ObamaCare 301: Essential Updates
Before Open Enrollment
About ITUP
ITUP is a non-partisan, non-profit health policy “think tank” based in Santa
Monica, CA.
We are funded by generous grants from The California Wellness Foundation,
The California Endowment, Blue Shield of California Foundation, California
Community Foundation, Kaiser Permanente, and The California HealthCare
Foundation.
ACA Refresher
Medi-Cal Expansion
Covered California
Insurance Market Reforms
ACA Impacts in the Rural North
Coverage Expansions
The ACA expands healthcare coverage through two major
systems:
• MEDICAID (MEDI-CAL): public coverage program for lowincome Californians
• COVERED CALIFORNIA: Virtual “shopping mall” where
individuals, families, and employers can purchase
affordable health insurance and get help with the costs
of premiums, copays and deductibles
Medi-Cal
On January 1, 2014
Medi-Cal extended coverage to all citizens and legal permanent
residents ages 19 - 64 with incomes up to 138% of the federal
poverty level ($16,243 for an individual and $33,465 for a family
of four).
Increased income standard for parents from 100% to 138% FPL
Extended coverage to adults without dependent children to
138% FPL
Medi-Cal
Expanded Benefits
Mental health services and Substance Use Disorder treatments
are now more accessible.
• Mental health services for the severely and chronically
mentally ill are available through the county Mental Health
Departments.
• Psychological services for those with less severe mental illness
are provided through the Medi-Cal Managed Care plans and
their provider networks.
• Expanded Substance Use Disorder treatment services are
available to all Medi-Cal members.
Medi-Cal
Expanded Benefits
Dental services are now more accessible.
On May 1, 2015 dental benefits for adults were restored.
•Office visits
•Cleanings
•X-rays
•Fillings
•Crowns
•Complete dentures
•Root canals
Medi-Cal
Enrollment
The ACA helps to streamline and modernize the enrollment
process for Medi-Cal applicants.
• Central application and enrollment system for both
Medi-Cal and Covered California – “CalHEERS”
• Electronically processed applications with income and
residency information verified electronically
• Eliminated asset tests
• Except for seniors, Medi-Medis, and individuals in
long-term care
• Improves renewal process with pre-populated forms
California’s Health Insurance Exchange is:
Covered California
www.coveredca.com
One-stop shopping for quality, affordable health plans.
Covered California
Individuals and households with incomes between 138% and 400%
FPL qualify for premium subsidies.
•
138% FPL - $16,244/year (individual); $33,466/year (family of 4)
•
400% FPL - $47,080/year (individual); $97,000/year (family of 4)
In addition, Individuals and households with incomes between 100% and
250% FPL qualify for cost-sharing subsidies that reduce copays and
deductibles, but only for those selecting “enhanced” silver plans.
Covered California
All plans must include the 10 essential health benefits
•
•
•
•
•
•
•
•
•
•
Ambulatory patient services
Emergency services
Hospitalization
Maternity & newborn care
Mental health & substance use disorder services
Prescription drugs
Rehabilitative & habilitative services & devices
Laboratory services
Preventive & wellness services, chronic disease management
Pediatric services, including oral & vision care
Standardization of plans’ benefit packages makes them easy to
compare
• Copays, deductibles, and out-of-pocket maximums vary with metal tiers
Covered California
Four tiers of health plans
•
•
•
•
•
Platinum (90% actuarial value)
Gold (80%)
Silver (70%)
Bronze (60%)
Minimum Coverage Plans (Catastrophic Coverage)
• Only available up to age 30 or to those who can prove they are
experiencing financial hardship
Prices of plans vary within each tier.
Plan choices apply for one year – you cannot change tiers
or plans until annual open enrollment or special
enrollment.
Covered California
People can only buy health insurance through Covered
California during a specified time period called open
enrollment.
Open enrollment for 2016 will reopen in the fall (Nov. 1 – Jan.
31).
But people with certain life events qualify for special
enrollment.
Medi-Cal is open year-round.
Insurance Market Reforms
Insurance plans:
• Cannot cancel existing coverage, except for cases of fraud
• Cannot refuse to sell health insurance to individuals based on
pre-existing conditions (e.g. asthma, diabetes, etc.)
• Cannot impose lifetime limits on coverage
• Must provide coverage for dependent children up to age 26
• Must provide recommended preventive services without costsharing or co-payments (wellness visits, mammograms,
colonoscopies, vaccinations)
• Can vary premium costs only based on age, location, and family
size
Individual Mandate (Shared Responsibility)
The ACA requires individuals to have health
insurance.
Individuals must have health insurance through an employer, union,
Exchange plan, individual plan, Veteran’s Administration, Indian
Health Services, Medicare, or Medi-Cal. Native Americans are exempt.
Individual tax penalty increases in 2016:
The greater of flat dollar amount or income formula, whichever is
more
•$95 per adult + $47.50 per child or 1% of income in 2014
•$325/adult + $162.50/child or 2% of income in 2015
•$695/adult + $347.60 /child or 2.5% of income in 2016 and thereafter
Employer Mandate
In 2015: Employers with 100 or more full-time
equivalent employees must offer health insurance.
In 2016: Employers with 50 or more full-time
equivalent employees must offer health insurance.
Employers must pay 60% of the lowest cost bronze
plan for their employees and dependent children.
Or pay fees if a full-time employee uses tax credits in the Exchange
• Fee of $2,000 per employee, excluding the first 30 employees,
for failing to offer insurance to full-time employees
• Fee of $3,000 per employee for failing to offer “affordable”
coverage (employee contribution is more than 9.5% of
income) for each employee who uses tax credits
Year 2: Results &
Lessons Learned
1.3 million
individuals enrolled in plans
through Covered California
3.4 million
individuals newly enrolled in
Medi-Cal since December 2013
Source: ITUP Health Care Financing Report 2015
Impacts of ACA In California
•Medi-Cal managed care enrollment increased by 58%
between December 2013 and July 2015
•Covered California enrollment increased from zero to
1.3 million between December 2013 and July 2015
•90% are in subsidized coverage
•92% of those in subsidized coverage are in silver or
bronze; the percentages enrolling in bronze are
increasing
•Covered California premiums increased by 4% in year 3;
savvy shoppers could decrease their premiums by 4.5% by
choosing the lowest cost plans in their coverage tier
Impacts of ACA for California Clinics
Composition of Community Clinic Visits changed
dramatically
• Medi-Cal managed care visits increased by 55%
•Privately insured (includes Covered California) visits
increased by 19%
•Uninsured visits declined by 28%
•Bottom lines at Community Clinics increased from
$0.21 to $3.50 per visit
The Affordable Care Act Has Changed Health Care in
California
The Affordable Care Act has dramatically changed the health insurance landscape in the
state with the expansion of Medicaid, Covered California and new protections for all
Californians.
1.5 million ineligible for
Covered California due
to immigration status
35
UNINSURED
2.8
UNINSURED
From 2013 to 2015, the number of uninsured
Californians has been reduced by almost
half.1
5.1
30
MEDI-CAL
25
12.4
9.2
Californians, in millions
subsidized, unsubsidized
As of March 2015, Covered California has
approximately
1.3 million members who have active health
insurance. California has also enrolled nearly 3
million more into Medi-Cal, of whom over
2 million are newly eligible.
and new Medi-Cal
20
1.5
1.3
INDIVIDUAL MARKET
COVERED CALIFORNIA
0.9
15
Consumers
in the individual market
(off-exchange) can get identical prices and
benefits as Covered California enrollees
10
18.8
17.8
EMPLOYER
SPONSORED
5
EMPLOYER
All Californians now benefit from insurance
policy changes.
0
2013
2015
Source: Data shown in above graph is from California Health Benefits Review Program, Center for Medicare and Medicaid Services, California HealthCare
Foundation and Covered California (May 2015).
Notes: Medicare recipients and other publicly funded insured are not included in the graph.
1
http://www.commonwealthfund.org/publications/press-releases/2014/jul/after-first-aca-enrollment-period
2
1
Lessons Learned
• One third of those eligible for premium assistance are not
aware of their eligibility
• Extensive education on health insurance basics and details
needed
• Differences between HMO, PPO, EPO
• Differences between premiums, tiers and cost-sharing
obligations
• How to utilize coverage
• Education and outreach must be tailored to different
communities, education levels, regions, and nationalities
• Mixed immigration status families fear legal repercussions of
disclosing personal information
Challenges
Several challenges presented during open enrollment.
• Interfaces between County social services and CalHEERS
• Understanding and awareness of premium assistance
• Provider directory inaccuracies and adequacy of provider
networks
• Linkages between plan enrollment and provider enrollment
• Understanding the differences between bronze and
enhanced silver
• Understanding insurance concepts like copays, deductibles
and premium payments
Essential Updates
Covered California
People with certain life events qualify for special enrollment.
•Events that cause people to lose health insurance
• Job loss or reduction in hours
• Divorce or death of policy-holder family member
• Turning 26 and aging out of parent’s insurance
• Becoming ineligible for Medi-Cal
• Expiration of COBRA
•Marriage
•Native Americans
•Becoming a citizen or legally present individual
•Moving to an area with different plans
•Birth or adoption
•Exceptional circumstances – loss of eligibility for hardship, natural disasters,
etc.
•Error by Covered California or enrollment counselor
MUST enroll within 60 days of the “life event”
Covered California
Filing Taxes and Reconciling Subsidies
 The federal government will determine if an individual or
household received the proper amount of premium subsidies
when taxes are filed. Actual earned income for the year and the
subsidies received vs. entitled to will be examined.
 Some individuals may be given refunds OR may have to repay a
portion of the subsidies they received, depending on their
income or other changes during the year.
 It is extremely important for households to update their income
information as frequently as needed during the year.
 It is extremely important for households to file their income
taxes each year or they will lose their eligibility for subsidies.
 Married couples must file jointly to receive premium subsidies.
Covered California
Late Premium Payments
Have 90 days after first late payment to become current
Coverage is active for first 30 days
After 30 days, coverage is suspended for a 60 day period
Coverage can be reactivated at any time by day 90 by paying full
premium balance
If full premium balance has not been paid after 90 days, coverage is
terminated
After termination, must wait until next open enrollment period to reenroll
Covered California
An “embedded” medical and dental plan will be offered in
2015 to children and families.
No dental deductible; dental services are not subject to the
medical deductible.
Preventative dental care (cleanings, x-rays, sealants/fluoride)
are covered with no cost sharing.
Cost-sharing subsidies cannot be applied to lower the cost of
services like fillings, extractions, and braces.
Covered California
Open Enrollment for Plan Year 2016:
November 1, 2015 – January 31, 2016
Covered California’s 2016 Standard Benefit Designs
In California, standard benefits allow apples-to-apples plan comparisons and seek to encourage
utilization of the right care at the right time with many services that are not subject to a deductible.
Benefits in blue are not subject to any deductible.
Section 1115 Medicaid Waiver
Renewal: Whole person pilots
Top 1% of most costly users
• Full scale local partnerships
• Fully integrated services and shared savings
• Reinvest savings
• Care manager and other enhanced services
• $1.5 billion over 5 years
Medi-Cal Waiver Renewal:
Denti-Cal Outcomes
Better fee for service outcomes
• Denti-Cal
• Better fees, better access to and use of
preventive dental services
• $750 million over 5 years
Medi-Cal Waiver Renewal: Public
Hospital Transformation
DSRIP (now PRIME) and DSH global value
payments
•Public hospitals and district hospitals
•Build ambulatory care capacity and re-orient
towards value based care
•$3.2 billion for public hospital systems
•$467 million for district hospitals
•Independent study of “uncompensated care”
linked to future funding
New Substance Use Disorder
Waiver
Full complement of services
• Early intervention
• Outpatient and intensive outpatient
• Partial hospitalization
• Low intensity and high intensity residential
• Medically monitored and medically managed
inpatient
• Opioid treatment
New SUD Waiver
Better controls
• MOUs between county Drug Medi-Cal and
local MCOs
• Flexible local rate setting with state approval
• ASAM criteria must be met for waiver
services
• 100% FFP for new eligibles
Medi-Cal Assets Test
Medi-Cal enrollees only age 65 or older, disabled, OR individuals in longterm care are subject to assets tests.
Cannot have property worth more than:
 $2,000 for an individual
 $3,000 for a couple
 Home you live in, one car, personal effects are exempt
If you cannot pass the assets test, you must “spend down” to qualify for
Medi-Cal.
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Pay medical bills
Pay debts, mortgage, car loan
Buy clothes, home furnishings, home repairs
Liquidate non-liquid assets
Medi-Cal Estate Recovery
Medi-Cal enrollees only age 55 or older OR members utilizing long-term
care services are subject to estate recovery after the death of the
beneficiary.
The State can make a claim against the estate of a Medi-Cal member
equal to the cost of care or what was paid to the managed care plan
Exemptions to estate recovery:
A spouse is alive (recovery can be made after the death of the spouse)
Member had a minor, blind, or disabled child
There is nothing left in the estate
A lien can be placed on the home of a Medi-Cal enrollee in long-term care
Only if s/he does not intend to return home
Exempt if a spouse, child under 21 or blind/disabled, or sibling lives in the
home
Medi-Cal for Former Foster Youth
Young people who were in the foster care system on their
18th birthday qualify for Medi-Cal up to age 26.
 Regardless of income
 Regardless of state residency while in foster care
 Simplified one-page application
 No recertification until age 26
 Exempt from managed care
 Apply via county social services offices
 Foster Care Ombudsman available for assistance –
fosteryouthhelp@dss.ca.gov or 1-877-846-1602
Immigration
U.S. Citizens and Lawful Permanent Residents (LPRs) have full
access to coverage and financial assistance based on income.
There is no waiting period or 5-year ban for legal immigrants
newly in the U.S.
Undocumented Immigrants
o Not eligible for full scope Medi-Cal or Covered California
o Eligible for Emergency Medi-Cal (limited scope)
o Children will be eligible for full scope effective May 2016
Deferred Action for Childhood Arrivals (DACA)
o Not eligible for Covered California
o Eligible for Medi-Cal
Maternity Benefits
• Pregnant women with incomes up to 138%
are now eligible for full scope Medi-Cal
• AIM (now MCAP, the Medi-Cal Access
Program) covers pregnancies for women
with incomes over 138% of FPL up to 300%
of FPL as does Covered California.
• The MCAP premiums are less than Covered
California; there are no copays or
deductibles for those women eligible, and
the provider networks are different.
• Women may choose which program they
prefer for their pregnancy.
Insurance 101
Health Insurance Terms
• Premium – monthly amount paid for insurance coverage
• Example: Michael, age 40, lives in Redding and makes $18,000/year. He
pays $55 a month in premiums, after premium assistance is applied, for
the lowest cost Silver plan, and the federal government pays $308. If he
earned $48,000 a year, the federal government would pay nothing.
• Copay – fixed amount paid at the point of service for a covered health care
service
• Example: if Michael earns $18,000, he pays $15 for a primary care visit
and $25 for a specialist in the enhanced silver plan. If he earns $48,000,
Michael pays a $45 copay when he sees his primary care provider, $75 for
a specialist.
Health Insurance Terms
• Deductible – amount you owe for health care services before your health
insurance begins to pay
• Example: If Michael earns $18,000 a year, Michael has a $550 medical
deductible and a $50 brand name drug deductible in the enhanced silver
plan. If Michael earns $48,000 a year, Michael has a $2,250 medical
deductible and a $250 brand name drug deductible, but most outpatient
services are exempt from the deductible in the silver plan. If he is
hospitalized, he will have to pay $2,250 before his plan starts paying.
Health Insurance Terms
• Coinsurance – your share of the costs of a covered health care service
• Example: After Michael hits his deductible, he pays 20% of the
negotiated rate of hospitalization services.
• Out-of-Pocket Maximum – the maximum total costs of health care
services you are responsible for in a year
• Example: Once Michael has paid $6,500 in medical expenses (not
including premiums), he hits his out-of-pocket max, and the plan
pays any remaining expenses, at no cost to Michael.
Deductibles
• Bronze, Silver, and Catastrophic plans have deductibles
• In Bronze and Catastrophic, 3 non-preventative
primary/urgent/mental health care visits are not subject to the
deductible
• Most outpatient services, generic drugs, and durable medical
equipment are exempt from the deductible in Silver plans
• Prenatal care, immunizations, other preventative care, and
children’s eye exams and glasses are never subject to
deductibles or cost sharing
Out-of-Pocket Maximums
$6,250
$6,250
$6,250
$5,200
$4,000
Bronze
Silver
Enhanced
Silver 73
(200250%
FPL)
$2,250
$2,250
Enhanced
Silver 88
(150200%
FPL)
Enhanced
Silver 94
(100150%
FPL)
Gold
Platinum
Medical
Deductible
Brand-name
Drug
Deductible
Out-ofPocket Max
Provider Networks
Each health plan has its own network of doctors, hospitals, and
other providers that contract with the plan to care for enrolled
members.
Out-of-network means that a provider is not contracted with
the health plan to serve its members, and the services may not
be paid for by the plan.
To minimize costs, patients should seek care from providers in
network.
To find out which providers are in network, check the health
plan’s website, call the health plan, and ask the provider.
Covered California
Health plans are participating in Covered California.
• Anthem Blue Cross of CA –
EPO, HMO
• Blue Shield of CA – PPO
• Chinese Community Health
Plan – HMO
• Health Net – PPO, HMO
• Kaiser Permanente – HMO
• L.A. Care Health Plan – HMO
• Molina Healthcare – HMO
• Oscar Health Plan – EPO
•
•
•
•
Sharp Health Plan – HMO
Valley Health Plan – HMO
United Health Plan – PPO
Western Health Advantage –
HMO
Covered California
Factors to Consider in Selecting a Plan
•
•
•
•
•
•
Premium cost
Outpatient providers in network
Hospitals in network
Drug formulary
HMO vs. PPO vs. EPO
Premium and cost-sharing trade off
• How much care do you anticipate
using?
• Do you qualify for cost-sharing
subsidies?
Covered California
Steps after enrollment
• Pay premium!!
• Receive ID card
• Find out what providers are in network and pick
your preferred primary care doctor
• Primary care & specialty
• Local hospitals
• Urgent care centers
• Hours
• Schedule initial primary care appointment
• Transfer prescriptions
• Compile medical records
The Remaining
Uninsured
2013:
7 million
uninsured (under age 65)
Medicaid
Expansion
Covered
California
2019:
2.7 million
remaining uninsured
Not eligible:
Immigration
status
Eligible, but
not enrolled:
Medi-Cal
Eligible, but
not enrolled:
Exchange
State Programs
Restricted Scope Medi-Cal
 Emergency coverage only, plus prenatal care and delivery for pregnant women
 For individuals who do not qualify for Medi-Cal
 For adults with incomes up to 138% FPL, pregnant women 213% FPL, &
children 266% FPL
 Budget for FY 2015-16 funds full-scope Medi-Cal for children under 266% FPL
(SB 4)
 Pregnant women with incomes less thand 138% of FPL can be eligible for full
scope Medi-Cal. Over 133% and up to 300% of FPL can be eligble for MCAP
State Programs
Access for Infants and Mothers (AIM) MCAP now

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Comprehensive care for pregnant mothers, including post-partum care
Women up to 300% FPL
Must be uninsured and ineligible for Medi-Cal
Modest premiums
As of July 1, AIM operates under the Department of Health Care Services,
renamed “Medi-Cal Access Program”
Family PACT
 Family planning, reproductive, & sexual health services for uninsured men and
women
 For individuals with incomes up to 200% FPL
 Must not be eligible for Medi-Cal, or must have no coverage for family
planning
State Programs
California Children’s Services (CCS)
 Children (under 21) with specific diseases or disabilities like cystic fibrosis
 Covers only services relating to the qualifying conditions
 Family must have income ≤ $40,000, or out-of-pocket medical expenses must
be more than 20% of family income, or child must be enrolled in Medi-Cal
 May become more fully integrated with Medi-Cal
Genetically Handicapped Persons Program (GHPP)
 For adults (over 21) with specific qualifying genetic conditions like hemophilia
 Not limited to services for the qualifying conditions
 No income limit, but must apply for and be found ineligible for Medi-Cal and
Covered California
State Programs
Every Woman Counts (EWC)
 Free clinical breast exams & mammograms for uninsured low-income women
40 or older
 Free pelvic exams & pap smears for uninsured low-income women 21 or older
 Treatment for women diagnosed with breast or cervical cancer, with incomes
up to 200% FPL
 Must apply for and be ineligible for Medi-Cal and/or Covered California
Improving Access, Counseling & Treatment for Californians
with Prostate Cancer (IMPACT)
 Provides 12 months of free treatment for low-income men diagnosed with
prostate cancer
 Must be uninsured or underinsured, with incomes up to 200% FPL
 Must apply for and be ineligible for Medi-Cal and/or Covered California
Local Programs
County Indigent Services
• CMSP counties provide limited primary care services to the remaining uninsured
• Public health entities typically provide care regardless of patient’s immigration
status
• Counties, such as Sacramento and Fresno, are beginning to restore limited
coverage to some patients regardless of immigration status
All programs vary significantly by county.
Covered CA Without Subsidies
(Above 400% FPL)
400% FPL
Covered CA With Subsidies
200% FPL
(up to 200% FPL for
Pregnant Women)
133% FPL
Medi-Cal
(up to 138% FPL for all other groups)
0% FPL
California Children's Services (CCS)
(up to 250% FPL)
(up to 250% FPL for
Children)
Genetically
Handicapped
Persons
Program
(GHPP)
(all income
levels)
Healthy Kids
(up to 400% FPL)
250% FPL
Healthy Way LA Unmatched
(up to 133% FPL)
You may also be eligible for Medi-Cal Medically Needy, Cancer Screening & Treatment,
AIDS Drug Assistance Program etc)
Family PACT
(up to 200% FPL)
300% FPL
Access for Infants &
Mothers
(200-300% FPL)
(138-400% FPL)
FAQs & Resources
Covered California
SHOP Exchange
For small employers that would like to offer health coverage to employees
•Open to employers with ≤ 50 employees in 2014, will expand to employers with
100+ employees in 2016
•Up to 50% refundable tax credit for small, low-wage employers (< 25 employees
with average wages < $50,000) with a two year limit
Employers will choose the level of coverage (share of employees’ medical costs
covered) and the “reference” plan.
Employees will choose the plan—giving employees a choice of insurance carriers.
Employees pay the difference in cost above the reference plan.
Troubleshooting
For questions about coverage, call your insurance
company.
If you have a complaint, file a grievance or appeal with
the insurance plan.
For Medi-Cal eligibility issues, contact your county DPSS
office. For benefits issues, contact the managed care
plan.
Persistence is key.
Enrollment Systems
Roles in Enrollment
Navigator Program
Integrated education, outreach, and enrollment program pays
application counselors through grants
Brokers: sell insurance to individuals and employers
Centralized call centers: work with county enrollment systems to answer
questions, submit applications, and enroll consumers.
Covered California
To apply or get help applying:
Call 800-300-1506
Go to CoveredCA.com
Get in-person assistance at local health clinics, county
social services offices, brokers’ offices, & nonprofit
organizations
Resources
Health plan help:
Department of Managed Health Care
888-466-2219
www.dmhc.ca.gov
Department of Insurance
800-927-4357
www.insurance.ca.gov
Health Care Options
1-800-430-4263
www.healthcareoptions.dhcs.ca.gov
Access & eligibility issues:
Health Consumer Alliance
(800) 896-3203
www.healthconsumer.org
Medi-Cal questions:
Managed Care Ombudsman
Medicare questions:
1-888-452Center for Health Care Rights
8609 MMCDOmbudsmanOffice@dhcs.ca.g 213-383-4519
ov
www.healthcarerights.org
Final Thoughts
1. Think beyond premiums. Recognize various cost
sharing obligations.
2. Get informed. Know the details of your plan.
3. Have problems? Be persistent.
4. Pick your doctor; use your coverage!
5. Need help? Ask! Call your plan and additional
resources.