New Mexico Health Care Reform May 28, 2013 Paige Duhamel, Esq. - - PowerPoint PPT Presentation

New Mexico Health Care Reform

May 28, 2013

Paige Duhamel, Esq. Southwest Women’ s Law Center

What Does the Affordable Care Act Do?

• New Law (“Obamacare”)

–Hold insurance companies more accountable –Lower health care costs –Guarantee more health care choices –Enhance quality of care –Through:

• Expanding Medicaid to new populations
• Creates insurance marketplaces called Exchanges
• Reforms the private insurance market
• All by January 1, 2014 (October 1, 2013)

How Do We Get to 2014?

• 1. Insurance Coverage

–Gain coverage under Medicaid Expansion, purchase insurance through the Exchange, or acquire insurance through another, as yet to be determined basic health care

• ption.
• 2. Insurance Reforms

–Consumer Protections (e.g. – no pre-existing conditions exclusions)

• 3. Personal Responsibility

–Individual Mandate (But wait! Native American Exception)

Medicaid Expansion

• Governor agreed to expand New Mexico’s

Medicaid program in 2014.

– Yay!

• Medicaid Expansion will make approximately

160,000 new New Mexicans eligible for Medicaid coverage.

• Adults, age 19-64 with incomes below

138% of the federal poverty level, will become eligible.

• Including single adults and working adults.

Medicaid Expansion

• Newly Eligible Medicaid Populations

– Adults, age 19-64 with incomes below 138% of the federal poverty level.

Single Adult Family of Four $15,000 in annual income

• r less

$32,000 in annual income

• r less

Medicaid Expansion

• Newly Eligible Medicaid Populations

Medicaid Expansion

• Monthly eligibility income levels –

Medicaid Expansion

• State Coverage Insurance (SCI)

– If you or someone you know has State Coverage Insurance (SCI) this program will end in 2013. – Don’t worry! Many individuals currently on SCI will now qualify for Medicaid or substantial financial assistance to purchase private health insurance coverage through the Exchange (and you can’t be denied if you have a pre-existing condition).

What is an Insurance Exchange?

• The Affordable Care Act creates health

insurance marketplaces called “Exchanges” where individuals:

– can purchase insurance – qualify for premium subsidies to make health care coverage more affordable – Offer plans that have standardized benefits

• ptions called “Qualified Health Plans.”

What is an Insurance Exchange?

• The Idea Behind Exchanges –

–By pooling people together, and creating economies of scale, Exchanges create more buying power. –Exchanges leverage that buying power to

• Reduce transaction costs
• Increasing transparency
• Create more efficient and competitive markets for individuals and small

employers.

–Historically, the individual and small group health insurance markets have suffered from adverse selection and high administrative costs, resulting in low value for consumers.

Who Gets Insurance Through Exchange?

• Who gets covered?

–Individuals and families who make more than 133% and 400% of the federal poverty level in annual income will be able to purchase insurance through the Exchange and receive premium subsidies. –Individuals above 400% FPL who do not receive coverage through their employers, and who do not qualify for subsidies. –Ultimately, about 400,000 New Mexicans.

• Single Adult
• Family

Individual Family of Four $44,000 in annual income or less $89,000 in annual income or less

Exchange Eligibility

• Monthly eligibility income levels –

Insurance Coverage Offered Through Exchange

• Exchange must offer “Qualified Health Plans.”

– A qualified health plan (QHP) is a plan that is certified by and offered through the Exchange:

• Essential health benefits
• Fully insured plans only
• Accreditation on clinical quality measures
• No pre-existing coverage exclusions for all ages
• No annual limits on essential health benefits
• No lifetime dollar benefits on essential health benefits
• Minimum levels of coverage ( no cost-sharing for preventative

services)

Insurance Coverage Offered Through Exchange

• Essential health benefits

– Ambulatory patient services – Emergency services – Hospitalization – Laboratory services – Maternity and newborn care – Mental health and substance use disorder services, including behavioral health treatment – Prescription drug coverage – Rehabilitive and habilitative services and devices – Preventative and wellness services, and chronic disease management – Pediatric services, including oral and vision care.

Consumer Protections

• Insurance Reforms and Regulations

– The Affordable Care Act contains many consumer protections that have been designed to preserve the continuity of doctors’ care of patients and patients’ access to health care services, without arbitrary limitations.

Individual Mandate

• Most individuals who can afford it will be required to
• btain basic health insurance coverage or pay a fee

to help offset the costs of caring for uninsured Americans.

• If coverage is not available to an individual, he or she

will be eligible for an exemption.

• American Indians are automatically exempt – AI’s are

not required to obtain health insurance coverage.

Employer Responsibility

• Employers Have Responsibility to Offer Coverage

–Employers with more than 50 full-time employees are required to offer minimum essential health coverage. –Employers who do not comply and whose employees are forced to seek a subsidy for health care coverage will be penalized. –TRIBES ARE NOT EXEMPT FROM EMPLOYER COVERAGE REQUIREMENT. –Tax credits available to small businesses that provide employees coverage.

Consumer Enrollment

• Ways an Exchange will help consumers enroll

in insurance coverage:

– Must provide

• A consumer-friendly website.
• A toll-free hotline
• A Navigator Program (state and federally mandated)

– Can provide additional enrollment assistance

• ptions
• An in-person assister program
• Brokers and insurance agents
• Health care providers

What Are Navigators?

• Navigators are entities that will assist

consumers and small employers with enrollment in the Exchange.

–Conduct public education activities to raise awareness of the Exchange –Help people enroll in and apply for insurance coverage through the Exchange –Must provide culturally and linguistically sensitive services –Offer referrals to ombudsman programs to assist in conflict dispute resolution. –Funded by the state – NO FUNDING ALLOCATED IN NM IN 2014.

Who can be a Navigator?

• Navigators must come from two categories of
• rganizations, one of which must be consumer-
• riented non-profit.

–Navigator entities can include:

• Tribes
• State or local human services agencies
• Other public or private entities that are capable of carrying out the

required duties and providing information that is fair, impartial, culturally sensitive, and accurate.

• Insurance carriers CANNOT be Navigators.

Navigators and Medicaid

• What are Navigators’ relationship to

Medicaid?

–Training requirements mandate that Navigators must be trained in Medicaid/other affordability programs eligibility. –Duties do not require Navigators to include Medicaid enrollment. – Only duty is to refer individuals to Medicaid and other affordability programs where appropriate. –Application will screen for both Medicaid and Exchange.

Who Are In-Person Assisters?

• Surge workers

–Perform similar functions in enrollment assistance as Navigators. –Intent is to supplement the Navigator program in its first year –Help enroll large numbers of individuals newly eligible for coverage –Proposed regulations - must meet same federal conflict of interest standards as Navigators, plus additional federal standards

Difference Between In-Person Assisters and Navigators

In-Person Assisters Navigators Salaries federally funded Salaries state funded Temporary program – Surge workers to address high-volume enrollment needs Permanent program/workforce Paid through contract, direct hiring, or grants, at state’s discretion Paid for by grant-award program NM has applied for some federal funding No funding currently allocated

Assisters and Medicaid

• What are Assisters’ relationship to Medicaid?

– Training requirements mandate that Assisters must be trained in Medicaid/other affordability programs eligibility. – Duties require Assisters to discuss full range of insurance affordability programs, including Medicaid, with consumers, and direct individuals to enrollment resources. – Application will screen for both Medicaid and Exchange.

What Are Certified Application Counselors?

– Two different kinds of Certified Application Counselors (CAC)

• Exchange CAC - mandatory
• Medicaid CAC –

by option of state

What Are Certified Application Counselors?

• Exchange CAC’

s

–Mandatory state program –Exchange must provide training and certification to Exchange and Medicaid-designated organizations for staff and volunteers. –Intention is to have a training and certification program for staff employed by FQHC’ s, hospitals, and

• ther agencies that have staff that work with

consumers on coverage issues.

What Are Certified Application Counselors?

• Medicaid CAC’

s- optional program

– Duties include –

• Provide information about coverage options
• Help individuals complete an application or renewal
• Gather required documentation
• Submit applications and renewals
• Assist with any communications from the Medicaid agency
• Help with case management services between the eligibility

determination and regularly scheduled renewals.

Who Can Be Certified Application Counselors?

• Certified Application Counselors Can Be

– Broader eligibility

• Individuals/entities can have conflicts of interest,

so long as conflicts of interest are disclosed.

• Must be trained and pass certification test on

–Conflicts of interest –Privacy and Security –Program eligibility and enrollment

– No federal or state funding to be applied for salaries

Difference Between In-Person Assisters, Navigators, and CAC’s

In-Person Assisters Navigators CACs Salaries federally funded Salaries state funded Salaries privately funded Temporary program – Surge workers to address high-volume enrollment needs Permanent program/workforce Permanent program/workforce Paid through contract, direct hiring, or grants, at state’s discretion Paid for by grant-award program Paid by employer NM has applied for some federal funding No funding currently allocated Medicaid CAC’s ? Exchange CAC’s – no program yet developed

No Wrong Door Policy

– Individuals seeking health care coverage, either at the Exchange or through Medicaid, should be provided information and application resources about program that they qualify for if they approach either Medicaid or the Exchange seeking coverage.

Exchange Timeline

Questions?

Paige Duhamel pduhamel@swwomenslaw.org 505-244-0502