Presentation on theme: "Federal Health Care Reform: The Impact on NYS Programs Buffalo, NY October 13, 2010 Presented by: Trilby de Jung Senior Health Law Attorney."— Presentation transcript:
Federal Health Care Reform: The Impact on NYS Programs Buffalo, NY October 13, 2010 Presented by: Trilby de Jung Senior Health Law Attorney
2 Today’s Agenda Overview of PPACA New coverage options already in effect Major provisions most relevant to low-income populations Public Program Expansion State Exchange & Coordinated Enrollment Selected service Delivery Reforms What we still don’t know - questions/choices for policy makers
3 Overview PPACA has a two-fold vision – universal coverage and cost control. Most of the provisions we will look at today fall into the universal coverage bucket. We will also look at some of the service delivery reforms that are aimed at controlling costs. The reforms in both areas are phased in gradually – lots of discretion during implementation (with HHS and the states)
Universal Coverage? million uninsured in New York PPACA approach to universal coverage as a three-legged stool Employer coverage (reforms w/out reductions) Public programs (significant expansion) Affordable private insurance w/mandate New marketplace (> 1 M will be eligible for coverage through the Exchange) Tax subsidies (of those in Exchange, 700,000 eligible for tax subsidies)
Who is left behind? 5 Dramatic expansion of coverage – another 1.2 million will be covered in NY. But some are left behind Undocumented immigrants (400,000) Eligible but unenrolled in public programs (up to 1 M could remain) Those qualifying for hardship exemptions (200,000) Those paying penalties (190,000) Between 1.4 and 1.8 million New Yorkers could remain uninsured
New Coverage Options Already in Effect
High Risk Pools – NY’s Bridge Plan 7 Temporary coverage through GHI Includes pharmacy and vision care with no deductibles and very low co-pays For individuals only, no family or dependent coverage is available Individuals must have a pre-existing condition, be uninsured for 6 months, a resident of NYS and lawfully present (immigration status) Premiums are standardized: $362 for counties above the Hudson Valley, $421 for downstate For more information,
8 Young Adults Coverage PPACA requires insurers to allow young adults to remain on parents’ policy up to age 26, if no other coverage available Beginning in 2014, coverage extension is an option even if other coverage is available (HHS requirements)HHS requirements The rule takes effect on all plans or policy years starting September 23, 2010 or later. Special 30 day re-enrollment opportunity must be provided no later than the start of the new plan/policy year.
Public Program Expansion
Medicaid to 133% of FPL by New mandatory eligibility category created Traditional eligibility categories remain New category is all who are not: Age 65 or older Pregnant Entitled to or enrolled in benefits under Medicare Part A Enrolled under Medicare Part B or Included in any other mandatory groups (Sections I – VII of SSA 1902(a)(10)(A)(i)
Public Program Eligibility in NYS, 2010 Slide courtesy of the United Hospital Fund Notes: Eligibility for all programs is expressed as a gross income standard. The 2009 Federal Poverty Level (FPL) is $10,830 for an individual and $18,310 for a family of three. Children with gross family income above 160% FPL are charged an income-related premium in Child Health Plus. “ “ refers to the federal minimum Medicaid eligibility level under the Patient Protection & Affordable Care Act. “----” refers to the enacted Family Health Plus eligibility expansion which is contingent upon federal approval. “No ceiling” refers to the fact that workers with income above Medicaid/Child Health Plus/Family Health Plus levels are eligible for the FHP buy-in although they are not eligible for state premium subsidies; and small businesses are eligible for the HNY program if at least one third of their employees have income below $40,000 and one lower-income employee enrolls.
MAGI Budgeting 12 New Income test based on Modified Adjusted Gross Income of 133% FPL Flat deduction of 5% takes income up to 138% MAGI will not apply to the following groups, absent a waiver (waivers for duals are explicitly mentioned) Those over 65 SSI recipients, SSI-related & foster care kids Medically needy MSP enrollees Those using chronic care services
MAGI Budgeting 13 No asset test Gross test – no disregards for earned income, child care However, certain income will not be counted (IRS/tax rules) Child support SSI, Survivor’s benefits (see IRS publication 17)IRS publication 17 Family size is who files taxes together Step-parents & grandparents may be included MAGI parents must enroll children MOE provision in effect until 2014
Alignment is not perfect… Traditional Eligibility Categories MAGI New Eligibility Group
15 Benchmark Benefits Mandatory expansion covers only “benchmark” benefits for most Benchmark coverage to include at least essential health benefits required of plans in the exchange Secretary approved benchmark can include full Medicaid benefits Thus benchmark is floor not ceiling
16 Basic Health Plan Option States can create a Basic Health Plan for newly eligibles up to 200% of FPL Lawfully present immigrants subject to 5 year bar can participate in the Basic Health Plan States will receive 95% of what the federal government would have paid in subsidies for enrollees Currently, no federal contribution for lawful immigrants in Medicaid – except pregnant women and children
State Exchanges & Coordinated Enrollment
18 State Insurance Exchanges Exchange will function as a new marketplace for “qualified health plans” and the subsidies that help lower costs How to conceptualize the Exchange? Only qualified people can buy products…but can anyone enter? Because of the new systems, education and assistance available to users of the Exchange, we are urging NYS to open the door to all, even those who will not get coverage through the Exchange
19 State Insurance Exchanges Primary purpose of Exchange – facilitate coverage for individuals and small businesses Only qualified individuals can buy insurance and apply for subsidies Residence in state running the Exchange “Lawfully present” immigration status (no five year ban) Subsidies are available up to 400% of FPL (using MAGI from last tax filing)
20 Coordinated Enrollment PPACA requires Exchange(s) to also serve as a portal for applications for public programs and hardship exemptions Single application for Exchange, tax subsidy, Medicaid and Child Health Plus Applications must have on line, in person, mail and telephone options States must screen those ineligible for Medicaid/CHP for tax subsidy Data matching through SSA, Treasury & Homeland Security
21 Consumer Education & Navigational Assistance PPACA requires states to create and fund a Navigator function within their Exchanges. Duties of Navigators: Engage in public education re enrollment and subsidies Provide culturally & linguistically appropriate materials Facilitate enrollment Refer for complaints and/or grievances Also some funding for Consumer Assistance Programs
22 Exchange Communications Notification of eligibility for Tax subsidy Other cost sharing Public Plan Hardship exemption Appeal rights when denied Confirmation of plan choice Appeals rights for recoveries? Opportunity to ensure consistent, consumer friendly tone, culturally and linguistically appropriate notices
23 Maximizing Exchange Potential Allow all to benefit from new systems, improved communications and assistance of Navigators Educate people who will be left behind regarding charity care, Emergency Medicaid How about pre-screening for these programs? How about education regarding penalties, reconciliation, recoveries?
Delivery System Reforms
25 Primary Care Investments Temporary rate boost to Medicare levels with 100% federal funding $9.5 Billion for Community Health Centers
26 Two New Federal Offices The Center for Medicare & Medicaid Innovations >$10 B for new patient care and payment models, includes state flexibility to assume management of Medicare funds to better integrate care Federal Coordinated health Care Office Better coordination of coverage & payment for dual eligibles
27 Improvements in Part D No less than seven adjustments to cost-sharing, premiums, enrollment periods, donut hole calculations (plus $250 checks!) Inspector General to do study related to dual eligibles and comparative drug costs under Part D and Medicaid Outreach and assistance funding
28 New Home Care Options The Balancing Incentive Program – $$ for structural changes to strengthen community-based long term care The Community First Choice Option – a new state plan benefit for ADL services Stronger HCBS state plan benefit Spousal Impoverishment protections in all waiver programs (temporarily)
29 Addressing Disparities Health programs subject to non- discrimination provisions of Title VI Age Discrimination Act Section 504 of the Rehabilitation Act Data collection by race, ethnicity, language, gender and disability – to be reported publicly, and analyzed for trends
Policy Choices for New York
31 Questions regarding existing programs Will New York maintain FHPlus for parents and young adults? Will it create a Basic Health Plan? Will it maintain its CHP program once the Exchange is fully functioning? How will NY ensure coverage for all immigrant children?
32 Questions re Public Program Enrollment & the Exchange How will NY coordinate the enrollment and eligibility rules and systems for MAGI and Non-MAGI populations? Will the Exchange be open to all? How will else can we provide seamless transitions between coverage options? What role will counties play in eligibility and enrollment?