Navigating open enrollment in Texas: Plans, problems and tools for assisters and community organizations Dec. 12, 2014 Download the slides & materials at Start the conversation on Twitter. Use #GetCovered, #StayCovered, #EnrollmentYR2, #ACA and #HIV.

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AND DON’T FORGET TO SPEAK UP! With support from the M·A·C AIDS Fund, a team of national and state partners has established “SPEAK UP” to monitor, assess and document ACA implementation success and barriers to HIV care Through SPEAK UP we see patterns of discrimination emerging that need to be addressed, educate state and federal officials about what’s happening on the ground, advocate for change, and report back to the community Monitoring and documentation is critical to help inform and shape state and federal policy to ensure the needs of people living with HIV are addressed as the ACA is implemented To SPEAK UP!, visit:

Today’s Agenda 1.Affordable Care Act & Open Enrollment Landscape in Texas - Januari Leo, Director of Public Affairs, Legacy Community Health Services 2.Texas Marketplace Plan Analysis Carmel Shachar, Staff Attorney, Center for Health Law & Policy Innovation, Harvard Law School 3.Affordable Care Enrollment (ACE) TA Center - Molly McAndrew, Policy Manager, AIDS Foundation of Chicago

Affordable Care Act & Open Enrollment Landscape in Texas Januari Leo Director of Public Affairs Legacy Community Health Services

Texas Marketplace Plan Analysis 2015 Carmel Shachar Staff Attorney Center for Health Law and Policy Innovation Harvard Law School

Enrollment Timeline Enroll by December 15, 2014 to get coverage by January 1, 2015 Open Enrollment began November 15, 2014 and runs through February 15, 2015

Download from: Assessment Tools: Marketplace Health Plans Template Assessment Tool/Workbook

Part 1 Understanding Cost-Sharing Structures

Insurance Terms: Cost-Sharing Structures Premium: monthly fee an insurance plan charges for plan membership Advance Premium Tax Credit (APTC): money that the government pays directly to a health plan (or to the consumer at the end of the tax year) in order to reduce a consumer’s premium ___________________________________________________________________ Co-pay: a set fee a consumer pays for each provider visit, prescription refill, lab test, or other healthcare service (e.g., $10, $20, or more) Co-insurance: a percentage of the cost of the healthcare service that the consumer must pay (e.g., 30% of the cost of a provider visit or of a procedure) Deductible: a set annual amount the consumer must pay before the insurance plan pays for any of the costs of care (e.g., $2,500) Cost-sharing Subsidy (Reductions): money that the government pays directly to a health plan in order to reduce a consumer’s out-of-pocket costs (silver plans only)

Marketplace Qualified Health Plans 4 Coverage Levels Platinum Gold Silver Bronze PremiumsCost Sharing $$$$ $

Marketplace Premium Tax Credits Tax credits reduce the premium cost depending on how much income you make (sliding scale) Tax credits can be used at any plan level (bronze, silver, gold, plantinum), but not for catastrophic coverage NOTE: There is a reconciliation process at the end of the year, so it’s critical for clients to keep the Marketplace updated on any income changes Tax credits are available to those earning 100% - 400% FPL ($11,670-$46,680)

Premium Tax Credit Example Earns $16,000/year - about 140% FPL He is expected to pay about 4% of his income for premiums = $640 per year, or about $53 per month. Let’s say the second-cheapest Silver plan costs $500 per month. John’s subsidy will be: $500 - $53 = $447 per month. He can get this as a tax refund or have it paid for him each month. John

Cost-Sharing Subsidies and Out Of Pocket (OOP) Maximums Cost-Sharing Subsidies: Available for an applicant: (1) whose income is between % FPL and (2) who chooses a silver plan Includes: 1.Deductible (if any) 2.Co-insurance for in-network services 3.Co-pays for in-network services Does NOT Include: 1.Premium 2.Costs for out-of-network services IncomeOOP Max % FPL$2, % FPL$2, % FPL$5, % and above$6,600

Ryan White (RW) Payer of Last Resort for Individuals Living with HIV/AIDS Cannot be used – For “any item or service to the extent that payment has been made or can reasonably be expected to be made” by another payer Can be used – During gaps in other coverage – IF client misses open enrollment, BUT must ensure that client does not miss next enrollment opportunity – For services not covered or partially covered by other insurance. RW in TX Income Limit: 200% FPL Other Qualifications: – HIV positive – Texas state resident – Otherwise uninsured or underinsured

Part 2 Evaluating Qualified Health Plans (QHP)

How to Choose a Qualified Health Plan Pick a Coverage LevelCheck if providers in networkCheck drug formularies Check coverage of other healthcare needs Check cost-sharing for healthcare needs

The Online Marketplace Find Marketplace plans for TX residents at healthcare.govhealthcare.gov

Assessing Plans on Online Marketplace

After entering your information, a summary of available plans will appear To make it easier to find a particular plan, narrow your results by “Health plan categories” (e.g., silver) or by “Insurance companies.”

In order to fully assess a plan, you will need to review the linked documents, especially: Summary of Benefits List of covered drugs Assessing Plans on Online Marketplace Search results provide basic information, including estimates for: Monthly premium Deductible Out-of-Pocket Maximum

Assessing Plans on Online Marketplace Summary of Benefits: Provides a limited summary of plan benefits, including cost- sharing rules, referral requirements, and exclusions.

Assessing Plans on Online Marketplace List of Covered Drugs (“Formulary”): Provides a list of drugs covered by the plan. Also Provides Information Regarding: Usage Limitations (e.g., prior authorization, quantity limits, etc.) Tiering MAY NOT BE A COMPLETE LIST! If the document indicates that the formulary is not comprehensive, you may need to contact the insurer for further coverage information

Assessing Plans on Online Marketplace Use the information that you find during your assessment to fill out the Plan Comparison Chart Make sure to note any limitations to your research (e.g., full formulary not available)

Part 3 Overview of Available Qualified Health Plans

Blue Cross Blue Shield Pros – Covers most HIV medications, including single tablet regimes such as Atripla, Stribild and Complera – Covers most HCV medications, including Sovaldi Cons – Generally requires 20-30% co-insurance for HIV medications (but better than other insurers) – Most plans have high deductibles (only the Gold plans have deductibles under $3,000)

Humana Pros – Some plans with “flat” formulary structures: Humana Bronze 6300 and Humana Silver 3650 Cons – Virtually all HIV and HCV drugs are in the specialty tier – Generally 50% co-insurance for these medications – “Flat” plans have very high deductibles ($6,300 for Bronze and $3,650 for Silver)

Cigna Pros – Very few Cons – Does not cover a significant number of HIV related medications, including Humira, Enebrel, Simponi, Xelianz – Many HCV drugs “not listed” (and likely not covered), including Sovaldi and Olysio – Most other drugs at 40% co-insurance

Next Steps Forthcoming: a fuller analysis of the plans offered in Texas – Will cover more plans – Will analyze in depth the deductibles, premiums, co-payments and coverage for other services and medications On the ground assistance – Contact Carmel Shachar at with further questions

Affordable Care Enrollment (ACE) TA Center Molly McAndrew Policy Manager AIDS Foundation of Chicago

Resources, Tips, and Tools for Enrolling RWHAP Clients in Coverage

Eligibility Decision Tree

Health Care Plan Selection Worksheet

Fact Sheet: Topics to Consider When Helping People Living With HIV to Enroll in Health Care Coverage

Common Questions & Suggested Responses for Engaging Clients in Health Coverage (English)

Common Questions & Suggested Responses for Engaging Clients in Health Coverage (Spanish)

41 Plain Language Quick Reference Guide Plain Language Quick Reference Guide (English)

42 Plain Language Quick Reference Guide Plain Language Quick Reference Guide (Spanish)

Special Enrollment Periods Fact Sheet

Questions? Ask your questions using the webinar chat feature. If we don’t get to your question it will be logged and we’ll do our best to follow up!

AND DON’T FORGET TO SPEAK UP! With support from the M·A·C AIDS Fund, a team of national and state partners has established “SPEAK UP” to monitor, assess and document ACA implementation success and barriers to HIV care Through SPEAK UP we see patterns of discrimination emerging that need to be addressed, educate state and federal officials about what’s happening on the ground, advocate for change, and report back to the community Monitoring and documentation is critical to help inform and shape state and federal policy to ensure the needs of people living with HIV are addressed as the ACA is implemented To SPEAK UP!, visit: