Federal Health Care Reform: The Impact on NYS Programs

Buffalo, NYOctober 13, 2010

Presented by:

Trilby de JungSenior Health Law Attorney

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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

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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?

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2.6 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?

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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

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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, www.nybridgeplan.com

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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)

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 2014

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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, 2010Slide 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

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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

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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)

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

MAGINew

Eligibility Group

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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

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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

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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

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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)

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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

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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

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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

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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

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Primary Care Investments

Temporary rate boost to Medicare levels with 100% federal funding

$9.5 Billion for Community Health Centers

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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

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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

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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)

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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

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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?

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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?

For questions or comments:

Trilby de Jung tdejung@empirejustice.org