The following is the background research and content for a presentation given at the AIDS Education Month Prevention and Outreach Summit at the Philadelphia Convention Center. It updates this blog after a long hiatus.
Goal: To give an overview of how Obamacare (ACA) is impacting Philadelphians living with HIV and what is likely ahead for those in HIV treatment in Pennsylvania.
The ACA is complicated legislation and there is a need for presentations like this one to help ensure people understand these new health care coverage options and to provide eligible individuals assistance to secure and retain coverage.
The Current System: The ACA is helping Philadelphians by 1) expanding coverage and 2)new patient protections. So far, the expanding coverage has been through The Health Insurance Marketplace.
For this last open enrollment, you were eligible to by Health Insurance if you made over:
$11,670 for individuals
$15,730 for a family of 2
$19,790 for a family of 3
$23,850 for a family of 4
Through the Health Insurance Marketplace Pennsylvanians can compare qualified health plans, get answers to questions, find out if they are eligible for lower costs for private insurance or health programs like Medicaid and the Children’s Health Insurance Program (CHIP), and enroll in health coverage.
At the end of the first annual open enrollment period, enrollment in the Marketplace surged to eight million people nationwide. In Pennsylvania alone, 318,077 individuals selected a Marketplace plan.
Of the Pennsylvanians who selected a plan:
54% are female and 46% are male;
33% are under age 35;
73% selected a Silver plan, while 8% selected a Bronze plan; and,
81% selected a plan with financial assistance.
Although open enrollment for 2014 coverage is over, the next open enrollment period begins on November 15, 2014 for coverage that can begin as early as January 1, 2015.
Pennsylvania has received $35 million in grants for research, planning, information technology development, and implementation of its Marketplace.
Unlike the Marketplace that has an open enrollment period and special enrollment throughout the year, enrollment in Medicaid and CHIP is open year round. An additional 40,988 Pennsylvanians enrolled in Medicaid and CHIP through the end of March 2014, compared to enrollment before the Marketplace opened October 1, 2013. To find out if you are eligible for Medicaid or CHIP visit HealthCare.gov or CuidadoDeSalud.gov if you prefer Spanish.
Under the health care law, if your plan covers children, you can now add or keep your children on your health insurance policy until they turn 26 years old. Thanks to this provision, over 3 million young people who would otherwise have been uninsured have gained coverage nationwide, including 91,000 young adults in Pennsylvania.
As many as 5,489,162 non-elderly Pennsylvanians have some type of pre-existing health condition – including people living with HIV, as well as 656,877 children. Today, most insurers can no longer deny coverage to anyone because of a pre-existing condition, like asthma or diabetes, under the health care law. And they can no longer charge women more because of their gender.
Health insurance companies now have to spend at least 80 cents of your premium dollar on health care or improvements to care, rather than administrative costs like salaries or marketing, or they have to provide you a refund. This means that 123,581 Pennsylvanians with private insurance coverage benefited from nearly $7 million in refunds from insurance companies in 2012, for an average refund of $77 per family covered by a policy.
In every State and for the first time under Federal law, insurance companies are required to publicly justify their actions if they want to raise rates by 10 percent or more. Pennsylvania has received $5,312,084 under the new law to help fight unreasonable premium increases. Since implementing the law, the fraction of requests for insurance premium increases of 10 percent or more has dropped dramatically, from 75 percent to 14 percent nationally. To date, the rate review program has helped save Americans an estimated $1 billion.
The law bans insurance companies from imposing lifetime dollar limits on health benefits – freeing cancer patients and individuals suffering from other chronic diseases from having to worry about going without treatment because of their lifetime limits. Already, 4,582,000 people in Pennsylvania, are free from worrying about lifetime limits on coverage. The law also restricts the use of annual limits and bans them completely starting in 2014.
What does all this mean to Pennsylvanians living with HIV?
It depends on what your insurance status was before ACA implementation.
1) If you had private insurance, it might have given you an option to buy into the Health Insurance Market place if your plan cost too high a percentage of your income or your plan didn’t have minimum Essential Benefits. However, most people kept their private plans.
2) If you already had Medicaid, the ACA doesn’t impact you directly very much.
3) If you had Medicare, the ACA is progressively closing the “donut hole” in drug benefit coverage. In 2013, people with Medicare in the “donut hole” received a 52.5 percent discount on covered brand name drugs and a 21 percent discount on generic drugs. And this will continue to increase until there is no more “donut hole.”
4) The biggest change is if you were uninsured and working. The Health Insurance Marketplace is a historic opportunity to get heavily subsidized health insurance.
5) Now, many Pennsylvanians who have SPBP believe they had health insurance, but it only covers medications and labs. The HIV clinics cover their cost of services, but this leaves you without coverage for hospital stays, specialty care, home health, and many other important services.
6) One of the biggest changes is directly to HIV clinics themselves. While this might not seem like it directly impacts patients, if you like your HIV clinic and you want to keep going there- this does impact you. While the elaborate complexities of HIV Clinic funding is beyond the scope of this talk, I’d like to talk a little about how the ACA will likely impact HIV Clinics. Some have argued that the ACA renders the Ryan White Program redundant because “everyone” has health insurance, while others, including Neeraj Sood and colleagues, urge continuation of the program because of the proven benefit of its wraparound approach to care for people living with HIV/AIDS. Reauthorization of the Ryan White Program has been stalled in Congress since the latest funding measure expired in September 2013.
7) Finally, if you are uninsured , don’t work, and are currently ineligible for Medicaid, you could be eligible for Medicaid if Pennsylvania leadership allows the ACA to expand Medicaid. Part of the expansion is also simplification: eligibility criteria would be simplified down only to income level and not the current system of categories.
Pennsylvania Governor Tom Corbett has consistently refused to expand Medicaid in the Commonwealth and proposed a plan called Healthy Pennsylvania, which has some similarities to an Arkansas plan that was accepted. Because Healthy Pennsylvania, unlike the Arkansas plan, contained provisions that created more restrictions on current Medicaid recipients, the Obama Administration rejected Healthy Pennsylvania. The Governor offered to amend Health Pennsylvania so that it no longer includes the restrictions on current Medicaid recipients and there is wide speculation that the amended plan will be accepted in the Summer of 2014. In the absence of expanded Medicaid plans in Pennsylvania, Pennsylvanians under 100 percent of Federal Poverty Level (FPL) do not have increased access to health care at this time. Also, Pennsylvanians between 100 and 133 FPL are not eligible for Medicaid at this time.
Under the ACA, individuals with incomes between 100 to 400 percent Federal Poverty Level (FPL) may be eligible to receive advance payments of premium tax credits and/or cost-sharing reductions to help pay for the cost of enrolling in qualified health insurance plans and for coverage of essential health benefits.
Increased access to insurance : Open Enrollment and Special Enrollment Periods
We’ve worked with patients who have said they can’t buy through the Health Insurance Marketplace because Open Enrollment has closed. Fortunately, there are many reasons you can buy through the Marketplace throughout the year. We will quickly run through the reasons you can quality for a Special Enrollment Period.
Did you or anyone in your household lose health coverage in the last 60 days OR do you expect to lose it in the next 60 days?
Examples of coverage loss that qualify you for a special enrollment period (voluntarily giving up coverage does not qualify you for a special enrollment period):
Lost coverage due to divorce
Policy or plan year ended for policy you bought yourself
COBRA coverage expired
Turned 26 and aged off a parents health plan
Lost eligibility for Medicaid or CHIP
Did you or anyone in your household experience any of the following in the past 60 days?
Had a baby
Adopted a child or had a child placed for foster care
Death of person whose insurance you were on
Moved to a new address
Had a change in income
Gained citizenship or lawful presence in the U.S.
Released from incarceration (prison or detention)
Are you a member of a federally recognized tribe, or an Alaska Native?
Existing coverage gap: The (controversial) Individual Mandate.
The ACA requires people to carry health insurance only if it is affordable. If worker premiums for adequate employer-sponsored coverage cost less than 9.5% of household income, insurance is deemed “affordable.” Employed workers with an offer of such affordable coverage do not qualify for tax credits through the health insurance exchanges. The administration found, to its dismay, that the law bases affordability on the premium for single-worker coverage, even for workers with dependents whose premiums are higher.
The ACA provides a new tax credit to help you afford health coverage purchased through the Marketplace. Advance payments of the tax credit can be used right away to lower your monthly premium costs. If you qualify, you may choose how much advance credit payments to apply to your premiums each month, up to a maximum amount. If the amount of advance credit payments you get for the year is less than the tax credit you’re due, you’ll get the difference as a refundable credit when you file your federal income tax return. If your advance payments for the year are more than the amount of your credit, you must repay the excess advance payments with your tax return. (This is called premium tax credit.)
Philadelphia needs to help the formerly incarcerated.
Compared with the general public, people who populate jails—disproportionately male, minority, and poor—have higher rates of communicable diseases such as HIV/AIDS; tuberculosis; mental illnesses and substance abuse disorders; and chronic conditions, including asthma, diabetes, and hepatitis B and C. Regardless of where these people reside, it is important that their conditions be treated, particularly because currently 95 percent of them return to the community without coverage.
If Medicaid expansion occurs in PA, the ACA will offer coverage to people released from jails by reducing the financial barriers through Medicaid expansion (in twenty-six states thus far) and subsidized insurance through exchanges.
The ACA does not change Medicaid’s prohibition on paying for eligible services while people are incarcerated; once jailed individuals are released, benefits could accrue to those who are eligible and enroll. Some researchers estimate that 25–30 percent of people released from jails could enroll in Medicaid in expansion states and that about 20 percent could enroll in an exchange, depending upon their reported income. But this will occur only if correctional facilities and community providers work more closely together. Fortunately, there are several initites to do just this for Pennsylvanians living with HIV/AIDS.
Protections for Pre-existing conditions like HIV
The ACA prevents health insurance companies from raising rates or denying coverage because of a pre-existing condition like HIV/AIDS, cancer, or mental health concerns – or because they happen to be LGBT.
Thanks to the ACA, insurance companies can no longer impose a lifetime limit on coverage. This is particularly important to HIV/AIDS patients, and anyone else who have a chronic condition.
The landmark civil rights provision, Section 1557 of the ACA, prohibits discrimination against individuals based on sex, which includes discrimination based on sex stereotyping and gender identity. While implementing regulations are being drafted, HHS is accepting complaints and enforcing the law.
Insurance companies are prohibited from discriminating against individuals on the basis of sexual orientation or gender identity, including against same-sex spouses with respect to an offer of spousal coverage. So it is now illegal for insurance companies that offer coverage to discriminate on the basis of sexual orientation or gender identity and legally married couples are treated equally when it comes to coverage and financial assistance.
Prior to implementation of the ACA, dollar caps on annual and lifetime coverage led to huge bills and crippling debt – or the inability to get care when it was most needed — for many individuals with chronic conditions such as HIV/AIDS. Now, lifetime and annual dollar caps are a thing of the past and no one can be denied coverage based on their health history.
Mental health and substance abuse parity
The ACA increases access to comprehensive coverage by requiring most health plans to cover ten essential health benefit categories, to include hospitalization, prescription drugs, maternity and newborn care, and mental health and substance use disorder services. The health care law expands mental health and substance use disorder benefits and federal parity protections for 62 million Americans nationwide, including 2,260,075 Pennsylvanians.
For this to change, however, we need your advocacy. Specific people who have been denied behavioral health services need to be willing sue insurers in PA for this law to be effective in Philly. Please email this author at firstname.lastname@example.org if you have been denied services.