navigating open enrollment in texas: plans, problems and tools for assisters and community...
TRANSCRIPT
Navigating open enrollment in Texas:Plans, problems and tools for assisters and community
organizations
Dec. 12, 2014
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AND DON’T FORGET TO SPEAK UP!• With support from the M·A·C AIDS Fund, a team of national and state
partners has established “SPEAK UP” to monitor, assess and document ACA implementation success and barriers to HIV care
• Through SPEAK UP we see patterns of discrimination emerging that need to be addressed, educate state and federal officials about what’s happening on the ground, advocate for change, and report back to the community
• Monitoring and documentation is critical to help inform and shape state and federal policy to ensure the needs of people living with HIV are addressed as the ACA is implemented
To SPEAK UP!, visit: http://www.hivhealthreform.org/speakup/
Today’s Agenda
1. Affordable Care Act & Open Enrollment Landscape in Texas - Januari Leo, Director of Public Affairs, Legacy Community Health Services
2. Texas Marketplace Plan Analysis 2015- Carmel Shachar, Staff Attorney, Center for Health Law & Policy Innovation, Harvard Law School
3. Affordable Care Enrollment (ACE) TA Center - Molly McAndrew, Policy Manager, AIDS Foundation of Chicago
Affordable Care Act & Open Enrollment Landscape in Texas
Januari LeoDirector of Public Affairs
Legacy Community Health Services
Texas Marketplace Plan Analysis2015
Carmel ShacharStaff Attorney
Center for Health Law and Policy InnovationHarvard Law School
Enrollment Timeline
Enroll by December 15, 2014 to get coverage byJanuary 1, 2015
Open Enrollment began November 15, 2014 and runs through February 15, 2015
Download from: http://www.hivhealthreform.org/assessment/
Assessment Tools: Marketplace Health Plans Template Assessment Tool/Workbook
Part 1
Understanding Cost-Sharing Structures
Insurance Terms: Cost-Sharing Structures
•Premium: monthly fee an insurance plan charges for plan membership •Advance Premium Tax Credit (APTC): money that the government pays directly to a health plan (or to the consumer at the end of the tax year) in order to reduce a consumer’s premium ___________________________________________________________________•Co-pay: a set fee a consumer pays for each provider visit, prescription refill, lab test, or other healthcare service (e.g., $10, $20, or more)
•Co-insurance: a percentage of the cost of the healthcare service that the consumer must pay (e.g., 30% of the cost of a provider visit or of a procedure)
•Deductible: a set annual amount the consumer must pay before the insurance plan pays for any of the costs of care (e.g., $2,500)
•Cost-sharing Subsidy (Reductions): money that the government pays directly to a health plan in order to reduce a consumer’s out-of-pocket costs (silver plans only)
Marketplace Qualified Health Plans4
Cove
rage
Lev
els
Platinum
Gold
Silver
Bronze
Premiums Cost Sharing
$$$$ $
$$$ $$
$$ $$$
$ $$$$
Marketplace Premium Tax Credits
• Tax credits reduce the premium cost depending on how much income you make (sliding scale)
• Tax credits can be used at any plan level (bronze, silver, gold, plantinum), but not for catastrophic coverage
• NOTE: There is a reconciliation process at the end of the year, so it’s critical for clients to keep the Marketplace updated on any income changes
IncomePremium Limit as % of Income
Premium Limit / Year
100-150% FPL
2.01 – 4.02%
$234.57- $703.70
150-200% FPL
4.02 – 6.34%
$703.70- $1,479.76
200-250% FPL 6.34 – 8.1% $1,479.76 -
$2,363.18
250-300% FPL 8.1 – 9.56% $2,363.18 -
$3,346.956
300-400% FPL 9.56% $3,346.96 -
$4,462.61
Tax credits are available to those earning 100% - 400% FPL ($11,670-$46,680)
Premium Tax Credit Example
• Earns $16,000/year - about 140% FPL
• He is expected to pay about 4% of his income for premiums = $640 per year, or about $53 per month.
• Let’s say the second-cheapest Silver plan costs $500 per month.
• John’s subsidy will be: $500 - $53 = $447 per month. He can get this as a tax refund or have it paid for him each month.
John
Cost-Sharing Subsidies and Out Of Pocket (OOP) Maximums
Cost-Sharing Subsidies: Available for an applicant: (1) whose income is between 100-250% FPL and (2) who chooses a silver plan
Includes: 1. Deductible (if any)2. Co-insurance for in-network
services 3. Co-pays for in-network
services
Does NOT Include:4. Premium5. Costs for out-of-network
services
Income OOP Max
100-150% FPL $2,250
150-200% FPL $2,250
200-250% FPL $5,200
250% and above $6,600
Ryan White (RW)Payer of Last Resort for Individuals
Living with HIV/AIDS
• Cannot be used – For “any item or service to the extent
that payment has been made or can reasonably be expected to be made” by another payer
• Can be used – During gaps in other coverage– IF client misses open enrollment, BUT
must ensure that client does not miss next enrollment opportunity
– For services not covered or partially covered by other insurance.
RW in TX• Income Limit: 200% FPL• Other Qualifications:
– HIV positive– Texas state resident– Otherwise uninsured or underinsured
Part 2
Evaluating Qualified Health Plans (QHP)
How to Choose a Qualified Health Plan
Pick a Coverage Level
Check if providers in network
Check drug formularies
Check coverage of other healthcare needs
Check cost-sharing for healthcare needs
The Online Marketplace
Find Marketplace plans for TX residents at healthcare.gov
Assessing Plans on Online Marketplace
Assessing Plans on Online Marketplace
• After entering your information, a summary of available plans will appear
• To make it easier to find a particular plan, narrow your results by “Health plan categories” (e.g., silver) or by “Insurance companies.”
In order to fully assess a plan, you will need to review the linked documents, especially:• Summary of Benefits• List of covered drugs
Assessing Plans on Online Marketplace
Search results provide basic information, including estimates for:• Monthly premium• Deductible•Out-of-Pocket Maximum
Assessing Plans on Online Marketplace
Summary of Benefits: Provides a limited summary of plan benefits, including cost-sharing rules, referral requirements, and exclusions.
Assessing Plans on Online Marketplace
List of Covered Drugs (“Formulary”): Provides a list of drugs covered by the plan.
Also Provides Information Regarding:• Usage Limitations (e.g., prior authorization, quantity limits, etc.)• Tiering
MAY NOT BE A COMPLETE LIST!
If the document indicates that the formulary is not comprehensive, you may need to contact the insurer for further coverage information
Assessing Plans on Online Marketplace
Use the information that you find during your assessment to fill out the Plan Comparison Chart
Make sure to note any limitations to your research (e.g., full formulary not available)
Part 3
Overview of Available Qualified Health Plans
Blue Cross Blue Shield
• Pros– Covers most HIV medications, including single tablet
regimes such as Atripla, Stribild and Complera– Covers most HCV medications, including Sovaldi
• Cons– Generally requires 20-30% co-insurance for HIV
medications (but better than other insurers)– Most plans have high deductibles (only the Gold
plans have deductibles under $3,000)
Humana
• Pros– Some plans with “flat” formulary structures:
Humana Bronze 6300 and Humana Silver 3650• Cons
– Virtually all HIV and HCV drugs are in the specialty tier
– Generally 50% co-insurance for these medications– “Flat” plans have very high deductibles ($6,300 for
Bronze and $3,650 for Silver)
Cigna
• Pros– Very few
• Cons– Does not cover a significant number of HIV related
medications, including Humira, Enebrel, Simponi, Xelianz
– Many HCV drugs “not listed” (and likely not covered), including Sovaldi and Olysio
– Most other drugs at 40% co-insurance
Next Steps
• Forthcoming: a fuller analysis of the plans offered in Texas– Will cover more plans– Will analyze in depth the deductibles, premiums,
co-payments and coverage for other services and medications
• On the ground assistance– Contact Carmel Shachar at
[email protected] with further questions
Affordable Care Enrollment (ACE) TA Center
Molly McAndrewPolicy Manager
AIDS Foundation of Chicago
Resources, Tips, and Tools for Enrolling RWHAP Clients in Coverage
Eligibility Decision Tree
Health Care Plan Selection Worksheet
Fact Sheet:Topics to Consider When Helping People Living With HIV to Enroll in Health Care Coverage
Common Questions & Suggested Responses for Engaging Clients in Health Coverage (English)
Common Questions & Suggested Responses for Engaging Clients in Health Coverage(Spanish)
41
Plain Language Quick Reference Guide
Plain Language Quick Reference Guide (English)
42
Plain Language Quick Reference Guide
Plain Language Quick Reference
Guide
Plain Language Quick Reference Guide (Spanish)
Special Enrollment Periods Fact SheetSpecial Enrollment Periods Fact Sheet
www.targethiv.org/ace
Questions?
• Ask your questions using the webinar chat feature.
• If we don’t get to your question it will be logged and we’ll do our best to follow up!
AND DON’T FORGET TO SPEAK UP!• With support from the M·A·C AIDS Fund, a team of national and state
partners has established “SPEAK UP” to monitor, assess and document ACA implementation success and barriers to HIV care
• Through SPEAK UP we see patterns of discrimination emerging that need to be addressed, educate state and federal officials about what’s happening on the ground, advocate for change, and report back to the community
• Monitoring and documentation is critical to help inform and shape state and federal policy to ensure the needs of people living with HIV are addressed as the ACA is implemented
To SPEAK UP!, visit: http://www.hivhealthreform.org/speakup/