Covered California Overview and Resources Tribal Consultation October
Covered California Overview and Resources Tribal Consultation October 10th, 2019 COVERED CALIFORNIA OVERVIEW 2 Major Changes to the Health Care System Because of the Affordable Care Act Before the Affordable Care Act Today Many consumers denied coverage by insurers because Guaranteed coverage for all no screening or price of pre-existing conditions. differences due to health status. Many consumers with insurance bankrupted by gaps in Insurers are prohibited from setting lifetime limits on coverage and annual or lifetime limits.
essential health benefits, such as hospital stays. Subsidies making coverage affordable to 9 million Health coverage unaffordable for millions without millions more have affordable options employer coverage except the healthy (underwritten) Americans; through Medicaid expansion, 7 million unsubsidized and wealthy (those making enough to foot the bill) struggling with rising costs. Insurers could remove young adults from their parents policies, leaving them uninsured. Dependent children up to age 26 must be offered coverage under a parents insurance plan. Children under 19 could be denied coverage because of a chronic condition.
Insurers may not exclude children under the age of 19 from coverage due to a pre-existing medical condition. Medicaid only covered low-income children, pregnant women, elderly and disabled individuals, and some parents, but excluded other low-income adults. For Medicaid expansion states, Medicaid covers all adults under 65 with income up to 133 percent on the federal poverty level. 3 FEDERAL REFORMS UNDER THE AFFORDABLE CARE ACT Health Benefit Exchanges and Federal Subsidies: Federal and state-based marketplaces to buy health insurance and receive financial assistance. Insurance Market Reforms: Guaranteed issue and renewal; no annual or lifetime limits;
coverage for essential health benefits; and dependent coverage up to age 26 Medicaid Expansion: Inclusion of low-income childless adults. Individual/Employer Mandate: Most U.S. citizens and legal residents required to have health coverage. *Beginning in 2019, the individual mandate tax penalty has been reduced to $0. 4 ESTABLISHMENT OF THE CALIFORNIA HEALTH BENEFIT EXCHANGE (COVERED CALIFORNIA) California was first state in nation to enact legislation creating a health benefit exchange under the Affordable Care Act o o Assembly Bill 1602 (Prez, 2010) - California Patient Protection and Affordable Care Act in California Senate Bill 900 (Alquist, 2010) established structure and requirements for the states health benefit exchange
Independent public entity, governed by a five-member Board: o o o o Two members appointed by the Governor One member appointed by Senate Rules Committee One member appointed by Speaker of the Assembly Secretary of the California Health and Human Services Agency - ex-officio, voting member Self-sustaining entity no monies from the state General Fund 5 Comparing Californias uninsured rate to the rest of the nation Uninsured rate increased from 6.8% in 2017 to
7.7% in 2018 6 Californians Facing New Opportunities for Coverage The Affordable Care Act has dramatically changed the health insurance landscape in California with the expansion of Medicaid, Covered California and new protections for all Californians. Californias 2017 Health Care Market (in millions ages 0-64) As of June 2018, Covered California had approximately 1.3 million members who have active health insurance. California has also enrolled nearly 4 million more into Medi-Cal.
Consumers in the individual market (off-exchange) can get identical price and benefits as Covered California enrollees. From 2013 to 2017, the U.S. Census Bureau states California cut its uninsured rate by 58 percent. Accounting for those ineligible because of their immigration status, Californias eligible uninsured population is 1 million. California administrative data sources are used for enrollment totals when possible. All other enrollment estimates are from the 2017 American Community Survey. The total enrollment population sums to more than Californias total population as some Californians were covered by more than one type of insurance during the same year. 7 OVERVIEW: BENEFITS FOR AMERICAN INDIANS IN COVERED CALIFORNIA
8 BENEFITS FOR AMERICAN INDIANS/ALASKAN NATIVE (AI/AN) Many AI/ANs currently receive health care from Indian health care providers, which include health programs operated by the Indian Health Service (IHS), tribes and tribal organizations, and urban Indian organizations. If AI/ANs enroll in a plan through Covered California, they can continue to receive services from their local Indian health care provider. AI/ANs can enroll or switch plans in Covered California throughout the year, not just during the annual open enrollment period. Depending on income, AI/ANs can enroll in a zero cost or limited cost sharing plan. 9 AMERICAN INDIAN/ALASKAN NATIVE PROGRAM ELIGIBILITY Program Eligibility by Federal Poverty Level-2020 Plan Year Note overlapping programs by income level
10 AI/AN ELIGIBILITY: ZERO COST SHARE PLANS AI/AN applicants are eligible for a zero cost sharing qualified health plan (QHP) if the applicants: Meet the eligibility requirements for APTC (Advance Premium Tax Credit) and CSR (Cost-Sharing Reduction) Are expected to have a household income that does not exceed 300 percent of the federal poverty level (FPL) for the benefit year for which coverage is requested
If the AI/AN applicant meets the above eligibility requirements for zero cost sharing plans, that applicant must be treated as an eligible insured and the QHP must eliminate any cost sharing AI/AN consumers can only access these benefits if enrolled in a zero cost sharing plan through Covered California Consumers can enroll in a non zero cost sharing plan, but will not receive the zero cost sharing benefit 11 AI/AN ELIGIBILITY: LIMITED COST SHARE PLANS
AI/AN applicants are eligible for limited cost sharing plans when their household income exceeds 300 percent of the FPL for the benefit year for which coverage is requested If the AI/AN applicant meets the above eligibility requirements for limited costsharing plan, the QHP must: Eliminate any cost-sharing under the plan for the services or supplies received directly from an Indian Health Service, an Indian Tribe, Tribal Organization, or Urban Indian Organization Apply standard cost-sharing for the QHPs provider network outside of Indian and Tribal providers
AI/AN consumers can only access these benefits if enrolled in a limited cost sharing plan through Covered California Consumers can enroll in a non limited cost-sharing QHP, but will not receive the reduced cost-sharing benefit 12 AI/AN BENEFIT EXAMPLE The following is an example of the differences in cost-sharing between a Bronze standard plan, a zero cost share AI/AN plan and a limited cost share AI/AN plan for some covered services. Bronze Standard Plan Bronze Zero Cost Share AI/AN Plan
Bronze Limited Cost Share AI/AN Plan Primary Care Visit $75 $0 $75* Specialist Visit Laboratory Tests $105 $40 $0
$0 $105* $40* Urgent Care Visit $75 $0 $75* *This cost share would be $0 if the AI/AN member received services from an Indian Health Service, an Indian tribe, Tribal Organization, or Urban Indian Organization. 13 AI/AN QUALIFIED HEALTH PLAN REQUIREMENTS
QHPs offering additional plans that do not include a Bronze plan, must offer the AI/AN Zero Cost Share plan variation at the lowest cost If a QHP offers a HMO product for Platinum, Gold and Silver metal tiers, the QHP must offer a Silver AI/AN Zero Cost Share plan because its the lowest cost premium QHPs are required to offer Limited Cost Share plans at all metal levels for all product types 14 CERTIFIED ENROLLMENT ENTITIES (21) Name of Entity American Indian Health and Services, Inc California Rural Indian Health Board, Inc Consolidated Tribal Health Project, Inc
Elk Valley Rancheria Feather River Tribal Health, Inc Fresno American Indian Health Project Indian Health Center of Santa Clara Valley Indian Health Council, Inc. Karuk Tribe Lake County Tribal Health Consortium, Inc. Lassen Indian Health Center MACT Health Board, INC. Northern Valley Indian Health, Inc. Pit River Health Service, Inc Riverside San Bernardino Co Indian Health San Diego American Indian Health Center Santa Ynez Tribal Health Clinic Shingle Springs Tribal Health Program Southern Indian Health Council, Inc. Toiyabe Indian Health Project Tule River Indian Health Center, Inc.
CAC CAC CAC 15 *Updated October 2019 HEALTH COVERAGE RESOURCES 16 Resolving Questions or Concerns-Covered California Covered California is always here to assist our consumers who are AI/AN navigate their Covered California Coverage Contact External Affairs at: [email protected] This mailbox is always monitored by External Affairs staff who are ready to connect consumers to the Tribal Liaison or to specially trained staff in our service center to get cases resolved as quickly as possible
You should receive a call back from the same day or no later than the next business day All consumers, including AI/AN consumers are also always welcome to contact our service center at: (800) 300-1506 17 What Kinds of Issues Can Covered California Address Directly? Most Health Plan design and issuer contract terms and rates, within the confines of federal and state law, rules, and regulators approval Enrollment assistance, including routing individuals to Medi-Cal instead when appropriate Covered California customer care: Covered California Service Centers, online complaints about Covered California staff or enrollment partners Covered California appeals and hearings 18 Connecting Consumers to Other Entities to Resolve
Complex Cases There are some issues that Covered Californias AI/AN consumers face that are not directly under Covered Californias Control For those cases, Covered Californias Tribal Liaison will work with consumers to connect them to the appropriate resources 19 Roles and Resources Offered by Other CA Departments Department of Health Care Services: Medi-Cal regulations, Medi-Cal and Medi-Cal Dental eligibility and enrollment; state fair hearings regarding Medi-Cal services or eligibility determinations, Ombudsman Department of Managed Health Care: HMO (and some PPO/EPO) regulations; plan licensing; health plan member complaints and Independent Medical Review; managed care consumer Help Center; final approval of health plan rate changes Department of Insurance: Some PPO/EPO regulation; consumer complaints and Independent Medical Review; provider complaints; final approval of health plan rate changes; Ombudsman
20 Issues Requiring Federal Action: The federal Affordable Care Acts definition of Indian for Health Insurance Marketplace purposes (only a member of a federally recognized tribe) Marketplace income requirements, expressed as percentages of the Federal Poverty Limit, affecting eligibility for zero cost sharing and limited cost sharing plans Required documentation of membership in a federally recognized tribe The classification of health plans into four metal levels (bronze, silver, gold, platinum) Minimum coverage requirements (essential health benefits) Medicare and Social Security 21 DISCUSSION: What types of resources would you recommend Covered California produce? 22
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