The Affordable Care Act:
Implementation in Illinois
Impact on People with Disabilities and Special Health
Care Needs
Stephanie F. Altman, J.D.
December 2013
ACA 101
ACA signed into law on March 23, 2010 with major
provisions to start January 1, 2014.
“Health Insurance Marketplaces” opened October 1,
2013: Get Covered Illinois operates the marketplace and
enrollment for Medicaid expansion.
Individuals are responsible to obtain health coverage
through an employer, directly from an insurance company
or through the Marketplace, Medicaid or Medicare.
Employers over 50 FTE are responsible for providing
coverage but employer penalty delayed for one year.
2
ACA 101: Key Components
Available Now…
• 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
2014 and Beyond…
•
•
•
•
•
•
•
•
•
•
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
(exception for some current plans)
No annual limits on care
No gender rating
Closing Medicare Part D donut hole
Individual and Employer Responsibility (but
employer penalty delayed)
3
ACA 101: Essential Health Benefits
All health plans in the
Marketplace, individual &
small group, are qualified
health plans (QHP).
• Ambulatory patient services
• Emergency services
• Hospitalization
• Maternity and newborn care
• Mental health and substance use
disorder services
Illinois’
Benchmark
Federal VIP for
vision for children
Supplemented by All
Kids for dental for
children
BCBS Blue
Advantage
• Prescription drugs
• Rehabilitative and habilitative
services and devices
• Laboratory services
• Preventive and wellness services
including chronic disease
management
• Pediatric services including oral
and vision care
4
ACA 101: New Pathways to Coverage
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Get Covered Illinois
• www.getcoveredillinois.gov
• Media and Marketing Campaign
• Administered by Governor’s Office
Marketplace Team in partnership with DOI,
HFS, DPH and DHS as well as other state
agencies.
• Community enrollment assistance.
• Includes both insurance and Medicaid.
7
Important Dates
• OCTOBER 1, 2013
- Open Enrollment in the Marketplace/New Medicaid Begins.
• DECEMBER 23, 2013
- Must be enrolled by this date for Marketplace health
coverage to begin by 1/1/14
• JANUARY 1, 2014
- New Medicaid Adult Group Coverage begins. (No
backdating before this date.)
• MARCH 31, 2014
- Open Enrollment for Marketplace ends (Medicaid is
always open).
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In Person Assistance
Navigators
• Federally funded (Just over $3 million via 11 awards in IL)
• Duties: Outreach, Facilitate Enrollment, Provide Ongoing Support
• Who: Cannot be a health insurance provider or someone paid by
an health insurance provider to enroll individuals
In Person
Counselors (IPCs)
• State funded (just over $28 million via 44 awards in IL)
• Duties: Outreach, Facilitate Enrollment, Provide Ongoing Support
• Who: Cannot be a health insurance provider or someone paid by
an health insurance provider to enroll individuals
Certified
Application
Counselors (CACs)
• Volunteers—no funding
• Will participate in a training to provide application assistance
• Who: Anyone that submits an application to the federal
government and is approved. You must demonstrate that you have
procedures in place to protect personal information.
THE UNINSURED
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1.5 million uninsured non-elderly adults in Illinois
11
Young adults in Illinois are the most likely to be uninsured
3,500,000
35%
29%
3,000,000
30%
25%
2,500,000
25%
19%
2,000,000
20%
16%
13%
1,500,000
15%
1,000,000
500,000
10%
4%
1%
-
5%
0%
Under 19
19 to 25
26 to 34
with HI
35 to 44
w/o HI
45 to 54
55 to 64 65 and over
% Not Covered
12
The Uninsured: Past Experiences
44%
have shopped for
insurance outside
their job
67%
have been
uninsured for 2
years or more
Connecting Communities to Coverage
2013
13
The Uninsured: Understanding of
Law
Do you feel you have enough information about the health reform law to
understand how it will impact you personally, or not?
NOTE: Don’t know/Refused answers not shown.
SOURCE: Kaiser Family Foundation Health Tracking Poll (conducted March 5-10, 2013)
ILLINOIS MEDICAID
EXPANSION
Medicaid in IL: New Programs
Pre-ACA
• FamilyCare for parents and other
caretaker relatives of children under
19
• All Kids
• Moms and Babies
• Aid to the Aged Blind and Disabled
(AABD)
• Health Benefits for Workers with
Disabilities (HBWD)
• Health Benefits for Persons with
Breast and Cervical Cancer (apply
with Illinois Dept. of Public Health)
Post-ACA
• ACA Adult
• Former Illinois Foster Child
• FamilyCare for parents and other
caretakers of children under 18
• All Kids
• Moms and Babies
• Aid to the Aged Blind and Disabled
(AABD)
• Health Benefits for Workers with
Disabilities (HBWD)
• Health Benefits for Persons with
Breast and Cervical Cancer (apply
with Illinois Dept. of Public Health)
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Medicaid Expansion
•
•
•
•
19-64 and not eligible for other Medicaid category
No asset or disability test
Under 138% FPL
State currently seeking input from stakeholders in
coverage package called ABP
• Waiver programs and LTSS
• Managed Care Roll Out
• Interaction with Medicare
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ILLINOIS MARKETPLACE
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Marketplace Overview
 Get Covered Illinois is a web-based portal for individuals and
small businesses to enroll in coverage. Can also access by mail,
on phone, or in person.
 Enroll in public and private health insurance, as well as access
financial assistance to pay for coverage.
 Federally Facilitated Marketplace is linked to Get Covered Illinois
 Gives consumers the tools and power to have control over their
insurance decisions
 Apples-to-apples comparison of plans
 Plan Finder and Individual Pricing
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2014 Open Enrollment
Enrollment Date/Period
Effective Coverage Begins
Oct. 1 – Dec. 23, 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
***Those who are eligible for Medicaid can apply for coverage
any day of the year!
Note: Coverage is not retroactive
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Insurance Rating and Pricing
Demographics
•
•
•
•
•
Age (3:1)
Household Income
Family size
Tobacco use
Location/Zip code (13
rating areas)
Plan factors
• Out-of-Pocket limits
• Benefit levels
• Insurance Affordability
Programs
– Premium tax credits
– Cost-Sharing
Reductions (CSR)
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Cost: Two Types of New Financial
Assistance
Premium
Tax Credits
• Helps people pay the monthly
cost to have a plan
CostSharing
Reductions
• Decrease the charges (e.g.,
copays, deductibles) enrollees
must pay when receiving health
care services covered by the plan
22
Who Is Eligible for Tax Credits/Subsidy?
A U.S. Citizen and
• Unable to obtain affordable minimum essential coverage, such as coverage provided through an
employer, Medicaid or the Marketplace
• Eligible to enroll in a QHP through the Marketplace
• Part of a tax filing unit
• Has household income between 100% and 400% FPL
A non-citizen who is lawfully present and
• Unable to obtain affordable minimum essential coverage, such as coverage provided through an
employer, Medicaid or the Marketplace
• Eligible to enroll in a QHP through the Marketplace
• Part of a tax filing unit
• Has household income between 0-400% FPL
Cost sharing subsidies are provided if eligible for a tax credit with an income
between 100%-250% FPL and enrolled in a silver plan through the Marketplace
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Potentially eligible: for Premium Tax Credit/ Marketplace
Potentially eligible: AllKids
Marketplace
Potentially eligible: Moms and Babies (Pregnant or child
under 1)
Potentially eligible: ACA
Adult Medical or Family
Care
Marketplace
Marketplace
Household
Size
100%*
133%
138%
200%
250%
300%
400%
1
$11,490
$15,282
$15,856
$22,980
$28,725
$34,470
$45,960
2
15,510
20,628
$21,404
31,020
38,775
46,530
62,040
3
19,530
25,975
$26,951
39,060
48,825
58,590
78,120
4
23,550
31,322
$32,499
47,100
58,875
70,650
94,200
5
27,570
36,668
$38,047
55,140
68925
82,710
110,280
6
31,590
42,015
$43,594
63,180
78,975
94,770
126,360
7
35,610
47,361
$49,142
71,220
89,025
106,830
142,440
8
39,630
52,708
$54,689
79,260
99,075
118,890
158,520
For each
additional
person, add
$4,020
$5,347
$5,548
$8,040
$10,050
$12,060
$16,080
Connecting Communities to Coverage
* lawfully present residents below
100% FPL2013
and ineligible for Medicaid may qualify
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Impact of Marketplace Financial Help
on People with Employer Insurance
• Not intended for those with employer
coverage.
• Provisions in place to discourage those with
employer offer buying into exchange with
financial help.
• Employer offer to employee is not more than
9.5 % of the HH income.
• Dependent coverage “glitch”
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Exemptions from Shared
Responsibility
Income or
Affordability
Membership/
Affiliation
Legal or
Residential
• Hardship or domestic circumstances
• Lacks coverage for less than three months (one 3month period per year)
• Household income below threshold for federal taxes
• Contribution for single coverage exceeds 8% of
household income
• Religious conscience
• Membership in a health care ministry
• Member of an Indian tribe
• Incarceration
• Not lawfully present in the U.S. or non-resident aliens
• U.S. citizens living abroad for 330+ days in 12-months
• Residents of U.S. territories
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How To Stay Informed in Illinois
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•
•
Bookmark www.illinoishealthmatters.org
To Enroll: www.getcoveredillinois.gov
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