women and aca: how to use your new health coverage (like a pro)

© 2014 Enroll America and Get Covered America EnrollAmerica.org | GetCoveredAmerica.org

Women and ACA: How to Use Your New Health

Coverage (Like a Pro)

May 6, 2014

© 2014 Enroll America and Get Covered America EnrollAmerica.org | GetCoveredAmerica.org 2

Agenda

I.  Introduction and Special Enrollment Periods •  Ambar Calvillo, Women’s Engagement, Enroll America

II. Health Insurance 101: Understanding Your Health Plan •  Lauren Birchfield Kennedy, Senior Health Policy Counsel, National Partnership for Women & Families

III. Guaranteed Benefits Important to Women •  Karen Davenport, Director of Health Policy, National Women’s Law Center •  Mara Gandal-Powers, Counsel for Health and Reproductive

Rights, National Women’s Law Center

IV. Questions •  Submit at any time via chat.


BASICS OF SPECIAL ENROLLMENT PERIODS


Marketplace vs Medicaid

Health Insurance in the Marketplace: •  Must be a U.S. citizen or legal immigrant and not

incarcerated •  Depending on your income, you may qualify for

financial help •  Has an ‘open enrollment’ window: November 15-

February 15 •  Special enrollment periods available to people who

have certain life changes (stay tuned for more info!)

Medicaid: •  Medicaid provides free or low cost health coverage •  Visit your state’s Medicaid website to see if you are

eligible •  If eligible, you can enroll today!

Visit Getcoveredamerica.org


Enrollment Timeline

Annual open enrollment period à Nov 15, 2014 –

Feb 15, 2015

Medicaid & CHIP à year-round

Special enrollment period because of a life-change à year-round


Post-Open Enrollment: Three Types of Situations

Already enrolled in some form of coverage

Eligible to enroll between

April and November

Uninsured but not eligible to

enroll until November


Eligible to Enroll between April and November 2014


Medicaid and CHIP

Medicaid and CHIP enrollment is open year-round!


Life Changes that May Trigger a Special Enrollment Period

I had a(nother)

baby!

I’m a new citizen! I turned 26

I got married!

I got out of prison

Resource: https://www.healthcare.gov/how-can-i-get-coverage-outside-of-open-enrollment/#part=2


Experience a life change

Report the life change to the marketplace/ complete the application

Enroll and pick a plan

Report the change as soon and possible. Individuals have 60 days from the date of the event to

complete this process.

Reporting a Life Change to the Marketplace


•  Individuals may also be able to get a special enrollment period after experiencing other limited circumstances related to system or display errors.

• Consumers should work with local help for further information regarding their specific situation.

• To get a special enrollment period in these cases, the consumer or assister needs to call the Marketplace Call Center (1-800-318-2596).

Additional resource: http://www.cms.gov/cciio/Resources/Regulations-and-Guidance/Downloads/complex-cases-SEP-3-26-2014.pdf

Special Enrollment Periods in Complex Cases


Enrollment Assistance

Who Can Provide Help?


Already enrolled in some form of coverage

14 © 2014 Enroll America and Get Covered America

EnrollAmerica.org | GetCoveredAmerica.org

Keeping Coverage Marketplace Pay premiums. Pay them on time. Report life changes In October or November, individuals will get a renewal notice. They may need to send information back to the Marketplace to stay covered.

Medicaid Pay premiums. Pay them on time. Report life changes Every 12 months, individuals will get a renewal notice. They may need to send information back to the Medicaid office to stay covered.


Experience a life change

Report the event/Complete the application

process

Change Marketplace

plans (or enroll in Medicaid)

Report the change as soon and possible. You have 60 days from the date of the event to

complete this process.

Reporting Changes to the Marketplace


Uninsured but not eligible to enroll until November


Consequences for Individuals Without Coverage

Individuals who had

affordable options but

did not enroll

Individuals without

access to affordable coverage

Individuals who lose coverage during the

year


•  You most likely will pay a fine at tax time in 2015.

•  Fine is $95 or 1% of annual income, whichever is greater.

Uninsured Individuals with Affordable Options


Individuals Without Affordable Options

•  If you’re in the “Medicaid gap”, you should apply for coverage through the Marketplace. You will automatically get an exemption that protects you from the fine. You will also have access to a special enrollment period if your income increases later in the year.

•  You can also apply for an affordability exemption through the Marketplace or when filing taxes.


Individuals Who Lose Coverage During the Year

•  Report the loss to the Marketplace and apply for coverage. You may get a special enrollment period.


Summary 1.  Seek In-Person Help

•  For questions or help applying 2.  Already Covered / Stay Covered

•  Pay your premiums •  Look for communication from the Medicaid

office •  Report life and income changes

3.  Uninsured Looking to Be Insured: •  Life changing events may qualify you to get

insured before next open enrollment period. •  If in the “Medicaid gap” apply for coverage

through the Marketplace to get an exemption from the fine and access to coverage later in the year if your income increases

Health Insurance 101 : Understanding Your Health Plan

Lauren Birchfield Kennedy

Senior Health Policy Counsel

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About us

The National Partnership for Women & Families is a nonprofit, nonpartisan advocacy group dedicated to promoting fairness in the workplace, access to quality health care, and policies that help women and men meet the dual demands of work and family. More information is available at www.NationalPartnership.org.

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 Keeping Your Coverage: Monthly Premiums

 Cost-Sharing & Out-of-Pocket Expenses

  Finding a Provider

 Understanding Your Benefits   Health Care Services   Pharmacy Services (Prescription Drugs)

Just the Basics: Health Insurance 101

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 What is a premium?

 How do I pay my premium?

 What happens if I miss a premium payment?

 What does it mean to be eligible for financial help or premium assistance?

Keeping Your Coverage: Premium Payments

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Eligibility for premium assistance depends on income and family size:   If your income falls within the following ranges you'll likely

qualify for a premium tax credit. The lower your income is within these ranges, the larger your credit.   $11,490 to $45,960 for individuals   $15,510 to $62,040 for a family of 2   $19,530 to $78,120 for a family of 3   $23,550 to $94,200 for a family of 4   $27,570 to $110,280 for a family of 5   $31,590 to $126,360 for a family of 6   $35,610 to $142,440 for a family of 7   $39,630 to $158,520 for a family of 8 Source: Healthcare.gov

Premium Assistance

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  Insurance plans often require you to cover part of the cost of a covered health care service out-of-pocket. Examples of cost-sharing include co-pays, co-insurance, or a deductible.   Co-Pays   Co-Insurance   Deductible

 What does it mean to be eligible for cost-sharing assistance?

 How can I learn more about a health plan’s cost-sharing requirements?

 Are there limits on out-of-pocket expenses?

Cost-Sharing & Out-of-Pocket Expenses

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 Co-Pay: A fixed amount (for example, $15) you pay for a covered health care service, usually when you get the service. The amount can vary by the type of covered health care service.

 Co-Insurance: Your share of the costs of a covered health care service, calculated as a percent (for example, 20%) of the allowed amount for the service.

 Deductible: The amount you owe for covered health care services before your health plan begins to pay. For example, if your deductible is $1,000, your plan won’t pay anything until you’ve met your $1,000 deductible for covered health care services subject to the deductible. The deductible may not apply to all services, like preventive care.

Source: Healthcare.gov

Cost-Sharing

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  If your income falls within the following ranges you'll likely qualify for cost-sharing assistance if you purchase a silver-level plan. The lower your income within these ranges, the more you’ll save on out-of-pocket costs.   $11,490 to $28,725 for individuals   $15,510 to $38,775 for a family of 2   $19,530 to $48,825 for a family of 3   $23,550 to $58,875 for a family of 4   $27,570 to $68,925 for a family of 5   $31,590 to $78,975 for a family of 6   $35,610 to $89,025 for a family of 7   $39,630 to $99,075 for a family of 8

Source: Healthcare.gov

Cost-Sharing Assistance

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  Plans in the Marketplace are primarily separated into four health plan categories. The plan category you choose affects the total amount you'll likely spend for covered health benefits during the year.   Bronze (60%)   Silver (70%)   Gold (80%)   Platinum (90%)

What to Expect: Cost-Sharing Requirements

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 Out-of-Pocket Costs: Your expenses for medical care that aren't reimbursed by insurance. Out-of-pocket costs include deductibles, coinsurance, and copayments for covered services plus all costs for services that aren't covered.

  Limit on Out-of-Pocket Expenses: The most you pay during a policy period (usually one year) before your health insurance or plan starts to pay 100% for covered essential health benefits.   The maximum out-of-pocket cost limit for any individual Marketplace

plan for 2014 can be no more than $6,350 for an individual plan and $12,700 for a family plan.

  Check with your insurer to find out what expenses count towards your out-of-pocket limit and what expenses are not included.

Limits on Out-of-Pocket Expenses

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  To find a doctor covered by your plan, review your plan’s provider directory. This directory should be posted on your health plan’s website.

Finding a Provider

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  In-Network   Insurance companies contract with specific providers to accept their enrollees as covered

patients. Providers that have contracted with your health plan are considered “in-network.” Your health plan is responsible for providing you with a list of in-network providers.

  Out-of-Network   Providers that do not have a contract with your health plan are likely to be considered

“out-of-network.” Unless it’s an emergency, if you access care outside of your plan’s network, you likely will pay more than if you had accessed the same care in-network.

Provider Network

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Seeing a Specialist

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  Some plans require that you first get a referral from your primary care doctor before you see a specialist. If you don’t get the required referral, your plan may not pay for the services you receive from the specialist.

 Contact your plan to find out if you need a referral to see a specialist.

  You do not need a referral to see your OB-GYN. You don’t need to get a referral from a primary care provider before you can get obstetrical or gynecological (OB-GYN) care from a specialist.

What Health Services Does My Plan Cover?

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  All Qualified Health Plans cover essential health benefits, like maternity care.

  All Qualified Health Plans cover key preventive care services with no cost-sharing requirements.

  For questions about coverage of specific health care services, contact your insurer.

  Formulary: A list of prescription drugs covered by a prescription drug plan or another insurance plan offering prescription drug benefits. Also called a “drug list.”

Does My Plan Cover My Prescription?

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 Does Your Deductible Apply to Your Prescription?

 What tier is your prescription drug?

How Much Will My Prescription Cost?

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 What Tier or Level Is Your Prescription?


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  “Accessing Care 101”   NationalPartnership.org/Enroll

 Healthcare.gov

 Marketplace.cms.gov

Resources

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For more information

Find us:

www.NationalPartnership.org

Follow us: www.facebook.com/nationalpartnership www.twitter.com/npwf

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Karen Davenport and Mara Gandal-‐Powers National Women’s Law Center

May 6, 2014

*  In general, ACA guarantees coverage for: *  Maternity *  Mental Health/Substance Use Disorder Services *  Preventive Services *  Prescription Drugs *  Coverage may differ for individuals with Medicaid coverage through traditional pathways (e.g., children, parents, individuals with disabilities).

ACA-‐Guaranteed Benefits Important to Women

*  No common definition; typically health services related to prenatal, labor and delivery and postnatal care. Can include: *  Prenatal outpatient obstetrical visits *  Prenatal laboratory and diagnostic tests *  Inpatient care for delivery *  Newborn care *  Mix of preventive and non-‐preventive services, which drives what you should expect to pay

Maternity Coverage

*  New required benefit for individual, small group markets *  Plans must offer to same extent as other health services – e.g., at parity *  But parity requirements are phasing-‐in for some

services, will be fully implemented for Marketplace plans in 2015

Mental Health and Substance Use Disorder Services

A sampling of covered services includes: *  Cervical cancer screening every 3 years *  Mammography after age 40 *  Depression screening in adults and adolescents *  Well-‐woman visits *  Counseling and screening for HIV *  Screening for gestational diabetes *  Breastfeeding support, supplies, and counseling *  Screening and counseling for interpersonal and domestic violence *  All FDA-‐approved contraceptive methods, sterilization procedures, and

patient education and counseling for women with reproductive capacity HHS list of preventive benefits for women

Preventive Services

*  The law draws a distinction between preventive services and diagnostic services *  Preventive care may head-‐off a disease or condition, such as

medication for women with particular risks *  Folic acid, tamoxifen or aspirin

*  Preventive screenings look for disease or symptoms of disease, such as a lump seen on a screening mammogram

*  Diagnostic services follow-‐up on findings from screenings, such as a diagnostic mammogram or biopsy

*  You should not be charged cost-‐sharing for preventive services, but will likely pay cost-‐sharing for diagnostic services

Using Preventive Services

*  Office visits, covered without cost-‐sharing, that: *  Provide an opportunity for women to receive

recommended preventive services *  Enable women and their health care professionals to

talk about health concerns *  May be more than one visit per year *  Do not include visits for current illnesses or to diagnose symptoms

Well-‐Woman Visits

*  Adult immunizations covered without cost-‐sharing for those who meet age requirements and have not been previously vaccinated or infected: *  Flu shots *  Tetanus/tetanus boosters *  Chicken pox *  HPV *  Measles/Mumps/Rubella *  Zoster (regardless of previous infection)

Immunizations

*  New benefit – not previously covered by health insurance *  Includes lactation consultant services, breast pumps and other breastfeeding supplies *  Insurance plans and breastfeeding community are still getting up to speed – some problems with in-‐network coverage of pumps and lactation consultants, consumer information, coverage limitations

Breast-‐Feeding Supports and Counseling

*  Covered as a preventive service without cost-‐sharing every 10 years, beginning at age 50 *  Removal of polyps, if found, covered without cost-‐sharing for a preventive colonoscopy *  If you have a colonoscopy more frequently than every 10 years, or after a finding of pre-‐cancerous or cancerous tissue, you will need to pay cost-‐sharing

Colonoscopy

*  Covered once per year beginning at age 40 *  Coverage without cost-‐sharing does not include diagnostic mammograms *  Preventive coverage does not include other breast imaging, such as ultrasound or MRI

Mammograms

*  “All FDA-‐approved contraceptive methods, sterilization procedures, and patient education and counseling” *  FDA Birth Control Guide: http://www.fda.gov/downloads/ForConsumers/ByAudience/ForWomen/FreePublications/UCM356451.pdf

Birth Control

*  Sterilization surgery for women *  Sterilization surgical implant for women *  Implantable rod *  IUD Copper *  IUD with Progestin *  Shot/Injection *  Patch *  Vaginal Contraceptive Ring *  Oral Contraceptives (Combined Pill)

Birth Control Methods that Must Be Covered without Out-‐of-‐Pocket Costs

•  Oral Contraceptives (Progestin only)

•  Oral Contraceptives Extended/Continuous Use

•  Diaphragm with Spermicide •  Sponge with Spermicide •  Cervical Cap with Spermicide •  Female Condom •  Plan B/Plan B One Step/Next

Choice •  Ella

Examples: *  IUD insertion, ultrasound to confirm placement, and removal *  Sterilization anesthesia, confirmation tests Plans are required to cover “services related to follow-‐up and management of side effects, counseling for continued adherence, and device removal” without cost-‐sharing

Plans Must Cover Services Associated with Birth Control

*  Plans must cover all of the FDA-‐approved methods *  Very limited times that they can charge. Examples: *  Brand-‐name drugs when there is a generic *  When you go out-‐of-‐network *  If you don’t have a prescription for an over-‐the-‐counter

method (like emergency contraception) *  The “Waiver Process” *  Allows women to access medically appropriate method

without cost-‐sharing if plan typically imposes cost-‐sharing *  Typically involves providers completing paperwork

on why method is medically appropriate

Are there times it is OK for my plan to charge for my birth control?

*  www.nwlc.org/preventiveservices *  FAQs about the health care law’s preventive services requirements *  What plans are and are not allowed to do around cost-‐sharing *  Appeal letters for insurance companies: instructions and sample letters *  Hotline for help with women’s preventive services: 1-‐866-‐PILL4US [email protected]

What if I have a problem with my coverage?


QUESTIONS


Tools at

getcoveredamerica.org •  Calculator •  Find Help •  What Plan is Right for Me? •  Frequently Asked Questions

Resources


THANK YOU!

women and aca: how to use your new health coverage (like a pro)

Health & Medicine