44th Annual Arizona Rural Health Conference

AHCCCS-SB 1092 Waiver

Open Enrollment 2016-2017

Rule Changes and Open Enrollment 2017-2018

Topics today

AHCCCS-Arizona Health Care Cost Containment System

Largest insurer, 1.9 million members, $12 billion (federal + state)

Operates under a 1115 waiver (requests exemption from some federal requirements) submitted every 5 years

AHCCCS Waiver – SB1092

During the 2015 legislative session, legislators passed S.B. 1092

The waiver proposed new requirements for “able-bodied adults”

This legislation required AHCCCS to submit any unapproved waiver to CMS every March 30

Waiver information here

AHCCCS Waiver – SB1092

Waiver submitted previously had been rejected, waivers are approved at the discretion of the HHS secretary

SB 1092 elements first submitted by AHCCCS on 11/20/15 as part of the 1115 waiver submission

• Rejected on 11/30/16• Did not meet the objective of the Medicaid 1115 program

“strengthening coverage or health outcomes for low-income individuals in the state or increasing access to providers”

AHCCCS Waiver – SB1092

1. The requirement for all able-bodied adults to become employed or actively seek employment or attend school or a job training program

2. The requirement for members to verify on a monthly basis compliance with the work requirement and any changes in family income

AHCCCS Waiver Details

3. The authority for AHCCCS to ban an eligible person from enrollment for one year if the eligible person knowingly failed to report a change in family income or made a false statement regarding compliance with the work requirement

4. The authority for AHCCCS to limit lifetime coverage for all able-bodied adults to five years except for certain circumstances

AHCCCS Waiver Details

Work Requirement

Requires an eligible person to either become employed, actively seek employment (and be verified), and attend school/training for at least 20 hrs/week

Requires monthly verification of the requirements above

Requires income verification during the above employment/training verification and redetermination

Allows a one year enrollment ban if an income change is unreported or knowingly making false statements about employment requirement

AHCCCS Waiver Details

Work Requirement – Exceptions an individual who is at least 19 but attending high school full-time; sole care givers

for a family member <6 years; is receiving temporary or long-term disability benefits from a private insurer/government; Has been determined to be physically or mentally unfit for employment by a health care professional in accordance with rules adopted by the administration

AHCCCS Waiver Details

5-year lifetime limit for able-bodied adults

Begins with waiver approval (does not include previous time)

Does not include any time when:• the individual was pregnant

• the sole-caregiver for a family member < 6 years

• is receiving temporary or long-term disability benefits from a private insurer/government

• is at least 19 but attending high school full-time; Is employed full time but continues to meet the income eligibility requirements under this article

• Is enrolled before reaching nineteen years of age

• Under twenty-six years of age and who was in the custody of the department of child safety pursuant to title 8, chapter 4 when the person became eighteen years of age

AHCCCS Waiver Details

Cost-Sharing

Develop and impose meaningful cost-sharing requirements to deter both:

• The nonemergency use of emergency departments• The use of Ambulance services for nonemergency transportation

or when it is not medically necessary

AHCCCS Waiver Details

“Able-Bodied Adults”

"Able-bodied" means an individual who is physically and mentally capable of working

"Adult" means an individual who is at least nineteen years of age

Also excluded from work requirements are:• Individuals enrolled in the Arizona Long Term Care System (i.e., persons with an

institutional level of need).

• Individuals eligible for Medicare Cost Sharing (i.e., persons eligible for Medicare and Medicaid, Qualified Medicare Beneficiaries, Specified Low Income Medicare Beneficiaries, and Qualified Individuals)

AHCCCS Waiver Details

Must comply with Demonstration of Public Notice

Original bill posted on the AzLeg website

Posted for public comment here

Public notice in newspaper and online in Jan 2017

Tribal consultation, public meetings in Flagstaff, Phoenix and Tucson

Public comments submitted via email to AHCCCS, link posted on site

AHCCCS Waiver Feedback

Feedback submitted by AHCCCS with the waiver application IndividualOrganization, & Tribal comments

AHCCCS Waiver Feedback

Key Feedback:• Work requirements and life-time limits could undermine access to care

• Lifetime limits could hurt older adults

• Not good evidence that work requirements lead to employment or employment with sufficient income to get out of poverty

• Definition of “able-bodied” presents potentially burdensome requirement to be medically/psychologically assessed

• How to accurately define “able-bodied”, consideration of mental illness or cycles of physical/mental illness

• Administrative burden presented by monthly re-verification

• Caregivers for those older than 6

AHCCCS Waiver Feedback

AHCCCS current membership covers 1.9 million Arizonans

Possible impact to 242,000 over 5 years

Pending enrollment report from AHCCCS

AHCCCS Waiver Impact

Medicaid Expansion + Healthcare.gov & State-exchanges + Coverage up to 26 + Employer mandate + no exclusion for pre-existing conditions

National uninsured rate decrease from 16% to 8%

Uninsured rate decreased across all groups

Bigger improvements for poor/near-poor, Hispanic/Latino and Black/African American

Affordable Care Act Impacts

https://www.cdc.gov/nchs/data/nhis/earlyrelease/insur201609.pdf

Marketplace (healthcare.gov + state exchanges)• Total 17 million applications submitted for 23 million individuals • 15 million (65%) determined eligible, of this, 73% determined eligible

for financial assistance

National Open Enrollment Data

https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Marketplace-Products/Plan_Selection_ZIP.html

Arizona Insurance Coverage Rate

http://www.kff.org/state-category/health-coverage-uninsured/health-insurance-status/https://www.census.gov/content/dam/Census/library/publications/2014/demo/p60-250.pdfDerksen, D. Weathering the Perfect Storm Arizona’s Rural Health in Peril. July 26, 2017.

Employer Non-group Medicaid Medicare Other Public2013 44% 3% 20% 13% NA2015 41% 4% 25% 14% 3%

Insured +800,000

Uninsured2013 19%2015 11%

Big news prior to the start of OE4• “Bare” counties, &• Increased premiums (we know cost is still a barrier)

Struggle for the ACA marketplace enrollment?

Arizona Before Open Enrollment

So far the two insurers from 2016-2017 will continue to offer plans, providing at least one insurer in every county

Blue Cross Blue Shield and Ambetter/HealthNet

Arizona Open Enrollment 2017-2018

Arizona Open Enrollment 2016-2017

County Insurer Plan Type Metal Level (# plans)Apache, Cochise,Coconino, Gila,Graham, Greenlee, La Paz, Mohave, Navajo,Pinal, Santa Cruz,Yavapai, Yuma

BCBSAZ HMO Catastrophic (1), Bronze (2), Silver (1), Gold (1)

Maricopa Healthnet HMO Bronze (1), Silver (2), Gold (1)

Pima BCBSAZHealthnet

HMO Catastrophic (1)Silver(1), Gold (1)

If insurer participation remains the same

Premiums

The ACA shields against increased premium via the structure of the Advanced Premium Tax Credit (APTC)

• Eligible up to 400% FPL ($98,400 for family of 4)

• Amount received is based onThe second lowest cost Silver plan in a county

Family income

Sets a “max family contribution” then makes up the difference between the “max contribution” and the premium

Arizona Open Enrollment Data 2017-18

Average Premiums

$1,041

$611 $479

$290

$-

$400

$800

$1,200

AK WV

NC

OK

WY AZ NE TN MT AL DE

MN LA SD CT

PA IA ME IL WI

SC VT MO NJ HI

KS OR

MS

CO FL MD

GA ID IN AR OH KY VA TX MI

ND

NH NV

NM RI

UT

MA

MedianArizona

Average Premiums after APTC

$295 $199 $169 $111

$-

$400

$800

$1,200

MN

NH

WV

DE IL IN CO

OH

MD

OR NJ

CT AZ AK PA AR HI

WI

MI

KY MA LA MT

NM IA WY

ME VT ND KS ID VA SC SD NV

MO TN RI

NE TX NC

OK

MS

GA UT FL AL

Arizona Median

Average Premiums for Consumer Receiving APTC

$185 $124 $104 $72 $-

$400

$800

$1,200

MN IL NH IN OH DE

WV

AR VT MI

NJ

MD

OR KY HI

RI

CT IA WI

PA CO LA MA

ND

ME

MT

WY

NM KS SD NV AZ SC MO NE VA ID AK UT

MS

NC

GA TX FL TN OK AL

ArizonaMedian

Enrollment by Week

183236196291

0

50000

100000

150000

200000

250000

13,055

Total Applications

203,066196,291

179,445140,079

0

50,000

100,000

150,000

200,000

250,000

2015-2016 2016-2017Plan Selections Effectuated Enrollment

-19%-12%

Report from DHHS Likely that cost and insurer changes contributed to consumers ending

coverage after first month premium• Consumers with higher premiums were more likely to terminate or cancel

coverage• Consumers listed affordability as one of the common reasons for not paying for

the first month’s coverage • Disruptions in coverage options lead to fewer consumers retaining their

coverage• Consumers without financial assistance were more likely to terminate or cancel

coverage

Overall Enrollment

Connecting Arizonans to Coverage

ACA Repeal & Replace Update

Allen GjersvigArizona Alliance for Community Health Centers

How we spent our summer

Where are we???

What we know about Open Enrollment for 2018 New CMS Final Rules and how they impact consumers Qualified Health Plans How to find help

Repeal & Replace, Replace, or just Repeal?

Opportunities Outreach training Assister training

2014 AI 28.3%

Open Enrollment for 2018 Marketplace Plans

Six New Rules

1. Cutting the length of the Open Enrollment Period by half; Nov 1 – Dec 15, 2017.

2. Tightening up on Special Enrollment Periods (SEPs).

3. Requiring individuals to pay past-due amounts before they can gain coverage for 2018.

Three to impact Assisters and Consumers

#1 - From 3 months to 6 weeks

What can we do to build capacity?

How do you see as many consumers as possible in half the time?

Open Enrollment November 1 to December 15

#2 – Special Enrollment Period (SEP)

Tightening up on SEPs by strengthening the requirements that people applying during a SEP prove that they qualify (e.g., they really did get married, have a baby, get laid off).

Evidence of qualification prior to enrollment will be required.

• Upload • Mail

SEP: Pick a planWithin 60 days of qualifying event

30 days to prove SEP

eligible

How will you keep track to help your clients?

Multiple timelines; deadlines

All SEPs Are Not The Same

Some applicants will have a difficult time documenting eligibility, particularly immigrants, low-income workers, people with limited English proficiency, and residents of rural areas.

If a small employer, with no HR department, fires you -- how long will it take to get a letter from the X-boss???

What can you do to help?

#4 - Past Due Amount - Changes

Individuals who dropped out of a plan and later choose to re-enroll with the same company, may have to pay any back premiums before they can re-enroll.

Insurers do not have to apply this policy. If they do, they may accept installment payments or set a threshold of payments they will accept. AACHC has requested that BCBS-AZ and Ambetter by HealthNet

inform us ASAP.

A McKinsey study cited by HHS found that about 21 percent of consumers of individual market plans stopped premium payments at some point in 2015 and 87 percent of them repurchased plans in 2016.

Consumer Education Required

Lapse vs. Cancel

Simple Timeline

ID new partners• Build Rel.• Build on

their rails

Outreach• Media• Soc. Media• Presentations

OE5• Appts.• Limited

Outreach

Nov 1Now Sept 15

Build relationships Push the Message Fill all appointments

Statewide Scheduling

Talk to a Navigator

800.377.3536Appointments

www.coveraz.org/connector

Which Bill

Dead or Alive

Procedural Vote

Parliamentarian

Are We There Yet?

The Better Care Reconciliation ActThis is Senate Republicans' first attempt at a repeal bill, ends the Medicaid expansion and scales back the tax credits for middle-income Americans who purchase private coverage.

The Better Care Reconciliation Act 2.0After the BCRA failed, Republicans introduced an updated versionthat would allow insurers to reject Americans with preexisting conditions. The Cruz amendment, was meant to win over conservatives who wanted to deregulate the health insurance marketplace. BCRA 2.0 also kept certain Obamacare taxes on high-income Americans and created a $45 billion fund to fight opioid addiction.

Four Bills

Better Care Reconciliation Act 2.0 minus the Cruz amendmentThis version of the bill does have the Obamacare taxes and opioid funding from BCRA 2.0 but does not have the changes to the individual market (like the return of preexisting conditions). This version of the bill seems to exist solely to be scored by the CBO, which (as mentioned earlier) hasn't yet been able to score the very complex Cruz amendment.

Obamacare Repeal Reconciliation ActFinally, a bill with its own name! The ORRA was introduced on Wednesday. It repeals Obamacare without a replacement plan and is often referred to as the "repeal and delay" option.

Which Ones Will Get a Vote?

“Nobody is going to lose coverage”.

“Nobody’s going to pay more”.

“Nobody with a pre-existing condition is going to go back to being kicked around because they have an illness or a disability.”

“I’m not going to cut Social Security like every other Republican and I’m not going to cut Medicare or Medicaid.”

President Trump’s Four Promises

BRCAZero

out of Four

Your Opinion Counts

Click here to TAKE ACTION via the Health Center Advocacy Network.

http://p2a.co/59IM2Mh

Arizona ResultsReduced Uninsured

from 19% to about 11%

AHCCCS Expansion400,000+

Marketplace140,000

On Parents Ins 70,000

632,000Covered

KidsCare 22,000++

What is at risk . . .

Outreach Workshops –AugustOutreach and Marketing Staff

Assister Training – OctoberAssisters - Enrollment Staff

Planned Locations• Flagstaff• Yuma• Tucson• Phoenix

Training Opportunities