Agenda
 Coverage for care overview
 Health insurance customer protections
 New Health Insurance Marketplace
 How will Medicaid change?
 What does it mean for our state?
 Call to action
50 million Americans Uninsured (2009)
Financing Mental Health Care
Other federal
5%
Medicaid
27%
Other state
and local
18%
Out of
pocket
12%
Medicare
8%
Other private
3%
Private
insurance
27%
Source: Garfield (2011) Mental Health Financing in the US: A Primer
Kaiser Commission on Medicaid and the Uninsured
Coverage for Care
Federal/State Programs
• Medicaid:
–
–
–
–
Health finance program for the poor
Only covers some lower income people
Broad array of community mental health services
Does not cover inpatient care age 22 – 64
• Children’s Health Insurance Program (CHIP)
• Children not covered by Medicaid 100% - 200% FPL
• May or may not offer full range of Medicaid services
Coverage for Care
Federal Programs
• Medicare:
– Seniors, people who received SSDI for >24 months
– Limited array of mental health services
– Medicaid beneficiaries with very low incomes may
also qualify for Medicaid (dual-eligibles)
• Veterans/Military:
– VA health care: limited eligibility, but wide array of
mental health services
– TRICARE resembles private insurance
Coverage for Care
State and Local Public Systems
• State and county mental health authorities
• Serve people who fall through the cracks
• Provide services not covered by Medicaid
Private Health Insurance
•
•
•
•
•
Employer sponsored or purchased by individual/family
Varied benefits
Mental health parity requirements vary
Limited array of mental health benefits typical
Wider provider network
New Consumer Protections
Since 2010
• Youth up to age 26 covered on
parent’s health plan
• Children no denial for pre-existing
conditions
• No lifetime limits on benefits
• Temporary high-risk pools
• Rescission: Cannot drop for
intense service need
• Appeals process for denials
• Medical Loss Ratio: 80-85% spent
on direct care
2014 and forward,
Individual & small group plans
•
•
•
•
•
•
Essential health benefits (EHB)
MH/BH/SUD parity required
No denial for pre-existing conditions
No annual limits
Guaranteed coverage
Rates can only differ based on:
– Age, geographic area, tobacco use,
family size
• User friendly benefits statement
9
“My 21 year old daughter has had
major depression since she was a
child. We were very worried about
health insurance when she wanted
to leave home. Now she can stay
on our health plan until she is 26.”
The new health law allows parents
to keep adult children on their plan
until age 26.
Uninsured Adults with Mental Illness
Uninsured
11 million
24%
Covered
34.5 million
76%
US: Total of 45.6 million adults with mental illness
Source: SAMHSA, National Survey of Drug Use and Health, 2011
New Coverage Options
• Health Insurance Marketplace: private coverage
• Individuals
• Small Employers (SHOP)
• Medicaid expansion: 0 -138% FPL
• Parity required: 62M Americans Benefit
– All individual and small group plans
– All Medicaid Alternative Benefit Plans (Medicaid expansion)
– Traditional Medicaid managed care plans
Health Insurance Marketplace
= Health Insurance Exchange
Goals: Good health coverage at affordable cost
• Regulates:
“Qualified Health Plans”
“Essential Health Benefits”
• Rates Qualified Health Plans
• Unified online application for exchange, Medicaid, CHIP
• Toll-free telephone hotline
• Website to compare health plan information
• Standardized format to present health benefit options
• Electronic calculator to figure of coverage
Qualified Health Plans (QHP)
Only Qualified Health Plans allowed in
Health Insurance Marketplaces
– Must provide Essential Health Benefits
– Insurer must meet requirements:
• In good standing with the State
• Offers at least:
– One silver and
– One gold plan
• Offers the same premium for qualified health
plans inside and outside the Marketplace
Source: Illinois Department of Insurance
Health Insurance Marketplace Incentives
•
INDIVIDUALS
– Tax Credits for Premium Subsidies
– Cost-Sharing Subsidies
– Reduced OOP limits, annual cap
$6,350 (premium + deductible)
•
SMALL BUSINESS
– Small business Health Options
Program (SHOP)
– Help small employers enroll
employees in qualified health plans
– Small Business Tax Credit
Individual & Employer Penalties
• Individual: 2014 forward, greater of…
– 2014: $95 or 1% household income
– 2015: $325 or 2% household income
– 2016 and beyond: $695 or 2.5% household income
• Employer: 2015 forward
– Applies to employers with 50 or more employees
– Penalties from $2,000 to $3,000 per employee,
– If employer fails to offer coverage or offers bare bones coverage
• Exempted:
• Below tax filing threshold (Single, $10K, Jointly $20,000)
• Religious reasons
• Tribal member
• Undocumented immigrant
• Incarcerated
• If no plan is less than 8% annual household income
Who Should Apply?
• 85% of Americans already have health coverage
that meets ACA requirements – no need to apply
–
–
–
–
Private insurance
Medicare
Medicaid
VA benefits
• 15% may want to apply
– Uninsured
– Underinsured
• High health costs
– Premiums, deductibles, out of pocket costs
• High health needs
– Care you need is not covered
Essential Health Benefits
 Outpatient clinic services
 Prescription drugs
 Emergency services
 Rehabilitative &
habilitative services
 Hospital care
 Maternity, newborn care
 Mental health, behavioral
health, substance use
care
 Laboratory services
 Children’s services,
dental & vision care
 Wellness, disease
management
Benefit Continuity
Essential
Benefits
Package
Source: Sommers, B.D. & Rosenbaum, S. (2011). Health Affairs.
Presented by S Fields, NAMI 2011.
“I had a 4.0 GPA in school but I
dropped out after my insurance
stopped covering my medication. I
started hanging out with the wrong
crowd and self-medicating just to get
away from the pain and confusion.
Now I’m trying to get back on track,
but every day is a struggle.”
The new health law requires Medicaid expansion and
health insurance marketplace plans to provide medication
and lab work, but advocacy is needed.
Expanded Medicaid Eligibility
Now
Categorical
+ Financial
Criteria
•
•
•
•
•
Pregnant women
Infants/Children
Families with dependent children
Aged, Blind, Disabled
Assets and other income
2014
Financial
Criteria Only
•Single adults under 65:
•Incomes up to 138% of
the Federal Poverty Level
• Ag
ed
Dis
abl
ed
• Fa
mil
Infants/Children ies
ith
de
pe
nd
ent
chil
dre
n
“I was married and working, but
stopped taking my medications
because I didn’t feel sick. Things went
downhill fast. My wife left me, I lost my
job and had to move back in with my
parents.”
•
The Affordable Care Act provides a second chance in states that expand
Medicaid. Anyone with an income below 138 % FPL can enroll in Medicaid
and get treatment. It is also easier to return to work because private
insurance with mental health benefits will be available.
•
NEW DONUT HOLE! In states that do not expand Medicaid people with
incomes below 100 percent FPL will not get federal financial help to
buy a private plan.
Medicaid Expansion
Any uninsured ≤ 138% FPL
– 100% federal match for newly Medicaid eligible: 2014 – 2016
– Reduced gradually to 90% federal match, 2020 forward
•
Source: Kaiser Family Foundation http://kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-theaffordable-care-act/#note-1
Eligibility and Financial Assistance
Question:
Do the new rules help me get Medicaid?
Answer:
IF your state expands Medicaid and IF
your income is at or below 138% of
Federal Poverty Level, then yes.
Question:
Are you eligible for government help
buying insurance?
Answer:
The government will help pay part of
premiums and out-of-pocket costs for
people with incomes between 100
percent and 400 percent of the federal
poverty level.
Family Size
100% FPL
138% FPL
1
$11,490
$15,856
2
$15,510
$21,404
3
$19,530
$26,951
4
$23,550
$32,499
Family Size
100%
400%
1
$11,490
$45,960
2
$15,510
$62,040
3
$19,530
$78,120
4
$23,550
$94,200
The Marketplace is OPEN
Enroll TODAY
www.healthcare.gov
• Enrollment assistance - 24/7 call center
– Toll free: 1-800-318-2596
– TTY/TDD: 1-855-889-4325 for assistance
– English, Spanish, 150 languages
In-State Update
Call to Action
• Contact your legislator today! Call or email!
– Visit state legislature website for contact information
– Schedule a visit in the district
• ASK:
– Health care coverage will help people with mental
illness recover and contribute to their communities.
• Can I count on your support to expand good,
affordable health coverage to all households with
incomes from 0 to 138 percent of poverty?
• Can I count on you to advocate for mental health
coverage on par with medical/surgical care?
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