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Eligibility & Enrollment Briefing

September 17, 2013

Presentation Overview

Outreach

Affordable Care Act Basics

Governance

Eligibility Operations

Challenges

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Outreach

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Covered California

Local Partners

Regional Covered California Grant – Central Labor Council,

COPA, Nonprofit Alliance, United Way, CSUMB, MPUSD,

NMCUSD, plus in-kind partnership with NMC, Health

Department and Department of Social Services

Blue Shield Grant – Central Labor Council lead

HRSA Grant – Clinica De Salud De Valle Salinas

Other partners in the network – CCAH, CCCIL, ACTION

Council, health providers, Statewide Covered California

grantees and numerous committed individuals

Affordable Care Act Basics

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Affordable Care Act passed in 2010

Various market reforms effective already: Access for uninsured children with pre-existing conditions and

establishment of a pre-existing condition insurance plan for people who have been unable to arrange coverage for at least six months

Coverage for young adults until 26 on a parent’s plan

Coverage for preventive services such as mammograms and colonoscopies

Mechanisms for expanding coverage: 1. Medi-Cal expansion for households with income under 138% of

poverty

2. Premium assistance for tax-based subsidies through Covered California for households with income between 100% of poverty and 400% of poverty

Affordable Care Act Basics

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Individual Mandate In general all US citizens and legal immigrants must maintain health coverage or

pay a penalty on their taxes. Some exceptions exist including for households with income below the threshold for filing taxes (in 2013 $10,000 for an individual or $20,000 for a family) For 2014, $95 per uninsured adult ($47.50 per child) or 1 percent of household income

over the filing threshold,

For 2015, $325 per uninsured adult ($162.50 per child) or 2 percent of household income over the filing threshold,

For 2016 and beyond, $695 per uninsured adult ($347.50 per child) or 2.5 percent of household income over the filing threshold.

Large Businesses (50+ fulltime employees) Must provide coverage for employees or pay a penalty (postponed till 2015)

Small Business (under 50 employees): Can participate in the Small Business Health Options Program (SHOP) which

provides small business with affordable options for providing employees with health insurance

Affordable Care Act Basics

Medi-Cal Expansion

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138% of the Federal

Poverty Level

• $15,856 - single adult

• $32,499 - family of 4

Newly eligible:

Childless, non-disabled,

non-elderly adults

100 - 400% of the Federal

Poverty Level

• $45,960 - single adult

• $94,200 - family of 4

Not eligible for Medi-Cal

Premium Assistance/ Tax

Subsidy For Covered

California Health Plans

Affordable Care Act Basics

Medi-Cal Expansion

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27,651 in Monterey County will

be newly eligible for Medi-Cal

There is no open enrollment

period for Medi-Cal, enrollment

is year-round

Benefits for expanded Medi-Cal

begin Jan. 1. ViaCare recipients

will be automatically transitioned

into Medi-Cal

27,329 in Monterey County will

likely qualify for tax credits

Open enrollment runs from Oct.

1-Mar 31 for this year, and Oct.

15-Dec. 7 next year

Benefits through Covered

California become effective Jan. 1.

If a household has a qualifying

event they can apply outside of

the open enrollment period.

Tax Subsidy

Exchange-Based Coverage

Premium Assistance/ Tax

Subsidy For Covered

California Health Plans

Affordable Care Act Basics

Health Plan - Medi-Cal Expansion

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Medi-Cal beneficiaries will be served through the

Central California Alliance for Health

No monthly premium

In general, no co-payments or deductibles except

for individuals in the Share of Cost Medi-Cal

programs.

http://www.ccah-alliance.org/

Source: UC Berkeley / UCLA CalSIM version 1.8

Affordable Care Act Health Basics Covered California Health Exchange Marketplace

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Affordable Care Act Health Basics Covered California Health Exchange Marketplace

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http://www.coveredca.com/

Example of sliding scale premiums and costs: - Silver Plan, Single person

What is it?

New Medi-Cal mental health and substance use disorder

benefits coming to plans

Needed for mental health parity under ACA

Coming January 1, 2014 with ACA implementation

State policy still being formed

Affordable Care Act Health Basics Expanded Behavioral Health Coverage

Eligibility Processes Governance

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Center for

Medicare &

Medicaid

Services

Internal

Revenue

Service Federal

Covered

California

Department

of Health

Care Services State

Department

of Social

Services County

Operations With Covered California -

Phone Network

80% of calls to counties must be answered by live person within 30 seconds

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Warm hand off

Operations – Culture Change for All

MAGI Medi-Cal

Covered California Programs

Non-MAGI

Medi-Cal

CalFresh, CalWORKs,

General Assistance

All doors lead to

coverage

Enrollment in all

available coverage

First-class customer

experience

Coordinated services

(horizontal integration)

Example: CalFresh

The question is no longer, whether a client is eligible, but rather,

for what is a client eligible?

Department

of Social

Services

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Key Implementation Challenges –

Policy Decisions

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• Counties are implementers

• Not primary policymakers

• Can’t implement without rules & forms

Critical

• Single streamlined application not finalized

• New eligibility rule policies not defined Example

• CWDA & counties working with State

• Approval goal of October 1 Response

Key Implementation Challenges –

Training

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• Our staff are key to coverage

• Will administer new rules, understand tax implications, assist families with plan selection

Critical

• Material lacked sufficient detail

• Staff could not be effectively prepared to implement rules

Example

• CWDA & counties provided supplemental training

• More under development Response

Key Implementation Challenges –

Automation

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• Backbone of our operations Critical

• State automation strategy not optimal Background

• SAWS-CalHEERS interface delayed

• October 1, 2013 to January 1, 2014 Example

• Duplicative entry

• Customer service & workload implications Response

Questions?

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