Patient Access and the Healthcare Exchange Buddy Holt

Patient Access and the Healthcare Exchange Buddy Holt Eligibility Consultants, Inc. 2013 -November

What is Medicaid? • Government run health coverage program for low-income individuals and families since 1965 • It is jointly administered and funded by the federal government and the states • The federal government sets basic guidelines, and the states have broad authority to modify their Medicaid programs respective to the needs of their state

Who is Eligible? • A person has to satisfy two tests: 1) Belong to a "categorically" eligible group (generally: children, pregnant women, blind or disabled persons, and the elderly) 2) Meet the financial test set by the state for that group • The federal government mandates eligibility levels for children and pregnant women be at least 100 -133 percent • Eligibility levels for parents can be much lower • States are not required to cover adults without dependent children

The Current Medicaid Eligibility Levels

Key Provisions of the ACA • Maintains an employer based system with employer requirements • Maintains a private insurance market • Enacts an “Individual Mandate” requiring most people to have insurance • Allows coverage for young adults on their parent’s policy • Enacts health insurance reforms (i. e. No preexisting condition exclusions) • Requires creation of health insurance exchanges • Expands Medicaid significantly (138% FPIL)

Medicaid Expansion • Eligibility based on Modified Adjusted Gross Income (MAGI) • New categories of Medicaid eligibles: • Single, childless adults, not disabled • Parents • Former foster children (aged out up to 26) • All “newly eligible” adults will receive a benefit package or benchmark -equivalent that meets the minimum essential health benefits available in the Exchange.

What does this look like pragmatically? • Jan to Mar 2013, ECI screened 16, 427 individuals • Under the current rules 5384 of these were sponsorship eligible • Applying the new rules of the Affordable Care Act to this same population would have resulted in 13, 162 being potentially eligible for Medicaid • Under the new rules the remaining portion of these individuals, unless claiming an exemption, would be mandated to obtain coverage through an employer or an exchange or pay an additional tax (a. k. a. penalty)

The Reimbursement Shift 185 Avg Discharge Bal. $10, 278. 21 Avg Paid to Hospital $ 2, 827. 08 133 100 Avg Discharge Bal. $ 2, 944. 92 Avg Paid to Hospital $ 525. 81 55

The undetermined future of CHIP • Extends the current CHIP authorization through 9/30/2015 • CHIP-eligible children, who cannot enroll in CHIP due to federal allotment caps, will be deemed ineligible and will then be eligible for tax credits in the exchange. • ACA provides that after FY 2015 states may enroll targeted lowincome children in qualified health plans via the exchanges • Much of what will happen with CHIP still remains to be determined by the consensus which must be reached between the state and the federal HHSC

Changes in funding • Increase Medicaid payments for primary care to 100% of the Medicare rates for 2013 and 2014 with 100% federal funding • Reduces Disproportionate Share Hospital (DSH) payments by $14 billion through 2019 • “New eligibles” will be covered through federal funds at 100% for 2014 -2016. • 6 new agencies are being created to resolve underfunding and provider participation issues (i. e. CMI)

Expansion and the June 2012 Ruling • The Supreme Court upheld the Medicaid expansion of the Affordable Care Act as constitutional • It limited the federal government’s ability to penalize states that don’t implement the expansion • ACA assumed all states would comply with setting up exchanges and made no provision legally or economically for the 17 states electing not to set up the exchanges • Heavy funding from the federal government is being used to entice the state’s cooperation. The next legislative session will significantly shape future Texas Medicaid

Making the ACA Work • 47 major changes to the revenue code • 2, 000 new IRS agents just for the ACA Office • The Federal Data Services Hub (Wall Street Journal, 5/15/13) – IRS records for income and employment status – Social Security records for identity – Homeland Security records for citizenship – Justice records for criminal history – HHS records for enrollment in entitlement programs and medical claims data – State Government records for residency

Pathways to Enrollment • Navigators: Funded through grants; provide outreach and assistance in addition to help consumers identify tax credits. • Certified Application Counselors: Certifies application counselors which educate consumer and assist in the completion of applications for coverage. • Champions for change: Educates consumers in general and make referrals to Navigators, CACs and the Healthcare Marketplace • Self Application: Via Healthcare. gov, paper application, or 1 -800 call center • State Assistance Application:

ACA Exchanges (a. k. a. Healthcare Marketplace) • Anyone can shop for insurance through an exchange • Plans are offered on 4 tiers: • • Bronze Plan Silver Plan Gold Plan Platinum Plan • Tax subsidies are offered for applicants who fall between 133% to 400% of FPIL • Open enrollment began October 1, 2013

Exchanges – Premium Assistance To qualify for premium assistance credit, you must: • Not be eligible for employer-sponsored plan • Have a household income between 100% and 400% FPIL • Not receive Medicare, Medicaid, CHIP, Tricare, or VA benefits • Be a citizen of legal permanent resident • Be a resident of a state where a state exchange is available • Not an dependent on someone else’s tax return • Purchase a non-catastrophic plan through the Exchange

Exchanges – Premium Assistance • The amount of the tax credit is based on the premium for the cost of the silver plan in the exchange area where the applicant lives. • The amount varies with income so that the premium will not exceed a specified percentage of their income (adjusted for family size): FPIL Income Range Applicable Portion Level 1 <133% 2. 00%-2. 00% Level 2 133%-150% 3. 00%-4. 00% Level 3 150%-200% 4. 00%-6. 30% Level 4 200%-250% 6. 30%-8. 05% Level 5 250%-300% 8. 05%-9. 50% Level 6 300%-400% 9. 50%-9. 50%

What’s a Poor State to Do? • Texas has a 133% to 185% FPIL window for potential Marketplace enrollees who can still be on Medicaid • All Marketplace eligible Medicaid applicants are being forward to the fed Jan 1, 2014 for outreach. • Texas has a designated unit in Austin to receive application referrals through the Healthcare marketplace • New training is being made available to State HHSC workers in mid-December along with a new Medicaid application. • Texas will be moving to the MAGI calculation method

What’s in the Future? • The employer mandate has been pushed to 2015 and given the current problems the potential of pushing the individual mandate is gaining traction • The fed has set a goal of 700, 000 enrollees to meet their numbers • 400, 000 have lost insurance so far and a reversal would require at least 6 months with state insurance commissions • No provisions for undocumented aliens, prisoners, income exempt (8%), religiously exempt, non-filers, Native Americans, lapsed policies of less than 3 months, or individuals below tax filing threshold. • 40% increase in insurance policies • Lots of new individual TAXES!!! • Decreased levels of hospital and provider reimbursement