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Frequently Asked Questions on Healthcare Reform and Colorado ADAP

Adapted from a document prepared by the Henry J. Kaiser Family Foundation

Insurance Will everyone have to have health insurance? What happens if they dont? How will people prove they have health insurance? Starting in 2014, most people will be required to have health insurance or pay a penalty if they don't. Coverage may include employer-provided insurance, coverage someone buys on their own, Medicare, or Medicaid. Several groups are exempt from the requirement to obtain coverage or pay the penalty, including: people who would have to pay more than 8% of their income for health insurance, people with incomes below the threshold required for filing taxes (in 2012, $9,750 for a single person and $26,000 for a married couple with two children), those who qualify for religious exemptions, members of Indian tribes, undocumented immigrants, and people who are incarcerated. Medicaid or private health insurance plans will provide documents to people they insure that will be used to prove that they have the minimum coverage required by law. If I am exempt from paying a penalty, why cant I stay on Ryan White, CICP and ADAP? The federal government, which funds the Ryan White program and Colorado ADAP, says that Ryan White has to be the payer of last resort. This means that if you are eligible for Medicaid, Medicare, employer based insurance, or now insurance through the health insurance marketplace (effective January 1, 2014), you will have to sign up for it. Colorado ADAP will help you to pay for some of the costs you would otherwise have to have paid to Medicaid or private health insurance plans. Medicaid and CHIP Who will be eligible for Medicaid? Signed into law in 2010, the Affordable Care Act -ACA (also known as Obamacare) expands state Medicaid programs beginning in 2014 to cover nearly all individuals under age 65 with incomes up to 138% of the federal poverty level ($15,856 for an individual or $26,951 for a family of three in 2013). Approximately 65-70% of uninsured people who currently get their medications through Colorado ADAPs HIV Medication Assistance Program (HMAP) will move to Medicaid in 2014. The ACA establishes a uniform definition of what is counted as income, as well as what is defined as a household across all states. Undocumented immigrants are not eligible for Medicaid regardless of their income. Legal immigrants who have resided in the U.S. for less than five years are also not eligible for Medicaid, although they can buy insurance (and can get help paying for it) through the Colorado Health Insurance Marketplace, Connect for Health, Colorado. If you make more than 138% of federal poverty level (see above), skip to What is the Health Insurance Marketplace below. How is Medicaid different from CICP and Ryan White? Medicaid (for newly eligible persons) covers many more services than Ryan White and CICP does, and unlike CICP, it is considered insurance. There are many more doctors and hospitals that accept Medicaid. Under law, it has to cover 10 essential health services: Emergency services Hospitalization Maternity and newborn care Mental health and substance abuse Treatment services Prescription drugs (many more than are covered under Colorado ADAP) Rehabilitative and habilitative services and devices Laboratory services Preventive and wellness services and chronic disease management

For most people, Medicaid will take the place of CICP where they get their care. Is there a cost for Medicaid Services? Yes, there is a set fee for most services that you will receive through Medicaid. If you received a Z or N rating on CICP, you usually did not have to pay any money to get seen at a Ryan White-funded clinic. Outpatient Hospital Services - $3.00 per visit Doctors Visit $2.00 per visit Lab work $1.00 per time Psychiatric Services $ .50 per unit of service (1 unit = 15 minutes) Prescription Services (each prescription or refill) Generic drugs $1.00 Brand name drugs $3.00

What if I dont have the money to pay these costs? Colorado ADAP is starting a new program called SWAP (Supplemental Wrap Around Program) that will pay for the copays for the drugs that are currently free of charge on ADAP. Planning bodies are working on plans to help people who have trouble paying for their medical co-pays if they cannot pay themselves. For now, talk to your clinic about these charges if there is no way you can come up with the money (one less Big Mac combo a month, maybe)? What is the Health Insurance Marketplace? Almost everyone who does not qualify for Medicare, Medicaid, or insurance through their job will now have access to the Health Insurance Marketplace. This marketplace is a new organization that has been set up to create more organized and competitive markets for buying health insurance. They will offer a choice of different health plans, certifying plans that participate and providing information to help consumers better understand their options. Colorado created its own health insurance marketplace, known as Connect for Health Colorado Beginning October 1, 2013, Connect for Health Colorado will open to help primarily individuals buying insurance on their own and small businesses with up to 100 employees. The insurance plans that will be offered in Colorado will be based on three tiers or levels: Metal Tier Bronze Silver Gold Platinum Insurance Plan pays: 60% of cost of care 70% of cost of care 80% of cost of care 90% of cost of care You would pay: 40% of cost of care 30% of cost of care 20% of cost of care 10% of cost of care

In general, the bronze plans will have the cheapest premiums, and the highest out of pocket costs during the year. The platinum plans would have the most expensive premiums during the year, but you would pay less for each visit or other service throughout the year. Also, if you make less than $28,725 (single), you will also get a reduction in your out of pocket costs if you buy a silver plan. These savings make the silver plan as good as a platinum plan if you are eligible. How will the health reform law help people pay for the cost of this insurance? The new law has a lot of ways to make private health insurance more affordable that will take effect in 2014: The cost of an insurance premium: For those with incomes up to 400% of the poverty level (estimated at about $46,000 for an individual or $94,000 for a family of four in 2014) the government will pay a part of the premium for the insurance plan that you choose, based on your income. This subsidy will be paid directly to your insurance plan by the Internal Revenue Service.

Colorado ADAP will pay the remainder of your premium, but only if you buy a preferred silver plan that has been approved by the ADAP. Cost Sharing Assistance In addition to premium tax credits, people with incomes up to 250% of the poverty level (estimated at about $29,000 for an individual or $60,000 for a family of four in 2014) will be eligible for costsharing subsidies that will reduce what they will have to pay out-of-pocket for covered health services. Colorado ADAP will help pay the cost of this cost sharing after the subsidy is applied through the Health Insurance Assistance Program. What is Cost Sharing? Most insurance plans have costs that you have to pay in addition to your monthly premium. These include: A deductible, or money that you have to pay at the beginning of the year before your insurance kicks in; Co-insurance, when the insurance plan covers most of the cost (say 70%, and you would have to pay 30% yourself) A copay, or a set amount of money you would have to pay per doctor appointment or prescription drug.

Colorado ADAP will help pay the cost of these deductibles, co-insurance, and co-pays through the Health Insurance Assistance Program. The ACA law sets annual limits on what people buying insurance in the exchanges and some others will pay outof-pocket for services covered by health plans. These limits are set initially at $6,400 for an individual and $12,800 for a family. For people purchasing coverage in the exchanges that have incomes at or below 250% of the poverty level, the out-of-pocket limits will be reduced. Once an annual limit is met, there will be no more out of pocket costs for the rest of the calendar year. Who is going to help me figure this all out? If you are eligible for insurance through Connect for Health Colorado, you will work with a health coverage guide who has been trained to understand all of the various insurance plans, which doctors offices accept those plans, what medications are covered, etc. For the most part, these health coverage guides will reach out to you to set up an appointment to help you enroll in an insurance plan, or they will be available at HIV clinics, case management agencies, and enrollment events between now and March 31st, 2014. How do I get my premiums and other costs paid once Im enrolled in a plan? Once you are enrolled in a private insurance plan, you will become a member of the Health Insurance Assistance Program (HIAP). You will arrange an intake appointment with the HIAP Coordinator in your regional office and they will explain your next steps. You will be given a Ramsell HIAP prescription drug co-pay card that you will present with your new insurance card at any HIAP network pharmacy to pay for your medications. This network includes Denver Health, University, Childrens, Walgreens, and King Soopers/ City Market stores. Your HIAP Coordinator will explain how to submit bills that you receive to be paid as well. Please note that you do not have to be case managed at your regional HIAP office to receive assistance. Regional HIAP Enrollment and Assistance Sites are at: Boulder County AIDS Project (303) 444-6121 Denver Colorado AIDS Project (303) 837-1501 Northern Colorado AIDS Project (970-484-4469 Southern Colorado AIDS Project (719) 578-9092 Western Colorado AIDS Project (970) 243-2437 Ask for the Health Insurance Assistance Program Coordinator.

What protections are there in the new health reform law for people with pre-existing conditions like HIV? Starting in 2014, all health insurers will have to sell coverage to everyone who applies, regardless of their medical history or health status. At that time, insurers will not be allowed to charge more to individuals with pre-existing conditions, nor will they be able exclude coverage of those conditions from the insurance plans they sell. The law provides new protections for children with pre-existing conditions that will take effect on September 23, 2010. Insurers will not be permitted to deny coverage to children due to their health status, or exclude coverage for pre-existing conditions. How does the provision allowing young adults to remain on a parent's insurance work? The health reform law contains a provision that requires private insurers to continue dependent coverage of children until age 26. Department of Health and Human Services regulations specify that a young adult can qualify for this coverage even if he or she is no longer living with a parent, is not a dependent on a parent's tax return, or is no longer a student. Both married and unmarried young adults can qualify for the dependent coverage extension, although that coverage does not extend to a young adults spouse or children. Insurers that do not offer coverage to dependent children will not be required to offer this coverage to young adults. Regulations also state that young adults who gain dependent coverage under the health reform law cannot be charged more for coverage than similar individuals who did not lose coverage due to the end of their dependent status. Young adults newly qualifying as dependents under the health reform law must also be offered the same benefits package as similar individuals who were already covered as dependents. How will existing employer health plans be affected by health reform? Employer plans that were in place on March 23, 2010, the date the new health reform law was enacted, are referred to as "grandfathered plans" and are subject to some of the new rules but exempt from others. Beginning on September 23, 2010, grandfathered employer plans are required to eliminate any lifetime limits on coverage and restrict any annual limits on coverage, eliminate pre-existing condition exclusions for children, and if the plan provides dependent coverage, extend that coverage to adult children up to age 26. Beginning in 2014, grandfathered employer plans will be required to eliminate any annual limits on coverage, eliminate pre-existing condition exclusions for adults, and limit waiting periods for coverage to no more than 90 days. Grandfathered employer plans will not, however, be required to alter their benefits to meet the new minimum benefit standards nor will they have to limit enrollee cost sharing or provide coverage for preventive services with no cost-sharing. In order to maintain its grandfathered status, a plan cannot reduce or eliminate benefits to treat particular conditions, increase employee cost-sharing (including deductibles, co-insurance, and co-payments) above certain thresholds, reduce the employer share of the premium cost, or change insurers. Once a plan loses its grandfathered status, it will have to comply with all the new rules. What preventive services will be covered? Since July 2010, any new plans offered by employers or insurers not including so-called "grandfathered" coverage that people already have have to provide coverage for a range of preventive services, including: services recommended with a rating of "A" or "B" from the U.S. Preventive Services Task Force, immunizations recommended by the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices, and additional services for women contained in guidelines issued by the Health Resources and Services Administration (including routine mammograms for women over age 40). HIV testing is also considered a preventative service. In addition, plans are required to cover these preventive services without any costsharing for patients. Medicare How does the Affordable Care Act (ACA) of 2010 change the Medicare Part D coverage gap, sometimes called the "doughnut hole"? The ACA gradually reduces the amount that Medicare Part D enrollees are required to pay for their prescriptions when they reach the coverage gap. When the coverage gap is fully closed in 2020, beneficiaries will be responsible for paying 25 percent of the cost of their prescriptions under the standard drug benefit. Medicare Part D plans will cover 75 percent of the cost of generic prescription drugs and 25 percent of the cost of brand-name prescription drugs, in

addition to a manufacturer discount of 50 percent on brand-name drug prices for prescriptions filled in the coverage gap. What will happen to Medicare Advantage plans? The health reform law reduces payments to Medicare Advantage plans, gradually bringing them closer to the average costs of traditional Medicare. In 2011, the law froze the maximum county-level payments to plans (called "benchmarks"). In 2012, to reduce payments, based on the Medicare costs in the county relative to other parts of the country. In addition, the law reduces the amount plans are permitted to keep when bids come in below the benchmark (known as "rebates"), which achieves savings for Medicare but also reduces the amount available to plans to provide extra benefits. In 2012, some Medicare Advantage plans began to receive bonuses based on quality ratings, as the result of both the health reform law and a CMS demonstration program. The effect of the reductions in benchmarks and rebates is expected to vary across counties and by firm. Companies offering Medicare Advantage plans may respond to these payment changes in several different ways, depending on the circumstances of the company, the location of their plans and their historical commitment to the Medicare market. Plans will continue to be required to provide all benefits that are covered by traditional Medicare, but may charge higher premiums, increase cost-sharing, reduce their network of providers, or reduce "extra benefits" such as dental care or eyeglasses. The law also includes new consumer protections. Plans are subject to new rules that limit cost-sharing that can be imposed on enrollees for certain services. Medicare Advantage plans will also be required to maintain a medical loss ratio of at least 85 percent beginning in 2014, restricting the share of federal payments and premiums that Medicare Advantage companies can use for administrative expenses, including profits.

If someone age 65 or older does not qualify for Medicare, can they purchase coverage through the Marketplace and are they eligible for a premium tax credit? The number of people age 65 and older who do not qualify for Medicare is small. They include people who are not U.S. citizens or permanent residents, and those who have not worked, or do not have a spouse who worked, at least ten years in Medicare-covered employment. As long as these individuals are not undocumented immigrants, they may purchase coverage in the Marketplace. To be eligible for premium tax credits to make the coverage in the Marketplace more affordable, these seniors must have income between 100% and 400% of the federal poverty level (about $11,500 to $46,000 for an individual in 2013) and must not have access to other health coverage such as through an employer (their own or a spouses), through Medicaid, or through the military (VA or TRICARE). Seniors age 65 or older who qualify for Medicare may choose to purchase coverage in the Marketplace in addition to, or instead of, enrolling in Medicare; however, they will not be eligible for premium tax credits and must pay the full cost of the coverage. Beginning in 2014, most people, including those age 65 and older, will be required to have health coverage or pay a penalty. Seniors are exempt from this requirement if they are undocumented immigrants, incarcerated, or have religious objections. In addition, they do not have to pay the penalty if they cannot find affordable coverage (coverage that costs 8% or less of their income), they are a member of an Indian tribe, they have income below the tax filing threshold, they would have qualified for Medicaid except that their state did not expand the program, or they are determined to face a financial hardship.

For Questions related to this document, please contact your case manager, social worker, or the ADAP Helpdesk at (303)692-2783.

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