January 2014

1. January 2014 CO Coalition for Elder Rights & Abuse Prevention

2. Presentation Outline • Overview of the Affordable Care Act • The Marketplace/Connect for Health Colorado • Medicare and the ACA

3. What is the Affordable Care Act (ACA) • Refers to the federal laws and regulations contained in the Patient Protection and Affordable Care Act and the subsequent Health Care and Education Reconciliation Act have come to be called the Affordable Care Act (ACA). • The main goal of the ACA is to provide insurance coverage, both public and private, to reduce the number of Americans who are uninsured.

4. Key Features of the ACA • New Consumer Rights and Protections • Individual Mandate/Shared Responsibility • Affordable Health Insurance Marketplace • Strengthening Medicare • Medicaid Expansion

5. New Consumer Rights and Protections • Stops insurance companies from dropping coverage • Adds more preventive care • Extends coverage for young adults • Stops insurance companies from denying coverage because of pre-existing conditions • Bans lifetime limits

6. Shared Responsibility/The Individual Mandate Important Points: • Starting in 2014, individuals must either have health care coverage, an exemption from coverage, or pay a penalty on their tax return for not having insurance. • Only health plans with minimum essential coverage will fulfill the mandate. • Some populations are exempt from the mandate.

7. Penalties for Not Having Health Coverage The penalty in 2014 is calculated one of two ways. You’ll pay whichever of these amounts is higher. The fee increases every year. • 2014: 1% of your yearly household incomeor $95 per person for the year ($47.50 per child under 18). • 2015: 2% of income or $325 per person. • 2016 and later: 2.5% of income or $695 per person. • After: Adjusted for inflation. • If you’re uninsured for just part of the year, 1/12 of the yearly penalty applies to each month you’re uninsured. • If you’re uninsured for less than 3 months, you don’t have a make a payment.

8. Minimum Essential Coverage • Ambulatory patient services • Emergency Services • Hospitalization • Maternity/newborn care • Mental health/substance abuse

9. Minimum Essential Coverage, cont. • Prescription drugs • Rehab/habilitative services and devices • Laboratory services • Preventive and wellness care/chronic disease management • Pediatric services, including oral and vision care

10. Plans that Meet the Individual Mandate • Any Connect for Health Colorado Marketplace plan, or any individual insurance plan that you may already have • Any employer plan (including COBRA) with or without "grandfathered" status, including retiree plans • Medicare • Medicaid • Child Health Plan Plus (CHP+) • TRICARE (for veterans and veteran families) • Veterans health care programs • Peace Corps volunteer plans • Other plans may qualify: ask your health coverage provider

11. Exceptions to the Individual Mandate • Uninsured for less than 3 months of the year • The lowest-priced coverage available to you would cost more than 8% of your household income • You don’t have to file a tax return because your income is too low (Learn about the filing limit.) • You’re a member of a federally recognized tribe or eligible for services through an Indian Health Services provider • You’re a member of a recognized health care sharing ministry

12. Exceptions, cont. • You’re a member of a recognized religious sect with religious objections to insurance, including Social Security and Medicare • You’re incarcerated, and not awaiting the disposition of charges against you • You’re not lawfully present in the U.S. • Hardship Exemptions. (Examples include: Homeless, eviction, death in immediate family, bankruptcy filing and others)

13. Hardship Exemptions • If you have any of the circumstances below that affect your ability to purchase health insurance coverage, you may qualify for a “hardship” exemption: • You were homeless. • You were evicted in the past 6 months or were facing eviction or foreclosure. • You received a shut-off notice from a utility company.

14. You recently experienced domestic violence. • You recently experienced the death of a close family member. • You experienced a fire, flood, or other natural or human-caused disaster that caused substantial damage to your property. • You filed for bankruptcy in the last 6 months.

15. You had medical expenses you couldn’t pay in the last 24 months. • You experienced unexpected increases in necessary expenses due to caring for an ill, disabled, or aging family member. • You expect to claim a child as a tax dependent who’s been denied coverage in Medicaid and CHIP, and another person is required by court order to give medical support to the child. In this case, you do not have to pay the penalty for the child.

16. As a result of an eligibility appeals decision, you’re eligible for enrollment in a qualified health plan (QHP) through the Marketplace, lower costs on your monthly premiums, or cost-sharing reductions for a time period when you weren’t enrolled in a QHP through the Marketplace. • You were determined ineligible for Medicaid because your state didn’t expand eligibility for Medicaid under the Affordable Care Act. • Your individual insurance plan was cancelled and you believe other Marketplace plans are unaffordable.

17. ACA Key Takeaways • New consumer rights and protections • Shared Responsibility/Individual Mandate • New Health Insurance Marketplace • Medicare Improvements • Medicaid Expansion

18. The Marketplace/Connect for Health Colorado What is Connect for Health Colorado? • Colorado’s state health insurance marketplace • Browse, compare, and purchase plans online • Only way to access the federally subsidized discounts.

19. Key Features of Connect for Health Colorado • Apply online, on paper, in-person or on the phone • Determine Medicaid Eligibility • Apply for financial assistance • Shop and Compare Health Plans • Purchase and Manage Your Plan Online

20. Application Process • Paper • Phone • Online • In-Person

21. Medicaid Determination • In order to be eligible to purchase a plan the Marketplace, customers must first be determined ineligible for Medicaid. Currently, the Medicaid determination must be completed on PEAK.

22. Application Flow Chart Connect for Health Colorado Manage Coverage on Connect for Health Colorado Apply for Financial Assistance Shop for Health Plan Purchase Plan Ineligible Medicaid Application PEAK Manage Coverage on PEAK Eligible

23. Shop and Compare Plans • Comparison Shopping • Metal Tiers • Carriers

24. Comparison Shopping • All plans offer minimal benefits • Beyond minimal coverage, benefits may differ from plan to plan. • Health Plans are also divided in four categories or “metal tiers”, based on actuarial value.

25. Actuarial Value • Actuarial value= the average percentage of the health care expenses the carrier expects to pay. A health plan’s members pay the remaining expenses in the form of cost sharing like deductibles, copays, and coinsurance. *The percentage does not reflect non-covered expenses. *Premiums are not calculated into actuarial value. *Higher premiums tend to accompany higher actuarial values.

26. Metal Tiers • Bronze-tier health plans have a value of 60 percent • Silver-tier health plans have a value of 70 percent • Gold-tier health plans have a value of 80 percent • Platinum-tier health plans have a value of 90 percent

27. Medical Plans • Access Health Colorado • Anthem Blue Cross and Blue Shield / HMO Colorado • Cigna • Colorado Choice Health Plans • Colorado HealthOP • Denver Health Medical Plan • Humana • Kaiser Permanente • Rocky Mountain Health Plans • UnitedHealthcare

28. Dental Plans • Anthem Blue Cross and Blue Shield / HMO Colorado • BEST Life and Health Insurance Company • Cigna • Delta Dental of Colorado • Dentegra Insurance Company • Premier Access Dental and Vision

29. Apply for Financial Assistance Two types of financial assistance available to offset costs of plans purchased on the Marketplace: • Advance Premium Tax Credits (APTC) • Cost-sharing Reductions (CSR)

30. Advance Premium Tax Credit (APTC) • Tax credit available to lower the cost of health insurance premiums. • Available to individuals and families with incomes between 100% and 400% of the federal poverty line. • Available only for plans purchased on the Marketplace. • Available to citizens and lawfully present residents.

31. APTC, cont. • Two choices for how to receive the APTC: • Applied directly to your premium cost through the carrier. • Received as a tax rebate at the end of the year. • Discrepancies in your APTC due to differences between predicted (as reported on the financial application) and actual income will be reconciled by the IRS at the end of the year.

32. Cost Sharing Reductions (CSR) • A federal benefit that reduces the out-of-pocket charges for health plan (co-pays, deductibles, and co-insurance). • Three levels of cost-sharing reductions based on income. • Available to individuals with income up to 250% of the federal poverty line. • Available to citizens and lawfully present residents. • Must purchase a Silver-tier plan to receive the benefit.

33. How the CSR is Provided • Federal government pays the health insurer upfront. • Enrollee cost sharing charges are automatically reduced when an eligible person or family enrolls in a silver plan . • People do not have to keep track of their spending or get reimbursed. • Not provided as a tax credit. • Not “reconciled” at the end of the year.

34. Marketplace: Key Takeaways • Connect for Health Colorado is the State of Colorado’s new Health Insurance Marketplace • You can browse, compare, and purchase a plan online. • You can also apply on paper, over the phone, or in person. • Purchasing on the Marketplace is the only way to access federally subsides discounts on health coverage.

35. Medicare and the ACA: Important Changes • Closes the “Doughnut Hole” • Improves Access to Primary Care • Changes to Medicare Advantage Plan • Changes to Premiums based on Income • Crackdowns on Fraud

36. Closes the “Doughnut Hole” The “doughnut hole” is a gap in coverage in Medicare Part D Drug costs. Here’s how it works: • You pay out-of-pocket for monthly Part D premiums all year. • You pay 100% of your drug costs until you reach the $310 deductible amount. • After reaching the deductible, you pay 25% of the cost of your drugs, while the Part D plan pays the rest, until the total you and your plan spend on your drugs reaches $2,800. • Once you reach this limit, you have hit the coverage gap referred to as the “donut hole,” and you are now responsible for the full cost of your drugs until the total you have spent for your drugs reaches the yearly out-of-pocket spending limit of $4,550. • After this yearly spending limit, you are only responsible for a small amount of the cost, usually 5% of the cost of your drugs.

37. “Doughnut Hole,” cont. Under the ACA, if you reach the Medicare Part D coverage gap, you can get discounts on your prescription drugs. The discounts will gradually increase until the coverage gap disappears in 2020. • 2014: 52.5% discount on brand-name; 28% discount on generic drugs. • 2015: 55% discount on brand-name; 35% discount on generic drugs. • 2016: 55% discount on brand-name; 42% discount on generic drugs. • 2017: 60% discount on brand-name; 49% discount on generic drugs. • 2018: 65% discount on brand-name; 56% discount on generic drugs. • 2019: 70% discount on brand-name; 63% discount on generic drugs. • 2020: The Medicare Part D coverage gap is completely closed.

38. Improves Access to Primary Care • Gives incentives to physicians and nurses who provide primary care in areas with doctor shortages. • Gives primary care providers who treat people with Medicare bonus payments for providing quality care.

39. Changes to Medicare Advantage Plan • New rating system. Plans that rate at least four out of five stars will receive bonus payments for providing better quality care. You can review your plan’s rating on Medicare’s website www.medicare.gov/find-a-plan. • Plans must use some of the bonus payments they receive for extra benefits and rebates to people participating in Medicare Advantage plans. • Plans must now limit how much they spend each year on administrative costs. For each dollar received in premiums, Medicare Advantage plans must spend at least 85 cents on care.

40. Changes to Premiums based on Income • In 2010, beneficiaries filing singly became subject to increased premiums if their MAGI is over $85,000; married beneficiaries filing joint returns are subject to increased premiums if their MAGI is over $170,000.  In 2010, about 5 percent of Medicare beneficiaries pay the higher income-related premium. • Since 2011, income-related premiums now also apply to those who have Part D prescription drug coverage. The income levels are the same as for Part B. • These income levels will stay the same until 2020, not increasing for inflation, which means that more individuals will be subject to the premium increase at a faster rate until that time.

41. Crackdowns on Medicare Fraud Medicare fraud results in higher health care costs for everyone. Eliminating fraud cuts costs for families, businesses, and the federal government. It also increases the quality of services for those who need care. Examples of Medicare Fraud include: • A healthcare provider bills Medicare for services you never received. • A supplier bills Medicare for equipment you never got. • Someone uses your Medicare card to get medical care, supplies, or equipment. • A company offers a Medicare drug plan that has not been approved by Medicare. • A company uses false information to mislead you into joining a Medicare plan.

42. ACA Fraud-Reduction Provisions • Tough new rules and sentences for criminals: The law increases federal sentencing guidelines for health care fraud by 20-50% for crimes with over $1 million in losses. • Enhanced screening: Providers and suppliers who may pose a higher risk of fraud or abuse are now required to undergo more scrutiny, including license checks and site visits.  • State-of-the-art technology: To target resources to highly suspect behaviors, the Center for Medicare & Medicaid Services now uses advanced predictive modeling technology.  • New resources: The law provides an additional $350 million over 10 years to boost anti-fraud efforts. • These provisions have recovered over $10.7 billion since 2010.

43. Medicare: Key Takeaways • Closes the “Doughnut Hole” • Increases access to Primary Care • Changes to Medicare Advantage • Changes to premiums based on income • Crackdowns on Fraud

44. On to Medicaid and Peak…