The Affordable Care Act & California
August 27, 2013
The Affordable Care Act
Section I
Presented
by
Carmen Burgos
Introduction
“ The YouToons Get Ready for Obamacare:
Health Insurance Changes Coming Your
Way Under the Affordable Care Act"
http://www.kff.org/video-download/
Authorization to present granted by Kaiser on 8/1/2013
The Affordable Care Act
Does not apply to you if you have:
 Medicare
 Medi-Cal or the Children’s Health Insurance Program
(CHIP)
 TRICARE (for service members, retirees and their
families)
 The Veteran’s Health Plan Program
 An employer plan
 Insurance you bought that is at least at the Bronze level
 A grandfathered health plan
The Affordable Care Act
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On March 23, 2010, Congress passed and the President
signed The Affordable Care Act into law.
Requires most U.S. Citizens and Legal Permanent
Residents to have health insurance or pay a penalty
(exceptions apply)
Creates a “State Based” Exchange where individuals can
buy affordable coverage when not covered by employer
or eligible for public programs
Requires employers with 50 or more full-time employees
to offer coverage
Medi-Cal Expansion to new groups
The Affordable Care Act
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Tax credits and cost sharing subsidies to individuals
Basic Health Plan Option for States*
(In California for incomes between 138% -200% FPL)
Plans offered through the Exchange will be required to
meet a minimum set of standards.
Insurers will offer four levels Platinum, Gold, Silver, Bronze
plus a catastrophic coverage plan for individuals under 30
years of age .
Gives individuals the opportunity to comparison shop for
coverage from a variety of plans through the
Exchange/Covered California.
The Affordable Care Act con’t
 All new plans must offer certain free preventive services
 Prohibits insurance companies from rescinding coverage
 Insurance companies are prohibited from imposing lifetime dollar
limits on essential benefits
 Individuals with incomes between 138 - 400% of the FPL who do not
have access to affordable insurance through an employer or
government program can buy insurance through the Exchange
 A cap on out-of-pocket expenses (co-pays, deductibles)-$5,950 for an
individual and $11,900 for a family
 Insurances cannot charge you more due to your health condition
Essential Health Benefits/Minimum
Standards
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Ambulatory patient services
Emergency services
Hospitalization
Maternity and newborn care
Mental health and substance abuse disorders
Prescription drugs
Rehabilitative and habilitative services and devices
Laboratory services
Preventive and wellness services
Pediatric services including oral and vision
Covered California/Market Place
Kern County-Health Plans
Region 14
Anthem-PPO
Blue Shield-PPO
Health Net-PPO
Kaiser-HMO
Comparing Insurance Plans
Category
% of expenses
paid by health
Plan
% of expenses
paid by
Individual
Platinum
90%
10%
Gold
80%
20%
Silver
70%
30%
Bronze
60%
40%
Tax credits and cost sharing
*Based on 2013 income levels
You are
You qualify for
Your estimated cost to
buy health insurance
One person making less than
$15,856
Medi-Cal
No cost
One person making
$20,000
A tax credit of $2,304 that you
can use to pay for your
premium and subsidies
Your premium cost is $1060
per year or $89 per month
Family of 4 making less than
$31,810
Medi-Cal
No cost
Family of 4 making $40,000
A tax credit of $4,140 that you
can use to pay for premiums
and subsidies
Your premium cost is $2,028
per year or $169 per month
Family of 4 making $80,000
A tax credit of $4,740 that you
can use to pay for premiums
Your premium cost is $7,596
per year or $633 per month
Health Reform Exclusions
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Health Care reform does not change current eligibility
rules or scope of benefits for individuals without
immigration status
People who would have to pay more than 8 % of their
income for health insurance
People with incomes below the threshold required for
filing taxes (in 2013, $10,000 for a single person)
People who qualify for religious objections
American Indians
Those without coverage for less than three months
Incarcerated individuals
Immigrant Eligibility
&
The Affordable Care Act
Naturalized Citizens
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No difference between U.S. born citizens
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Must buy health insurance or pay tax penalty
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Verification of citizenship status in the exchange:
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Can first be verified via Social Security Administration
(SSA) records
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If unable to verify via SSA, will go to Department of
Homeland Security’s (DHS) records to verify
citizenship
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Will have opportunity to provide other proof or
correct records if unable to be verified electronically
Legal Immigrants
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“Lawfully present”
Broader group of legal immigrants
Includes green card holders, refugees, asylees, as well as T
and U visa holders, and others in process of adjusting their
status
No waiting periods for exchanges or tax credits
Federal Medicaid still restricted to narrower group of legal
immigrants (“qualified” immigrants) with 5 year waiting
period and other barriers
CA provides state funded Medi-Cal to these immigrants
and should continue to do so after 2014
Legal Immigrants
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Immigrants who are “lawfully present” in the U.S.
can:
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Buy health insurance in the state exchanges
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Apply for tax credits for premiums and copayments
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Eligible for Pre Existing Condition Insurance Plans
(PCIP)
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Eligible for Basic Health Program (BHP)
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Are subject to the individual mandate
Children of Undocumented Immigrants
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U.S. citizen or legal immigrant children of
undocumented parents should have the same
access to health insurance and health services as
other children
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Eligible for Medi-Cal
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Eligible to buy health insurance and get tax credits
in the exchange via “child only plans”
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Can seek health care services anywhere, including
community health centers or school based clinics
Undocumented Immigrants
Under the ACA
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Cannot buy health insurance in the State Based Exchange
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Cannot apply for tax credits for premiums or co-payments
Exception: Eligible family members of mixed-status family
should be eligible for tax credits
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Explicitly excluded from individual mandate to have
insurance and related tax penalty
Remain ineligible for:
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Federal Medicaid, Children’s Health Insurance Program
(CHIP) or Medicare
Undocumented Immigrants
Exceptions:
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Eligible for Emergency Medicaid (Restricted MediCal)
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Eligible family members of undocumented family
can apply for these federal health programs
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States like CA can still choose to cover a broader
group of immigrants in their state-funded health
programs
Undocumented Immigrants
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Remain eligible for health programs that are available regardless
of immigration status (e.g., public health)
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Hospitals must still provide emergency care regardless of
insurance or immigration status (EMTALA)
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Community health centers can continue to provide nonemergency health care regardless of immigration status
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Eligible to be covered in group health insurance as dependent
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Insurance companies may offer insurance outside the state
exchange that are available to undocumented, but may or may not
be affordable or comprehensive
Important dates to remember
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October 1, 2013 open enrollment begins for plans offered
through Covered California
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January 1, 2014 healthcare coverage begins for plans
purchased through Covered California
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March 31, 2014 open enrollment closes for plans purchased
through Covered California except for life changing events i.e.
loss of a job, death of a spouse, birth of a child,
*Remember, you must buy your insurance through Covered California to be
eligible for premium assistance/tax credits
Medicaid
Medi-Cal
Medi-Cal Expansion
Current Provisions (LIHP)
Section II
Presented
by
Yvonne Hernandez
Medicaid
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Federal Program
Purpose – provide “medically necessary” treatments,
services, medicines and devices to certain groups of low –
income people
Generally
Families
Pregnant women
Physically and mentally disabled individuals
Those suffering with chronic diseases
Seniors
Determines who qualifies for Medi-Cal
For U.S. Citizens and LPR’s except CA
Medi-Cal
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State Version
Medi-Cal is California's Medicaid Program
Administered by the state Department of
Health Care Services (DHCS)
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You can learn more about Medi-Cal at
www.dhcs.ca.gov
Medi-Cal Expansion
MAGI Medical
Age 19 -65
Effective
January 1, 2014,
Medi-Cal
eligibility will
expand to those
who are:
Childless
adults
non-disabled
non-elderly
Foster youth will
be covered until
age 26
133 % FPL, with a 5
% income disregard,
resulting in eligibility
for individuals in
households up to
138 % FPL
Key changes for the expansion
population
Definition of
household size
Calculation
of income
Elimination
of the asset
test
MAGI
Modified Gross Adjusted Income
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Household income will be calculated using MAGI, based on
tax filing units (including anyone claimed as a dependent)
using standard IRS guidelines for defining income and
household in addition to foreign income and tax exempt
income
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Undocumented individuals are excluded from the count of
household members
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All MAGI household income is counted, whether or not the
individual is applying for coverage
Differences
MAGI Income and current Medi-Cal income
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The federal income tax code excludes some types of income
currently used in calculating Medi-Cal income, therefore the
following will not count as income for MAGI households
Veterans Benefits
Child Care
Child Support Received
Retirement Savings
Alimony Received
Some Health Premium Costs
Workers’ Compensation
Scholarships, grants, awards used for education
purposes
Most Social Security Benefits
Gifts and Inheritances
Paid Alimony
Lump Sums
American Indian / Alaskan Native Income
Non - MAGI
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Will remain unchanged for the following populations
Aged
Blind
Disabled
Long Term Care
Medically Needy
Individuals deemed
eligible for Medi-Cal as a
result of other programs
such as CalWORKs,
Adoption Assistance
Program, or Foster Care
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They will remain subject to the current income and asset test
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Undocumented will remain eligible for restricted-scope Medi-Cal
Current Provision (LIHP)
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State
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County
Low Income Health Plan (LIHP)
Kern Medical Center Health Plan (KMCHP)
LIHP
KMCHP
Medi-Cal
Medi-Cal
General Eligibility
Requirements
• Age 19 -64
• NOT enrolled or eligible for other
State health plans
• Has income at or below the 133 %
FPL ( 1 Single Adult - $ 1,273.50 )
• Resident of Kern County for 30 days
• U.S Citizen or LPR for 5 yrs
Supporting Documentation
• Proof of Kern County Residency
• Valid Picture Identification
• Proof of U.S. Citizenship or Legal
Residency
• Social Security card for all applicants
• Verification of all income in household
• Record of application/ denial for state
benefits / health plan
Small Businesses
&
The Affordable Care Act
Section III
Presented
by
Ruben Cortez
Small Business
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7.2 Million Small Businesses
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½ of the private workforce
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Most are very small
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80% have less than 10 workers
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2 in 5 do not have health coverage
Advantages of offering Coverage
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Compete
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Retain quality workers
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18% more than larger business
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Double by 2018 to $243 Billion in CA
Small business employer & tax credits
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Half did not know about the credit
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More likely to offer coverage
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Purchase insurance through exchange
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Most small firms lack HR departments
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Save employers’ valuable time
Shared Responsibility
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Businesses with fewer than 50 workers
(There will be no penalty)
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96% of all businesses are exempt from
any requirement to offer insurance.
Covered California/The Exchange
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Individual responsibility requirement
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Small employers still eligible for Tax Credit up
to 35%
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Up to 50% next year through Small Business
Health Option Program (SHOP)
Helpful links
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Affordable Health Insurance / Covered California (AKA The
Exchange): 1-888-975-1142
http://www.coveredca.com/
Health Insurance Marketplace 1-800-318-2596 (24 hours a day, 7
days a week ) marketplace@healthcare.gov
Low Income Health Plan
http://www.dhcs.ca.gov/provgovpart/Pages/lihp.aspx
Kern Medical Center Health Plan
http://www.kernmedicalcenter.com/
Businesses
www.healthlawguideforbusiness.org
Small Business Health Insurance Options Program (SHOP) Monday
through Friday hours 9am-5pm Eastern time-1-800-706-7893
Contact information:
Kern Health Consumer Center
a Unit of Greater Bakersfield Legal Assistance, Inc.
615 California Avenue Bakersfield, CA 93304
Office: (661)321-3982
Fax: (661)325-4482
Section I
Section II
Section III
Carmen Burgos/Project Manager
cburgos@gbla.org
(661)321-3980
Yvonne Hernandez/Case Manager
yvonnehernandez@gbla.org
(661)326-4785
Ruben Cortez/Case Manager
rcortez@gbla.org
(661)321-3982