The Affordable Care Act
Impact to those with
Chronic conditions in
Four Buckets of the ACA Coverage Continuum
Classic Medicaid For Current Medicaid Recipients Medicaid Expansion 0% - 138% FPL regardless of health status Dual Eligible Medicaid & Medicare / Poor, sick, disabled, aging Washington Healthplanfinder – More than 138% FPL; Premium subsidies for 138% - 400% FPLJanuary 1, 2014
January 1, 2014 Rolling out by region between
July 1, 2103 and July 1, 2014.
Part I: Four Buckets - WA State
Medicaid Expansion - 500,000 to become eligible and 250,000 of the 500,000 anticipated to enroll Duals
Medicare & Medicaid eligible 115,000
Health Benefits Exchange
- persons more than 138% FPL enroll through
Healthplanfinder starting October 1, 2013.
Classic Medicaid –
sometimes called Healthy Options. HIV includes 2,500 people disabled and poor statewide.
January 1, 2014
January 1, 2014 Rolling out by region between
July 1, 2103 and July 1, 2014.
Part I: Four Buckets - WA State
Medicaid Expansion - 500,000 to become eligible and 250,000 of the 500,000 anticipated to enroll Duals
Medicare & Medicaid eligible 115,000
Health Benefits Exchange
- persons more than 138% FPL enroll through
Healthplanfinder starting October 1, 2013.
Classic Medicaid –
sometimes called Healthy Options. HIV includes 2,500 people disabled and poor statewide.
Current
Classic Medicaid –
sometimes called Healthy Options. HIV includes 2,500 people disabled and poor statewide.
Classic Medicaid
Poor and disabled adults
Medicaid Now: Adults below 75% of Federal
Poverty Level (FPL) who are also disabled. The
largest current Medicaid program is also known as
Healthy Options.
Existing Medicaid cont...
Persons currently covered by Medicaid:
• Although it’s an option, Fee for Service is not a good route for people with chronic conditions!
Classic Medicaid cont...
MCO - Managed Care Organization - there are five authorized in Washington State with most counties covered by all five. Persons (members) will be auto-enrolled by the state. Members can move from one to another throughout the year.
The five Managed Care Organizations: • Molina
• United Healthcare Community Plan • Coordinated Care (Centene)
• Community Health Plan WA • Amerigroup
January 1, 2014
January 1, 2014 Rolling out by region between
July 1, 2103 and July 1, 2014.
Part I: Four Buckets - WA State
Medicaid Expansion - 500,000 to become eligible and 250,000 of the 500,000 anticipated to enroll Duals
Medicare & Medicaid eligible 115,000
Health Benefits Exchange
- persons more than 138% FPL enroll through
Healthplanfinder starting October 1, 2013.
Classic Medicaid –
sometimes called Healthy Options. HIV includes 2,500 people disabled and poor statewide. Current January 1, 2014 Medicaid Expansion - 500,000 to become eligible and 250,000 of the 500,000 anticipated to enroll
What is Medicaid Expansion?
Medicaid Expansion - Washington residents who earn up to 138% of FPL; diagnoses or pre-existing
January 1, 2014
January 1, 2014 Rolling out by region between
July 1, 2103 and July 1, 2014.
Part I: Four Buckets - WA State
Medicaid Expansion - 500,000 to become eligible and 250,000 of the 500,000 anticipated to enroll Duals
Medicare & Medicaid eligible 115,000
Health Benefits Exchange
- persons more than 138% FPL enroll through
Healthplanfinder starting October 1, 2013.
Classic Medicaid –
sometimes called Healthy Options. HIV includes 2,500 people disabled and poor statewide.
Current
Duals
Medicare & Medicaid eligible 115,000
Rolling out by region between July 1, 2103 and July 1, 2014.
Dually Eligible Definition
Duals - Persons who qualify for Medicaid (poor) AND
Medicare (sick/disabled) and/or are or over age 62.
HealthPath Washington is a program for dually
eligibles that will allow people with chronic disease
receive high touch care coordination. HealthPath is
rolling out by region
across the state between
July 1, 2013 and July 1,
2014.
January 1, 2014
January 1, 2014 Rolling out by region between
July 1, 2103 and July 1, 2014.
Part I: Four Buckets - WA State
Medicaid Expansion - 500,000 to become eligible and 250,000 of the 500,000 anticipated to enroll Duals
Medicare & Medicaid eligible 115,000
Health Benefits Exchange
- persons more than 138% FPL enroll through
Healthplanfinder starting October 1, 2013.
Classic Medicaid –
sometimes called Healthy Options. HIV includes 2,500 people disabled and poor statewide.
Current
January 1, 2014
Health Benefits Exchange
- persons more than 138% FPL enroll through
Healthplanfinder starting October 1, 2013.
Insurance Exchange Definition
The Exchange works like this:
Eligibility:
• Income of 139% FPL or more • (Premium support if
between 139% - 400% FPL) • No other coverage
Enrollment: Through Healthplanfinder starting October 2013. Here in Washington, most people living with HIV will be
able to also have co-pay assistance for premiums, office visits, and pharmacy coverage from the Early Intervention Program (EIP).
Insurance Exchange Definition cont...
What you need to do:
If you have Medicaid now
• You will remain on Medicaid and will be sent information, and you will be able to have assistance through your doctor's office, clinic, or case manage.
If you have EHIP now
• You will be on Medicaid, or keep your employer-sponsored
coverage, or obtain new coverage through the Healthplanfinder for private insurance.
What does all this mean to me?
It depends on how you are covered today. The next
slides will address each of the following:
• Through my employer, I'm on a group plan.
• Through my spouse/family and their coverage is an employer group plan - and/or other type of family coverage.
• Through EHIP - Evergreen Health Insurance Program.
• Through Medicaid (Healthy Options) and I've been on it for awhile. • Through Medicaid & Medicare - I'm a dually eligible person.
• Medicare
• VA – Veterans Affairs • COBRA
• I'm not currently seeing a doctor/not on medication, and I have no coverage. • My coverage is currently something else...
• Tribal
• Undocumented resident/immigration status • I buy my own insurance
My coverage is through my employer, I am on a
group plan through work and am still employed.
Your employer will continue to provide your
insurance. No active changes are needed.
Please Note:
What is covered could change
(improve/reduce). Employers with less than 50 employees may also change.
My coverage is through my spouse/family and
their coverage is an employer group plan, or
some other type of ongoing coverage.
The Affordable Care Act will either improve
or not change for these groups
My spouse/family coverage is through: • Veterans - coverage through VA
• Federal Employee - coverage through government
• On Medicare - will stay on Medicare
Please note: Family definition now includes legally married same-sex couples
Definition of EIP / EHIP / ADAP
Early Intervention Program (EIP) -
There are just over 4,000 persons with HIV whose income qualifies them to receive EIP services. These services
include co-pays to ensure access to care and treatment for HIV.
Definition of EIP / EHIP / ADAP cont...
Evergreen Health Insurance Program (EHIP) -
Of those in EIP, approximately 2,400 persons receive financial assistance by having their insurance paid by EHIP. This
includes those who receive coverage through WSHIP
(Washington State High Risk Insurance Pool) program, work or COBRA, Medicare drug plans, and private plans. If you receive insurance assistance through EHIP, you have EIP service options.
Definition of EIP / EHIP / ADAP cont...
AIDS Drug Assistance Program (ADAP) -
This is the name of the fund that pays for EIP services. The money comes through the Ryan White Act Part B program. At present, Congress funds this program at $1 billion. With the next appropriations, the dollar amount will dramatically
decrease. This is because medications will be covered through various plans in the Affordable Care Act.
EHIP assists with my coverage
Evergreen Health Insurance Program
• If you earn more than 138% of the FPL and do not have access to coverage through work, family, or Medicare, you will get coverage through the
Healthplanfinder. EHIP will help you select a plan between October 2013 and January 2014 and will help you pay the premium.
• Co-pays (deductibles, office visits, prescription co-pays) will be required but some may be covered by EIP.
• If you earn 138% or less than of the FPL as a single person you will be in the Medicaid Expansion plans.
Please Note:
• Your current physician may, or may not continue to see you with your new insurance coverage. You are encouraged to talk with your providers or case manager to inquire and plan for any potential changes.
Medicaid 138% & below FPL Healthplanfinder 139% or more FPL premium subsidy if 139%-400% FPL Co-pays covered by EIP
My coverage is through Medicaid
(Healthy Options) and I've been covered for awhile
• There are limited changes as to how your coverage will continue. • It is very likely that your current provider will remain your current
provider.
• There is not expected to be an increase in co-pays for medication, office visits.
My coverage is through Medicaid/Medicare -
I am dually eligible
• There are a limited number of persons who fit this category. • There will be new insurance carrier options. Your insurance
may change or may stay the same. Your provider may or may not change, depending on the plan
My Coverage is through Medicare Only
• The Part D Doughnut Hole (prescriptions/medicine) will slowly close over several years. EIP will continue to pay co-pays as long as funds are available.
• Benefit packages will likely improve and co-pays for labs, doctor visits, and services will reduce over several years. EIP will continue to pay co-pays on services as long as funds are available.
• EHIP can pay your Medicare Prescription Drug Plan premium.
My Coverage is through the Veteran's Affairs (VA)
or coverage through Department of Defense
• Coverage remains the same as it is now.
• Includes active duty, reserves, and any other non VA Defense Department areas of health coverage.
COBRA
My coverage is through my previous employer where I am no longer employed and am I receiving coverage in the 18-month separation window.
• You may switch to a private plan through the
Healthplanfinder. This may cost you less because of the premium subsidies.
I'm not currently seeing a doctor
and I have no coverage OR
Nothing else applies to me
Please contact:
• Your case manager if you have one.
• The Evergreen Health Insurance Program at www.ehip.org, 206-323-2834, or 1-800-945-4256
• An HIV physician or practice to gain entry into care. • Other leads...?
What I need to do:
• Talk with your provider • In-person Assister
Tribal healthcare benefits
Please contact your provider and/or Indian Health
Services for further assistance.
Immigrant Populations
• Naturalized citizens are eligible for all ACA changes
• Legal immigrants in the US less than 5 years (5 year bar): – Are not eligible for Medicaid Expansion
– Can purchase coverage and receive premium subsidies (down to 0% FPL) in the Healthplanfinder
• Immigrants who are not lawfully present in the US are not eligible for Medicaid Expansion, coverage or premium
subsidies from the Healthplanfinder, or Medicare – Private insurance plans offered outside the
Healthplanfinder do not check for citizenship but may be expensive
– WSHIP closed to new enrollment – EHIP can pay premiums
