June 26, 2012 Stephanie Altman, Programs & Policy Director

1. How Will the Affordable Care Act Impact the Chronically Homeless and other Low Income Vulnerable Populations June 26, 2012 Stephanie Altman, Programs & Policy Director Stephani Becker, HDA Senior Health Policy Advisor

2. Presentation Agenda • 1:00 – 1:15 pm Cartoon video “Illustrating the Success of Health Care Reform” • 1:15 – 2:15 pm: Powerpoint Presentation • 2:15 – 2:45 pm: Questions from Audience • 2:45 – 3:00 pm: Tour of IllinoisHealthMatters.org and Neighborhood Story video [time permitting] • Evaluation forms

3. Overview of Health & Disability Advocates • Based in Chicago – but state and national in scope • Lawyers, social workers and policy analysts on staff • Client Representation • Medical Legal Collaborations • Training and Technical Assistance to Community Based Providers • Policy/Advocacy (Health, Special Education, Issues impacting People with Disabilities)

4. “Health Care Law – it’s a trek not a sprint” [AP News, March 11, 2012] • Patient Protection and Affordable Care Act passed March 2010

5. Overview of Affordable Care Act – Health Care Reform • Signed into law on March 23, 2010 • Establishes a floor, not a ceiling • States are largely responsible for implementation • Phases-in changes to private health insurance coverage and expands public coverage • Enacts tax credits to help individuals and small businesses access more affordable insurance options • Reforms Medicare • Individual and employer responsibility provisions • Authorization of numerous grant programs and pilot projects

6. Key Components of the Affordable Care Act Available Now… In 2014…and beyond Individual Mandate Employer Responsibility State or federal “Health Insurance Exchanges” – new marketplaces with Essential Health Benefits package Large Medicaid Expansion to Adults up to 138% FPL No pre-existing condition exclusion Consumer protections – no annual limits, no rating except by age/location & smoker/non-smoker Closing Medicare Part D Donut Hole • IPXP (IL Pre-Existing Condition Plan) • Dependent Coverage up to age 26 • No pre-existing condition exclusion for children • No insurance recissions except in cases of fraud/intentional misrepresentation • Small business tax credits • Preventative Services – no co-pay • Consumer protections – no lifetime limits

7. Essential Benefits Package: What is it? • All health plans sold through the health care exchange must cover these essential benefits at a minimum • States can use State Employee Health Plan, large insurers, or largest small group plan as benchmark package. • States have to decide on their benchmark plan by 3rd Q -2012. • Ambulatory patient services; • Emergency services; • Hospitalization; • Maternity and newborn care; • Mental health and substance use disorder services; • Prescription drugs; • Rehabilitative and habilitative services and devices; • Laboratory services; • Preventive and wellness services including chronic disease management; • Pediatric services including oral and vision care.

8. ACA and Non-Citizens • Medicaid eligibility remains the same for non-citizens; in general, must be a LPR in country for 5 years exceptpregnant women and children. • To purchase insurance through exchange with subsidy only need to be lawfully present. • No coverage for undocumented non-citizens.

9. Status of ACA Litigation in Supreme Court • Supreme Court Heard the Case in March 2012/Decision expected this week! • Major Challenges: Individual Mandate and Medicaid Expansion. • Can the ACA survive without the individual mandate? • Political Considerations in Congress of the “threat” to repeal and replace. • “Defunding” of Innovations Grants and other provisions. • Even if ACA is declared unconstitutional, Medicaid Managed care is an Illinois mandate, so all the work the state is doing to build electronic eligibility systems, to create quality, integrated care models and to build adequate health infrastructure will still be needed.

10. The Individual Mandate • Requires most individuals to carry “minimum essential” health coverage • According to Kaiser Family Foundation, Almost 9 in 10non-elderly people in the US would either satisfy the mandate automatically or be exempt from it. • Exemptions include: religious reasons, undocumented immigrants, very low income so do not file taxes, insurance premiums exceed 8% of family income • If individual mandate applies, the penalty is assessed per individual or dependent without coverage and will be phased in over three years: $95 for 2014; $325 for 2015; and $695 in 2016 & thereafter. Capped at three times this amount per year

11. How Many Could be Affected by the Individual Mandate in 2016? 32 millionpreviously uninsured affected by the mandate 24 million qualify for exemptions from the mandate 219 million insured by employers, Medicaid, Medicare’s disability coverage, or individual insurance and not affected by the mandate Projected Non-Elderly in 2016 = 275 million Source: Kaiser Family Foundation analysis; Congressional Budget Office; Jonathan Gruber

12. Medicaid Expansion: What is it? • In 2014, anyone under 65, not in Medicare and under 138% of the Federal Poverty Level (about $1,400 per month) will be eligible for Medicaid. • Federal government pays for much greater percentage of this expansion than for Medicaid now (100% in the first three years.) • Primary Care rates increased to 100% of Medicare for 2013 and 2014. • Most applications will be filed electronically through an Integrated Eligibility System with Medicaid and Health Insurance Exchange.

13. Medicaid Expansion: Who is it?

14. Medicaid Expansion: Who is it? • 610,821 uninsured individuals in Illinois will be eligible for new Medicaid “Adult Group” in 2014 • Less than those who become eligible to purchase insurance through the exchange (1,036,706 with or without a premium subsidy.) • In Rockford, 11,362 uninsured individuals will be eligible for new Medicaid. • In Winnebago County (except Rockford), 6,572 uninsured individuals will be eligible for new Medicaid.

15. Medicaid Expansion: Health Status of Population • Fair/Poor Health: 17.7% • Two or More Chronic Conditions: 18.2% • Limited or Unable to Work: 14.8% • More Likely to Be Childless Adults Than Parents • Likely to be healthier than nondisabled adults currently enrolled in Medicaid, but the least healthy and older individuals are among the new Medicaid expansion group and are more likely to enroll. Source: Robert Wood Johnson Foundation and the Urban Institute, The Health Status of New Medicaid Enrollees Under Health Reform, August 2010

16. Homeless Individuals – Most likely a subset of New Medicaid Group “Chronically homeless individuals are homeless repeatedly - four or more times in the past three years - or for long periods of time. They suffer from serious mental illnesses, substance abuse disorders, and physically disabling conditions. Typically uninsured, they frequently use emergency room services to address complicated health needs exacerbated by living on the streets or in shelters.” The City of Chicago reported in 2011 that 14% [of homeless population] were employed, 10% were veterans, 15% were physically disabled, 4% were HIV positive, and 20% were severely mentally ill. -National Alliance to End Homelessness - U.S. Conference of Mayors 2010 Survey on Hunger & Homelessness

17. Health Care Exchange Legislation • SB 1555 (now Public Act 097-0142) was signed into law in August 2011 by the Governor. • Created a Legislative Task Force to Recommend Implementation and Design of the Illinois Health Care Exchange. • Governance and Financial Sustainability are the major issues. • State must continue to progress toward an implementation design and then get approval for final implementation by January 1, 2013 to continue to get federal funding. • Several bills including HB 4141 were introduced to establish exchange board and rules but did not pass; Governor may establish Health Benefits Exchange by Executive Order.

18. Enrollment and Eligibility Issues in 2014 • Enrollment Procedures for Medicaid and Health Care Exchange applications online, by mail and in person. • Eligibility Determinations. • Roles for Community Based Providers such as clinics, permanent supportive housing providers, homeless service providers, hospitals. • Navigator System will be created using community based providers, medical providers (most likely only for individual enrollment) and the insurance broker community (most likely only for the small business market.)

19. Going Backward Before Going Forward • Medicaid Reform Legislation passed in Illinois in December 2010 and signed by Governor. • Caps AllKidsat 300% FPL for new enrollees after 7/1/2011 (grandfathers in current AllKidsenrollees over 300% FPL until 7/1/2012.) 4,000 children will be affected. • Imposes new verification of residency, a potential eligibility barrier, for Medicaid. • Requires 50% of Medicaid enrollees to be in risk based coordinated care by 2015. • Moratorium on Medicaid expansions until 2013.

20. Medicaid Reform 2012 • Medicaid Reform Signed into Law 2 wks ago – includes over $2 Billion in Medicaid cuts including: • elimination of Illinois Cares Rx; elimination of Family Care coverage over 133% FPL; elimination of Adult Dental Coverage except emergencies; and elimination of GA Medical among other cuts. • Cook County Waiver pending. • Will ACA be able to pick up the pieces? • What damage could result in the interim? • What will be the effect on the safety net?

21. Current Major Medicaid Programs as of July 1, 2012 • All Kids – comprehensive health insurance coverage for kids <300% FPL • FamilyCare – coverage for parents and relative caregivers <133% FPL • Moms & Babies – coverage for pregnant women and infants up to 1 year of age <200% FPL • Illinois Healthy Women – limited family planning coverage to women <200% FPL • Illinois Breast and Cervical Cancer Program – for uninsured women 35-64 years, no income limit • AABD – Aid to Aged Blind and Disabled to 100% FPL. Visit www.health.illinois.gov for more information

22. Managed Care and Coordinated Care in Illinois • States have a wide range of delivery systems for Medicaid including fee for service, managed care, capitated HMOs and coordinated care such as primary care case management and disease management. • These are all different types of systems to pay providers and to coordinate care for recipients. • Depending upon the arrangement, Medicaid recipients may or may not be able to choose their providers or switch providers easily. • State embarking on Care Coordination Entities and expanded managed care. • Integrated Care Pilot operates in Collar County for over 19 with disabilities. • Cook County Waiver Pending.

23. What is IllinoisHealthMatters.org? Mission of IHM: • To help Illinois individuals, small businesses, policymakers and community organizations understand and benefit from improvements and access to health care under national health care reform.

24. Illinois Health Matters – a way to organize and mobilize • Find HCR resources: Helpful for grant writing, program development, client questions • Ask HCR questions: Your Questions/Answered. Submit questions to our experts, we will feature on website • Read blog posts…or become a guest blogger! Good way to communicate your story or advocate for your cause – we promote to social network • Share “Neighborhood Stories” How is health care reform impacting real people? • Find out about local HCR events/webinars: Publicize your events or find out about other events • Connect with others about HCR: Engage with us on Facebook/Twitter/YouTube/LinkedIn to amplify message

25. Interactive health insurance data by regions and community areas throughout the State of Illinois

26. Under-represented multimedia accounts of impact of health care reform on the South and West Sides of Chicago Neighborhood stories

27. Questions? About Illinois Health Matters? Or Health Care Reform? • Questions: • Stephanie Altman, saltman@hdadvocates.org • Stephani Becker • sbecker@hdadvocates.org • Please Join IHM Listserv, Facebook or Follow us on Twitter