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Health Reform and
Health Coverage:
Changes Ahead for Kids and Families
Kim VanPelt
St. Luke’s Health Initiatives
September 16, 2013
Coverage Expansion
The “Exchange”
Medicaid Expansion
• Over 300,000 Arizonans will benefit
• Provides coverage up to 138% of the federal poverty level
(approximately $32,500 for a family of four)
• Supported by the Governor, passed by the Legislature
• Restores the will of the voters
• Approximately 60 percent of voters support restoration or
• Eligibility screening begins in October, coverage begins on January
1, 2014
Improvements to Coverage
• Prevents discrimination in pricing based on preexisting conditions
• Essential benefits chosen by Arizona allows for
coverage of many services
• Those who have self-insured or grandfathered plans
will not benefit from essential benefits, elimination
of cost-sharing
Essential Benefits
Emergency services
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
Chronic disease management
Pediatric services, including oral and vision care
Essential Benefits
• Arizona picked state employee plan,
administered by United Health Care, as
• www.cms.gov/CCIIO/Resources/DataResources/Downloads/arizona-ehbbenchmark-plan.pdf
The Marketplace
• Exchange now called the Marketplace
• Arizona deferring to the federal government to run
• Online site for individuals and small businesses to compare
and purchase health coverage
• Intended to simplify and structure health insurance choices
for individuals, families and small businesses
• Exclusive mechanism for receiving federal subsidies and
plans with cost-sharing limits
The Marketplace
• Open enrollment begins October 1
• Open enrollment will occur through the end of
• 1.3 million Arizonans predicted to eventually
receive coverage through the marketplace
The Marketplace
Expected Enrollment by Type
• Individual Exchange:
• AHCCCS (assuming Medicaid expansion):
Plan Levels of Coverage
Level of Coverage
Plan Pays on Average
Enrollees Pay on Average
(In addition to the
monthly plan premiums)
Catastrophic Plans
• Eligible to adults under 30 years of age
• Also available to those who obtain a hardship
waiver from the marketplace
• Includes plans with high deductibles, lower
• Includes coverage or three primary care visits and
preventive services
Premium Subsidies
• Tax credit is advanceable or refundable
• Eligibility is based on
Projected household income and family size
100 – 400% FPL ($23,550 -$94,200 for a family of four in 2013)
Obtaining qualified coverage through the marketplace
Ineligible for government-sponsored coverage, affordablesponsored insurance, or certain other minimum essential
• Tax credits available to immigrants who are lawfully present
Cost Sharing Reduction
• Eligibility for reduced cost sharing is based on
– Incomes at or below 250% of FPL ($58,875
annually for a family of four in 2013)
– Receiving the new premium tax credit
– Enrolling in a marketplace silver-level plan
– No cost sharing for members of Tribes
Individual Mandate
• Beginning in 2014, most people must have
health coverage or pay a fee when you file
your tax return
• Some people may qualify for an exemption
Cover Arizona
• Builds off of the successful outreach efforts for the Pre-Existing
Conditions Insurance Pool
• More than 300 members
• Two goals:
– Maximize enrollment of individuals and families in the new insurance
marketplace and Medicaid
– Identify and assess outreach efforts so that we can build on our
Local Action Needed to Ensure Success
• Awareness
• Outreach
• Enrollment Assistance
Enrollment Assistance
• Navigators
• Certified Application Counselors
• Toll Free Hotline
• Brokers
Special Issues for Kids and Families
• Members of the same family may qualify for
different programs
• KidsCare II disappears in 2014
• Businesses may begin dropping family
Two Doors
• Health E Arizona Plus
• Marketplace
• August – Navigator grants awarded
• August – September – Navigators and certified enrollment assisters
• October – Determination of which plans will participate in the
• October - Open enrollment in the exchange begins
• October - Media campaign begins, driving people to Healthcare.gov
• January 1, 2014 – Coverage purchased through exchanges takes
Need more information
• www.healthcare.gov
• Marketplace Call Center (Consumers) - 24/7
English and Spanish and 150 Languages 1-800-3182596, 1-855-889-4325 (TTY)
• www.marketplace.cms.gov
• www.coveraz.org

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