Presentation on theme: "Disability Program Manager"— Presentation transcript:
1 Disability Program Manager Health Care ReformPresented byBen Jauregui, MPADisability Program Manager
2 What’s new? Benefit Limits Pre-Existing Conditions Medical Expenses 2014: Prohibits Lifetime Benefit limitsPre-Existing Conditions2010: No denial for children2014: No denial for adultsMedical Expenses2011: 85% MLR for Large Employer Group2011: 80% MLR for Individual and Small Employer2014: 85% MLR for the Medicare Advantage plans*MLR-Medical Loss (Cost) Ratio
3 Employer Group Mandate Taking effect in January 2015Employers with less than 50 full-time (30+ hours) employees can purchase coverage through the Health Exchanges.Employers with 50 or more full-time employees are required to provide coverage orface penalty (excluding first30 employees).
4 Individual Mandate Beginning in January 2014: Mandate to have basic coverageEnforce penalty at tax filing time:YearPer adultPer childFamily maxor% of taxable income2014$95$47.50$2851%2015$325$162.50$9752%2016$695$347.50$2,0852.5%
7 Medicaid Expansion: Overview Effective January 1, 2014:Expands Medi-Cal eligibility to income up to 133% FPL (an increase from 100% FPL) plus a 5% income disregard.Eliminates asset or resources test.Simplifies Medi-Cal application.Requires the transition of persons currently enrolled in a Low-Income Health Program (LIHP) to Medi-Cal.****Children now qualify for Medi-Cal up to 250% after the closing of the Healthy Families Program.
8 Medi-Cal Expansion: Populations New populations include:Childless adults.Adults with kids over 21.Parents of existing Medi-Cal kids who currently fail asset test or do not meet other Medi-Cal eligibility requirements.Former foster youth up to 26 years old.Current LIHP enrollees.*New MAGI calculation of household income
9 Medi-Cal Expansion: Benefits Benefits are the same as Medi-Cal today including:LTSS Services (requires asset test)County can choose to provide enhanced benefits for substance use disorders.Restoration of dental benefits (State’s legislation) – May 1st, 2014.
11 Covered California: Overview A market place where people can purchase health insurance.Initial open enrollment starts October 1, 2013 through March 31, 2014.For a January 1, 2014 effective date.Low-income individuals (up to 400% FPL or $93,000 a year for a family of 4) will get help paying for their premiums.
13 Potential Mixed Families Mom, dad and 2 kids – make 200% of FPLWhat will the parents qualify for?What will the children qualify for?Answer: Adults in Covered CA, and kids in Medi-Cal
14 CalHEERS and Qualified Health Plans Covered California:CalHEERS and Qualified Health PlansWorking togetherto get Californians coveredMedi-Cal2014 Covered California Qualified Health PlansAlamedaContra CostaKaiserSharpBlue CrossChinese CommunityL.A. CareWestern Health AdvantageBlue ShieldHealth NetMolina*QHPs in red are available to I.E. residents.
15 Covered California: Benefits PlatinumGoldSilver100%-150% FPL150%-200% FPL200%-250% FPLBronzeDeductibleNone$2,000/medical$250 brand drugs$0$500/$1,500/$250/brand drugs$5,000integratedMed/RxDoctor$20$30$45$3$15$40$60-deductible after 3Specialist$50$65$5$70Urgent Care$60$90$6$80$120-deductible after 3Generic Drugs$19ER$150$250$25$75$300Out-of-Pocket for Individual$4,000$6,350$2,250$5,250Benefits in orange are subject to deductible. Others aren’t subject to the deducible and count towards annual out-of-pocket maximum.
16 Covered California: Rates The table below is an example of the rates a 40 year old single individual might pay for a Silver Plan.SilverPlan150% FPL200% FPL250% FPL400% FPLHealth Net HMO$44$202$108$139$180$67$246$0MolinaHMO$57$121$193$259Blue Shield PPO$62$125$198$264AnthemPPO$88$151$223$290Kaiser$98$161$233$300*The federal subsidies are shown in red.
17 Covered California: Financial Assistance Overview Starting in 2014, individuals seeking health coverage through Covered California may eligible for one of two types of financial assistance:Premium Subsidies (for up to 400% FPL)Lowers the cost of health coverage for individuals and families who meet certain income requirements and do not have affordable health insurance from an employer or a government program that meets minimum coverage requirements.Credits can be immediately applied.Copayment Subsidies (for up to 250% FPL)Reduces the out-of-pocket amount of health care expenses.Varies by the type of covered health care service.Tax creditsTax credits are available to help lower the cost of health coverage for individuals and families who meet certain income requirements and do not have affordable health insurance from an employer or a government program that meets minimum coverage requirements. When you enroll in a health plan through Covered California, tax credits can be immediately applied to the insurance premium, which reduces the amount you pay each month. The tax credits are available when you buy insurance so you do not have to pay all of the premium costs up front and wait for reimbursement. The tax credits will be available to all people who are eligible for them, whether they file taxes or not. The credits are only available for health insurance purchased through Covered California and will be paid directly to your private health plan by Covered California.Cost-sharing subsidiesCost-sharing subsidies reduce the out-of-pocket amount of health care expenses an individual or family has to pay. These expenses might include copayments. The amount can vary by the type of covered health care service. You may be eligible for cost-sharing subsidies if your income is less than about $27,936 for a single person and less than about $57,636 for a family of four in 2012, which represents about 2.5 times FPL.Premium SubsidiesFederalAssistanceCopayment
18 Covered California: Dental Benefits Children’s DentalStand-alone plans for children’s dental coverage in 2014.Working towards embedding pediatric dental in its 2015 portfolio ofcomprehensive medical insurance products.Rates as low as $8 per month in some regions.Five insurance companies will offer plans to families who buy insurance throughCovered California in 2014:Blue CrossBlue ShieldPremier AccessDelta DentalLiberty Dental*At this time, adults dental benefits are not being offered through Covered California.
19 Covered California: Subsidies Individuals with income less than 400% Federal Poverty Level ($92,200 for a family of four) will get the premium subsidies on sliding scale basis:Federal Poverty Level (FPL)Premium Spending Limit (% of income)Up to 133%2%%3 - 4%%%%%%%%9.5%