Changes and Impacts. Healthcare Reform Overview: Changes and Impacts

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1 Healthcare Reform Overview: Changes and Impacts Healthcare San Diego Reform County Overview: Changes and Impacts Child Care and Development Planning Council October 14, 2013 Peter Shih, MPH Health Care Policy Administration

2 Provide an overview of the Patient Protection and Affordable Care Act (PPACA) Key Components Medi-Cal: What is changing and what is staying the same Discuss implementation in California and San Diego Basics of Covered California, CA s Health Marketplace Relationships between Covered California and Medi-Cal HHSA roles in PPACA implementation County response Objectives

3 Key Components of PPACA Major Components of ACA Insurance Reform- Titles I and II What will happen? More people covered Improved benefits Guarantees coverage: must cover pre-existing conditions and can not drop clients for being sick Lower costs (consumers, govt.) No lifetime or annual limits How will this be accomplished? Medi-Cal expansion Insurance exchanges & exchange subsidies Dependents under 26 covered Preventive services coverage Minimum coverage provision Health System Reform Titles III - VIII What will happen? Improved quality and efficiency Stronger workforce & infrastructure Greater focus on public health & prevention How will this be accomplished? Prevention & Public Health Fund, including Community Transformation Grants (CTG) Accountable Care Organizations Care coordination Public health workforce development Community health needs assessments

4 How does the PPACA translate in CA? Prevention and Public Health Fund Medi-Cal being expanded to new populations 1 in 6 San Diegans will now be on Medi-Cal (up from 1 in 8) California s new health insurance exchange 1 in 9 San Diegans are projected to purchase products via exchange Funds community and state prevention; Tobacco prevention; Obesity prevention; Access to wellness & preventive services; Behavioral health integration; Public health infrastructure and training; and Research and tracking.

5 The Triple Aim Better Health for the Population Better Care for Individuals Lower Costs per Capita

6 Essential Health Benefits Required Health plans offered in the individual and small group markets, both inside and outside of the Exchanges, must include services within at least these 10 categories: 1. Ambulatory patient services 2. Emergency services 3. Hospitalization 4. Maternity and newborn care 5. Mental health and substance use disorder services, including behavioral health treatment 6. Prescription drugs 7. Rehabilitative and habilitative services and devices 8. Laboratory services 9. Preventive and wellness services and chronic disease management 10. Pediatric services, including oral and vision care

7 Medi-Cal Eligibility Expanded to Fill Coverage Gaps for Adults Medi-Cal Eligibility Today Limited to Specific Groups Medi-Cal Eligibility in 2014 Extends to Adults 138% FPL* Elderly & Disabled Pregnant Women Children Parents Adults *138% FPL =$15,856 for an individual and $26,951 for a family of three in 2013

8 Medi-Cal Expansion Medi-Cal Today Medi-Cal coverage for adults is limited to: Adults aged 65 and older Persons blind or with disability Adults who have at least one child in the home that meets deprivation requirements Pregnant Women Adults in Long term Care Foster Youth to Age 21 Children Under and Beyond Most childless adults who are at or below 138% of FPL will qualify for Medi-cal. Adults aged 65 and older Persons blind or with disability Adults who have at least one child in the home that meets deprivation requirements Pregnant Women Adults in Long term Care Foster Youth to Age 26 if they were enrolled in Medi-cal at age 18 Children Under 21

9 Covered CA + Medi-Cal: The Coverage Continuum Private Insurance (400% +) APTC/CSR(200%-400%) FPL Advanced Premium Tax Credit/Cost Sharing Reduction Proposed Bridge Health Plan (139%-200%) FPL MAGI Medi-Cal (Modified Adjusted Gross Income) (0-138%) FPL Non-MAGI Medi-Cal (ABD, LTC, etc.)

10 MAGI Medi-Cal Groups Children (infants to 18 yrs) age and income determined with or without premiums (up to 250% FPL) Parents/Caretaker Relatives (< 139% FPL) Pregnant Women (< 139% FPL for full scope/ % FPL for pregnancy services) Adults (19-64 yrs) (< 139% FPL)

11 Non-MAGI Medi-Cal Groups Aged (65+ yrs), Blind or Disabled (ABD) individuals Long-Term Care (LTC) individuals Medicare eligibles (Part A/B) for Medicare Savings Programs (QMB/SLMB/QI-1) Individuals eligible for SSI, Foster Care, or Adoption Assistance programs Individuals/Families eligible as Medically Needy (AFDC-MN) with a dependent child (Absent/Deceased/Incapacitated/Unemployed parent)

12 Covered California s Target Market 5.3 million uninsured or purchase own insurance 2.6 million qualify for subsidies 2.7 million purchase affordable care 1.4 million newly eligible for Medi-cal

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14 Covered AFFORDABLE, California QUALITY HEALTH Eligibility CARE HEALTH INSURANCE PLANS

15 Covered California AFFORDABLE, QUALITY Qualified HEALTH CARE Health Plans HEALTH INSURANCE PLANS Announced May 24, 2013

16 Covered California Outreach and Education Statewide Grantees California NAACP California Rural Indian Health Board Catholic Charities of California The Actors Fund The Regents of the University of California United Ways of California San Diego Grantees 211 San Diego Council of Community Clinics Social Advocates for Youth, San Diego (SAY San Diego)

17 Covered California Enrollment Initial Open Enrollment October 1, March 31, 2014 Future Open Enrollment: October December annually Special circumstances: 60 days within life-changing event, such as a divorce, birth of a child, or loss of a job Coverage effective January 1, 2014 Counties are expected to: Conduct eligibility for MAGI Medi-Cal (0-138% FPL) and mixed household ( % FPL) Covered California health plans (beginning April 2014) Serve Family Resource Center (FRC) walk-in customers and direct calls to HHSA ACCESS, US mail, and MyBenefits CalWIN for MAGI Medi-Cal and Covered California health plans

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21 Penalty for No Insurance Law requires most people over age 18 to have public or private health insurance by January 2014 or face financial penalties Penalty phases in over 3 years and becomes increasingly large In 2014, penalty will be 1% of annual income or $95, whichever is greater By 2016, penalty will be 2.5% of income or $695, whichever is greater Penalty assessed based on the number of months without coverage; paid as part of income tax filing

22 Low Income Health Program (LIHP) Created under California s Bridge to Reform Medicaid Section 1115 Waiver to prepare for Medi-Cal expansion Enrolls uninsured adult county residents with incomes <133% FPL to provide medical care and limited mental health services Uses a network of local service providers 22 hospital sites (13 hospital organizations) 58 community health clinic sites (16 parent organizations) 20 mental health clinics 122 specialty groups, including more than 345 individual providers Enrollment has grown from 14,000 in July 2011 to more than 39,978 in August 2013 All LIHP enrollees will transition to MediCal January 1, 2014

23 LIHP Transition LIHP Program ends December 31, 2013 Projected 43,000 enrollees transitioning to Medi-Cal Managed Care on January 1, Medi-Cal Managed Care Health Plans in Healthy San Diego Care1st Health Plan Community Health Group Molina Healthcare Health Net Kaiser Permanente Established Local Transition Team Continuity of Care and Communication Workgroups to assure smooth transition Healthy San Diego Health Care Options (HCO) staff will assist enrollees with education and health plan choices

24 County Medical Services (CMS) Program County Section Indigent Care obligation remains even after ACA coverage expansion Active CMS participants have declined from >4,000 in July 2011 to <2,000 as LIHP has grown CMS Program will continue to serve residents of San Diego who Meet income eligibility requirements (0 350% FPL) and are not enrolled in Covered California Missed Open Enrollment period and do not have a qualifying event Refuse to apply for Covered California Not willing to pay monthly premium HHSA Health Care Reform Committee established Reviewing CMS Program for possible changes Data analysis to forecast number remaining uninsured

25 Messages Being Communicated to the Public Key call to action : those without insurance should contact Covered California Outward-facing County website under development to include information on PPACA what it does, what it does not do, & what the County s role is Leveraging relationships with community partners funded by Covered California, the California Endowment, etc. for outreach and targeted communication Reaching out to Advisory Boards to ensure messaging efforts are aligned

26 Risks and Unknowns Unknowns and Challenges Actual uptake of new coverage options unknown and hard to predict Processes for expanded Medi-Cal enrollment will be manual, not automated during first few months Funding for Medi-Cal administration being increased, while Realignment funds are decreased with coverage expansion Impact to existing programs (increase or shrinkage) Unknown size and costs of County Medical Services (CMS) program Uncertainty surrounding immigration reform linked with refugee needs

27 Integration of services and communication across service areas will be critical:

28 Risks and Unknowns Implementation Timeline Oct 2013 Nov 2013 Dec 2013 Jan 2014 Feb 2014 Mar 2014 Open Enrollment Period GoLive Phases SDG CalHEERS Call Center Processing Center ACA Implementation Begins LIHP program sunsets LIHP Conversion

29 Application Channels Now In-Person Oct. 1st In-Person On-Line On-Line Mail-In Mail-In Phone (2-1-1) Phone (2-1-1) CalHEERS Call Center

30 Warm Handoff Call Routing

31 Q & A Aligning with by Building Better Delivery System