Clearing Up Confusion About Health Reform’s Out-of-Pocket Protections

Recent media coverage may have sown confusion about health reform’s requirement that health insurance plans cap how much consumers can pay out-of-pocket each year for medical care. The bottom line: for many plans, the protections will take effect as scheduled in 2014. Some plans will be able to wait an extra year to fully comply.

The health reform law requires that, starting next year, private insurance plans limit how much in cost-sharing charges — deductibles, copayments, and coinsurance — that people enrolled in a plan must pay each year for covered benefits provided by the plan’s network of health care providers. (This includes plans offered in the individual market or through employers. The requirement doesn’t apply to “grandfathered” plans.) In 2014, this “maximum out-of-pocket limit” will be $6,350 for an individual and $12,700 for a family.

Back in February, the Obama Administration provided an additional year to fully comply with this requirement but only for certain plans offered by employers.

Here are some clarifications about the February policy:

Health insurance plans in the individual market: In 2014, the maximum out-of-pocket limit will apply, as scheduled, to the individual (non-group) health insurance market. Millions of people are expected to gain coverage in this market in 2014, as health reform’s new improvements and federal subsidies significantly increase access to affordable coverage.

Employer-sponsored health insurance plans: The maximum out-of-pocket limit will also continue to generally apply to non-grandfathered plans offered by employers, including small group, large group, and self-insured plans. Employer plans that have a single insurer or administrator have to fully comply with the limit next year.

Employer plans that have “separately administered” benefits: The Administration provided the exception in February for these plans, in which an employer has one insurer or administrator for its primary package of health benefits and a different insurer or administrator for discrete benefits, such as prescription drugs. Because employers and insurers have claimed it will be difficult to coordinate an overall maximum out-of-pocket limit across separately administered benefits, they sought and received the ability to avoid full compliance for one year.

Even those employer plans with “separately administered” benefits that qualify for the delay still must apply some out-of-pocket limits in 2014. As the February guidance explained, these plans must ensure that their primary package of health benefits has an out-of-pocket limit of no more than $6,350 for individuals and $12,700 for families. A separately administered benefit, such as prescription drugs, that already has an existing limit on out-of-pocket costs must comply with the limits of $6,350 for individuals and $12,700 for families in 2014.

An employer plan wouldn’t have to add a cap to a separate benefit if the separate benefit currently lacks one. But this exception shouldn’t be misunderstood as broadly waiving the important out-of-pocket protection that health reform will bring in 2014.

Sarah Lueck
Center on Budget and Policy Priorities

(This was originally posted here on the Off the Charts Blog)

Consumers Need Protection from Health Insurance Company Plan Year Manipulation

It was disappointing—infuriating actually—to learn that some of the nation’s health insurance companies are trying to take advantage of their current customers by manipulating plan years. They are doing so to avoid having to pass on to these customers the benefits of national health reform.

These insurers are reaching out to current customers, taking advantage of their uncertainties, and luring them to switch to health plan years that begin in 2013. By substituting 2013 plans for their current plans that run through early 2014, customers will lose important Affordable Care Act (ACA) protections that must apply to plans issued on or after January 1, 2014. For example, plans issued in 2014 must offer a comprehensive range of benefits and have rates based only on the customer’s age, geographic location, number in family, and tobacco usage. Discrimination based on gender or pre-existing conditions is banned by federal law in 2014 plans. Health insurance insider turned critic, Wendell Potter, recently wrote in detail about this outrage in the Huffington Post.

So insurers are trying to have the best of both worlds. They want all the goodies the ACA offers them, including hundreds of millions of new customers (many of whom will only be able to afford coverage because they qualify for the federal financial help in the form of advance premium tax credits and cost sharing subsidies available under the ACA), but they also want to deprive their existing customers of the benefit of ACA reforms.

Fortunately, insurance regulators can and are protecting customers from such manipulation. Illinois Department of Insurance Director Andrew Boron issued Bulletin 2013-07 on April 29, 2013, telling Illinois health insurers that they won’t get away with such manipulation. “The Department will not approve…filings for such arrangements,” the bulletin says. That should bring these threatened manipulations to an end in Illinois, and we hope regulators in other states take similar actions.

Health insurance has been baffling to most individuals and small businesses. The federal government, many states, and many non-profit organizations are working hard to inform citizens of the reforms, benefits, and opportunities the Affordable Care Act has already brought and the major improvements coming in 2014. Actions like these plan date manipulations simply have no place in the picture. Thank goodness regulators can and are stepping it to ensure a happy ending.

Margaret Stapleton

Community Justice Director
Sargent Shriver National Center on Poverty Law

Governor Quinn Enacts Largest Increase in Health Care Coverage in State History

Governor Pat Quinn today signed legislation that enacts a critical part of President Obama’s Affordable Care Act (ACA) by making Medicaid coverage available to all low-income adults in Illinois. Today’s action delivers on a major priority announced by Governor Quinn in his 2013 State of the State address and is part of his agenda to improve the health of the people of Illinois and increase access to quality health care.

“In the home state of President Obama, we believe access to quality health care is a fundamental right and we proudly embrace the Affordable Care Act,” Governor Quinn said. “This legislation will greatly improve the health of hundreds of thousands of people across Illinois, strengthen our health care system and create thousands of good jobs in the health care field. Thanks to this law and our shared commitment to increasing access to health care coverage in Illinois, the people of Illinois will be healthier and have a higher quality of life.”

Sponsored by State Senator Heather Steans (D-Chicago) and State Representative Sara Feigenholtz (D-Chicago), Senate Bill 26 will make Medicaid coverage available to adults with annual income below 138 percent of the federal poverty line, which is $15,860 for individuals and $21,408 for couples. The measure is expected to enroll 342,000 people by 2017. Currently, Medicaid is only available to children, their parents or guardians, adults with disabilities or seniors. Enrollment for the newly eligible population will begin Oct. 1 with coverage starting on Jan. 1.

Under the ACA, for the first three years, coverage of newly eligible adults will be 100 percent federally funded. The reimbursement rate will phase down to 90 percent by 2020. State officials estimate this will bring more than $12 billion in new federal funding to support the state’s health care system from 2014 to 2020.

“The Affordable Care Act gives Illinois the resources to provide critical health care services to a population that desperately needs it,” Illinois Department of Healthcare and Family Services Director Julie Hamos said. “Under Governor Quinn’s leadership, we are reforming our health care system so that it focuses on delivering coordinated care and keeping people healthy through better preventive care, not just paying the bills when they become sick.”

Under Governor Quinn's leadership, Illinois is also increasing access to health coverage through the Illinois Health Insurance Marketplace, another major feature of the ACA. The Marketplace, which also launches enrollment Oct. 1 with coverage starting Jan. 1, will be accessed through a user-friendly website where individuals, families and small businesses will be able to compare health care policies and premiums and purchase comprehensive health coverage. Those with income between 138 percent and 400 percent of the federal poverty level will receive subsidies on a sliding scale if they obtain coverage through the marketplace.

Governor Quinn has long championed access to decent health care for all people. In August 2001, he joined his then 78-year-old Doctor, Dr. Quentin Young, to walk 167 miles across Illinois to advocate for health care for all.

For more information about Illinois' implementation of the ACA, go to HealthCareReform.illinois.gov.

Related Documents
Senate Bill 26 and the Affordable Care Act (PDF)

(This post was taken directly from the Illinois Government News Network press release)

Accountable Care Entities (ACEs): A New Coordinated Care Model in Illinois

SB 26 to be signed by the Governor into law on July 22, 2013, will expand Medicaid to over 600,000 new potential enrollees but it will also usher in a new form of coordinated care in Illinois for these new Medicaid enrollees as well as existing families on Medicaid - the Accountable Care Entity.

An Accountable Care Entity (ACE) will be a new Illinois model of an integrated delivery system. This will be the fourth model providing “care coordination services” for Medicaid clients, which now includes Managed Care Organization (MCO), Managed Care Community Network (MCCN) and Care Coordination Entity (CCE). This infographic provides a great overview of the system so far.

The ACE will have these elements:

• Will be a provider-organized network of care -- providers working together collaboratively
• Will be large enough to have impact for a population: initially children and their family members in Illinois Medicaid, at least 40,000 in Cook County, 20,000 in collar counties, 10,000 downstate
• Will have at a minimum the following types of providers: primary care, specialty care, hospitals, and behavioral healthcare; will have a governance structure that includes each type of provider and works to create a shared culture of collaboration/transformation
• Will build an infrastructure to support care management functions among the providers in the network, such as health information technology, risk assessment tools, transparent data and data analytics, communication with Medicaid members, etc.
• Will work toward a new payment structure different from the current fee-for-service: shared savings within first 18 months, partial risk after 18 months and full risk after 3 years, which means capitated payments with financial incentives for the providers within the network

This is an opportunity for the hospital community and other providers to develop integrated delivery systems in Illinois that will manage Medicaid populations but are not traditional MCOs. Under SB 26, HFS will post a solicitation by August 1, and give 5 months to new entities to organize and apply.

The initial population assigned to ACEs will be children and family members (and likely newly eligible Medicaid clients under the Affordable Care Act.)

For more information check out the HFS Care Coordination Site

Stephanie Altman
Health & Disability Advocates

Illinois to Be Awarded Over $90 Million in Medicaid Funds for Home- and Community-Based Care

The Affordable Care Act (ACA) section 10202 establishes the Balancing Incentive Payments Program or BIP. BIP offers State Medicaid programs a financial incentive to offer home- and community-based services (HCBS) as an alternative to institutional care in nursing homes. In exchange for an increased federal matching rate (Medicaid is a State-Federal jointly paid program), States must implement 3 structural changes to their long-term services and supports (LTSS) system:

1. A No Wrong Door–Single Entry Point system (NWD/SEP)

2. Conflict-free case management services

3. A core standardized assessment instrument

In March, 2013, Illinois’ State Medicaid Agency, the Department of Healthcare and Family Services, submitted a proposal to the Centers for Medicare and Medicaid Services (CMS) to participate in BIP. On June 12, 2013, CMS announced their approval of Illinois’ BIP application, which will bring in $90.3 million of Federal matching funds into the State for Illinois projected HCBS expenditures over the next 2 years.

What Does Illinois’ Proposal Look Like?

Illinois’ BIP proposal is the most comprehensive overview of the State’s various LTSS programs: from aging, to development disabilities, to physical disabilities, to mental health, to substance abuse—Illinois’ BIP proposal covers it all. For anyone who wants a crash course on what Illinois is doing in the area of LTSS balancing—the development of a LTSS system that is more home- and community-focused than institutional focused—the BIP application is a great place to start.

In reading through the BIP proposal, you will see that Illinois is planning to integrate LTSS through collaboration across governmental department silos. The BIP operating agency will be the State Medicaid Agency: the Illinois Department of Healthcare and Family Services (HFS). HFS is already working in partnership with its sister agencies on implementing BIP:

• The Illinois Department on Aging (DoA)
• The Illinois Department of Human Services (DHS)
• Division of Developmental Disabilities (DHS/DDD)
• Division of Mental Health (DHS/DMH)
• Division of Rehabilitation Services (DHS/DRS) Division of Alcoholism and Substance Abuse (DHS/DASA)

Further, Illinois’ BIP goals will build off the existing work that Illinois is doing to balance LTSS in favor of HCBS. Existing LTSS balancing projects in Illinois include:

• the closing of State institutions,
• implementation of 3 Olmstead lawsuits [Williams, Ligas and Colbert],
• the Money Follows the Person Program,
• expansion of coordinated/managed care models,
• development of the state-wide community-based Aging and Disability Resource Center (ADRC) system, and
• ongoing provision of HCBS through Medicaid 1915 (c) waivers, of which Illinois currently operates 9 waivers.

The work described in the BIP application details how Illinois will implement the 3 structural requirements of BIP: a no wrong door–single entry point system (NWD/SEP), conflict-free case management services, and core standardized assessment instrument. These 3 areas are described below briefly. It is important to note that currently Illinois has separate systems for each sub-population served in its LTSS programs: aging, physical disability, mental health, substance abuse, development disability. BIP provides Illinois with the opportunity to coordinate across the population groups from the community and consumer level, all the way up to the State government level.

1. Illinois’ No Wrong Door–Single Entry Point system (NWD/SEP)
Entry points for LTSS are not currently coordinated across aging and disability populations. Current access points include: DHS local offices, Aging and Disability Resource Centers (ADRCs), Area Agencies on Aging (AAAs), Division of Rehabilitation Services local offices, Pre-Admission Screening agencies that serve persons with intellectual/developmental disabilities, community mental health centers and regional mental health points of contact, and State agency websites.

The ADRC network offers a starting place to coordinate across all of these different access points. Under the leadership of Illinois Department on Aging, the vision for the ADRC system is “a highly visible and trusted resource for all persons regardless of age, income and disability, to access a coordinated point of entry to public long-term support programs and benefits, and to obtain information on the full range of long-term support options”. [See page 31 of the BIP proposal].

Illinois’ ADRC system is already in development with 7 ADRCs up-and-running across the state—through AAAs in collaboration with disability organizations. It is anticipated that by September 2016, all of Illinois’ 13 Planning-and-Service-Areas (PSAs) will have designated ADRCs through leadership from Illinois’ AAAs. ADRC entities also currently include Care Coordination Units, Community Care Program providers, Centers for Independent Living, and DoA’s Senior Help Line (a State-wide toll-free phone number).

The NWD/SEP system will allow for individuals to receive a level 1 screen to determine which LTSS an individual should be assessed for. Access to this level 1 screen will be available online through a coordinated network of ADRC partners.

2. Illinois’ Conflict-Free Case Management Services
Illinois has different case management systems for each population group served. To ensure conflict-free case management, per Federal guidance, Illinois will work to separate the determination of eligibility process from case management, and from the direct delivery of services.

In the BIP proposal, Illinois describes the current developmental disability and physical disability processes to be conflict-free. However, more work needs to be done in the area of mental health/substance abuse and aging to ensure conflict-free case management [see pages 23-24 of the BIP proposal].

The expansion of managed care models in Illinois will help to promote conflict-free case management. With the help of BIP funds, Illinois will also continue to work with CMS to identify potential conflicts of interest and to develop the proper firewalls between eligibility determination, case management and service delivery.

3. Illinois’ Core Standardized Assessment Instrument
Over the past year, Illinois human service agencies have collaborated with Navigant consulting to review Illinois’ current assessment tools and methodology (each population currently has their own assessment tool). With Navigant, Illinois will develop a uniform assessment tool (UAT) for access to LTSS. Recently, HFS released a Request for Information related to the development of the UAT as the State seeks out vendors who can integrate and coordinate across populations and State departments.

A UAT will allow Illinois’ to develop a more consumer-centered LTSS system. Many individuals with LTSS needs require complex care and fall into more than one category across the current Medicaid HCBS waiver system. This means that consumers with mental health needs who are also 60 years or older must access two separate programs to have their needs meet: one in mental health and the other in aging. This makes it very challenging for consumers, and cumbersome and redundant for State agencies. BIP is intended to fix this, to ease access to LTSS in a more timely and appropriate way.

Further, Illinois is also replacing the 30-year old COBOL-based system that is currently in use to determine eligibility for: Medicaid, the Supplemental Nutrition Assistance Program (SNAP, formerly ‘food stamps’), Temporary Assistance for Needy Families program (TANF), and the new Health Benefits Exchange, or Marketplace, required by the ACA. The new Integrated Eligibility System (IES) is branded as Application for Benefits Eligibility, or ABE.

What all of this means for professionals and consumers is that Illinois is moving towards a system that will significantly streamline the determination of eligibility process for a variety of different programs, including LTSS. Part of this systemic upgrade includes ensuring better Information Technology (IT) integration and easier access to data about these publicly funded programs across population types.

Stay Tuned as Illinois Continues to Balancing LTSS in Favor of HCBS

As Illinois implements BIP and its other LTSS balancing programs, the State’s goal is to develop a new HCBS infrastructure that is consumer driven and easy to access and navigate. We look forward to reporting back as consumers across the State find it easier to live and receive care in their homes and communities.

Please let me know if you have questions, comments or responses to this blog post. You can reach me at: 312.372.4292 or kpavle@hmprg.org.

Kristen Pavle
Associate Director, Center for Long-Term Care Reform
Health & Medicine Policy Research Group

Federal Recognition of Same-Sex Marriage Could Mean Big Changes for Taxes and Health Care Reform

The Supreme Court issued two key rulings today on same-sex marriage, United States v. Windsor (regarding the federal Defense of Marriage Act or "DOMA") and Hollingsworth v. Perry (regarding California's Proposition 8). The Court struck down DOMA as unconstitutional and dismissed the appeal in the Proposition 8 case for lack of standing.

"These momentous decisions certainly have implications for taxes and the Affordable Care Act (ACA)," said Brian Haile, Senior Vice President for Health Care Policy, Jackson Hewitt Tax Service Inc. "Same-sex partners should understand some of the implications of marriage to their health insurance options under the ACA before they tie the knot. Simply put, getting hitched affects their health care."

Haile outlined the following:

1. Same-sex partners may now be able to file as "spouses." Under the federal income tax rules as currently written, taxfilers may be able to claim a same-sex partner as a dependent if they live together for the year, if the partner resides legally in the U.S., if the taxfiler provides at least 50 percent of the total support for the partner and the household, and if the partner has very limited income. This is a murky area – and the Court's decisions only partially clarify the law.

To the extent that the Court's rulings expand the federal definition of marriage, then many of these individuals in jurisdictions that recognize same-sex marriages may now be able to file as "spouses" rather than "dependents." Other same-sex individuals who did not meet the restrictive dependent test may now become part of the taxfiler's household as a spouse in those states that recognize same-sex marriage. (For reference, 12 states and the District of Columbia marry same sex couples.) However, the marital status vis-a-vis federal law of same-sex couples who live in states that do not recognize their marriage remains unclear.

2. Same-sex partners with similar incomes may lose out. For example, same-sex partners who each have an income of $40,000 may be eligible for the premium assistance tax credits under the ACA – but only if they remain single. If they marry (in those states that allow same-sex marriage), then they would lose eligibility because their income would be over the threshold for a household of two.

3. Same-sex partners with different incomes may gain. For example, two persons in a same-sex relationship who had incomes of $30,000 and $80,000, respectively, would not qualify for the tax credits if they were married in states that recognize same-sex marriage (because their combined income is above the limit for a couple). However, the individual making $30,000 would qualify for the tax credits if he or she remains unmarried (as that individual's income is below the threshold for a household of one). Of course, the couple may end up paying a lower marginal tax rate if they marry and exercise a new right to file jointly – so part of the decision about whether and when to marry in states that recognize same-sex marriage may involve a complicated trade-off between minimizing taxes and accessing insurance.

4. Same-sex couples who currently access domestic partner benefits may gain. Under the current federal income tax rules, the value of the benefits that employers provide to opposite-sex spouses is largely excluded from income; however, the opposite is true from same-sex partners – and they have to pay taxes on the full value of the employer's contribution for same-sex partner health insurance, etc. These taxfilers may no longer have to treat the value of the health insurance as imputed income if they get married in states that allow them to do so – meaning that their taxes may go down. The same is true for employers: they may pay lower payroll taxes if the couple marries and no longer has to treat the value of the employer's contribution as imputed income.

5. Same-sex couples who do not have or do not access domestic partner benefits may lose out. If the couple marries (assuming that they live in a state that recognizes same sex marriage) and one employer offers spouse or dependent coverage, then the same-sex spouse may lose eligibility for the ACA tax credits. The ACA limits the tax credits to spouses and dependents who do not have access to coverage. Even if the employer does not subsidize spouse or dependent health coverage, the fact that a spouse has access may disqualify him or her from the tax credit program.

6. Married same-sex couples receiving ACA tax credit will have to file jointly. If a same sex couple were to get married in a state that allows them to do so and claim the new tax credits under the ACA, then the ACA rules require them to file a joint return for the respective tax year (as is the case with opposite-sex married couples).

Even with the Court's decisions, HHS still faces several related policy questions. The final rules about the new insurance marketplaces clarify that the marketplaces and insurers must "…[n]ot discriminate based on race, color, national origin, disability, age, sex, gender identity or sexual orientation."* Consequently, many observers had a number of questions about how HHS would interpret these requirements in the context of the small group marketplace even before the Court's rulings. For example, must the small group marketplace require insurance companies to provide same-sex domestic partner coverage to participating employers and employees?

"To my knowledge," Haile added, "the agency's only requirement in this regard is that insurers in the federal marketplace self-attest that they do not discriminate on this basis."**

Surprisingly, many same-sex couples (particularly lower-income same-sex couples) may be better off if HHS answers "no" to such questions. The reason is simple but not intuitive: the final rule on premium tax credit eligibility states that individuals who have access to "affordable" employer-sponsored coverage are ineligible for premium tax credits. However, "affordability" of employer-sponsored insurance is determined only with regard to the employer contribution to the employee-only coverage. Consequently, a same-sex partner (and for that matter, any dependent) may be ineligible for tax credits if the employer offers same-sex coverage – even if the employer makes no contribution to toward the associated premium. However, if partner or other dependent coverage is unavailable, then a same-sex partner or other dependent may have some hope of qualifying for a tax credit.

The Internal Revenue Service and other federal agencies may issue interpretive guidance later this year to clarify some of the outstanding questions, but the implications of the Court's rulings today certainly complicate both the tax code and health care reform.

* 45 CFR Section 155.120(c)(2); 45 CFR Section 156.200(e).
** Letter to Issuers, April 5, 2013, available at http://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/2014_letter_to_issuers_04052013.pdf.

Brian Haile 
Senior Vice President for Health Care Policy
Jackson Hewitt Tax Service Inc. 

For more information about the Affordable Care Act and its impact on taxpayers, please visit Jackson Hewitt's public website or Brian Haile's Twitter channel.

(This post originally appeared on PRNewswire here)

Provider-Plan-Payer Alliance for Health - Your Input is Needed

Illinois was recently awarded a Model Design grant from the Center for Medicare & Medicaid Innovations (CMMI) for the development of a State Health Care Innovation Plan. Through these grants, CMMI is encouraging states to develop multi-payer approaches that send a consistent signal to providers and consumers incentivizing healthy behaviors, safe environments, and appropriate community supports linked to high quality care through accountable and comprehensive delivery systems. Illinois will develop its models to test over three years in the next round of funding. The grant period officially began April 1, and we must submit the comprehensive plan to CMS by September 30.

Over these six months, Illinois will develop its State Health Care Innovation Plan, which will focus on models to improve overall population health through collaboration among public health, health care, and community development sectors. The Innovation Plan will incorporate new initiatives, as well as build upon the delivery and payment system reforms already underway in Medicaid and the private sector. The planning process will require collaboration among health plans, providers, and payers to reform payment and delivery systems and the active engagement of community development and public health communities to enhance quality, improve health status and reduce overall costs.

Michael Gelder, Senior Health Policy Advisor to Governor Quinn, will lead the development of the plan in conjunction with the directors of Healthcare and Family Services, Human Services, Aging, Insurance, Professional Regulation, and Public Health. Staff workgroups will focus on delivery system/payment reform, data, and policy changes needed.

Overall, this grant is essential to achieve Governor Quinn’s goal to transform Illinois’ health care system to emphasize health, wellness, and independence. A healthy population is critical to keep health care costs affordable for businesses and families, which in turn will help Illinois attract jobs and continue to expand our economy.

Resources
Steering Committee Members
Steering Committee Presentation
State of Illinois Provider-Plan-Payer Alliance for Health
Letter from CMS Center for Medicaid Innovation Awarding Illinois the Model Design Award
CMS State Innovation Model Fact Sheet
Value of an All Payer Claims Database Webinar
Alliance Town Hall Meeting Notes - June 6, 2013

Comments
We welcome your feedback throughout the next 6 months as we develop our State Health Care Innovation Plan. Please submit your comments here and use the Town Hall Questions as a guide. Your comment and name may be made public on this site unless you indicate otherwise, with an exception for personal information or inappropriate language.

NOTE: All submissions are subject to the Freedom Of Information Act (FOIA).

[This was originally posted on the State of Illinois' Health Care Reform Website]

Illinois was recently awarded a Model Design grant from the Center for Medicare & Medicaid Innovations (CMMI) for the development of a State Health Care Innovation Plan. Through these grants, CMMI is encouraging states to develop multi-payer approaches that send a consistent signal to providers and consumers incentivizing healthy behaviors, safe environments, and appropriate community supports linked to high quality care through accountable and comprehensive delivery systems. Illinois will develop its models to test over three years in the next round of funding. The grant period officially began April 1, and we must submit the comprehensive plan to CMS by September 30.

Over these six months, Illinois will develop its State Health Care Innovation Plan, which will focus on models to improve overall population health through collaboration among public health, health care, and community development sectors. The Innovation Plan will incorporate new initiatives, as well as build upon the delivery and payment system reforms already underway in Medicaid and the private sector. The planning process will require collaboration among health plans, providers, and payers to reform payment and delivery systems and the active engagement of community development and public health communities to enhance quality, improve health status and reduce overall costs.

Michael Gelder, Senior Health Policy Advisor to Governor Quinn, will lead the development of the plan in conjunction with the directors of Healthcare and Family Services, Human Services, Aging, Insurance, Professional Regulation, and Public Health. Staff workgroups will focus on delivery system/payment reform, data, and policy changes needed.

Overall, this grant is essential to achieve Governor Quinn’s goal to transform Illinois’ health care system to emphasize health, wellness, and independence. A healthy population is critical to keep health care costs affordable for businesses and families, which in turn will help Illinois attract jobs and continue to expand our economy.

Consumer & Community Feedback Needed!
We welcome your feedback throughout the next 6 months as we develop our State Health Care Innovation Plan. Please submit your comments here (scroll down to the bottom of the page) and use the Town Hall Questions as a guide.

Your comment and name may be made public on this site unless you indicate otherwise, with an exception for personal information or inappropriate language.

NOTE: All submissions are subject to the Freedom Of Information Act (FOIA).
- See more at: http://heartlandpolicy.blogspot.com/2013/06/provider-plan-payer-alliance-for-health.html#sthash.g0hxlRcD.dpuf

Training for In Person Counselors and Navigators in Illinois

The State is preparing to award grants in early July to community based entities who will employ helpers to educate consumers about their new health care options under the Affordable Care Act and to assist people in enrolling in the new Medicaid expansion and Health Insurance Marketplace when open enrollment begins on October 1. These helpers will be called In Person Counselors (IPCs); however, there will also be other enrollment "helpers" called Navigators and Certified Application Counselors. The different names just refer to how the assister is funded; all of the assisters will help people choose and enroll in coverage.

In order to train these assisters, the State has partnered with the University of Illinois at Chicago School of Public Health to develop a curriculum and training program to begin by the end of July and go through the middle of September. The curriculum will consist of both online and in person learning modules. The training will be ongoing and will consist of a testing and certification process as required under state law. There will be continuing education and a backup technical assistance call center for individual questions.

In addition to the state training, IPCs and Navigators will also take a federal online Navigator training by the fall which will inform them about using the federal Marketplace portal. This is important, because all assisters in Illinois must be familiar with both the state Medicaid system as well as the federal Marketplace system since Illinois has chosen to be a partnership state and administer its health care reform programs jointly for the first year with the federal government. We are waiting on federal guidance regarding the Certified Application Counselors' training requirements.

Many other community based providers will help their clients understand and access health care coverage, even if they aren't designated "assisters" or "Navigators." These front line workers also need information on the ACA but may not need as intensive a training program as the certified assisters. There are training materials and presentations available to these organizations/ entities throughout the state including the Starting Strong Webinar Series and other events on the Illinois Health Matters events page.

Stephanie Altman
Health & Disability Advocates

An Ambitious Effort to Get Americans Covered

As the nation’s largest public health philanthropy, addressing the crisis of the uninsured is central to our mission.
 

A 2009 RWJF-funded study by the Institute of Medicine documented severe consequences to the long-term health prospects of people living without health insurance. Put simply, the uninsured live sicker, suffer more, and die younger. And beyond the impact on the individual and their families, high rates of uninsurance strain communities’ health systems, limiting access to quality care for those with insurance.

Sadly, 50 million of our fellow Americans—nearly one in six of us—are uninsured. For decades, RWJF has worked to remedy the crisis of the uninsured, and this week marks an especially important milestone, as “Get Covered America” kicks off across the nation. A grassroots, consumer-driven campaign, “Get Covered America” will educate Americans about new opportunities to obtain affordable health insurance in advance of open enrollment season this fall.

RWJF provided a grant earlier this year to Enroll America to organize the “Get Covered America” campaign, and also pledged an additional challenge grant to encourage other donors to join us in this effort to reduce the staggering number of uninsured Americans.

Our support for this campaign, along with other efforts to educate people about their options, is a continuation of RWJF’s effort over many years to enroll eligible people in health insurance programs. For example, starting in 1997, RWJF made a decade-long investment of nearly $150 million to enroll children and low-income adults in coverage for which they were eligible. During this time the total number of children covered by the Children’s Health Insurance Program doubled, from 2.2 million to 4.4 million, and total Medicaid enrollment increased by 10 million people. (Find more background here.)

Significantly, RWJF did not act alone. We partnered with government officials, as well as major health stakeholders to streamline eligibility and enrollment systems to reach out and enroll eligible people. More recently, expanding participation in the Medicare Part D prescription drug benefit followed a similar model of public-private cooperation. These examples highlight an important role for philanthropy as the Affordable Care Act’s coverage provisions take effect this fall: working closely with the public and private sectors to ensure robust enrollment.

With nearly 30 million of America’s uninsured eligible for new coverage options created under the law, “Get Covered America” has undertaken an ambitious series of goals. Over the summer, campaign volunteers and staff will fan out in communities across the nation to provide people with straightforward information about these new options: their ability to shop for insurance once the state and federal marketplaces open for enrollment in October, the availability of tax credits for which they may be eligible, and for the lowest income people, eligibility for Medicaid in states that have chosen to pursue that option.

To learn more about “Get Covered America” and what you can do to help, visit www.getcoveredamerica.org.

Andrew D. Hyman
Robert Wood Johnson Foundation

(This blog was originally posted on the RWJF "Culture of Health" blog here.)

New Options for States: Facilitating Medicaid and CHIP Renewal & Enrollment in 2014

States must prepare themselves for an efficient enrollment period in order to capitalize on the upcoming changes to Medicaid eligibility under the Affordable Care Act. The Centers for Medicare & Medicaid Services (CMS)/Center for Medicaid & CHIP Services, recently released a letter that identifies enrollment strategies to help with the anticipated increase in applications. These optional strategies may facilitate enrollment while lessening administrative demands on individual states.

Here are the strategies for those states interested in adopting them:

1) Implementing the early adoption of Modified-Adjusted Gross Income, (MAGI)-based rules

Under the ACA, eligibility for all health insurance programs will be determined by MAGI methodology, which uses different income-counting procedures than current Medicaid programs. During the open enrollment period, which begins on October 1st, 2013, individuals applying for coverage in 2013 will determine their eligibility through MAGI methodology. However, individuals renewing and applying for Medicaid during that 4-month period will have their income reviewed by both current rule and MAGI methodology. States can opt to change how they determine eligibility starting October 1st in order to simplify this process.

2) Extending the Medicaid renewal period

Anyone who has a Medicaid renewal which falls in the first quarter of 2013 will also have to have their eligibility determined by both pre-MAGI and MAGI rules. Extending the renewal period will allow the states to use only the MAGI eligibility rules for simplicity.

3) Enrolling individuals into Medicaid based on Supplemental Nutrition Assistance Program, (SNAP), eligibility

The majority of non-elderly, non-disabled individuals who receive SNAP benefits are also eligible for Medicaid. Enrolling individuals in Medicaid who also receive SNAP benefits without a separate, MAGI-based income determination can help ease a state’s administrative burden. This enrollment opportunity can be implemented for a limited amount of time as states handle the demands of the increase in applications.

4) Enrolling parents into Medicaid based on their children’s Medicaid eligibility

A large number of parents with Medicaid-eligible children will also be eligible for Medicaid when changes go into effect. Enrolling parents based on their children’s eligibility can also serve as a temporary way to facilitate enrollment.

5) Adopting 12 month continuous-eligibility for parents and other adults

Many states already have 12-month continuous-eligibility for children, meaning that children are guaranteed their Medicaid coverage for a full year despite changes to their family’s income. Extending this guarantee to families will reduce the amount of “churning” between different plans, and ensure that entire families have more consistent coverage.

States that wish to implement any of these strategies must get authorization from the federal government. CMS also is encouraging states to propose any other creative strategy that will facilitate enrollment.

Illinois should consider whether some or all of these options are optimal. Implementing these strategies could lessen the administrative burden on the state, maximize enrollment of uninsured populations, maximize eligibility for low income families, and increase federal financing for health care in the state.

Stephanie Altman & Kathryn Bailey
Health & Disability Advocates

Medicaid Expansion Passes Both Houses of the Illinois General Assembly

Earlier this week, the Illinois Legislature passed a bill (SB 26) to implement the Medicaid expansion option for adults without minor children on January 1, 2014. This expansion is a cornerstone of the Affordable Care Act and has the potential to cover over 600,000 low income adults in Illinois under the Medicaid program. The bill has overcome many hurdles along the way and now will be sent to the Governor's desk for his signature.

A year ago, the Supreme Court made the Medicaid expansion to adults an option that states did not have to take. However, the expansion is financially advantageous for states because the federal government pays all of the costs of the new Medicaid adult group for the first three years and thereafter, the state pays no more than 10% of the costs - making this the most lucrative Medicaid program in history for state governments. This coverage program will bring needed revenue to Illinois including to local entities such as Cook County and the City of Chicago as well as to hospitals and other safety net providers.

Illinois will begin accepting Medicaid applications for this new adult group on October 1, 2013, and coverage will begin on January 1, 2014.  For residents of Cook County, they can enroll right now and begin getting coverage into the CountyCare program which is an early implementation of the Medicaid expansion. The passage of SB 26 ensures that CountyCare enrollees will be able to continue to be covered under Medicaid along with the rest of the state in 2014.

In addition, SB 26 makes other changes to the Medicaid program including "fixing" some of the SMART Act Medicaid cuts by partially restoring dental care to pregnant women. Some mental health advocates were opposed to an amendment added onto the bill, that allowed a new category of mental health facilities for short term crises. For any questions, you can contact me at saltman@hdadvocates.org.
 
Stephanie Altman
Programs & Policy Director
Health & Disability Advocates

Visualize It!

For the second consecutive year, Health & Disability Advocates (HDA) has released its Visualizing Health Care Reform tool, a unique, interactive map that allows users to see a geographic and demographic breakdown of uninsured state residents who will be eligible for healthcare coverage when the Affordable Care Act (ACA) is fully implemented beginning in 2014.

The visualization is an especially practical tool for groups in the public, private and non-profit sectors, who are planning how they will meet the demand for information and for assistance to connect individuals with the new health care options. The interactive map allows users to pinpoint data for 87 Illinois communities, or roll up to larger regions around the state. The latest release of the tool provides geographic and demographic breakdowns of those who will become eligible for coverage in Illinois, as well as the undocumented non-citizens who do not have a new path to coverage.

The AP covered the tool yesterday and focused in on the over 40,000 uninsured veterans in Illinois - 32% (13,000) of whom will be newly eligible for Medicaid in Illinois, as long as the Medicaid expansion passes the legislature.

HDA CEO, Barbara Otto, was featured on WGN News illustrating how to use the tool.

With Visualizing Health Care Reform, we hope to help build an on-ramp to affordable health care for eligible individuals and families while also helping those on the implementation side to plan for a smooth and effective transition.

Please share the tool with your networks and email us if you have questions!

Illinois Senate Takes First Major Step To Passing A State Based Health Insurance Marketplace

Springfield - The State Senate Insurance Committee passed HB3227, formerly SB34, today, a major step in establishing a health insurance marketplace that helps small businesses and individuals in Illinois.

State Senator David Koehler (D-46 Peoria), chief sponsor of SB34 which was folded into HB3227, said, "To live up to the intention of the Affordable Care Act, we need to expand our help and support for the small businesses and consumers who will be using the new Illinois Health Insurance Marketplace. My bill does this, and I am pleased that my colleagues on the Insurance Committee were able to pass it."

Mark Burris of Springfield, the owner of MCCE Investments and owner of seven Subway Sandwich franchises, said, "Small businesses need a level playing field and there must be checks and balances with the insurance companies."

Burris continued, "In this bill, financing of the health insurance exchange under is through assessments of the insurers, as it should be. The insurance industry will benefit from the tax dollars used to create the infrastructure of the how the exchange is set up. It is only appropriate that they finance the day to day operations of the insurance health marketplace when an estimated one million new insurance customers will be purchasing private health insurance."

HB3227, formerly SB34, establishes a pro-consumer and pro-small business health insurance marketplace in Illinois. The health insurance marketplace will be the one-stop insurance shop for more than a million Illinoisans.

Jim Duffett, Executive Director of the Campaign for Better Health Care, said "This new marketplace will offer small businesses access to more affordable health insurance plans. Instead of paying 18% more than larger businesses, they will have a chance to compete for and retain good employees by providing affordable insurance. A win-win for small businesses and their employees because of the Affordable Care Act (ACA), commonly referred to as Obamacare."

HB3227, formerly SB34, ensures that the marketplace is governed by a diverse board that represents women, small businesses, communities of color, labor, public health, people with disabilities, and consumers, and provides for accountability of the insurance industry selling plans on the new marketplace.
 

Speaking on behalf of the National Association of Women Business Owners Chicago (NAWBO Chicago), Linda Forman said, "Who sits on the insurance exchange governing board is very important. We believe that a statewide governing board will be better able to understand the needs of women and the diversity of backgrounds and geography of small businesses throughout this state if the governing board is composed of the types of people who will be using the health insurance exchange marketplace."

"We can all agree that what we had has not worked very well, and to continue to do nothing is a bad mistake. We are excited to support HB3227, formerly SB34, and proud to be part of the Small Business Health Care Consortium. Our members are proud to see us take a step in the right direction on behalf of small business all across the state," said Larry Ivory, President of the Illinois Black Chamber of Commerce. "We congratulate the members of the Insurance Committee for taking that step for Illinois small businesses and individuals today."

ADDENDUM

HB3227 (containing SB34 language) Fact Sheet

Kathleen Duffy
Campaign for Better Health Care

New Study Builds Case for Expanding Medicaid

A new study in the New England Journal of Medicine confirms what consumer health advocates have known for decades: Medicaid is essential for keeping low-income households on stable financial footing. This should come as no surprise, since protecting families from unexpected and devastating medical costs is exactly what health insurance is meant to do. The study also proves that Medicaid coverage significantly improves beneficiaries’ mental health.

But opponents of Medicaid have distorted the study’s results; they claim it supports their agenda to block millions of low-income, uninsured families from accessing this vital coverage program. Their arguments are misinformed at best. The new study only strengthens the case for expanding Medicaid.

What the study tells us: Medicaid Works!

The researchers looked at the health and finances of low-income, uninsured Oregon residents who were given the opportunity to enroll in Medicaid through a one-time lottery, and compared it to their peers who remained uninsured.

The study shows that Medicaid virtually eliminated all catastrophic medical expenditures (medical expenses exceeding 30 percent of household income) for its beneficiaries. It also indicates that people with Medicaid coverage are significantly less likely to face any medical debt, borrow money to pay bills, or skip payments.

These results are extremely promising, especially in light of the fact that medical bills currently prompt more than 60 percent of U.S. bankruptcies. If we want to reduce the drag bankruptcies create on our economy and the ruin they leave behind in our communities, providing low-income families with Medicaid coverage is a good place to start.

The study also found that Medicaid is a powerful tool in combating mental illness. Medicaid beneficiaries in the study were 30 percent less likely to suffer from depression than those who remained uninsured. Given that suicide takes more lives in the US than any other form of injury and that depression accounts for more than $83 billion in the US between lost productivity and medical expenses, the impact of Medicaid on depression deserves attention and celebration.

File Under: Non sequitur

Instead of celebrating, opponents of Medicaid are arguing this study makes the case for withholding Medicaid coverage from millions of low-income, uninsured families. They base this on the study’s failure to detect statistically significant improvements in a handful chronic disease measures — blood pressure, cholesterol, or hemoglobin levels — in those with Medicaid compared to those without coverage.

That’s like saying because your blood pressure didn’t go down, we are going to prevent you from getting coverage for cancer treatment or a pap smear.

It’s certainly true that the U.S. health care system needs to be better at managing chronic conditions. We routinely lag behind other industrialized nations on measures of chronic care management, such as following medical guidelines for treating hypertension and diabetes. Plus, this study only looks at the impact of two years of coverage; significant improvements in these persistent chronic illnesses may take much longer to materialize.

This is hardly a reason to block millions of low-income families from gaining health coverage they need and deserve. We have no evidence that people with private insurance or Medicare fare any better than Medicaid beneficiaries on these measures, yet no one is suggesting we should all drop our health insurance.

Getting people covered is the first step in creating an effective health care system that works for everyone, but it is not the only step. The ACA contains numerous initiatives to improve the quality of health care.

File under: extremely relevant

Meanwhile, dozens of states are still trying to decide whether or not to take up the option to extend Medicaid coverage to millions of low-income, uninsured adults. This study confirms Medicaid can give beneficiaries peace of mind that they won’t go bankrupt when they experience that unexpected illness, and make staggering improvements in their mental health. It adds to the growing list of reasons why this decision should be a no-brainer for all 50 states.

Katherine Howitt, Senior Policy Analyst
Community Catalyst

(This blog was first published on the Community Catalyst Blog)