THE AFFORDABLE CARE ACT

September 17th, 2013

Heather Howard Director, State Health Reform Assistance Network

Lucinda JessonCommissioner, Minnesota Department of Human Services

Overview• Setting the stage• The Affordable Care Act• State of implementation

SCOTUS decision Optional Medicaid expansion Exchange development

• Eligibility Appeals

Affordable Care Act (ACA) Mandate +

Subsidies +

Medicaid expansion +

Insurance reform +

System Reforms (prevention and payment)+

Taxes =

Health Reform

Affordable Care Act (ACA)• Health Insurance Exchanges will offer a marketplace for individuals and small businesses to compare policies and premiums

• Medicaid eligibility expanded to include all individuals and families with incomes up to 133% of Federal poverty level (FPL)

• Requirement to purchase insurance, coupled with insurance reforms and subsidies for families with incomes up to 400% FPL

• Simplified Eligibility & Enrollment – No Wrong Door

Medicaid Has Many Vital Roles In Our Health Care System

Health Insurance Coverage

31 million children & 16 million adults in low-

income families; 16 million elderly and persons with

disabilities

State Capacity for Health Coverage

Federal share can range from 50 - 83%;

For FFY 2012, ranges from 50 - 74.2%

MEDICAID

Support for Health Care System and Safety-net

16% of national health spending; 40% of long-term care services

Assistance to Medicare

Beneficiaries

9.4 million aged and disabled — 20% of

Medicare beneficiaries

Long-Term Care Assistance

1.6 million institutional residents; 2.8 million

community-based residents

Changes in Uninsured Rate for Nonelderly Adults and Children, 2007-2010

Changes in uninsured rate for both nonelderly adults and children are statistically significant (p<0.05). SOURCE: KCMU/Urban Institute analysis of the ASEC Supplement to the CPS, 2008-2011.

Nonelderly Adults Children

20072010

19.1%

22.0%

10.9%10.0%

41%

37%

13%

10%

400% FPL and

Above

Characteristics of the Nonelderly Uninsured, 2010

The federal poverty level was $22,050 for a family of four in 2010. Data may not total 100% due to rounding. SOURCE: KCMU/Urban Institute analysis of 2011 ASEC Supplement to the CPS.

61%16%

24%16%

24%59%

Total = 49.1 million uninsured

1 or More Full-Time

Workers

No Worker

s

Part-Time Workers

100-250% FPL

<100% FPL

251-399% FPLChildren

Parents

Adults without

Dependent Children

Family Status Family Income

Family Work Status

Uninsured Rates Among Nonelderly by State, 2010-2011

Exchange Decisions Map

Source: kff.org/statedata

State Implementation Activity• Exchange Activity

• 16 states and D.C. have declared State-based Exchange and have been conditionally approved by HHS

• 7 states planning for Partnership Exchange and have been conditionally approved by HHS

• 27 will default to the Federal Exchange

• Grants• 48 states and D.C. have received Exchange planning grants• 36 states and D.C. have received Exchange Establishment

grants• Total of $3,836,179,544 awarded

Source: kff.org/statedata

Federal Appeals Regulations Overview

Proposed rules require states to coordinate MAGI Medicaid/CHIP and Qualified Health Plans and Advance Premium Tax Credits/Cost Sharing Reductions for Appeals

State option to delegate State Medicaid Agency Appeals Authority to the Exchange

Establish Exchange appeals process including HHS appeals

Steps in the Appeals Process

NOTICE OF APPEAL RIGHTS

1 4DESIGNATION OF AUTHORIZED REPRESENTATIVE

HEARING SCHEDULING/ NOTICE OF HEARING

7 9APPEALS HEARING MODALITY & ADJUDICATORS

10EXPEDITED APPEALS HEARING

11 HEARINGDECISION

REQUEST FOR APPEAL

2NOTICE OF RECEIPT OF APPEAL REQUEST

3 6INFORMAL RESOLUTION

Step-by-Step Appeals Process

EVIDENCE PACKET

8 12 POST-HEARING

5 DISMISSALS/ WITHDRAWALS

Delegation Authority: State Options

Entity Delegation Option

State Medicaid Agency may delegate Medicaid appeals authority to…

• State-Based Exchange (if a “government agency or public authority which maintains personnel standards on a merit basis”)

• HHS Appeals Entity (FFE Determination Model) • 3rd Party State Agency

State-Based Exchange

may delegate APTC/CSR appeals authority to…

• HHS Appeals Entity • State Medicaid Agency *• 3rd Party State Agency *

* Not specifically discussed in proposed regulations, but not prohibited.

Medicaid, CHIP, and Exchange Appeals: Legal Authority

Medicaid: Social Security Act §1902(a); 42 C.F.R.§431.200 et seq. (NPRM and Existing Regulations); Goldberg v. Kelly

CHIP: Federal Law 42 C.F.R.§457.1100 – 457.1190 (NPRM and Existing Regulations)

Exchange: ACA§1411(f)(1) – Federal Appeal

Exchange: 45 CFR§155.500 et seq.

Approach for State Appeal Process Design

Identify delegation approach and appeals process features.

Assess federal requirements for the IAP Appeal Process (final rules forthcoming).

Assess appeal process requirements in state statute and regulation, as well as current state process/practice.

Identify and resolve open policy, IT infrastructure, and personnel decisions for each appeal process feature.

Document operational requirements (e.g., needed legal/regulatory changes, inter-agency agreements, development of internal guidance/policy manuals and personnel training materials, hiring and training of personnel, IT system builds, etc.).

1

3

2

5

4

Steps in the Appeals Process: State Tool Example

NOTICE OF APPEAL RIGHTS

1 4DESIGNATION OF AUTHORIZED REPRESENTATIVE

HEARING SCHEDULING/ NOTICE OF HEARING

7 9APPEALS HEARING MODALITY & ADJUDICATORS

10EXPEDITED APPEALS HEARING

11 HEARINGDECISION

REQUEST FOR APPEAL

2NOTICE OF RECEIPT OF APPEAL REQUEST

3 6INFORMAL RESOLUTION

EVIDENCE PACKET

8 12 POST-HEARING

5 DISMISSALS/ WITHDRAWALS

Step-by-Step Appeals Process

Informal Resolution: Legal Requirements

• Required for HHS Appeals

• Option for State Medicaid Agency and SBE

• Medicaid agency must establish a secure electronic interface with the Exchange or Exchange appeals entity through which 1) the Exchange can notify the Medicaid agency that an APTC/CSR eligibility appeal has been filed triggering a Medicaid fair hearing request and 2) electronic account, including any information provided by the individual to the Medicaid agency or Exchange, can be transferred between programs.

• Medicaid agency must ensure that as part of hearing, it does not request information or documentation from the individual already included in her electronic account or provided to the Exchange or Exchange appeals entity.

• Exchange appeals entity must minimize burden on consumer by not requesting that he or she provide duplicative information or documentation previously provided during the application or IR process.

Many Types of Appeals

Individual Eligibility

Health Plan Purchase

Tax Credits

Cost Sharing Help

Level of Benefits

Tax Credits

Cost Sharing

Help

SHOP Appeals

Employer SHOP Appeal

Employee SHOP Appeal

Employer Shared

Responsibility

Possible Scenarios

Questions?