Health Reform and Health Coverage:

Changes Ahead for Kids and Families

Kim VanPeltSt. Luke’s Health Initiatives

September 16, 2013

Coverage Expansion

Employer-based coverage Medicaid

The “Exchange”

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Medicaid Expansion • Over 300,000 Arizonans will benefit

• Provides coverage up to 138% of the federal poverty level (approximately $32,500 for a family of four)

• Supported by the Governor, passed by the Legislature

• Restores the will of the voters

• Approximately 60 percent of voters support restoration or expansion

• Eligibility screening begins in October, coverage begins on January 1, 2014

Improvements to Coverage

• Prevents discrimination in pricing based on pre-existing conditions

• Essential benefits chosen by Arizona allows for coverage of many services

• Those who have self-insured or grandfathered plans will not benefit from essential benefits, elimination of cost-sharing

Essential Benefits

• 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• Chronic disease management• Pediatric services, including oral and vision care

Essential Benefits

• Arizona picked state employee plan, administered by United Health Care, as benchmark

• www.cms.gov/CCIIO/Resources/Data-Resources/Downloads/arizona-ehb-benchmark-plan.pdf

The Marketplace• Exchange now called the Marketplace

• Arizona deferring to the federal government to run

• Online site for individuals and small businesses to compare and purchase health coverage

• Intended to simplify and structure health insurance choices for individuals, families and small businesses

• Exclusive mechanism for receiving federal subsidies and plans with cost-sharing limits

The Marketplace

• Open enrollment begins October 1

• Open enrollment will occur through the end of March

• 1.3 million Arizonans predicted to eventually receive coverage through the marketplace

The Marketplace

Expected Enrollment by Type

• Individual Exchange: 496,000

• AHCCCS (assuming Medicaid expansion):343,000

Plan Levels of CoverageLevel of Coverage Plan Pays on Average Enrollees Pay on Average

(In addition to the monthly plan premiums)

Bronze 60% 40%

Silver 70% 30%

Gold 80% 20%

Platinum 90% 10%

Catastrophic Plans

• Eligible to adults under 30 years of age

• Also available to those who obtain a hardship waiver from the marketplace

• Includes plans with high deductibles, lower premiums

• Includes coverage or three primary care visits and preventive services

Premium Subsidies

• Tax credit is advanceable or refundable

• Eligibility is based on – Projected household income and family size– 100 – 400% FPL ($23,550 -$94,200 for a family of four in 2013)– Obtaining qualified coverage through the marketplace– Ineligible for government-sponsored coverage, affordable-

sponsored insurance, or certain other minimum essential coverage

• Tax credits available to immigrants who are lawfully present

Cost Sharing Reduction

• Eligibility for reduced cost sharing is based on – Incomes at or below 250% of FPL ($58,875

annually for a family of four in 2013)– Receiving the new premium tax credit– Enrolling in a marketplace silver-level plan– No cost sharing for members of Tribes

Individual Mandate

• Beginning in 2014, most people must have health coverage or pay a fee when you file your tax return

• Some people may qualify for an exemption

Cover Arizona

• Builds off of the successful outreach efforts for the Pre-Existing Conditions Insurance Pool

• More than 300 members

• Two goals:

– Maximize enrollment of individuals and families in the new insurance marketplace and Medicaid

– Identify and assess outreach efforts so that we can build on our successes

Local Action Needed to Ensure Success

• Awareness

• Outreach

• Enrollment Assistance

Enrollment Assistance

• Navigators

• Certified Application Counselors

• Toll Free Hotline

• Brokers

Special Issues for Kids and Families

• Members of the same family may qualify for different programs

• KidsCare II disappears in 2014

• Businesses may begin dropping family coverage

Two Doors

• Health E Arizona Plus

• Marketplace

Timeline• August – Navigator grants awarded

• August – September – Navigators and certified enrollment assisters trained

• October – Determination of which plans will participate in the exchange

• October - Open enrollment in the exchange begins

• October - Media campaign begins, driving people to Healthcare.gov

• January 1, 2014 – Coverage purchased through exchanges takes effect

Need more information

• www.healthcare.gov

• Marketplace Call Center (Consumers) - 24/7 English and Spanish and 150 Languages 1-800-318-2596, 1-855-889-4325 (TTY)

• www.marketplace.cms.gov

• www.coveraz.org

www.slhi.org