Perspectives in Policy - The Patient Protection and Affordable Care Act

Issue 6, 12/30/2013

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Articles in This Issue:


The Patient Protection and Affordable Care Act What Iowans with Disabilities Need to Know

The Patient Protection and Affordable Care Act (ACA) also known as “Obamacare” was signed into law in 2010 to increase the quality, accessibility and affordability of health insurance. 1 in 5 people in America have a disability and getting affordable coverage has been difficult if not impossible because their disabilities were considered to be pre-existing conditions and not covered by traditional health insurance plans.

One provision of the ACA allowed states to expand Medicaid, the government program that pays for health care for low income people and those that meet certain requirements such as pregnant women, children, parents of qualifying children and people with disabilities who receive Supplemental Security Income (SSI). Iowa legislators chose to develop an alternative plan, the Iowa Health and Wellness Plan, that creates a partnership between the State and Federal government to cover Iowans ages 19-64 who earn less than 138% of the Federal Poverty Level (FPL). The Iowa Health and Wellness Plan was approved by the federal government in early December and coverage will begin on January 1, 2014.

The Iowa Health and Wellness Plan includes two options that are based on income – the Iowa Wellness Plan and the Iowa Marketplace Choice Plan. The Iowa Wellness Plan provides health insurance for individuals with incomes up to 100% of the FPL ($11,490 for one person or $15,510 for a family of two). They will receive services through Medicaid with a benefit package similar to the state employee’s health insurance plan and they will either select or be assigned a primary care provider for their health care. The second option, the Iowa Marketplace Choice Plan, will cover individuals between 101 - 138% of the FPL ($11,491-$15,282 for one person or $15,511-$20,628 for a family of two). Coverage will be provided by private health plans available on the Health Insurance Marketplace. The premiums for this plan will be paid by Medicaid ifcertain conditions, such as wellness and prevention activities, are met. Both of the plans are considered “Alternative Benefit Plans” because they are different from the regular state Medicaid plan.

Federal law requires that some individuals with greater healthcare needs have a choice between the alternative plan and regular Medicaid services. The Iowa Health and Wellness plan then includes a third option for “Medically Frail” individuals who are living with “disabling mental disorders (including adults with serious mental illness), individuals with chronic substance use disorders, individuals with serious and complex medical conditions, individuals with a physical, intellectual or developmental disability that significantly impairs their ability to perform one or more activities of daily living, or individuals with a disability determination based on Social Security criteria”. Iowa Medicaid Enterprise (IME) will determine individuals that qualify through a screening process and those that qualify are automatically enrolled into the Medicaid State Plan unless they choose to opt-out and get services through the alternative plan.

How might these changes affect you?
• If you are currently receiving Medicare or Medicaid you will have NO change to your coverage.
• If you do not currently have insurance or are struggling to pay for insurance, you will now have the opportunity to go to the Health Insurance Marketplace to find affordable insurance. You may find that you qualify for federal premium payment assistance, the Iowa Wellness or the Marketplace Choice Plan or regular Medicaid through the “medically frail” determination process.
• If you qualify as “medically frail,” you will automatically be enrolled into the Medicaid State Plan and you will have the option to opt-out.

To see whether you qualify for the Iowa Health and Wellness plan you can simply go to www.healthcare.gov or you may call 800-318-2596.

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Healthcare Reform and the Impact for People with Disabilities

1. Plans must cover mental health and substance abuse services. Plans must cover “essential health benefits” which includes mental health. Plans will be required to cover a minimum number of mental health drugs in each category or class. You should compare plans carefully even though plans must cover mental health and prescriptions for mental health disorders, plans can vary what services and drugs they will cover. Each plan on the health care marketplace in Iowa is different so look at what is called the “Summary of Benefit Coverage” carefully to compare.

2. No pre-existing conditions can exist after 2014. No individual plan on the insurance exchange can reject you, increase your rate, or not cover your pre-existing condition after January 1, 2014. This was a big barrier for many people living with disabilities who were denied for coverage previously. The only things that can affect how much you pay for insurance are:
• Age
• Tobacco Use
• Geographic Area
• Family Size

3. No lifetime or annual limits. Insurance carriers can no longer put lifetime or annual limits on how much they will pay for care. This is important to many people with disabilities who receive healthcare services that are ongoing. Many people who had insurance saw gaps in coverage due to limits.

4. Plans must accept every individual who applies for coverage. Health plans will be required to accept every person who applies for coverage and must renew plans before they expire.

5. Individuals must enroll during the enrollment period. There is a lot of confusion in the marketplace so you should know that starting in 2014 there will be a requirement that individuals have health insurance. The open enrollment period (the time when you can sign up for insurance) started October 1 and will be open until March 31 of 2014; in future years open enrollment will run from October 1 – December 31. After that period you may not be able to sign up for individual insurance on the marketplace exchange until the next period unless there is a change in your life such as a loss of coverage, change in your employment status, marriage, divorce, death, birth of a child, or adoption.

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The Impact of Affordable Care Act on Regional MH/DS Services

By Linda Hinton, Government Relations Manager, Iowa State Association of Counties

This expansion of access to health insurance coverage under the Affordable Care Act will provide medical insurance for many Iowans who are currently served by county General Assistance, Community Services and Public Health Departments. This expansion of health insurance under the Iowa Health and Wellness Plan coincides with the implementation of the redesign of disability services in Iowa. All of the Regional Mental Health and Disability Services regions must be operational on July 1, 2014.

There are services that are currently paid for by the county’s mental health budgets (soon to be regions) that will now be covered under the health insurance programs provided through the Iowa Health and Wellness plan. In particular, it is expected that inpatient and outpatient mental health services will be paid for through health insurance plans. In addition, case management services will largely be replaced by individual health homes and paid for by the insurance expansion. Legislation passed last session requires that the counties/regions return to the state 80% of the savings that result from those changes in coverage. Some state legislators have concerns about the the fairness of that requirement and plan to discuss it during the session that begins in January. Whether the savings are allowed to stay at the local level or are remitted to the state, it is important that they be used to invest in improvements in Iowa’s disability services system.

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The Affordable Care Act and Disabilities - Visiting Nurse Services of Iowa

By Karen Sullivan, Program Manager and Lead Navigator, Visiting Nurse Services of Iowa

Visiting Nurse Services of Iowa (VNS of Iowa) was one of three organizations in Iowa to receive a federal grant to connect Iowans with one-on-one assistance enrolling in the new health insurance marketplace via trained and licensed “navigators”. In the past month, our navigators have been holding enrollment events throughout our 38-county service area, where about half of Iowa’s uninsured reside. These events offer opportunities for those who need additional assistance navigating the marketplace, including persons with disabilities.

Under the Affordable Care Act, individuals may be able to get lower costs on health insurance coverage, and pre-existing conditions will be covered. Consumers may apply for insurance through the new marketplace by phone, online, via a paper application or with the assistance of a Certified Application Counselor. However, an appointment with a navigator offers the most hands on assistance identifying a plan that best meets consumers’ needs — an ideal option for those with intellectual disabilities and/or their designated health care advocates. VNS of Iowa is committed to providing enrollment assistance to all individuals, specifically vulnerable or underserved populations, including those with disabilities or special needs.

Navigators have received extensive training, including in serving those with a variety of disabilities. In these situations, having family caregivers present is also recommended. The enrollment process takes about one hour, provided individuals bring all necessary documentation: Social Security numbers; employer and income information, such as W-2 tax forms, for every member of the household needing coverage; policy numbers for any current health-insurance plans; and information about any health insurance made available by employers.

The Navigator program embraces our mission and continues to build on our endeavors to be recognized by the community as a premier organization at the center of providing access to quality health services for all in need. Visit www.vnsia.org for a list of upcoming enrollment events. Appointments are strongly encouraged, and may be made by calling 515-288-1516

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The Patient Protection and Affordable Care Act - Where To Get Help

If you need help or have questions about your options, you can contact a navigator or a certified application counselor (CAC). Navigators have been trained and are certified to provide unbiased information about health insurance options. They can also prepare applications and establish eligibility. While navigators and CACs can provide information, they are not allowed to make recommendations on your health insurance coverage. To find local help from a navigator or CAC go to https://localhelp.healthcare.gov/ or contact one of the navigators directly:

Planned Parenthood of the Heartland
1171 7Th St
Des Moines, IA 50322
Phone: (877) 811-7526 (main)
(877) 811-7526 (toll free)
Web: http://www.PPHeartland.org
Email:Ianavigator@ppheartland.org

Visiting Nurse Services of Iowa
1111 9Th Street, Suite 320
Des Moines, IA 50314-2527
Phone: (515) 288-1516 (main)
Web: http://www.vnsia.org
Email:info@vnsdm.org

In the Quad Cities Area:
Genesis Health
Phone:(563)-421-3675
Web: genesishealth.com/enroll
Email: enrollment@genesishealth.com

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