Medicaid expansion estimated to cover ~16 million people who otherwise would be uninsured

15. Which states chose to expand?

16. Health Insurance Marketplaces (Exchanges) – What are they? • Marketplaces available both for individuals and small employers • One-stop shopping – single application for Exchange, Medicaid, and CHIP • Affordable options for people with limited income (tax credits, reduced cost-sharing) • Can’t be denied insurance even with pre-existing conditions (“Guaranteed Issue”) • Premiums can only vary by family size, geographic location, tobacco use and age, not by health status. • Standard offering of health benefits (“Essential Health Benefits”)

17. Subsidies for premiums and cost-sharing • There is a tax credit/subsidy to help lower the premiums for people with low and modest incomes who purchase insurance on the “exchanges.” • Financial assistance to pay premiums is provided to individuals with incomes between 100 to 400% of FPL • Amount of tax credit is based on cost of second lowest cost silver plan in the area where person lives • Financial assistance to pay other cost-sharing to those with income between 100 to 250% of FPL • But only for “silver” level plans

18. “Coverage Gap” Question: What happens to individuals who: • Are not currently eligible for Medicaid, • Live in a state that did NOT expand Medicaid to 138% of poverty, • And whose income is not 100% of FPL and therefore not eligible for the tax credit/subsidy? Answer: They may not be eligible for either Medicaid or the subsidy. • Approximately 4.8 million affected

19. How are the Exchanges (Marketplaces) run? • Exchanges (aka Marketplaces): • Must be a government agency or non-profit • Must serve both individual and businesses • Can form regional Exchanges, or have multiple exchanges operating in one state • States can choose from three models: • State-based exchange • State-federal partnership • Federally-facilitated exchange (FFE)

20. Exchange models • State-based exchange • State runs its own exchange • May have an Exchange Board to settle on policy decisions (i.e., model type, benefits package, IT structure, contracts) • State-federal partnership • State works with federal government, likely help with plan management functions such as certifying qualified health plans, oversight, etc. • Federally-facilitated exchange (FFE) • Federal government ensures state has Exchange in place, will still need help from states • Default model if states did not choose a model by Feb 15, 2013

21. Health Exchange Status

22. Streamlined, dynamic application process • Streamlined application can be used to apply for: • Insurance through the Individual or SHOP Exchanges • Medicaid • SCHIP • http://www.cms.gov/CCIIO/Resources • Applications can be submitted: • Online via the Exchange Website • Call Center • By Mail • In-Person • Information collected includes: • Baseline information • Income information (for Medicaid or tax credits) • Program specific information

23. Marketplace application

24. What plans will be available? • Qualified health plan required to offer uniform benefits package • Scope of benefits: 10 “general” essential services • Four levels of coverage: bronze, silver, gold and platinum • Insurer must offer at least one silver & gold level plan in the Exchange • Maximum out of pocket costs for enrollee for 2014 - $6,350

25. Essential Health Benefits Qualified health Plans cover Essential Health Benefits which include at least these 10 categories

26. New Qualified Health Plans - Metals • Metal plans – bronze, silver, gold, platinum • Differentiated by the actuarial value - the average amount of insurance expenses that would be paid by the plan. • The higher the actuarial value of the plan, the lower the out of pocket costs for the plan member. • The more the insurer pays out, the higher the premium

27. Plan Coverage of Expenses

28. Individual Market Premiums: Why will they change • Prohibition against discrimination against people with pre-existing conditions • Elimination of surcharges based on health status • Limiting of premium variation due to age (can only charge 3 times more for older individuals) • Elimination of gender-based rating • Minimum essential coverage • Premiums will be higher for some, lower for others • Will only be based on age, family size, geographic location, and smoking status.

29. Penalty if don’t get insurance • 2014 - $95 per adult ($47.50 per child) or 1% of family income, whichever is greater • Up to $285 for a family • 2015 - $325 per adult ($162.50 per child) or 2% of income, whichever is greater • Up to $975 for a family • 2016 and beyond - $695 per adult ($347.50 per child), or 2.5% of income, whichever is greater • Up to $2,085 for a family • No penalty if family income is below the threshold for filing tax return

30. Who will help consumers of the Exchanges? • Navigators • Provides public education - objective, trustworthy • From at least two agencies/organizations with one being a community-based partner • Receive grant funding by the Exchange • ~200 Navigators in MD • In-Person Assisters • Only available for state-based and partnership exchanges, not federal facilitated exchanges • Must be funding through separate grants • ~300 In-person assisters in MD • Certified Application Counselors

31. Key enrollment dates through the Marketplace • Initial Open Enrollment Period: • October 1, 2013 - March 31, 2014 • Coverage effective no sooner than January 1, 2014 • Annual Open Enrollment Period (starting in 2015) • October 15 – December 7, coverage effective following January 1 • Also, Special Enrollment Periods (SEP) for exceptional situations (see next slide for SEP situations) • Note: Medicaid & CHIP applications can go through the Exchange or through Medicaid offices, and anytime of the year

32. Special Enrollment Periods • Special Enrollment Periods (SEPs) outside the initial or annual enrollment period may include: • Loss of minimum essential coverage • Gain or become a dependent • Become a U.S. citizen • Enrollment errors • Plan violates their contract • Gain or lose eligibility for tax credits or cost-sharing subsidies • Move outside of the Exchange service area • Exceptional circumstance

33. Healthcare.gov - Marketplaces

34. Maryland Health Connection

35. Special considerations for boomers • Many people aged 60-64 will likely be participating in Exchanges, especially if they’ve lost jobs during the recession, retired or are underemployed and lack insurance • Those receiving subsidies likely eligible for other benefits, such as SNAP, LIHEAP, and (once 65) Medicare Savings Programs and Low Income Subsidy • How will they get connected to these other programs? • Do they know when and how to transition to Medicare?

36. Medicare & the Marketplace • Most people with Medicare will not benefit from the Marketplace • Marketplace significantly more expensive • No premium or cost-sharing subsidies if have Medicare • However, some people may want to consider their options: • People under 65 and disabled and waiting for Medicare • People without guaranteed issue right for Medigap • Marketplace plan does not protect against late-enrollment penalty, so clients need to sign-up for Medicare on time! • Fact sheets available on http://www.ncoa.org/assets/files/pdf/center-for- benefits/medicare-and-marketplace.pdf

37. Beware of Scams • Higher risk of fraud due to confusion between the two open enrollments • There are no “Obamacare” cards and no need to replace Medicare card • No one should share their Social Security or Medicare number with anyone who knocks on their door or solicits them uninvited

38. General ACA-related resources • Health care reform: www.Heathcare.gov, and about Marketplace: www.marketplace.cms.gov • Where states stand on Medicaid expansion: http://ahlalerts.com/2012/07/03/medicaid-where-each-state-stands-on-the-medicaid-expansion/ (updated regularly) and www.nasuad.org/medicaid_expansion_tracker.html#WA • Affordable Care Act and Health Exchanges status: http://healthreform.kff.org/ • Center for Consumer Information and Insurance Oversight (CCIIO): http://cciio.cms.gov/

39. Resources for checking facts/myths • PolitiFact (Pulitzer Prize winning site that researches common claims about health care reform): http://www.politifact.com/subjects/health-care/ • Fact Check (project of Annenberg Public Policy Center): http://www.factcheck.org/ • AARP health reform fact sheets (multiple languages): http://www.aarp.org/health/health-care-reform/health_reform_factsheets/

40. Stay in touch Visit us on the web at: www.CenterforBenefits.org And for your clients: www.MyMedicareMatters.org www.BenefitsCheckUp.org Contact today’s presenter: Leslie.Fried@ncoa.org

41. Questions/comments

42. Use of Out-of-Network Providers for Emergency Care • Many plans will have provider networks which plan members may be required to use for non-emergency care • Insurance plans are prohibited from charging members higher co-payments or coinsurance payments for out-of network emergency services • Insurance plans cannot require members to get prior approval before getting emergency room services from a hospital outside the plan’s network