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

ObamaCare Is Here – But Is It Working for People with HIV?

Read AFC's CountyCare report and press release. 

On January 1, 2014, national health care reform will kick into high gear, providing new health insurance options for millions of people across the country. And thanks to visionary leadership from Cook County Board President Toni Preckwinkle, Cook County Health and Hospitals System Board CEO Dr. Ram Raju, and the Obama administration, the Affordable Care Act (ACA) is already being implemented in Cook County in the form of CountyCare.

This new program implements a provision of national health care reform that allows states to expand Medicaid programs to cover most low-income adults. The federal Center for Medicare and Medicaid Services (CMS) granted Cook County permission to implement the program in October 2012. Previously, as many as 250,000 Cook County residents were excluded from Medicaid because they did not meet the program’s restrictive eligibility requirements, such as being totally disabled. The AIDS Foundation of Chicago (AFC) estimates that 1,800 or more Cook County residents with HIV could benefit from CountyCare.

While CountyCare is a sign of great things to come, it also provides some critical lessons that can be applied later this year when health care reform rolls out statewide. AFC recently released a new report, CountyCare & the Ryan White Program: Working Together to Optimize Health Outcomes for People with HIV, that details the importance of CountyCare and the role it can play in improving access to health care for HIV-affected individuals. It also contains a number of policy recommendations for the city and state departments of public health, Cook County, and the federal government that aim to improve the program for people with HIV and avoid problems in the future.

The most significant issue with CountyCare for people with HIV is that nine HIV clinics  in Chicago are excluded from the primary care network. As a result, 500 or more patients with HIV could be forced to switch doctors to receive care at a clinic that’s already enrolled.

Many low-income people with HIV have connections to the health care system that are tenuous at best. They are facing not just HIV and its paralyzing stigmas, but also homelessness, mental illness, substance use, and chronic physical health conditions, such as diabetes and heart disease. Large numbers live in violence-plagued communities in Chicago, where a trip to the corner store can mean getting caught in turf-war crossfire. In such contexts, HIV care is the last thing on a person’s mind, and something as simple as having to find a new doctor can cause them to drop out of medical care entirely.

Delayed or disrupted health care harms people with HIV and also worsens the health of our communities.  People who are not taking HIV medications face a far greater risk of transmitting HIV to their partners. In fact,research shows that people whose HIV is controlled with medications have a 96 percent lower risk of transmitting HIV to their partners.

If those nine clinics are unable to join the CountyCare network, their HIV-positive clients will be forced to switch to new health care providers. The federal Ryan White Program, which subsidizes medical care for low-income uninsured patients with HIV, is mandated by law to be the payer of last resort, tapped only when people have exhausted all other sources of coverage. In fact, federal law prohibits clinics from serving patients with Ryan White dollars if their insurance could be used. Thus, people with HIV are caught in a bind: They are required to apply for all insurance for which they are eligible, but if they enroll, they might be forced to leave their current health care provider of choice.

The Ryan White Program’s payer-of-last-resort provision is a double-edged sword. Despite being a resource for people without coverage, it has the potential to disrupt existing doctor/patient relationships, something all of us – and especially people with chronic, complex health conditions like HIV and other co-occurring diagnoses – want to avoid.

Such potential disruptions occur because different federal government entities routinely drop the ball in coordinating and communicating their strategies. One of the lessons we have learned as we prepare to implement health care reform nationwide is to closely monitor the interactions and implications of various programs.  We cannot rely on the federal government to communicate across or even within agencies. Sustained advocacy and vigilance will be needed as health reform kicks off.

So what are other lessons we are learning from the CountyCare rollout, and what can we do to avoid situations like this in the future?

It’s clear that the transition to new health care reform programs will be slower than we want. Case managers and other staff at community clinics are already overwhelmed by the flood of clients they see every day; it will be challenging to help thousands more people apply for new ACA programs, connect them important resources, and ensure they’re receiving optimal HIV care. New federal funding for ACA enrollment staff will hopefully help with this task.

Moreover, the HIV community needs to better prepare itself for health reform programs. Most importantly, clinics should aggressively reach out to new Medicaid and private insurance programs to make sure they are part of these new programs, and the insurance companies must do their part and enroll HIV clinics in their networks.  Clients can’t be stripped of medical options because their doctor doesn’t accept their insurance.

Establishing the right enrollment and service systems under CountyCare is paramount for people living with HIV. We have a unique opportunity to improve health care access and services for individuals with this disease. Getting this right is imperative, so we can learn from this rollout and help tens of thousands of other Illinoisans affected by HIV, who will have new insurance options in 2014 when the ACA goes into full swing.

The new report from AFC also details recommendations for service organizations, case managers, government officials, and people with HIV, so that all can take full advantage of CountyCare. It’s available at www.aidschicago.org/countycare.

David Ernesto Munar
AIDS Foundation of Chicago 

(This post was originally published on the AIDS Foundation of Chicago blog). 

Illinois Senate Moves Towards Passing State Based Health Insurance Marketplace

In passing HB3227 (formerly SB34) today, the Illinois Senate took a major step in establishing a state based health insurance marketplace that helps small businesses and individuals in Illinois.

State Senator David Koehler (D-46 Peoria), chief sponsor of SB34 (now contained in HB3227) commented after the vote, "I am pleased that a super majority of my colleagues in the Senate voted for Illinois to establish its own state health insurance marketplace. Expanding help and providing a voice for small businesses and individuals who will be utilizing the new Illinois Health Insurance Marketplace is the intention of the Affordable Care Act, and I am proud that the Illinois Senate has made that commitment."

Brigid Leahy, Director of Legislation at Planned Parenthood of Illinois, said, "If we're running things at the state level, we can fix things, we can make them better, we have better control over making sure that it works for consumers. If it’s in the hands of the feds, we don’t have that power."

HB3227 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.

Speaking on behalf of the Illinois Public Health Association, Tom Hughes said, "The diversity of this board will best represent the population of Illinois and protect consumers in the new marketplace."

HB3227 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.

Jim Duffett, Executive Director of the Campaign for Better Health Care, said, "This historic vote by the Illinois Senate today shows the Senate's commitment to Illinois small businesses and individuals who will be eligible for the new Illinois health insurance marketplace. When fully implemented nearly 1.2 Illinoisans will be utilizing this marketplace. HB3227 will provide small businesses and consumers a direct voice in developing and implementation a State Based Marketplace that meets the needs of Illinoisans. Now it is up to the Illinois House to show their commitment and support to small businesses and individuals, and to President Obama's Affordable Care Act."

ADDENDUM
HB3227 Fact Sheet

Media Contacts:

Jim Duffett, CBHC Executive Director
217.352.5600 office / 217.840.5850 cell

Kathleen Duffy, CBHC Communications Director
312.913.9449 office / 773.934.4754 cell

Immigrant Health Care Access & The Affordable Care Act

A recently released report entitled “Affordable Care Act Implementation in Illinois: Overcoming Barriers to Immigrant Health Care Access” demonstrates the need for a culturally competent market place and navigator program that will cater to the complex needs of the immigrant population of Illinois. Luvia Quiñones of the Illinois Family Resource Program and Abdelnasser Rashid of the Illinois Immigrant Integration Institute collaborated on the report. They address the following questions:   

Who are the uninsured immigrants in Illinois?

• Illinois is home to 1,754,808 immigrants. 45% are naturalized U.S. citizens and 55% are either Legal Permanent Residents, (LPR’s), or undocumented. Of the immigrant population:
  
  • 77% are Latino 
• 16% are White
• 11% are Asian
• 30% of the total uninsured population in Illinois is comprised of immigrants. 

  How will the uninsured immigrant population benefit from the ACA?

•  48% of the immigrant population will be eligible for coverage in the state of Illinois.

What are the current and future barriers immigrant families face while trying to access health and human services?

1. Language, literacy and cultural barriers, (Illinois has the 5th largest limited English proficiency population in the country).
2. Complexity of application process and of eligibility rules
3. Logistical and Public Education Challenges  
4. Administrative burdens, (many cases are left open as agencies wait to determine the legal status of a client).
5. Limited computer proficiency
6. Climates of fear and mistrust (particularly common among mixed status families, which comprise around 25% of all immigrant families in the U.S). 

How can IL best serve and enroll the maximum number of uninsured immigrants through the marketplace?

The report highlights the strategies already employed by the Immigrant Family Resource Program, (IFRP). IFRP subcontracts with 37 community organizations that work with immigrant populations, and over the past 13 years has worked to improve the lives of over 425,000 immigrants and refugees by:

• Ensuring that a diverse population of immigrants are able to connect to services through the capacity to communicate in 45 languages,
• Collaborating with community members and state staff to clarify what documents are required for assistance and insurance program applications, AND 
• Engaging trusted community organizations already frequented by immigrant populations and educating them on pertinent issues.

Incorporating these strategies into the Illinois health insurance marketplace will be instrumental in reaching the immigrant population in Illinois.

Click here for coverage of the report in last week’s Tribune!

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