CMCS Connections

2 C M C S c o n n e c t i o n s 1 s t q u a r t e r 2 0 1 4 By Chris Hueber, CPA; Managed Care Services, St. Vincent Hospital T he most sweeping changes to our healthcare system in a generation are due to the enactment of the Affordable Care Act (ACA) of 2010. Many provisions (eliminating pre-existing c o n d i t i o n s f o r c h i l d r e n a n d extension of children up to age 26 on a parent's medical plan) have already gone into effect. The intent of the Act is to provide new coverage to individuals previously denied, o r t h o s e w h o c o u l d n o t a f f o rd coverage and expansion of Medicaid eligibility. The State of Indiana has chosen NOT to expand Medicaid at this time. Therefore, approximately 450,000 Hoosiers will remain in the gap without insurance coverage. To qualify for the Marketplace, an individual must live in the service area of the chosen Marketplace health plan, be a US citizen or national or be lawfully present* and not be incarcerated. An individual cannot be eligible for other insurance through an employer or other government program such as Medicare, Medicaid, TriCare, etc. Individuals between 100-400% of the Federal Poverty Level (FPL) will qualify for Premium Tax Credits; and those between 100-250% of the FPL on a silver plan will also qualify for cost sharing (deductible, co-pay, and co-insurance) reductions. Enrollment began 10/1/13 and runs through 3/31/14. Coverage is effective 1/1/14-12/31/14 or the first month after the premium is paid. The Act does require most individuals to have health insurance or be subject to a penalty. In 2014 the penalty is the greater of: 1% of taxable gross household income or $95. This penalty gradually increases to 2.5% of income or $695 in 2016. Individuals can pick platinum, gold, silver, and bronze products with varying amounts of costs covered by the plan or themselves. Health plans must offer the same Essential Health Benefits for all products as outlined in the ACA. These include: • Ambulatory Patient Services • Emergency Services • Hospitalizations • Maternity & Newborn Care • Mental Health & Substance Abuse Services • Prescription Drugs • Rehabilitative & Habilitative Services & Devices • Laboratory Services • Preventative & Wellness Services & Chronic Disease Management • Pediatric Service (including Vision and Dental) Fo u r h e a l t h p l a n s w i l l o f f e r Marketplace insurance for 2014 in the State of Indiana. Each plan covers specific service areas defined by counties, and does not necessarily cover the entire State. Therefore, individuals will only be able to pick health plans and products offered in the county where they reside. Health plans include: Managed Health Services (MHS), Physicians Health Plan (PHP), Anthem, and M D w i s e . M D w i s e w i l l o p e r a t e under a Delivery System model similar to their Medicaid plan. Delivery Systems include: Select Health (St. Joseph Hospital, South Bend); IU (IU Hospitals outside the Indianapolis area); and Hoosier Alliance (IU Hospitals inside the Indianapolis area, St. Francis, St. Vincent, and Eskenazi Hospitals as well as other contracted hospitals throughout the State). Both MDwise and Anthem have formed narrow networks in the I n d i a n a p o l i s a re a . A n t h e m i s contracted with only Community a n d E s k e n a z i H o s p i t a l s i n Indianapolis. This is important because members have NO out of network benefits. Therefore if an individual chooses the Anthem M a r k e t p l a c e , t h e y m u s t s e e Community or Eskenazi providers and hospitals to receive in network benefits. Otherwise, the member w i l l b e b i l l e d f u l l c h a r g e s a n d responsible for the entire bill. Providers will obtain eligibility and benefit information from the health plan chosen by the individual. Phone numbers will be on the back of the member card or accessed through health plan web pages. Drug formularies and prior authorization lists are also on these web pages for reference. The Marketplace will be a growing product in 2014 as members and providers get to know how it works and its value. Expansion will continue in 2015 with the addition of small employers and then large employers in 2017. *healthcare.gov/immigration- status-and-the-marketplace Affordable Care Act: T h e M a r k e t p l a c e i n I n d i a n a The intent of the Act is to provide new coverage to individuals previously denied, or those who could not afford coverage.

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