Texas Well and Healthy

It was a busy day for health care in a couple courtrooms today. KeepCalmStudio.com-[Crown]-Keep-Calm-And-Know-You-re-Covered

But Texans can rest assured that financial assistance is still available for the insurance they bought on healthcare.gov; their insurance hasn’t been affected; and financial help should still be available to buy insurance when open enrollment for healthcare.gov starts again on November 15th.

So what happened?

Today the D.C. Circuit Court of Appeals ruled that the Affordable Care Act (ACA) does not authorize the financial subsidies that consumers have used to buy health insurance on healthcare.gov in Texas and other states that did not set up their own online health insurance marketplaces.

A couple hours later, the 4th Circuit Court of Appeals contradicted the earlier ruling by concluding in a separate case that the subsidies are perfectly legal.

The ACA, the health insurance that over 700,000 Texans bought through the federal Marketplace, and those financial subsidies all remain untouched as the case works its way through the appeals process.

Most observers expect the subsidies will be upheld as the case moves forward.

You can follow the blow-by-blow here.

And if you’re thinking about getting health insurance on healthcare.gov when open enrollment starts again in November, you can calculate here just how much financial assistance you can receive to make sure your insurance policy is affordable.

 Written by Peter Clark, Texans Care for Children.

Just weeks away from the March 31 closing of the Affordable Care Act’s (ACA) open enrollment period for 2014, thoughts are turning to how to help the folks who will remain uninsured.  The open enrollment process has brought home to low-income Texans—and the community groups and health care providers helping them to apply—the stark reality of the Coverage Gap: the lack of an affordable coverage option for an estimated one-million-plus working-age, US citizen Texans living below the poverty line, both with and without dependent children.

As of today, 25 states are moving ahead with the ACA’s Medicaid Expansion or a state-customized alternative. Of those, 22 are using Managed Care to deliver coverage, which requires no special “waiver” approval from federal Medicaid officials.  Another three (AR, IA, MI) are closing their Coverage Gaps with managed care plus “1115 waivers,” special agreements with the federal Medicaid agency that can allow states to test out new approaches.

One more state, PA (the 26th state), recently submitted its formal 1115 waiver request to close the Coverage Gap, and negotiations will follow.

NH, UT and VA (that would make 29) are all in legislative processes around closing the Gap.  The NH Senate approved a bill to pursue a Medicaid Managed Care-1115 waiver approach and sent it on to a supportive House.

Both UT and VA adjourned their legislatures without completing the Coverage Gap conversation, but their Governors have signaled they will call special sessions to work on the issue.

Looking further ahead, ME, IN, and OK are all looking at the upcoming end dates/renewals of their Medicaid 1115 waivers, and discussions around how to maintain the successes gained from these waivers are expected to also involve consideration of Coverage Gap solutions.

Common themes: what has been approved? 

When tracking state’s Coverage Gap proposals, be sure to notice whether or not a proposed state variation has received federal approval.  For example, several states have expressed interest in requiring premiums for folks below the poverty line, but so far only premiums for individuals above poverty have gained federal approval.  Pennsylvania’s Governor originally proposed making new adult coverage conditional on participation in a job search, training and employment program, but has now altered his 1115 waiver request to include a “voluntary, 1-year, incentive-based pilot.” Neither the new optional work program nor his proposal to eliminate some Medicaid benefits for the current Medicaid population has yet been approved by the federal government.

As noted, most states are maximizing the use of HMO-style managed care, as many states now have “mature” Medicaid Managed Care sectors with the capacity to serve more adults. Arkansas got permission to enroll all of its adult expansion group in Marketplace coverage, because managed care markets were not well established for either Medicaid or private commercial insurance.  In contrast, in Texas and PA three out of four insurers who sell insurance in the new Marketplace also already have Medicaid-CHIP health plans.  Some states are seeking a combination of Medicaid Managed Care and Marketplace coverage, e.g. using Medicaid Managed Care for people below poverty and Marketplace coverage for adults from 100-138% of the federal poverty line (FPL).

Newly-covered adults can be provided a commercial-style benefit package rather than the traditional Medicaid benefit package which includes long term care.  Medicaid “alternative benefit plans” (i.e. commercial-style benchmark plans) and Marketplace plans both include the ten essential health benefits and are subject to mental health and substance abuse parity, so both provide a good standard of basic coverage.

States using the commercial-style benefits for newly-covered adults must also determine how to ensure access to federally qualified health centers, family planning providers, non-emergency medical transportation, and comprehensive care for youth ages 19 and 20.  Approved variations include Iowa’s waiver to experiment for a year with whether and how non-emergency medical transportation is provided to the newly-covered adults.

Also, states must screen for “medically frail” persons in the newly-covered adult population, to make sure those with complex medical needs retain access to traditional Medicaid benefits.

Cost-sharing for the newly-covered adults is allowed, with the majority of states following federal law and rules that exempt children and pregnant women, and set upper limits based on income-to-poverty levels. Waivers experiment with new approaches outside of the basic federal rules, including modest premiums and $10 co-pays for non-emergency ER visits, mostly targeted to the new adults who are above the poverty line.  Protections that mirror those in the Marketplace cap premiums at 2% of family income, and total combined costs at 5% of family income, consistent with federal standards.  Both MI and PA are looking at reducing out-of-pocket costs for enrollees who get check-ups or meet other wellness goals.

Flexibility—Within Limits. 

Flexibility is available to state and federal Medicaid officials, but it is not unlimited.  The part of the Social Security Act that allows 1115 waivers requires that exceptions to federal law under a waiver must “further the objectives” of the federal Medicaid law.  Some of the requests that have been turned down to date include reducing benefits for the traditional Medicaid population (as opposed to the newly covered adults). Moreover, in order to capture the 100% federal matching funds available through 2016, states may not cap enrollment and must cover the full adult coverage expansion income range (up to 138% of the FPL), not just stopping at the poverty line.

How to Keep Up?

As noted above, the landscape is changing every day. One of the most reliable and timely sources of waiver and Medicaid Expansion news is the Georgetown University Center for Children & Families “Say AAh” blog. The Kaiser Family Foundation follows waiver developments and keeps an updated tally of state actions, and this report from the Center for Health Care Strategies summarizes key recent developments in AR, IA, and MI.

Keep following the CPPP and Texas Well and Healthy blogs, too, and for a deeper dive, you can get involved in closing the Texas Coverage Gap through the Cover Texas Now coalition’s Texas Left Me Out campaign.

It’s thrilling to know over seven million people enrolled for health coverage by the March 31st deadline and will now have access Missed deadlineto quality, affordable health care. If you happen to not be one of the millions of people with a newly purchased plan, all hope is not lost. Here are a few ways you can still enroll in coverage:

  • If you began enrolling in the Marketplace before the March 31st deadline, but weren’t able to complete the application because of issues with the website, overwhelmed phone lines, or other technical issues, you have until April 15th to enroll. Visit Healthcare.gov or call 1-800-318-2596 for assistance.
  • If you qualify for a Special Enrollment Period you may be eligible to enroll in coverage. Call 1-800-318-2596 for assistance. Here are some examples of circumstances that would make you eligible to sign up for coverage outside of open enrollment:
    • A qualifying life event, which includes:
      • Loss of other health coverage
      • Change in your family size like having a baby or getting married.  Note that getting pregnant does NOT qualify you for a special enrollment period
      • Moving to a different state
    • Special circumstances or complex cases, which include:
      • An exceptional circumstance, such as a serious medical condition or natural disaster that prevented you from enrolling
      • Other examples include misinformation, victims of domestic abuse, system errors, and more. View a more comprehensive list  of special circumstances that may qualify for a special enrollment period here.
  • Though Texas leadership decided to not expand Medicaid in our state, people eligible for Medicaid (including low-income children, pregnant women, and some parents) may enroll at any time during the year. Similarly, families can apply for CHIP for their children year round.
  • If none of these options apply to you, the next open enrollment period starts November 15th.

The Supreme Court will hear arguments Tuesday on a lawsuit involving women’s preventive health care benefits guaranteed by the Affordable Care Act (aka Obamacare).  At issue is whether for-profit employers can opt out of covering contraception in their health insurance plans  if the business owner has a religious objection to birth control.  The ACA requires most health insurance to cover a full range of cost-effective and proven preventive health care services, including but not limited to, contraception.  The ACA already exempts religious employers, like churches, from the contraception requirement.

Polling finds that a majority of Americans believe that employers should not be able to opt out of including contraceptive benefits in health insurance plans.  Birth control is one of the most-used preventive health services among women.  Insurance coverage for it should be standard issue, just as recommended preventive care services for children and men are included in insurance plans.

Making sure all women have access to the tools they need to plan the timing and size of their families is a critical piece of the puzzle in building equal economic opportunity for Texans who aspire to overcome poverty, join the middle class, and enjoy prosperity.  Birth control is also critical for improving public health. Women’s preventive health care—including birth control—helps women stay healthy, have healthy pregnancies, and avoid unplanned pregnancy. Today, over half of Texas births are unplanned. When women lack the tools to plan and space their pregnancies, babies face higher risks of prematurity and low birth weight.

Despite popular misconceptions about the low cost of contraception, many women struggle to afford birth control. The most effective forms of birth control, like IUDs, have up-front costs of up to $1,000 and some birth control pills can cost $60 a month.  And even more affordable generic birth control pills require regular doctors’ office visits.  The cost of contraceptives prevents many women, especially low-income women, from using birth control consistently or choosing the best and most effective form of contraceptive for them.  The ACA’s guarantees that contraception: (1) will be covered by most health insurance, and (2) will not be subject to a copayment or a deductible, mean more women will have financial access to the tools needed to prevent unintended pregnancies and have healthier pregnancies.

The women’s preventive health care benefits under the ACA took effect in August 2012.  Since then more than 1.9 million (and counting) women in Texas have been guaranteed access to birth control coverage in their health insurance plan without an additional out-of-pocket expense.  This increased access to basic preventive health care supports women’s health, the health of babies, and family economic security.

Written by Stacey Pogue, Center for Public Policy Priorities. Cross-posted from Better Texas blog.

The Texas Department of Insurance recently finalized rules that require “navigators” to register with the state and take additional training. CPPP chronicled the changes made in the final rule and questions moving forward in a new policy page.

Navigators under the Affordable Care Act are organizations and individuals who are trained, certified, and funded by the federal government to help people enroll in coverage options through the Health Insurance Marketplace, including private insurance, Medicaid and CHIP. Insurance is difficult to understand, especially for people who haven’t had it before. Navigators provide in-person help—answering questions, deciphering plan options, and helping people enroll. Their help is crucial in a place like Texas, with more than 6 million uninsured individuals.

Changes in the Final Rule
The proposed rules for navigators proved contentious. Advocates raised concerns that the proposal would be expensive and prevent navigators from helping consumers compare the benefits of different plans in the Health Insurance Marketplace. The Texas Department of Insurance (TDI) held two public hearings on the rules and sifted through nearly 300 pages of comments. In the end, the final rule was much improved, but the aggressive timelines in the final rule present challenges for navigators and TDI alike. TDI removed the prohibition related to comparing benefits, took steps to reduce the cost of training, and clarified limits on the use of the term “navigator” (people who serve as patient navigators or cancer navigators will still be able to use the word “navigator” in their job titles without running afoul of the law).

The rule, which took effect on February 10, requires many organizations and individuals who help consumers apply for or enroll in coverage through the Marketplace to:

  • Complete registration with the Texas Department of Insurance by March 1. Navigators will undergo fingerprinting and a background check as part of registration.
  • Take 20 hours of state mandated training by May 1, 2014. This extra state training is required on top of the 20-30 hours of federal training provided to federally grant-funded navigators

Certified Application Counselors are exempt from the new rule, as are organizations and individuals who are performing application assistance under state law or federal law, other than the Affordable Care Act. The flowchart on page 6 of our report can help organizations and individuals who provide application and enrollment assistance determine whether and how they are subject to the new rule.

Update on Registration
Both navigators and the Texas Department of Insurance have been working diligently to ensure navigators come into compliance according to the rule’s very tight timeline. Some navigators reported initial challenges accessing the state’s electronic fingerprinting process. But leading up to March 1, all federally grant-funded navigator organizations report having submitted their organization’s registration materials and registration materials for most or all individual navigators as well. TDI reports quick turnaround times when processing complete applications, and TDI staff worked over the weekend of March 1-2, to help ensure applications submitted near the deadline were not held up.

Next Hurdle
TDI’s rule leaves it up to private vendors or navigators themselves to create, get certified through TDI, and deliver training to navigators statewide. The next challenge will be ensuring that training is available to and completed by navigators across the state by May 1, 2014.

Written by Stacey Pogue, Center for Public Policy Priorities. Cross-posted from Better Texas blog.

Do you want to help spread the word about the March 31st deadline enrollment? Below are resources, images, in Spanish and English, and sample tweets you can share with your networks. With only a few weeks left before the enrollment deadline, all hands on deck are needed to help connect Texans with their new health care options, and your help is appreciated and necessary. Thank you!

A list of helpful tools consumers can use to help guide them through the process of enrolling in coverage:

  • Enroll America has a Get Covered Calculator, which is free, easy to use, and provides realistic cost estimates for new coverage. If you’d prefer free, in-person application assistance, you can use the Get Covered Locator tool to find enrollment sites within 25 miles of your zip code.
  • On our website, we have a guide with helpful tips on how to protect yourself from health insurance scammers and identity thieves. Most people will not encounter any fraudulent activity, but it’s is important to be informed of the risk and of ways you can protect yourself.
  • A new resource, Financial Help for Health, features stories of people who have enrolled through the Marketplace and are saving hundreds of dollars on their monthly insurance premiums through tax credits. The website has a tool that explains the tax credit and how to use it.
  • Visit Healthcare.gov or call 1-800-318-2596 for help with the enrollment process.

Sample Tweets (Copy and paste tweets as they are, or feel free to modify them however you’d like.)

You may be eligible to receive financial assistance to pay for health coverage! Find out here: www.healthcare.gov #LetsEnrollTX

The enrollment deadline is March 31st. Connect with affordable health care options here: www.healthcare.gov #LetsEnrollTX

El 31 de Marzo es el ultimo dia para comprar un seguro medico en el nuevo Mercado. Vaya a www.cuidadodesalud.gov

¿Necesita seguro médico? ¿Califica para costos reducidos? Vaya a www.cuidadodesalud.gov o llame al 1-800-318-2596

Enrollment Deadline Images (Right click and save the images to your computer to share on social media and elsewhere.)

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In a short month’s time, the number of Texans who have selected a healthcare insurance plan through the Marketplace has increased by 57% — from 118,532 Texans in January to 207,546 enrolled in Deadline Visual 3_NewFebruary, according to a new study released this month by the Department of Health & Human Services.

This increase in enrollment was accompanied by a notable increase in the proportion of young adults (ages 18-34) who have selected a Marketplace plan. The percentage rose from 24% to 27% over the last month. Along with the age group of ages 55-64, young adults now have the highest percentage of Marketplace enrollees. According to the Department of Health & Human Services, this growth has been consistent with expectations.

Other notable characteristics of Texans who have selected a Marketplace plan included:

  • Gender
    • 56% Female
    • 44% Male
  • Plan Selections
    • 62% Silver
    • 21% Bronze
    • 11% Gold
    • 4% Platinum
    • 1% Catastrophic
      • Young adults (18-34) were the largest age group selecting this plan
  • Financial Assistance (subsidies)
    • 51% of Texans eligible to use Marketplace are also eligible for financial assistance
    • 79% of Marketplace-enrolled Texans received financial assistance
      • Increase from 74% in January
  • 21% purchased plans without any assistance
  • Medicaid/CHIP eligibility
    • 80,368 determined eligible by Marketplace

Despite increases in Texans receiving healthcare, these 207,546 Texans who have selected a health plan through Marketplace are only 35% of the 586,342 Texans who applied and were found eligible to enroll. We can only conclude there is still work to be done, much of which will begin with educating Texans about the options available to them with the Marketplace.

Fortunately, Texans have mobilized across the state, advocating for healthcare expansion and educating the public about options currently available to them. Organizers like Enroll America and partners of the Texas Well and Healthy campaign have made it their mission to help Texans find coverage and to answer questions about finding local Marketplace navigation assistance. With the number of Texans selecting Marketplace health plans increasing exponentially each month, we are optimistic that the number of insured Texans will continue to grow.

Marketplace open enrollment for 2014 is nearing its end on March 31, 2014, but passionate Texans will continue to push for education and awareness of the opportunities available through the Marketplace. When Marketplace enrollment opens again on Nov. 15, 2014, even more Texans will be ready to select a Marketplace health plan for their families.

Texas has the highest rate of uninsured in the country. With more than 4 million uninsured Texans eligible for health coverage through the health insurance marketplace—and the fact Deanne and Ken at trainingthat most of them can get help paying for coverage, due the financial assistance that’s here (which many, unfortunately still don’t know about it)—we’ve got a big job to do in Texas.

March 31st is the last day to enroll in coverage, and it’s coming up fast. So many people can get health coverage, but still so many still have no idea that this is an option for them. Roughly 120,000 Texans enrolled by the end of last year, and 3 out of 4 of them got help paying for coverage.

March 1st will kick off 31 days of a flurry of outreach. Be part of the historic opportunity to get Texans covered.  Join these trainings and you will develop your skills in outreach, learn how to talk to consumers about their options, and help make history by changing the lives of uninsured Texans.

February 22nd is Get Covered Training Day. Join us at one of the trainings below. Click on the link next to the event nearest you to RSVP.

Austin  RSVP
11:00 a.m. – 2:00 p.m.
Location: United Way
2000 E. MLK Jr Blvd
Host: Erica Gammill
Phone: 512-202-9260

Dallas RSVP
10:00 a.m.-5:00 p.m.
Location: Downtown Dallas Library
Host: Andrew Greenberg

El Paso RSVP
Multiple shifts available
Location: Enroll America office
4625 Alabama
Host: David Alexander

Houston RSVP
9:00 a.m.-1:00 p.m.
Location: Department of Health and Human Services
800 North Stadium
Host: Rosy Mota
Phone: 832-449-2534

Rio Grande Valley  RSVP
10 a.m. -1:00 p.m.
UTPA Engineering Building
1201 W. University Drive
Edinburg, TX 78539
Host: Jose Ibarra
Phone: 956-532-4194

San Antonio RSVP
10:00 a.m. 1:00 p.m
Location: Christus Santa Rosa
333 N. Santa Rosa St
Host: Edward Vargas
Phone: 210-540-0579

11:00 a.m.-3:00 p.m.
Location – West Waco Library
5301 Bosque Blvd
Host: Kelly McDonald
Phone: 254-405-2576

Written by Mimi Garcia, Enroll America. Cross-posted from Get Covered America.

According to a new report released by the National Women’s Law Center, low-income Texas women without health insurance are less likely to get basic and consistent health and preventive care services than low-income women with health coverage, underscoring the need for Texas’ leadership to expand Medicaid coverage to uninsured women below the poverty line. Without it,  women will continue to go without care, jeopardizing their overall health and well-being.

As the NWLC report highlights, over half a million uninsured Texas women below the poverty line–who make up a quarter of all uninsured women in Texas–fall into the Medicaid coverage gap and are left with no affordable health coverage option, while women living above the poverty line have the opportunity to shop for coverage in the Marketplace and get help paying for it.

As the report indicates, wide disparities exist between low-income women with and without health insurance, and these disparities will only continue to grow without expanded health coverage:

NWLC chart

In Texas, low-income women are only eligible for Medicaid if they are pregnant, have children and an income below 19 percent of the poverty line, or have a disability. So, the poor women who fall into the coverage gap created by Texas’ refusal to expand Medicaid are left to rely on a patchwork of services for care, leaving their options few and far between.

In 2011, the Texas Legislature gutted the state family planning program by cutting its funding by two-thirds, sending shockwaves throughout the state–family planning clinics scaled back their hours or closed entirely, and providers had to start charging for services that were once free. At the same time, the state fought and won to keep Planned Parenthood from offering family planning and preventive care services through the Medicaid Women’s Health Program. While the state created its own Texas Women’s Health Program absent the single largest reproductive care provider, and the 2013 Texas Legislature restored most of the money lost in 2011 by directing it to primary care providers, it’s unclear if the new system will serve as many women as before the massive cuts and whether or not there are enough providers throughout the state to perform the services. Early claims reports indicate fewer women are accessing services under the state-run program, and Sen. Jane Nelson has called an interim Senate committee hearing to assess where we are.

As the NWLC report highlights, Medicaid Expansion is one the best ways states can ensure low-income women can get the health services they need–Pap smears, mammograms, cervical screenings, etc.–and lead healthier lives.

Written by Alexa Garcia-Ditta, Center for Public Policy Priorities. Cross-posted from Better Texas blog.

Editor’s note: Clayton Travis is a volunteer with Insure Central Texas, assisting Texans with enrollment in the new Affordable Care Act Health Insurance Marketplace. CDF Health Care Kid Visual

Ava’s* second visit to the Foundation Communities’ Insure Central Texas enrollment site was when she started to really understand the opportunity of health coverage. Speaking only Spanish, she said she was there for her pre-scheduled appointment. The week before, Ava had come in curious about her health insurance options under Obamacare.  While on that first visit she had been eager to create her own personalized account and compare plans, the early glitches on the federal Healthcare.gov site had prevented her from doing so.

This time she worked directly with the volunteer staff at Insure Central Texas who answered her questions and helped her estimate what subsidies she and her husband might receive for insurance in the Health Insurance Marketplace. Healthcare.gov worked intermittently, but Ava remained resolved and pledged to come back once the site was fully functioning.  She – like many Texans – realizes the importance of health coverage for her whole family. It took a third visit, but eventually Ava was able to get covered.

The Affordable Care Act’s rollout of the Health Insurance Marketplace was marred by early technical glitches that impeded many Texans in accessing the federally facilitated portal. However, states that had opted to set up their own programs had fewer challenges. In California and New York, states that set up state-based Marketplaces, tens of thousands of residents completed insurance applications in just the first week of operation.

Texas could have been one of these examples. Instead, Governor Perry made it clear Texas would not participate in the creation of its own Marketplace, defaulting to the federally facilitated marketplace. Ava and hundreds of thousands of uninsured Texans and millions across the nation wound up all needing to use the same federal site at once as a result. An entire country’s pent-up demand for health coverage was pretty overwhelming, but the site is working today and the open enrollment period continues through March.

What has become clear is that uninsured Texans, eager to find care, remain undeterred by these challenges. The release of this month’s Health Insurance Marketplace data shows nearly half a million Texans have applied for coverage in the ACA Marketplace – 118,532 of whom have selected a plan and will have coverage starting February 1st. 74 percent of those who selected a plan received financial assistance to lower the cost of their monthly premiums. Furthermore, 47,000 Texans who applied through the new Marketplace have been determined eligible to enroll in the state’s existing Medicaid or CHIP plans.

During this critical window of opportunity, there are a few things uninsured Texans and those offering them assistance should know:

1)     The last day of open enrollment for 2014 is March 31st with coverage beginning in April. If you sign up before March 31st and in the first half of the month (1st – 15th) your coverage will begin the first day of the following month. If you enroll in the end of the month (16th – end of month) your coverage will kick in the first day of the following month.

2)     The website isn’t the only way to gain health coverage under the Affordable Care Act. The Healthcare.gov call center can help, too, and wait times are low. Families can go through the entire process of creating an account, comparing plans, and enrolling in health coverage by calling Call 1-800-318-2596.

3)     If you do use the website, allow time to compare and shop. Once you set up an account, identify the area you live in, and determine what type of coverage you are looking for, plans will be outlined by price. Then you can see various price reductions available, due to subsidies and varying coverage levels. Like Ava, you might opt to go to talk someone in your area to help walk you through the ins and outs of various plans in your price range and get you ready to purchase through the Marketplace.

Health insurance plans have never before been so clearly laid out in one place. Families can discover coverage options that will fit their needs and at an affordable price – safeguarding them against medical bankruptcy and providing financial stability and reassurance. Ava and countless Texas families know this peace of mind was worth the wait.

*Names have been changed.

 Written by Clayton Travis, Hogg Foundation Mental Health Policy Fellow for Texans Care for Children.