Dual Eligibles Next to Move into Managed Care in Illinois

On February 22, the U.S. Department of Health and Human Services announced a Memorandum of Understanding (MOU) with the state of Illinois for a demonstration project that will enroll approximately 136,000 dual eligibles in northeastern and central Illinois into managed care plans. (“Dual eligibles” are individuals who have coverage through both Medicare and Medicaid.) Illinois is the fourth state to receive an MOU for this demonstration, known nationally as the Medicare Medicaid Financial Alignment Initiative (MMAI).

AgeOptions and other organizations that serve older adults have been following the development of this new project, as it will significantly affect the lives of our clients. Here is what we have learned about this new initiative from our research and communications with the entities involved, including the Illinois Department of Healthcare and Family Services and various managed care organizations:

The MMAI project is part of a national effort to better coordinate care for dual eligible beneficiaries. Dual eligibles tend to be sicker and cost more than other Medicare and Medicaid beneficiaries. To address this, as part of the Affordable Care Act, the Centers for Medicare and Medicaid Services created a Medicare-Medicaid Coordination Office (MMCO) to “make sure Medicare-Medicaid enrollees have full access to seamless, high quality health care and to make the system as cost-effective as possible.” One of the MMCO’s first projects has been working with states to implement initiatives to coordinate care for dual eligibles.

Currently, dual eligibles must navigate and manage multiple systems of coverage in order to access the health care they need (Medicare, Medicare Part D prescription drug plans, and Medicaid). This can be very complex and taxing for individuals who have multiple complex health needs. Therefore, the goals of the MMAI project are to simplify this process and provide higher quality and more coordinated care for dual eligibles.

In January 2014, dual eligibles in the greater Chicago area and parts of Central Illinois will be enrolled into managed care plans. These plans must provide care managers and other supports to coordinate their members’ care, in addition to paying for members’ medical services and long term services and supports (LTSS). In exchange, these plans will be paid a capitated rate by the state of Illinois and CMS. (“Capitated rate” means the plans will receive a flat rate for each member that they serve, instead of being paid for each individual service that a member receives.) The inclusion of long term services and supports in this project is significant, as these services may be ‘new territory’ to some managed care organizations. In addition to providing coverage for LTSS provided in long term care facilities, MMAI plans will be responsible for covering home and community based services, such as the Community Care Program. This may cause confusion for dual eligible beneficiaries who are used to receiving Community Care Program services through the existing system, so agencies working with older adults will have to provide education and assistance to help our clients understand these new changes.

Illinois has selected eight managed care plans to provide MMAI coverage. Those eight plans are:

• Chicago area: Aetna Better Health, Blue Cross/Blue Shield of Illinois, HealthSpring, Humana, IlliniCare (Centene), and Meridian Health Plan of Illinois
• Central Illinois: Molina Healthcare, Health Alliance

Dual eligible beneficiaries in the target counties will be able to enroll in these plans voluntarily beginning October 2013. In January 2014, the state will begin passively enrolling additional beneficiaries into the plans. This passive enrollment will be conducted in phases, so it will take about 6 months to enroll everyone who will be affected. After a beneficiary has been passively enrolled into a plan, s/he may change plans at any time and will have some ability to opt out of the program (though this opt out privilege may be limited in certain cases).

Counties that will be part of the MMAI project:

• Greater Chicago area: Cook, DuPage, Lake, Kane, Kankakee, and Will counties

• Central Illinois: Christian, Champaign, DeWitt, Ford, Knox, Logan, Macon, McLean, Menard, Peoria, Piatt, Sangamon, Stark, Tazewell, and Vermilion counties

For more information about the Illinois MMAI project, please see the following resources:

CMS fact sheet
Illinois Memorandum of Understanding
Illinois Department of Healthcare and Family Services webpage on Illinois Care Coordination Initiatives (see section on MMAI)

Written by Erin Weir, Manager of Health Care Access at AgeOptions
erin.weir@ageoptions.org

For Better Healthcare Join The Small Business Healthcare Consoritum

Our changing health care system will have a profound effect on all of us. Now that the election is over and the Supreme Court has ruled, the Affordable Care Act (ACA) is not going away. It will not be repealed and it is up to us to make sure it will work for small businesses and individuals as it was intended to do.

That’s why I joined the Campaign for Better Health Care’s newly created Small Business Health Care Consortium (SBHCC). This consortium views the needs of small businesses and their employees as a top priority.

And, as a member of the Steering Committee of the SBHCC I am personally inviting you to join our network of small businesses who know that only through our collective voices that will assure that the Affordale Care Act live up to its goal of making healthcare affordable for all.

Discussions around health reform have been confusing and, sometimes, even misleading. It is the goal of the SBHCC to provide factual information about the changes that are already happening and those coming in the near future. The SBHCC discusses the benefits and opportunities of the ACA and what Illinois small businesses need to do to make sure this law will benefit them.

Many key components of the ACA are national in nature. For instance, small businesses currently providing health insurance to their employees could be eligible for a 35% tax credit. And, while employers with fewer than 50 full time employees are not required to provide health insurance, their employees can take advantage of the ACA’s benefits.

Other components will be implemented at the State level and these decisions will either enhance small businesses or provide another hurdle. One important component is that all states must implement a health insurance exchange (marketplace). These exchanges will include a rate review process with defined, easy to understand plans to consider and review side-by-side.

As small business owners we share many of the same, serious business challenges. It is my hope that you and your small business peers do want to learn more about the ACA. Let’s take this opportunity to act collectively to get control of health insurance costs and improve access to coverage. The opportunity to create positive change is now. It is about fairness and choices for small businesses. To that end I like for you to hear my own personal story about how the new healthcare law will effect me.

Howard Lee
CIO
Wirehead Technology

The Negative Impact of SMART Act Cuts

This post originally appeared as a letter from Age Options to the IL House of Representatives human Services Appropriations Committee, submitted on Feb. 20, 2013

The cuts to Medicaid that were implemented July 1, 2012 as a result of the SMART Act have had a serious negative impact on the lives of our clients. In particular, we would like to bring to your attention the hardship caused by the elimination of the Illinois Cares Rx program. Illinois Cares Rx provided critical pharmaceutical assistance to more than 160,000 older adults and people with disabilities in Illinois. Without this program, many of these individuals are struggling to pay for their medications.

Contrary to popular belief, implementation of the Affordable Care Act has not resolved the need for a state pharmaceutical assistance program. The ACA does not close the Medicare Part D “donut hole” until 2020. Further, Illinois Cares Rx provided much needed assistance with expensive Medicare Part D deductibles and copayments – the ACA does not do anything to address this.

To illustrate the difficulties that older adults are facing without this critical program, we would like to share with you the story of one of our clients. Lillian is an 89 year old resident of Berwyn, Illinois.  A widow for 53 years, Lillian worked multiple jobs to support her two children and pay off her mortgage. She had no money left over to save for retirement. Now, Lillian’s income of $1,648/month puts her above the income limits for assistance programs like Medicaid and the Part D Extra Help program, but is barely enough for Lillian to make ends meet with her expenses. She pays premiums each month for her Medicare and Part D prescription coverage. She also pays for an expensive Medicare Supplement Plan to cover her injections for macular degeneration, which cost $4,000 every two weeks, and bills for dental services out of pocket (Medicare does not provide dental coverage). In addition to all of her health care expenses, Lillian must continue to pay her utility bills, property taxes, and homeowner’s insurance. At the end of each month, Lillian has no extra money left in her bank account. In fact, lately she has had to put some of her bills onto a credit card, and then she skimps on groceries the following month to pay off the credit card bill.

Since Illinois Cares Rx was eliminated, Lillian has been unable to afford the costs of her medications. She takes nine prescription drugs every month, including two drugs that cost $70/month each in Part D copayments. Lillian has not been able to afford her three most expensive medications since January, so she has been going without them. These drugs help control Lillian’s blood pressure, cholesterol, and hypothyroidism; going without these medications is dangerous for her health and has the potential to instigate expensive emergency room or hospital care.  Unfortunately, without Illinois Cares Rx, Lillian has no other option to pay for her medications, so these are risks that she has been forced to take.

As a result of the SMART Act, thousands of older adults and people with disabilities in Illinois are in situations just like Lillian’s. They must make difficult choices every month regarding whether to pay for food, utility bills, or medications. The elimination of Illinois Cares Rx has created a tremendous financial burden for these individuals, and it is likely to create a significant financial burden for the state via costly emergency room and hospital care for individuals who cannot afford their prescription drugs.

We ask that the committee consider these burdens in future action regarding cuts to Medicaid, as well as in considering restoration of pharmaceutical assistance for older adults and people with disabilities. AgeOptions and the Illinois Association of Area Agencies on Aging fully support HB1286 (sponsored by Representative Jakobsson and cosponsored by Representatives Beiser and Burke), which would reinstate a pharmaceutical assistance program of this nature. 

IPXP To Stop Accepting Applications March 2nd

The federal office charged with implementing health care reform announced last Friday that the subsidized plans that are currently insuring more than 100,000 individuals nationwide, will be closing their doors to new enrollees months before other coverage is available on the new insurance exchanges.

Although most of the provisions of the Affordable Care Act do not become effective until January 1, 2014, the law set up interim plans, called “Pre-Existing Condition Insurance Plans” for people who could not buy health insurance on the private market because of serious health conditions, including HIV. In Illinois, the state opened the Illinois Pre-Existing Insurance Plan (IPXP) in August 2010. Approximately 3000 people now have insurance though IPXP. Although those people currently enrolled in those plans will continue to have coverage until January 1, 2014, when they will be able to move to private insurance coverage, Friday’s announcement means that no new applications will be accepted after March 2, 2013.

Ann Fisher, Executive Director of the AIDS Legal Council of Chicago, explained why this is bad news for people with HIV or any other pre-existing condition that blocks them from getting private insurance. “IPXP has been an important source of health care coverage for people with HIV, including people on the AIDS Drug Assistance Program whose income climbs above 300% of the federal poverty level (about $35,000) but do not have health insurance on the job and cannot afford to pay for their medications themselves. “

The state has been able to refer those individuals to IPXP, and to help pay the IPXP premiums, so that they do not lose access to their medications. Fisher explained that IPXP was always meant to be a temporary program, set to expire once pre-existing conditions no longer prevent people from buying insurance. “But,” she added “we always assumed, perhaps naively, that IPXP would continue to accept new enrollees until very close to January 1st.” “It appears,” she added,” that IPXP is a victim of its own success. There was a limited pool of money available for the plans, and in order to make sure they can continue to pay claims of current enrollees, they now have to cut off future ones.”

The AIDS Legal Council is trying to get out the word about the closing of enrollment, and encouraging anyone who has been without insurance for at least six months to quickly apply for IPXP. ALCC is available to answer questions or assist with the enrollment process. They can be reached at 312-427-8990.

Ann Fisher
AIDS Legal Council of Chicago
ann@aidslegal.com

IRS Issues Guidance on Health Insurance Premium Tax Credit - Clarification

The IRS issued a final regulations on when an employer-sponsored plan is considered "affordable" for an individual related to the employee for purposes of eligibility for a premium tax credit. Under Health Care Reform, employees may be eligible for a premium tax credit to purchase health insurance through the future health insurance exchanges if, among other reasons, the employer plan is deemed unaffordable.

The final regulations clarify that for taxable years beginning before January 1, 2015, an eligible employer-sponsored plan is affordable for related individuals if the portion of the annual premium the employee must pay for self-only coverage does not exceed 9.5% of the taxpayer's household income.

An employer plan will be affordable for family members if the cost of self-only coverage does not exceed 9.5% of the employee's household income. In other words, for purposes of whether family members are eligible for tax credits, the affordability of family coverage is not taken into account; all that matters is that the cost of self-only coverage is affordable to the employee

For purposes of applying the affordability exemption from the individual mandate in the case of related individuals, the required contribution is based on the premium the employee would pay for employer-sponsored family coverage.

For an employee eligible under an employer plan, affordability (for individual mandate exemption purposes) will be based on whether the cost of self-only coverage exceeds 8% of the employee's household income. For a related individual (such as a spouse or child), however, affordability for this purpose will be based on whether the cost of family coverage exceeds 8% of household income. Under these rules, members of an employee's family may qualify for an individual mandate exemption, even though the offer of affordable employer coverage to the employee would require the employee to enroll or risk paying a penalty.

These final regulations apply to taxable years ending after December 31, 2013.

For a copy of the final regulations, please click here.

This post originally appeared on February 5, 2013, on the Robert Slayton & Associates, Inc. blog. By Larry Grudzien, Attorney-At-Law

The HHS Secretary Visits Chicago

This week, U.S. Health and Human Services Secretary Kathleen Sebelius visited Chicago to speak about the Illinois Health Insurance Marketplace, a key provision of the Affordable Care Act.

Secretary Sebelius, accompanied by Governor Pat Quinn, announced on Wednesday that the Illinois Blueprint Application for a State-Partnership health exchange had been accepted by the federal government. The exchange will run as a federal-state partnership model until 2015, when the state may take over operations, depending on the State Legislature’s ability to pass a state exchange bill. Enrollment in the partnership exchange/marketplace opens in October, only eight months (229 days!) away.

Secretary Sebelius speaks to a full house at the Chicago Cultural Center

On Thursday, Sec. Sebelius spoke at the Chicago Cultural Center. Preceding her was Bechara Choucair, Commissioner of the Chicago Department of Public Health, who presented an overview of the Healthy Chicago program and its impact thus far. Sebelius delivered a call to action to those in attendance, citing the need for affordable, accessible health insurance for all as a crucial step in the national public health strategy. With only eight months before the state health marketplace is open for enrollment, and ten months before it is fully operational, promoting awareness of the health insurance exchange is the focus of HHS. 

Navigators, Assisters, and Counselors, Oh My!

By now we know that upwards of 30 million Americans will have new, more affordable health coverage options available to them by January 1, 2014. But what many don’t realize is how incredibly difficult it can be to understand and choose the right health insurance on your own.

The Wizard of Oz’s Dorothy had guides along the way, and the Affordable Care Act (ACA) provides some as well – hopefully, with fewer pitfalls. But not everyone can counsel people about health insurance. There are complex public and private systems to navigate, and most people who will likely get insurance in the new Health Insurance Exchanges, or Marketplaces, will be more racially diverse, less educated, and earn lower income than people in private insurance now. Most will have a high school education or less, and as many as one in four speak a language other than English at home. So it matters that the people who guide consumers along the path to coverage are trusted members of the community and understand their circumstances.

Luckily, the ACA provides different options for guides along yellow brick road.

Navigators are outlined in the ACA as helpers for people to enroll in coverage through the Exchange, and refer or assist with Medicaid enrollment. Navigators are funded through Exchanges, and regulations from the Department of Health and Human Services (HHS) are clear that anyone who gets payments from insurance companies cannot be a Navigator. Navigators also must meet cultural competency standards and go through training and certification. States running their own Exchanges are developing Navigator programs now and must fund these with state Exchange dollars. For Federal Exchanges and Partnership Exchanges, HHS has said that it will fund Navigators directly through an upcoming RFP process. Be on the lookout for this announcement in the next few weeks.

To add even more help on the ground, HHS recently outlined in regulations another program,Assisters (or, In-Person Assistance). Like Navigators, Assisters must meet training and conflict of interest standards. They could fill in gaps in areas that need more enrollment assistance, or provide outreach and education about the ACA’s new options. Funding for Assisters is a key difference from Navigators. States running Exchanges or opting for the Consumer Assistance Partnership can apply for funds for Assisters through their Exchange Establishment grants. A number of states are applying now for these funds. Unfortunately, Assisters currently are not an option for Federal Exchanges.

And when you thought there were enough new health-related terms, HHS regulations added yet another helper to enroll people, Certified Application Counselors. Every Exchange must have a Certified Application Counselor program, with similar training and privacy standards as Navigators and Assisters. A difference in this program is that there is no funding mechanism. It is unclear who will serve this role – although the regulation suggests it could be community-based organizations or health care providers. Stay tuned for further clarification on this new option.

But even these multiple types of help will not be enough to spread the word about the ACA. Helping people understand and choose the right health plan, especially given the amount of misinformation in the media and elsewhere, is going to be a huge task. Nevertheless, these resources in the ACA provide a foundation to start building greater understanding of health care options to get people into the right coverage.

This post originally appeared on Health Policy Hub's the Community Catalyst Blog. 

Written by Christine Barber, Senior Policy Analyst