Navigating open enrollment in Texas:
Plans, problems and tools for assisters and community
organizations
Dec. 12, 2014
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AND DON’T FORGET TO SPEAK UP!
• With support from the M·A·C AIDS Fund, a team of national and state
partners has established “SPEAK UP” to monitor, assess and document
ACA implementation success and barriers to HIV care
• Through SPEAK UP we see patterns of discrimination emerging that need
to be addressed, educate state and federal officials about what’s
happening on the ground, advocate for change, and report back to the
community
• Monitoring and documentation is critical to help inform and shape state
and federal policy to ensure the needs of people living with HIV are
addressed as the ACA is implemented
To SPEAK UP!, visit:
http://www.hivhealthreform.org/speakup/
Today’s Agenda
1. Affordable Care Act & Open Enrollment Landscape
in Texas - Januari Leo, Director of Public Affairs,
Legacy Community Health Services
2. Texas Marketplace Plan Analysis 2015- Carmel
Shachar, Staff Attorney, Center for Health Law &
Policy Innovation, Harvard Law School
3. Affordable Care Enrollment (ACE) TA Center Molly McAndrew, Policy Manager, AIDS
Foundation of Chicago
Affordable Care Act & Open Enrollment
Landscape in Texas
Januari Leo
Director of Public Affairs
Legacy Community Health Services
Texas Marketplace Plan Analysis
2015
Carmel Shachar
Staff Attorney
Center for Health Law and Policy Innovation
Harvard Law School
Enrollment Timeline
Open Enrollment began
November 15, 2014 and
runs through February
15, 2015
Enroll by December 15,
2014 to get coverage by
January 1, 2015
Assessment Tools: Marketplace Health Plans
Template Assessment Tool/Workbook
Download from: http://www.hivhealthreform.org/assessment/
Part 1
Understanding Cost-Sharing Structures
Insurance Terms: Cost-Sharing Structures
•Premium: monthly fee an insurance plan charges for plan membership
•Advance Premium Tax Credit (APTC): money that the government pays directly to a health
plan (or to the consumer at the end of the tax year) in order to reduce a consumer’s
premium
___________________________________________________________________
•Co-pay: a set fee a consumer pays for each provider visit, prescription refill, lab test, or
other healthcare service (e.g., $10, $20, or more)
•Co-insurance: a percentage of the cost of the healthcare service that the consumer must
pay (e.g., 30% of the cost of a provider visit or of a procedure)
•Deductible: a set annual amount the consumer must pay before the insurance plan pays
for any of the costs of care (e.g., $2,500)
•Cost-sharing Subsidy (Reductions): money that the government pays directly to a health
plan in order to reduce a consumer’s out-of-pocket costs (silver plans only)
4 Coverage Levels
Marketplace Qualified Health Plans
Premiums
Platinum
$$$$
Gold
$$$
Silver
$$
Bronze
$
Cost Sharing
$
$$
$$$
$$$$
Marketplace Premium Tax Credits
Tax credits are available to those earning 100% - 400% FPL ($11,670-$46,680)
• Tax credits reduce the
Premium
premium cost depending on
Premium Limit
Income
Limit as %
how much income you make
/ Year
of Income
(sliding scale)
• Tax credits can be used at any
plan level (bronze, silver, gold,
plantinum), but not for
catastrophic coverage
• NOTE: There is a reconciliation
process at the end of the year,
so it’s critical for clients to
keep the Marketplace updated
on any income changes
100-150%
FPL
2.01 –
4.02%
$234.57$703.70
150-200%
FPL
4.02 –
6.34%
$703.70$1,479.76
200-250%
FPL
6.34 – 8.1%
$1,479.76 $2,363.18
250-300%
FPL
8.1 – 9.56%
$2,363.18 $3,346.956
300-400%
FPL
9.56%
$3,346.96 $4,462.61
Premium Tax Credit Example
• Earns $16,000/year - about 140%
FPL
• He is expected to pay about 4% of
his income for premiums = $640
per year, or about $53 per month.
• Let’s say the second-cheapest Silver
plan costs $500 per month.
• John’s subsidy will be: $500 - $53 =
$447 per month. He can get this as
a tax refund or have it paid for him
each month.
John
Cost-Sharing Subsidies and
Out Of Pocket (OOP) Maximums
Cost-Sharing Subsidies: Available for
an applicant: (1) whose income is
between 100-250% FPL and (2) who
chooses a silver plan
Includes:
1. Deductible (if any)
2. Co-insurance for in-network
services
3. Co-pays for in-network
services
Does NOT Include:
1. Premium
2. Costs for out-of-network
services
Income
OOP Max
100-150% FPL
$2,250
150-200% FPL
$2,250
200-250% FPL
$5,200
250% and above
$6,600
Ryan White (RW)
Payer of Last Resort for
Individuals Living with HIV/AIDS
•
Cannot be used
– For “any item or service to the extent
that payment has been made or can
reasonably be expected to be made”
by another payer
•
Can be used
– During gaps in other coverage
– IF client misses open enrollment, BUT
must ensure that client does not miss
next enrollment opportunity
– For services not covered or partially
covered by other insurance.
RW in TX
•
•
Income Limit: 200% FPL
Other Qualifications:
– HIV positive
– Texas state resident
– Otherwise uninsured or underinsured
Part 2
Evaluating Qualified Health Plans
(QHP)
How to Choose a Qualified Health Plan
Pick a Coverage Level
Check if providers in network
Check drug formularies
Check coverage of other healthcare
needs
Check cost-sharing for healthcare
needs
The Online Marketplace
Find Marketplace plans for TX residents at healthcare.gov
Assessing Plans on Online Marketplace
Assessing Plans on Online Marketplace
• After entering your information, a
summary of available plans will appear
• To make it easier to find a particular plan,
narrow your results by “Health plan
categories” (e.g., silver) or by “Insurance
companies.”
Assessing Plans on Online Marketplace
Search results provide basic
information, including
estimates for:
• Monthly premium
• Deductible
•Out-of-Pocket Maximum
In order to fully assess a plan,
you will need to review the
linked documents, especially:
• Summary of Benefits
• List of covered drugs
Assessing Plans on Online Marketplace
Summary of Benefits: Provides a limited summary of plan benefits, including costsharing rules, referral requirements, and exclusions.
Assessing Plans on Online Marketplace
List of Covered Drugs (“Formulary”):
Provides a list of drugs covered by the
plan.
Also Provides Information Regarding:
• Usage Limitations (e.g., prior
authorization, quantity limits, etc.)
• Tiering
MAY NOT BE A COMPLETE LIST!
If the document indicates that the
formulary is not comprehensive, you may
need to contact the insurer for further
coverage information
Assessing Plans on Online Marketplace
Use the information that
you find during your
assessment to fill out the
Plan Comparison Chart
Make sure to note any
limitations to your
research (e.g., full
formulary not available)
Part 3
Overview of Available
Qualified Health Plans
Blue Cross Blue Shield
• Pros
– Covers most HIV medications, including single
tablet regimes such as Atripla, Stribild and
Complera
– Covers most HCV medications, including Sovaldi
• Cons
– Generally requires 20-30% co-insurance for HIV
medications (but better than other insurers)
– Most plans have high deductibles (only the Gold
plans have deductibles under $3,000)
Humana
• Pros
– Some plans with “flat” formulary structures:
Humana Bronze 6300 and Humana Silver 3650
• Cons
– Virtually all HIV and HCV drugs are in the specialty
tier
– Generally 50% co-insurance for these medications
– “Flat” plans have very high deductibles ($6,300 for
Bronze and $3,650 for Silver)
Cigna
• Pros
– Very few
• Cons
– Does not cover a significant number of HIV related
medications, including Humira, Enebrel, Simponi,
Xelianz
– Many HCV drugs “not listed” (and likely not
covered), including Sovaldi and Olysio
– Most other drugs at 40% co-insurance
Next Steps
• Forthcoming: a fuller analysis of the plans
offered in Texas
– Will cover more plans
– Will analyze in depth the deductibles, premiums,
co-payments and coverage for other services and
medications
• On the ground assistance
– Contact Carmel Shachar at
cshachar@law.harvard.edu with further questions
Affordable Care Enrollment
(ACE) TA Center
Molly McAndrew
Policy Manager
AIDS Foundation of Chicago
Resources, Tips,
and Tools for
Enrolling RWHAP
Clients in Coverage
Eligibility
Decision Tree
Health Care Plan
Selection Worksheet
Fact Sheet:
Topics to Consider When
Helping People Living
With HIV to Enroll in
Health Care Coverage
Common Questions &
Suggested Responses
for Engaging Clients in
Health Coverage
(English)
Common Questions &
Suggested Responses
for Engaging Clients in
Health Coverage
(Spanish)
Plain
Language
Plain Language
Quick
Quick
Reference
Reference
Guide (English)
Guide
41
Plain
Language
Plain
Language
Plain
Language
Quick
Quick
Reference
Quick
Reference
Reference
Guide (Spanish)
Guide
Guide
42
Special
SpecialEnrollment
Enrollment
Periods
PeriodsFact
FactSheet
Sheet
www.targethiv.org/ace
Questions?
• Ask your questions
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question it will be
logged and we’ll do our
best to follow up!
AND DON’T FORGET TO SPEAK UP!
• With support from the M·A·C AIDS Fund, a team of national and state
partners has established “SPEAK UP” to monitor, assess and document
ACA implementation success and barriers to HIV care
• Through SPEAK UP we see patterns of discrimination emerging that need
to be addressed, educate state and federal officials about what’s
happening on the ground, advocate for change, and report back to the
community
• Monitoring and documentation is critical to help inform and shape state
and federal policy to ensure the needs of people living with HIV are
addressed as the ACA is implemented
To SPEAK UP!, visit:
http://www.hivhealthreform.org/speakup/