Connecting Communities
to Coverage:
+
The Affordable Care Act in
IL
October 1, 2013
Connecting Communities to Coverage:
The Affordable Care Act in Illinois
About EverThrive Illinois
 Formally
known as Illinois
Maternal and Child Health
Coalition
 Our
Projects and Initiatives:
 Health Reform Projects
 School Health Project
 Immunization Project
 Health Disparities Project
 Premature Birth Project
 Cooking Matters Project
www.ilmaternal.org
@EverThriveIL
#NASWIL
Kathy Waligora, M.S.W
Manager, Health Reform Initiatives
kwaligora@ilmaternal.org
Learning Objectives
Understand
the basic
provisions of the law likely
to impact clients
Get
an introduction to the
new enrollment systems,
including the Marketplace.
Understand
the role of
social workers in
connecting communities to
coverage
Gain
access to tools and
resources which will help
you to connect with other
enrollment specialists and
stakeholders
ACA 101

The Affordable Care Act puts in place comprehensive
reforms that:

Ensure that all insurance is high quality,

Protect consumers from insurance industry practices which
limited access to coverage for many, and

Improve access to affordable health coverage.

If you are already insured, the only changes you will see
are new benefits, better consumer protections, and more
value for every dollar you spend on care. If you like your plan
you can keep it and don’t need to do anything differently.

If you are uninsured, new pathways to coverage will make it
easier than ever to get covered and stay covered. Financial
assistance will be available to guarantee you can pay for
coverage and health care.
Key Components
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Available Now…
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Extended dependent coverage
to age 26
No pre-existing condition
exclusion for children
Preventive services without
cost sharing
CountyCare-the early
expansion of Medicaid in
Cook County
No lifetime limits on care
Small business tax credits
No insurance rescissions except
in cases of fraud/intentional
misrepresentation
Connecting Communities to Coverage 2013
2014 and Beyond…
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New Marketplace to buy insurance and
receive financial help to pay for it
New Medicaid Adult Group available to
adults under 138% FPL
Financial Assistance to purchase private
insurance
Medicaid available to former foster
children up to age 26 at any income level
No pre-existing condition exclusion for
adults
All plans must cover Essential Health
Benefits
No annual limits on care
No gender rating
Closing Medicare Part D donut hole
Individual and Employer Responsibility
Essential Health Benefits
Individual Responsibility

The individual mandate requires most Americans to
purchase health insurance starting January 1, 2014 or pay the
shared responsibility payment if they do not comply

People are exempt from the shared responsibility payment if:
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They would have to spend more than 8% of household income on
the cheapest qualifying health insurance plan even after tax
credits and subsidies
Their income falls below the threshold for filing federal income
tax
They are undocumented or not a lawfully permanent resident
People already meet this requirement if:
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They have insurance through an employer or purchase individual
insurance.
They have insurance through Medicaid, Medicare, CHIP, Veteran’s
Administration and/or Tricare for active duty and retire military,
Indian Health Services
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+ Cost & Financial Assistance
Cost of Health Insurance
 There
are three factors that can determine an
individual’s premium:
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Age
 Up to 3x more for older adults
Tobacco Use
 Up to 1.5 times for tobacco users
Where you live
 IL
recently released premium rates and they were
25% lower than expected and much lower than other
states
Limits on Cost Sharing
“First-dollar” (no
preventive health
deductible/cost-sharing) coverage on
Limit
small group health plan deductibles in 2014 to
$2,000 for single, or $4,000 for family (adjusted annually)
Limit
out-of-pocket amount in 2014 to $6,350 for single
and $12,700 for family (adjusted annually)
Maximum
out-of-pocket limits are reduced further for
individuals and families below 250% FPL
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Financial Assistance
Premium
Tax Credits
• Helps you pay the monthly
cost to have a plan
CostSharing
Reductions
• Decrease the charges (e.g.,
copays, deductibles) you
must pay when receiving
health care services covered
by the plan
Premium Tax Credit
Take It Now! (Advanced)
Taking It Later! (Tax Time)
October 2013
– March 2014
• Enroll in health plan on
Marketplace
• Choose to take all your credit in
advance
– or just part of it
• Enroll in health plan on
Marketplace
During 2014
• Pay a lower premium each month
in 2014
– and now you are covered
• Pay full premium each month in
2014
– and now you are covered
January 2015 – • Get a statement from Marketplace
April 2015
showing how much credit you
received in 2014
• File your 2014 taxes, including
information about tax credit
already taken
• File your 2014 taxes
• Either subtract the amount of
tax credit from the taxes you
owe – or if you don’t owe
anything IRS may give you a
refund
IL Submitted Rates (non smoker)
Connecting Communities to Coverage 2013
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The REAL cost of Coverage in
Illinois
Kaiser Family Foundation: kff.org
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Access to Coverage
Getting Insurance in 2014
Medicaid Expansion
 The
ACA expands
Medicaid to cover all
people under 138% of the
federal poverty level
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Must be US Citizen or Legal
Permanent Resident of 5
years or more to qualify
Coverage begins January 1,
2014
100% federally funded in the
first three years, gradually
reduces to 90% by 2020
CountyCare: A New Medicaid
Program for Cook County

Who?
 Live in Cook County
 Be 19-64 years old
 Have income at or below 133% of the
Federal Poverty Level ($14,856 individual,
$20,123 couple – annually)
 Be a legal immigrant for five years or
more or a US citizen
 Have a Social Security number or have
applied for one
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Access services at Cook County Health and
Hospital System locations and some
participating federally qualified health
centers
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It is important to continue enrolling eligible
individuals into CountyCare as they can be
enrolled and back bill for services BEFORE
January 1, 2014
Existing Medicaid Programs
You might not need to wait until
January to enroll in Medicaid:
1. All Kids covers children under a
certain income regardless of
immigration status
Get Connected TODAY
2. FamilyCare covers parents of
1-800-843-6154
1-800-447-6404 TTY
children under 19 under a certain
income
3. Moms and Babies covers pregnant
women under a certain income
regardless of immigration status
4. Medicaid for the Aged, Blind, and
Disabled provides coverage for
older adults and disabled people
under a certain income
The Marketplace
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Enroll between Oct 1- March 31 for private insurance; by Dec 15
for coverage beginning Jan 1, 2014
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Enroll year round for Medicaid
Three ways to get connected:
1. On the web
www.GetCoveredIllinois.gov
2. On the phone
1-866-311-1119
3. In Person
Work with a Navigator to get
support and advice
The Marketplace in IL
Connecting Communities to Coverage 2013
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The Marketplace
Get Covered
Illinois
Healthcare.gov
SHOP
ABE
If potentially
eligible referred to
Medicaid/CHIP
Individual
Marketplace
Assess
Medicaid/CHIP
Eligibility
Application for
APTC/CSR
Eligibility
Determination
for APTC/CSR
Select and
enroll in QHP
without
APTC/CSR
Select and
enroll in
QHP with
APTC/CSR
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Application available
to state office
State worker Processes
Application
Eligibility
Determinatio
n
If denied for
Medicaid/CHI
P refer to
Marketplace
If eligible,
enroll in
Medicaid/CHIP
Open Enrollment Period
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Enrollment Date/Period
Effective Coverage Begins
Oct. 1 – Dec. 15, 2013
Jan. 1, 2014
1st – 15th of month
(Jan. – March)
16th – last day of month
(Dec. – March)
1st of following month
1st of second following month
Initial Open Enrollment Ends March 31, 2014
Changes can be made within 30 or 60 days of triggering
event (marriage, birth, move) that allows for a change
***Those who are eligible for Medicaid can apply for coverage
any day of the year!
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Role for Social
Workers
The Role for Social Workers
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Educate clients on health insurance
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Educate clients on the Affordable Care Act
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Connect uninsured clients to Assisters
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Become a Certified Enrollment Specialist
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Connect to larger campaigns to elevate messages or even
volunteer to canvass your community, host/participate in
phone banks, and support events
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Connect with other stakeholders across Illinois, using IHM
HelpHub
Education: Barriers
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Healthcare system
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Lack of knowledge/information
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Financial
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Attitudes and perceptions
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Culture
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Communication
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Professional Bias
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Physical and social environment
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Physical proximity
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Politics and Policy
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Key Messages
All insurance plans will
have to cover doctor
visits, hospitalizations,
maternity care, emergency
room care, and
prescriptions.
You might be able to get
financial help to pay for a
health insurance plan.
If you have a pre-existing
condition, insurance plans
cannot deny you coverage.
All insurance plans will
have to show the costs
and what is covered in
simple language with no
fine print.
One of these =
top message
for 89% of
population
Source: Enroll America, November 2012
Certified Application Counselors
Who? Community based organization that wants to
help by training your staff to assist people applying for
coverage through the Marketplace
What? Help people understand, apply, and enroll for
health coverage through the Marketplace. Your
organization must agree to make sure that designated
individuals complete required training, and that they
comply with privacy and security laws, and other
program standards.
How? Complete a brief application and access training
at: http://marketplace.cms.gov/help-us/cac.html
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Major Campaigns
Get Covered Illinois
BeCovered Illinois
Connecting Communities to Coverage 2013
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Enroll America-Get Covered
America
Many other groups will
run campaigns, so there
will be no shortage of
graphics, materials,
resources, or ideas.
Illinois Health Matters HelpHub

An online community where enrollment and outreach
stakeholders in Illinois can share their experiences and get
access to resources related to the ACA

To request an invite, email
helphub@illinoishealthmatters.org with the name of your
organization, lead agency (if part of IPC or Navigator grant)
and /or details of your ACA involvement.
Resources
Illinois Health Matters
http://www.illinoishealthmatters.org
EverThrive Illinois ACA
http://www.ilmaternal.org/hcr
Kaiser Family Foundation
http://healthreform.kff.org/
www.GetCoveredIllinois.gov
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Questions?
Kathy Waligora, M.S.W.
Manager
Health Reform Initiatives
EverThrive Illinois
kwaligora@ilmaternal.org
312-491-8161 x29