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Presented to: Medical Associations and Societies – Group Meeting

Presented by: Blake Fulenwider, Deputy Commissioner, DCH

June 12, 2013

Affordable Care Act (ACA) Update

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ACA Update Agenda

• DCH & The Affordable Care Act (ACA)• Medicaid Expansion• Health Insurance Exchange

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DCH & The Affordable Care Act

What’s DCH’s Role in all of this?• Medicaid Expansion• CHIP to Medicaid Transfer• Federal Premium Tax• Medicaid and CHIP Eligibility Determination• Health Insurance Exchange• State Health Benefit Plan

Other State Entities Involved:• Governor’s Office• OPB• Dept. of Insurance• Dept. of Human Services

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Medicaid Expansion

• Eliminate categorical eligibility for Low Income Medicaid (LIM)

• Make eligible and enroll virtually all individuals at or below 138% FPL– In Georgia, primarily childless adults– New eligibility categories match with substantial FFP– Currently eligible but not enrolled match with standard FFP

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Who is Eligible?

Covered GroupsMedicaid

Federal Poverty LevelPeachCare for Kids

Federal Poverty Level

Infants up to Age 1 Up to 185% 185% - 235%

Children Age 1 to 5 Up to 150% 150% - 235%

Children Age 6 to 19 Up to 100% 100% - 235%

Pregnant Women Up to 200% No coverage

Parents Up to 42% No coverage

Women with Breast and Cervical Cancer

Up to 200% No coverage

Aged, Blind and Disabled Not based on FPL No coverage

Childless Adults No coverage No coverage

Former Foster Care Children No income limits, age limit to 26 (w/ACA)

Covered to 19

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Who Are Our Members?

Expansion

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Medicaid Expansion

• Enrollment– Additional 620,000 enrollees in Medicaid in 2014– Grows to 695,000 enrollees by 2023

• Cost– 10-year Total Estimate

• $4.5 Billion in additional state expenditure• $40.8 Billion (State + Federal)

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Medicaid Expansion DecisionsBy State

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DCH: Health Insurance Exchange (HIX)

• Federally-subsidized coverage in a U.S. HHS-approved health plan – that meets Minimum Essential Benefits (MEB) and is certified as a Qualified Health Plan

(QHP) able to be offered on the exchange in a state or on the Federally Facilitated Exchange (FFE)

• Advance Premium Tax Credits (APTC) and Cost Sharing Reductions (CSR)

– for families with household income between 138% FPL to 400% FPL. Family expected contribution a percentage of household income, not to exceed 9.5%.

• Includes Plan Management, Consumer Outreach and Assistance– as well as ‘assisting in enrollment’ into a QHP

• Major IT infrastructure required

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Health Insurance Exchange (HIX) Options

• HHS Providing states with three optionsState-Based Exchange Federal-State Partnership Federally-Facilitated Exchange

State establishes and operates its own AHBE and SHOP functions in compliance with federal rules and requirements.

A federal exchange by definition, but state assumes responsibility for operation of any or all of these functions:

• Plan Management• Consumer Outreach and Assistance• Both

HHS operates all AHBE and SHOP functions in a state. State has the option to perform:

• Reinsurance program• Medicaid/CHIP eligibility determination

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Health Insurance Exchange Decisions By State

18 State-Based; 7 Partnership; 26 Federally-Facilitated ExchangesState-Based Partnership Federally-Facilitated

CaliforniaColorado

ConnecticutDistrict of Columbia

HawaiiIdaho

KentuckyMaryland

MassachusettsMinnesota

NevadaNew Mexico

New YorkOregon

Rhode IslandUtah

VermontWashington

ArkansasDelaware

IllinoisIowa

MichiganNorth CarolinaWest Virginia

Alabama TennesseeAlaska TexasArizona VirginiaFlorida Wisconsin

Georgia WyomingIndianaKansasLouisianaMaineMississippiMissouriMontanaNebraskaNew HampshireNew JerseyNorth DakotaOhioOklahomaPennsylvaniaSouth CarolinaSouth Dakota

Source: Kaiser Family Foundation; statehealthfacts.org; 5/07/2013.

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Health Insurance Exchange DecisionsMap View By State

Source: Kaiser Family Foundation; statehealthfacts.org; 1/14/2013

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AHBE and SHOP

AHBE (Individual Exchange)• Focus: Individuals

• Eligible Users:– Resident of state in which exchange is based– Not incarcerated– U.S. Citizen or legal alien

• Restrictions:To access Premium Tax Credits and Cost-Sharing Subsidies, must be:

– Between 138 – 400% FPL– Not offered AHBE-qualified coverage through

employer or government program

• No Cafeteria Plan Pre-Tax Treatment

SHOP (Small Business Exchange)• Focus: Employers

• Eligible Users:– Full Time Equivalent Employees of small

businesses with 1 to 100 workers

• Options:– State option to limit to businesses of 1-50 or

less until 2016– State may expand to 100+ as of 2017, with

approval of US HHS

• Subsidies:– Limited 2-year employer tax credit

• Section 125 “Cafeteria Plan” Pre-Tax Treatment

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Individual Applies Through FFE (FFE makes Medicaid/CHIP Assessment)

DRAFT

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HIX: A Regulatory Mechanism

• HHS using state-based exchanges, state partnership and Federally Facilitated Exchanges as regulatory mechanism

– Minimum Essential Benefits– Employer and Employee Mandate– Premium Subsidies– Assessment for Medicaid and CHIP– A gatekeeper to health insurers in the marketplace

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Georgia’s Response

• Georgia will not expand Medicaid eligibility– Lack of flexibility in management of the program– Uncertainty about cost and budget implications

• Georgia will utilize the Federally-Facilitated Exchange (FFE)– FFE will manage all exchange functions– DCH will continue to make final determination for Medicaid

eligibility

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Title or Chapter Slide

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