April 25 th , 2012 Stephanie Altman, Programs & Policy Director

1. How Will the Affordable Care Act Impact the Chronically Homeless and other Low Income Vulnerable Populations April 25th, 2012 Stephanie Altman, Programs & Policy Director Stephani Becker, HDA Senior Health Policy Advisor

2. Overview of Health & Disability Advocates • Based in Chicago – but state and national in scope • Lawyers, social workers and policy analysts on staff • Client Representation • Medical Legal Collaborations • Training and Technical Assistance to Community Based Providers • Policy/Advocacy (Health, Special Education, Issues impacting People with Disabilities) • Affordable Care Act implementation has been main focus of our work the past 2 years

3. Presentation Agenda • 10 – 10:15 am: Cartoon video “Illustrating the Success of Health Care Reform” • 10:15 – 11:15 am: Powerpoint Presentation • 11:15 – 11:45 am: Questions from Audience • 11:45 – 12:00 pm: Tour of IllinoisHealthMatters.org and Neighborhood Story video [time permitting] • Evaluation forms

4. Key components of Affordable Care Act • Individual Responsibility (the “individual mandate”) • Employer Responsibility (the “employer mandate”) • Create state-based “Exchanges” through which individuals and small businesses (# of employees to be determined by state) can purchase coverage. • Large Expansion of Medicaid to Childless Adults up to 138% FPL. • Significant Private Insurance Market Reforms including elimination of underwriting based on health status and ban on pre-existing condition exclusions. • Medicare Reform including Part D Donut Hole Closing

5. ACA Provisions Already In Place • IPXP: Illinois Preexisting Insurance Program at http://insurance.illinois.gov/ipxp/ • Dependent Coverage for Young Adults under Parents’ Plan up to age 26. • No pre-existing condition exclusions or denial of coverage based on health status for children. • Small Business Tax Credits available. • Insurance Rescissions are only allowed in cases of intentional fraud or intentional misrepresentation. • No Cost-Sharing for Preventive Care.

6. Essential Benefits Package: What is it? • All health plans sold through the health care exchange must cover these essential benefits at a minimum • States can use State Employee Health Plan, large insurers, or largest small group plan as benchmark package. • States have to decide on their benchmark plan by 3rd Q -2012. • Ambulatory patient services; • Emergency services; • Hospitalization; • Maternity and newborn care; • Mental health and substance use disorder services; • Prescription drugs; • Rehabilitative and habilitative services and devices; • Laboratory services; • Preventive and wellness services including chronic disease management; • Pediatric services including oral and vision care.

7. Status of ACA Litigation in Supreme Court • Supreme Court Heard the Case in March 2012/Decision in June 2012 • Can the ACA survive without the individual mandate? • Political Considerations in Congress of the “threat” to repeal and replace. • “Defunding” of Innovations Grants and other provisions. • Even if ACA is declared unconstitutional, Medicaid Managed care is an Illinois mandate, so all the work the state is doing to build electronic eligibility systems, to create quality, integrated care models and to build adequate health infrastructure will still be needed.

8. Medicaid Expansion: What is it? • In 2014, anyone up to 138% FPL is eligible for Medicaid, called “newly eligible” Medicaid. • Must be under 65, not entitled to or enrolled in Medicare A or enrolled in Part B. • Federal government pays for much greater percentage of this expansion (100% in the first three years) and Primary Care rates increased to 100% of Medicare for 2013 and 2014. • Most applications will be filed electronically through a Health Insurance Exchange. Others will be filed through more traditional methods.

9. Medicaid Expansion: Who is it? • 610,821 individuals in Illinois (13.1% of population) will be eligible for new Medicaid “Adult Group” in 2014 • Less than those who become eligible to purchase insurance through the exchange (1,036,706 with or without a premium subsidy) • Largest numbers in Cook County: 330,923 (28.3%) will be eligible for new Medicaid in 2014 • Interestingly, 42.8% in Algonquin & Grafton townships (McHenry county) and 35% in Milton and Downers Grove townships (Du Page county) of uninsured low income populations will be eligible for Medicaid.

10. Medicaid Expansion: Who is it?

11. Medicaid Expansion: Health Status of Population • Fair/Poor Health: 17.7% • Two or More Chronic Conditions: 18.2% • Limited or Unable to Work: 14.8% • More Likely to Be Childless Adults Than Parents • Likely to be healthier than nondisabled adults currently enrolled in Medicaid, but the least healthy and older individuals are among the new Medicaid expansion group and are more likely to enroll. Source: Robert Wood Johnson Foundation and the Urban Institute, The Health Status of New Medicaid Enrollees Under Health Reform, August 2010

12. Homeless Individuals – Most likely a subset of New Medicaid Group “Chronically homeless individuals are homeless repeatedly - four or more times in the past three years - or for long periods of time. They suffer from serious mental illnesses, substance abuse disorders, and physically disabling conditions. Typically uninsured, they frequently use emergency room services to address complicated health needs exacerbated by living on the streets or in shelters.” The City of Chicago reported in 2011 that 14% [of homeless population] were employed, 10% were veterans, 15% were physically disabled, 4% were HIV positive, and 20% were severely mentally ill. -National Alliance to End Homelessness - U.S. Conference of Mayors 2010 Survey on Hunger & Homelessness

14. Interactive health insurance data by regions and community areas throughout the State of Illinois A Quick Tour

15. Health Care Exchange Legislation • SB 1555 (now Public Act 097-0142) was signed into law in August 2011 by the Governor. • Created a Legislative Task Force to Recommend Implementation and Design of the Illinois Health Care Exchange. • Governance and Financial Sustainability are the major issues. • State must continue to progress toward an implementation design and then get approval for final implementation by January 1, 2013 to continue to get federal funding. • Several bills including HB 4141 pending to establish exchange board and rules; Governor may establish by Executive Order if compromise is not reached by May 31st.

16. Enrollment and Eligibility Issues in 2014 • Enrollment Procedures for Medicaid and Health Care Exchange applications online, by mail and in person • Eligibility Determinations • Roles for Community Based Providers such as clinics, permanent supportive housing providers, homeless service providers, hospitals • Navigator System

17. Providers and the Navigation Role • Navigators assist people seeking Medicaid or insurance coverage after 2014 enroll in and choose a health plan. • This is an unfamiliar process for low income vulnerable populations who have had no access to insurance. • ACA requires that Navigators must be coordinated with community based providers but could be insurance brokers. • Advocates and providers are supporting systems which use community based providers who have relationships with the populations they serve and are paid to enroll and counsel clients.

18. Going Backward Before Going Forward • Medicaid Reform Legislation passed in Illinois in December 2010 and signed by Governor • Caps AllKidsat 300% FPL for new enrollees after 7/1/2011 (grandfathers in current AllKidsenrollees over 300% FPL until 7/1/2012.) 4,000 Children Affected • Imposes new verification of residency, a potential eligibility barrier, for Medicaid. • Requires 50% of Medicaid enrollees to be in risk based coordinated care by 2015. • Moratorium on Medicaid expansions until 2013.

19. Medicaid Proposed Cuts • Governor’s Proposed Budget (April 19, 2012) – includes over $2 Billion in Medicaid cuts including: • elimination of Illinois Cares Rx; Family Care over 133%; Adult Dental Coverage; GA Medical • Will legislature vote for this budget and the legislative changes needed to eliminate eligibility and coverage? • Will ACA be able to pick up the pieces? • What damage could result in the interim? • What will be the effect on the safety net?

20. Medicaid Delivery System Changes Happening Now • Integrated Care Pilot 5 Years • Enrollment of 40,000 AABD recipients (non-dual eligibles) into managed care. • In Cook and Collar Counties with exception of City of Chicago. • Through Illinois Health Connect and managed care through Aetna and Illinicare. • Challenges with any Managed Care program: • Network issues and exception policies • Single Case Agreements and Continuity of Care

21. Managed Care and Coordinated Care • States have a wide range of delivery systems for Medicaid including fee for service, managed care, capitated HMOs and coordinated care such as primary care case management and disease management. • These are all different types of systems to pay providers and to coordinate care for recipients. • Depending upon the arrangement, Medicaid recipients may or may not be able to choose their providers or switch providers easily. • State embarking on Care Coordination Entities and expanded managed care . • Cook County Waiver Pending.

22. Questions From Group • How will the Affordable Care Act (ACA) benefit individuals who are homeless and uninsured? • How will the (ACA) impact persons who are currently insured? • Does the ACA have a sliding scale component - or is this closer to "Universal Healthcare?" • What are the limits of the ACA? (e.g.: Are there any procedures/tests/treatments that people will not be able to receive - even when recommended by a physician?) • How often will eligible individuals be able to access services, as a result of the ACA? • Others?

23. What is IllinoisHealthMatters.org? Mission of IHM: • To help Illinois individuals, small businesses, policymakers and community organizations understand and benefit from improvements and access to health care under national health care reform.

24. Illinois Health Matters – a way to organize and mobilize • Find HCR resources: Helpful for grant writing, program development, client questions • Ask HCR questions: Your Questions/Answered. Submit questions to our experts, we will feature on website • Read blog posts…or become a guest blogger! Good way to communicate your story or advocate for your cause – we promote to social network • Share “Neighborhood Stories” How is health care reform impacting real people? • Find out about local HCR events/webinars: Publicize your events or find out about other events • Connect with others about HCR: Engage with us on Facebook/Twitter/YouTube/LinkedIn to amplify message

25. Under-represented multimedia accounts of impact of health care reform on the South and West Sides of Chicago Neighborhood stories

26. Questions? About Illinois Health Matters? Or Health Care Reform? • Ask us: • Stephanie Altman, Programs & Policy Director saltman@hdadvocates.org312.265.9070 • Stephani Becker, • IHM Project Director and Senior Policy Advisor sbecker@hdadvocates.org312.265.9072