Morning Plenary: Implementation of The Affordable Care Act

Presented by: Johnston Associates

Sponsored by: Alliance InstituteNovember 15, 2013

Morning Plenary: Implementation of The Affordable Care Act

The Affordable Care Act & Access to Health Care Along the Gulf Coast: A Symposium

We need Access to Affordable Health Care on the Gulf Coast

Morning Plenary: Panelists

Marjorie PettyRegional DirectorRegion VIUS Department of HHS

Oscar GomezHealth Outreach Partners

Tony GarrEnroll America

Moderated by: Philip W. Johnston

Health Insurance Marketplace 101

The Marketplace is open!

Find healthoptions that meet

needs and fit

careyour your

budget.

November 2013

Presented by Marjorie Petty, HHS Regional Director, Region VI

GEOGRAPHIC DIVERSITYOF THE UNINSUREDNumber Uninsured Percent Uninsured

ch 2010, President Obama signed the

The Health Care Law

In MarAffordable Care Act into law allowing

• Young adults up to age 26 totheir parents’ plan

Additional drug coverage for with Medicare

stay on

• people

••

More free preventive services

Lifetime limits removed from health insuranceAnd more starting January 1, 2014•

November 2013 Health Insurance Marketplace 101 2

What’s new on January 1, 2014?

Discrimination due to pre-existing conditions orgender is prohibited

Annual Limits on Insurance Coverage are eliminatedAdvanced Premium Tax Credits are availableThe Small Business Tax Credit will increaseMore people are eligible for Medicaid (in some states)

Coverage through

beginsthe Health Insurance Marketplace

• As early as January 1, 2014

November 2013 3Health Insurance Marketplace 101

What is the Health Insurance Marketplace?

Part of the Affordable Care Act of 2010• Where qualified individuals directly compare private

insurance options

Known as Qualified Health Plans (QHPs)Can directly compare on the basis of price, benefits, quality, and other factorsAlso known as Exchanges or Obamacare

health

•

•

Small Business Health Options Program (SHOP)• Marketplace for small businesses

November 2013 Health Insurance Marketplace 101 4

The Marketplace…

It’s a way to shop for health coverage••

Simplifies the search

With one streamlined application an individual or familycan explore every qualified insurance plan in the area

Most people are able to get a break on costs• 90% of people who are currently uninsured will qualify for

savings on health insurance

Clear options with apples-to-apples comparisons• All health insurance plans in the Marketplace present their

price and benefit information in plain language

November 2013 Health Insurance Marketplace 101 5

Marketplace Establishment

Each state can choose to••

Create and run its own Marketplace

Partner with the Federal Government to run someMarketplace functions• Have a Marketplace establishedthe Federal Government

and operated by

November 2013 Health Insurance Marketplace 101 6

Qualified Health Plans CoverEssential Health Benefits

Essential Health Benefits include at least these 10 categories

• Ambulatory Patient Services• Emergency services• Hospitalization• Maternity and newborn care• Mental health and substance use disorder services,

including behavioral health treatment• Prescription drugs• Rehabilitative and habilitative services and devices• Laboratory services• Preventive and wellness services and chronic disease management• Pediatric services, including oral and vision care (pediatric oral

services may be provided by stand-alone plan)7

November 2013 Health Insurance Marketplace 101

How Qualified Health Plans Can Vary

Some plans may cover additional benefits

You may have to see certain providers or use certain hospitalsThe premiums, copays, and coinsurance are different different plansThe quality of care can varyThe coverage level can vary within each planSome special types of plans are structured differently

in

• Like high-deductible (catastrophic) plans

November 2013 Health Insurance Marketplace 101 8

Plan Levels of Coverage

Lowest PremiumsHighest Out-of-Pocket

Highest PremiumsCosts Lowest Out-of-Pocket Costs

60%

Covered70%

Percent of

80%

Total Cost of

90%

Care Covered

November 2013 Health Insurance Marketplace 101 9

Catastrophic Plans

What is catastrophic coverage?•••

Plans with high deductibles and lower premiums

You pay all medical costs up to a certain amount Includes coverage of 3 primary care visits per year preventive services with no out-of-pocket costsProtects consumers from high out-of-pocket costs

and

•

Who is eligible?••

Young adults under 30 years of age

Those who obtain a hardship exemption from the Marketplace

November 2013 Health Insurance Marketplace 101 10

Small Business Health Options Program(SHOP) Marketplace

A streamlined way for small businesseshealth insurance

Part of the MarketplaceOffers access to Qualified Health PlansWorks with new insurance reforms and

to offer

tax credits to

lower barriers to offering health insurance

SHOP Marketplace Help Desk for employers

• 1-800-706-7893 (TTY 1-800-706-7915)

November 2013 Health Insurance Marketplace 101 11

Eligibility in theIndividual

Marketplace Marketplace eligibility requires you to

•••

Live in its service area, and

Be a U.S. citizen or national, orBe a non-citizen who is lawfully present in

the U.S. forthe entire period for which enrollment is sought

Not be incarcerated• Can apply

charge

Can apply

for Marketplace if pending disposition of

for Medicaid/CHIP at any time

November 2013 Health Insurance Marketplace 101 12

Lower Premium Costs

A refundable or Advanced Premiumthe cost of Qualified Health Plans

Eligibility is based on

Tax Credit (APTC) lowers

• Household income, and family size (at end of year)

Income between 100% to 400% of the federal poverty level (FPL) ($23,550 – $94,200 for a family of four in 2013)

Obtaining qualified health insurance through the Marketplace Ineligibility for government-sponsored coverage, affordable employer-sponsored insurance, or certain other minimumessential coverage

••

November 2013 Health Insurance Marketplace 101 13

Ways to Use a Premium Tax Credit

*You should report changes in household size and income as soon as possible toensure you are getting the right premium tax credit amount and avoid having topay anything back.

November 2013 Health Insurance Marketplace 101 14

Will you get a Will you have toIs your monthly credit on Federal pay back

If you choose to… premium lower? tax return? money?*

Use all of your premium tax credit Use part of your premium tax credit Use none of yourpremium tax credit

Yes Not likely Maybe

Yes Maybe Not likely

No Yes No

Who is Eligible for a Cost-Sharing Reduction?

Eligibility for reduced cost sharing is based on• Income at or below 250% of the FPL ($58,875

annually for a family of four in 2013)

Receiving the Premium Tax CreditEnrollment in a Marketplace Silver-level plan

••

Members of Federally-recognized Indian Tribes

• No cost sharing if income is <300% FPL

November 2013 Health Insurance Marketplace 101 15

Medicaid Eligibility in 2014

States have the option to expand Medicaid eligibility to

• Adults ages 19 – 64 with incomes up to 133% of the federalpoverty level (FPL) ($15,282/year for an individual,$31,322/year for a family of 4 (2013 amounts))

Ensures Medicaid coverage for all children

• With incomes up to 133% of the FPLShifts to simplified way of calculating income to determineMedicaid/CHIP eligibility

• Known as Modified Adjusted Gross Income (MAGI)-basedmethod

November 2013 Health Insurance Marketplace 101 16

Starting in 2014, everyone must either:

OR OR

1. Have Minimum 2. Have a Coverage 3. Pay a feeEssential Exemption (SharedCoverage

They are already covered and don’t need to do anything.

November 2013

They don’t have to get coverage and won’t have to pay a fee for not having coverage.

Health Insurance Marketplace 101

ResponsibilityPayment)

They should consider getting coverage. If they don’t, they will pay a fee.

17

1. What is Minimum Essential Coverage?

If you have coverage from any of the following, you arecovered and don’t have to do anything•••••••

Employer-sponsored, including COBRA and retiree

MedicareMedicaidChildren’s Health Insurance Program (CHIP) Marketplace CoverageIndividual Coverage (outside the Marketplace)

TRICARE or certain types of VA coverage

coverage

About 85% of Americans already have Minimum Essential Coverage.November 2013 Health Insurance Marketplace 101 18

2. Who can get a coverage exemptionnot have to pay a fee?

and

You may get a coverage exemption if you•••••••

Are

AreAre

conscientiously opposed (religious conscience)

a member of a recognized health care sharing ministry a member of a Federally recognized Indian tribe

Don’t make the minimum income required to file taxes

Have a short coverage gap (>3 consecutive months) Suffered a hardshipDid not have access to affordable coverage (cost of available coverage >8% of household income)

••

Were

Wereincarcerated (unless pending disposition of charges)

not lawfully presentHealth Insurance Marketplace 101November 2013 19

3. You May Pay a Fee

You may pay a fee when you file your 2014Federal tax return in 2015 (and thereafter)• If you don’t have minimum essential coverage,

and

You don’t qualify for an exemption•

Paying thecoverage

fee does not provide health

November 2013 Health Insurance Marketplace 101 20

Less than 2% of Americans are expected to have to pay the fee.

You May Pay a Fee (Continued)

You pay the greater of the flat dollar amount or the percentageof income

*Maximum of $285 per family in 2014 (applies to those for whom the $95 peradult/$47.50 per child is less than 1% of income). Higher in subsequent years.

** After 2016 - Plus an increase based on cost of livingNovember 2013 Health Insurance Marketplace 101 21

2014 2015 2016 and beyondFlat dollar $95 per adult $325 per adult $695 per adult** amount 50% if under 18* 50% if under 18* 50% if under 18* (annual)

Or Or OrPercentage of 1% of household 2% of household 2.5% of income income income household (annual) income

When You Can Enroll in the Individual Market

Marketplace Initial Open Enrollment Period• October 1, 2013 - March 31, 2014

Annual Open Enrollment Periods• 2014 and beyond, October 15 - December 7

Special Enrollment Periods• Available in certain circumstances during the year

November 2013 Health Insurance Marketplace 101 22

How the Marketplace Works

Health Insurance Marketplace 101November 2013 23

4 Ways to Get Marketplace Coverage

November 2013 Health Insurance Marketplace 101 24

In Person Assistance

Marketplace in person help is available• Certified Assisters

Navigators Non-Navigator assistance personnel Certified Application Counselors

Agents and brokersTo find assistance in your area, go toLocalhelp.HealthCare.gov

••

Visit Marketplace.cms.gov for information on yourbecoming a Champion for Coverage

organization

November 2013 Health Insurance Marketplace 101 25

Marketplace and People With…

Medicare

• Medicare isn’t part of the Marketplace so you don’t need to doanything

COBRA

• You can drop COBRA and enroll in the Marketplace

During the Marketplace Open Enrollment Period Within 60 days of COBRA expiring (Special Enrollment Period)

Pre-existing Condition Insurance Plan (PCIP)

••

Ends December 31, 2013

Need to apply for Marketplace coverage by December 15, 2013, to avoid a break in coverage (no automatic transition)

November 2013 Health Insurance Marketplace 101 26

Key Points to Remember

The Marketplace is a new way to find and buyinsurance

Qualified individuals and small businesses can health insurance that fits their budget

health

shop for

States have flexibility to establish their own Marketplace

Individuals and families may be eligible for lower coststheir monthly premiums and out-of-pocket costs

There is assistance available to help you get the best coverage for your needs

on

November 2013 Health Insurance Marketplace 101 27

Open Enrollment StartedOctober 1, 2013

Last day to enroll for coverage to begin January 1, 2014

December 15, 2013

Coverage can start as early as

January 1, 2014

Open enrollment endsMarch 31, 2014

November 2013 Health Insurance Marketplace 101

Remember the Marketplace’sImportant Dates

AfterMarch 31, 2014,

you can onlyenroll after a

qualifying eventor during the

next annual openenrollment

(Oct 15, 2014 –

28

Dec 7, 2014).

Marketplace.cms.gov

Get the latestresources to helppeople apply, enroll,and get coverage2014

in

November 2013 Health Insurance Marketplace 101 29

Click “Get Training” for helpful videos

onnected

Want more informationabout the Marketplace?

Stay Connected• Sign up to get email and text alerts at

HealthCare.gov/subscribe

CuidadoDeSalud.gov for Spanish• Updates and resources for partner

available at Marketplace.cms.gov

Twitter@HealthCareGovFacebook.com/Healthcare.gov

organizations are

••

November 2013 Health Insurance Marketplace 101 30

Alliance Institute: ACA DiscussionNovember 15, 2013

Tony GarrSoutheast State Assistance Manage

Get Covered America Mission

37

Sampling of Our Partners

38

Enroll America’s Mission: Maximize Coverage For Uninsured Americans

1. Educate and Engage 2. Mobilize to Enroll 3. Work with Partners to Ensure System works

Enroll America is executing a national education and enrollment campaign

Successful implementation of ACA requires all-out effort by government, not-for-profits, insurers, hospitals, community health centers, health providers, and others

39

State Presence

40

AlaskaHawaii

As of September 23, 2013

Staff on the ground

Working with partners

Our Research Tells Us…

41

Alabama Assistance

Coordinating Organization: Alabama Arise http://www.arisecitizens.org/index.php/policy-research-topmenu-71/health-topmenu-29

Requesting Enrollment Assistance:o AIDS Alabama, Enroll Alabama: http://www.enrollala.com/o Access Alabama: http://www.alaaccess.com/AHA_Home.aspxo Alabama Primary Health Care Assn Outreach & Enrollment:

http://www.alaaccess.com/AHA_Home.aspxo Healthcare.gov – https://www.healthcare.gov/o Find Local Help: https://localhelp.healthcare.gov/o Call Center: 1-800-318-2596; TTY: 1-855-889-4325o Enroll America: http://www.getcoveredamerica.org/

42

Florida Assistance

Coordinating Organization: Florida Primary Care Association: http://www.fachc.org/Requesting Enrollment Assistance:

o Florida Consumer Services: 1-877-693-5236o Healthcare.gov – https://www.healthcare.gov/o Find Local Help: https://localhelp.healthcare.gov/o Call Center: 1-800-318-2596; TTY: 1-855-889-4325o Enroll America: http://www.getcoveredamerica.org/

43

Louisiana Assistance

Coordinating Organization: Southwest Louisiana AHEC - http://lahealthcarenav.com/

Requesting Assistance:o Reach us by Email at: info@lahealthcarenav.como By Phone: North LA - Toll Free - 1-877-946-4644; Central LA - 318-443-2855;

Southwest – Toll Free - 1-800-435-2432; Southeast – Toll Free - 1-866-428-4173o Enrollment Assistance: http://lahealthcarenav.com/request-enrollment-assistance/o Louisiana Primary Care Assn Outreach & Enrollment:

http://lpca.net/main/inside.php?page=Outreach_and_Enrollmento Events in Your Area: http://lahealthcarenav.com/events/o Healthcare.gov – https://www.healthcare.gov/o Find Local Help: https://localhelp.healthcare.gov/o Call Center: 1-800-318-2596; TTY: 1-855-889-4325o Enroll America: http://www.getcoveredamerica.org/

44

Mississippi Assistance

Coordinating Organization: Cover Mississippi - http://coverms.org/

Requesting Enrollment Assistance:o Coordinator: Morgan Miller, miller@mhap.org or 601-355.0025 (p)o Cover Mississippi: http://coverms.org/index.php/site/helpo Mississippi Primary Care Assn Outreach & Enrollment:

http://www.mphca.com/outreach-and-enrollment-resourceso Events in Your Area: http://coverms.org/index.php/eventso Healthcare.gov – https://www.healthcare.gov/o Find Local Help: https://localhelp.healthcare.gov/o Call Center: 1-800-318-2596; TTY: 1-855-889-4325o Enroll America: http://www.getcoveredamerica.org/

45

46

As A Result, Enrollment Will Be A Challenge To Overcome

Lack of awareness provides opportunity for education with effective messaging

Many of the uninsured still don’t know about their options

43%

Source: Enroll America, November 2012

of the uninsured don’t know about the new health insurance marketplace options

November 2012 August 2013

Source: Kaiser Family Foundation, August 2013

Enroll America still has work to do, but the uninsured are hearing more and more about the new options available to them

78%of the uninsured don’t know about the new health insurance options

Segmentation

47

Unnecessary & Uninterested – 24%• Skeptical Young Men

Reluctant, but Reachable – 21%• Young, Diverse Families

Connected, Low-Income Women – 11% • Medicaid, CHIP, SNAP connection

Desperate & Believing – 13%• Sick, Poor, Least Educated

Insured & At-Risk – 11%• Young, Under 250% FPL

Campaign Strategies and Tactics

48

Strategic Partners

Community Engagement

Data & Results Driven

Earned Media

Digital & Social Media

Paid Media

Surrogates

In-reach and Outreach tools

In-Reach

Text (and/or voice) messaging

Newsletter

Website

Social media

Direct mail

Appointment cards

On-site promotion

49

Outreach – Commitment Card

50

Outreach

51

Modeling And Testing Connect Individuals With Most Effective Messages And Tactics

Without Modeling, Campaign Would Miss Millions of Uninsured

Modeling Identifies Uninsured at

Individual Level

Additional Testing Identifies Best

Message + Tactic

Example: In Houston, 120K out of 800K uninsured live in areas

with low uninsured rates

Example: Individual level targeting increases efficiency

of volunteer outreach

Example: Experiments identify which individuals respond

better to mail or phone calls

119,508

Houston Uninsured Map Example Neighborhood

9% 49% 7%

23%54% 35%

Example Tactics + Message

Mail – Security Msg.

Call – Cost Msg.

52

53

Coordinate Outreach

54

Without coordination, what happens?o Limited resources are over-utilized & duplicatedo Public is confusedo Resources are wasted

With Coordination:o Consumers get the care they need but not more than they

needo Confusion is minimizedo Resources are better targeted

For More Information:

Tony Garrtgarr@enrollamerica.org

615-603-9747 http://www.getcoveredamerica.org/http://www.enrollamerica.org/

Implementing the Affordable Care Act: Outreach, Enrollment, Engagement, and Access to Care

The Affordable Care Act & Access to Health Care Along the GulfAlliance Institute SymposiumNew Orleans, LouisianaNovember 15, 2013

Oscar C. Gomez, CEOHealth Outreach Partners

Our vision is a country in which all people are valued and in which equal access to quality health care is available to everyone, thus enriching our collective well-being.

Our mission is to build strong, effective, and sustainable grassroots health models by partnering with local community-based organizations across the country in order to improve the quality of life of low-income, vulnerable, and underserved populations.

Health Outreach Partners

Who We Are? Since 1970, Health Outreach Partners (HOP) has

been at the forefront of elevating the importance of outreach, recognizing the critical role it plays in facilitating primary care, case management, health prevention and social services to underserved, vulnerable and/or marginalized populations.

We provide training, consultation, and information services to community health centers, free clinics, primary care associations, and other community based organizations supporting efforts to increase access to health care.

Take a step back and remember that the bigger goal of the Affordable Care Act is to increase access to quality health care.

Health Coverage Expansion/Enrollment is one key strategy to reach that goal.

◦ For low-income, underserved communities health care expansion may or may not be a relevant strategy to reach this goal.

ACA Implementation

Too many people in the U.S. lack coverage

U.S. health care spending is unsustainable

Despite high spending, health outcomes are poor

System emphasizes treatment instead of prevention

Health disparities exist among numerous populations

Why Was the ACA Established In the First Place?

Source: American Public Health Association: August 2012

Connecting Eligible Immigrant Families to Health Coverage and CareBackground: Health Outreach Partners and Kaiser Family

Foundation partnered to examine the impact of Affordable Care Act on immigrant population and how to connect eligible immigrant families to coverage and care

In July and August 2011, HOP held four focus groups with outreach and enrollment workers in DC, Florida, San Francisco, and Los Angeles

Analyzed findings and drafted report Released October 2011

“You can do really great eligibility [work] and get them benefits, but if you don’t do the teaching and education on how to use [the benefits] … you are not actually getting anybody access because they just have no idea that it doesn’t mean go to the ER.”

Outreach Worker, District of Columbia

Quotes from Outreach Worker Focus Groups

“If you are not in the right city and don’t have a car, you might have to take two, three, or four busses to get to a clinic. So you have to leave an hour and a half earlier and you might still have a wait once you get there. And then how long does it take to get home? You might have to take the whole day off work …”

Outreach Worker, San Francisco

Quotes from Outreach Worker Focus Groups

“Just having the access to Medi-Cal [Medicaid] opens up a whole new perception of health. Many people come from countries where there is no preventive health – you go to the doctor when you are deathly ill … We do a lot of education in our program about preventive health and that they get immunizations … So I think just changing their perceptions”

Outreach Worker, San Francisco

Quotes from Outreach Worker Focus Groups

Not as clear cut as it looks…

Citizen: Younger child, born in US

Non-Citizens: Mom, Dad, older child,

Dad’s sister

Lawfully present:

Dad’s sister

Not lawfully present: Mom,

Dad, older child

Key Findings: Enrollment Challenges and Barriers to Accessing Health Care Immigrant families encounter multiple

barriers, often simultaneously, to enrollment and accessing health care including:◦ Fear◦ Confusing enrollment processes◦ Difficulty meeting documentation requirements◦ Language and literacy◦ Limited access or familiarity with technology◦ Maintaining coverage◦ Transportation◦ Access to specialty care

Strategies to Consider Utilize trusted community organizations and

individuals to provide outreach and enrollment assistance

Provide direct one-on-one assistance for enrollment

Educate families about coverage options and enrollment processes

Maximize existing relationships and maintain ongoing contact over time to assist families with renewal and accessing necessary services

More Specific Strategies Form partnerships with trusted community business

and groups Direct one-on-one assistance from someone with a

shared background Educate about options and process List of required documents & alternatives Zero income/cash income forms Cards requesting translation assistance Maintain contact

Recommendations Recommendations include:

◦ Assuring trusted organizations and individuals are adequately prepared and supported to provide outreach and enrollment assistance.

◦ Meet immigrants where they are.◦ Provide simple and welcoming application

and enrollment processes that meet the needs of immigrant families

◦ Strengthen and reinforce messages to dispel fear among immigrant communities.

Changes in Outreach and Enrollment Strategies Strategies targeting newly eligible

populations Strategies will differ across states and

localities New community partners, such as

insurance brokers, small businesses, etc. to reach newly eligible populations

Messages need to be tailored to be effective with newly eligible populations

Needed Increase in Staff Capacity Knowledge of barriers and needs of newly

eligible populations Understanding of changes in health insurance

options Knowledge of new options and processes

specific to State Exchange/Marketplace Capacity to use new technological systems CHC’s Need to Plan and Adjust for Incremental

Cost of Care Customer Service and Cultural Competency at

All Levels of CHC – particularly front desk staff

Needed Education and Messaging Changes affecting those currently insured

by public health insurance Options for newly eligible populations Education to reduce stigma and dispel

myths Messenger Trumps Message – Especially in

Communities That Experience Distrust, Fear, or Marginalization.

Outreach Messages Must Resonate When Patient Walks in Health Center Door

Role of Outreach Reaching people within and beyond patient base Relationship/trust building Unique Marketing for CHC. Builds Brand Over

Time Community relations. Community Collaborations Cultural competency Organizational integration

Framework & Resources

National Outreach Guidelines

National Partners for Outreach Guidelines

Some Helpful Websites Health Outreach Partners www.outreach-partners.org Kaiser Family Foundation www.kff.org Association of Asian Pacific Health Care

Organizations (AAPCHO) www.aapcho.org National Association of Community Health Centers

(NACHC) www.nachc.com Farmworker Justice www.farmworkerjustice.org National Health Care for the Homeless Council

www.nhchc.org

“Outreach makes you realize that health is impacted by many issues beyond just the clinical – to include a person’s income, living conditions, occupation, etc.” “Advocacy is another key outreach principle. A doctor can heal but not necessarily advocate. Outreach workers are consistent advocates for access to health care and to ensure that the patient gets all the care needed.”

Marina Mezey, M.D.Current HOP Board Chair

Former HOP Outreach Worker 1996-97Presently: Family Care Physician in Portland, Oregon

An Outreach Workers Perspective

◦Be prepared.

◦Be persistent.

◦You are the real deal!!

Implementing the ACA

Oscar C Gomez– Oscar@outreach-partners.org

Health Outreach Partnerswww.outreach-partners.org

Q&A: Making Sense of the ACA

Please tell us: your name where you’re from your organization

Thank You!

For more information:

Phil JohnstonPhil@pwjohnston.com617-338-2726

Merrill PressMerrill@pwjohnston.com301-347-0414

www.pwjohnston.com