A Guide to the Affordable Care Act A Brief outline of choices of health care with emphasis on people with HIV/AIDS

Erik Walton *This information was updated on 9/29/2013

Table of Contents

Introduction ......................................................................................................................................................3 Flow Chart ........................................................................................................................................................4 If you are employed and have health insurance ...............................................................................................5 What Ryan White Will Still cover .................................................................................................................5 If you are uninsured and make more than $15k ..............................................................................................5 OA-HIPP ......................................................................................................................................................5 If you are Medi-Medi (Medicare/Medi-Cal) ......................................................................................................6 Cal Medi-Connect.....................................................................................................................................6 Medicare Advantage Options ...........................................................................................................................6 Opting Out Keeping your Medicare ........................................................................................................7 Assignment of Benefits if you keep your Medicare...........................................................................................8 Medicare/Medi-Cal differences ........................................................................................................................9 Full Scope Medi-Cal (Income less than 15k a year) ......................................................................................... 10 HMO Choices for San Diego County .......................................................................................................... 10 Veterans and the Affordable Care Act ............................................................................................................ 11 In Conclusion .................................................................................................................................................. 13 Important Phone Numbers and web sites ................................................................................................. 13 Source Material & Affordable Care Act information Websites ....................................................................... 14 Covered California FAQs ................................................................................................................................ 16 San Diego Insurance Marketplace Contact Information ............................................................................. 16 Definition of Terms ......................................................................................................................................... 19 People With Medicare and the Health Insurance Marketplace FAQs Handout from the US Department of Health and Human Services............................................................................................... 24

Introduction
Ive had a great deal of experience with health care issues. I am 25+ years POZ and have been a Peer advocate for over 5 years now. Im not an expert, Im just relaying information that I have researched, and experienced dealing with insurance and benefits over the years. This affects me as much as you, so thats why Ive taken the time and effort to prepare this. Having been through the maze of public programs over the years, Ive learned how to problem solve many iss ues and difficulties. I had the good fortune of having two people who inspired me to become a peer advocate counselor, John Kehoe, who was a Peer Advocate who helped me when I first came to San Diego In 1997, and Debra Burl, who was my case manager for many years, and literally saved my life. I watched, learned, took notes and most importantly, I asked a lot of questions! I vowed that I follow in their footsteps and would pay it forward, so here it goesThis health care law isnt the best that it could be but its a start. I hope this information helps alleviate some doubts and questions! Knowledge is Power!! (P.S. - if you have any comments, or things you would like me to add or correct, please e-mail me: erikwalton@hotmail.com)

Note: This is a dynamic document. I have had to revise this at least ten times already since June when I started compiling this information, due to changes that have been implemented since then and are ongoing. There are still many issues that need to be decided on, and are in negotiation between the Federal Government and the State of California The Date on the front and on the flow chart will be the date of the last revision! E-mail me for updates.

Copyright 2013 Erik Walton

FLOW CHART OPTIONS FOR HIV/AIDS HEALTH CARE UNDER THE AFFORDABLE CARE ACT: 9/29/2013

Here in this booklet I have outlined the situations under which most people find themselves, and what your choices are under the new Care Act. The flow chart on the previous page is designed to help you out with the process. (Remember this is subject to change, as things are changing just about daily.)

If you are employed and have employer paid health insurance:

Your access to health care will not change. Subject to the same regulations as outlined here: https://www.healthcare.gov/how-does-the- health-care-law-protect-me/ For coverage gaps, i.e., things that you may need that may not be covered, Ryan White and ADAP will still be in effect.

NOTE: ADAP AND RYAN WHITE ARE NOT GOING AWAY!

What Ryan White will continue to cover: ADAP-Medication Co-Pays Some Dental, depending on budgeting OA-HIPP Premiums Medical care will be rolled over into expanded Medi-Cal coverage

*Ryan White is still the payer of last resort. A great deal will depend on how Congress votes when renewal comes up on September 30 2013. You can call the California office of AIDS (I will provide a list of important resource numbers at the end of this document) if you have questions.

If you earn between $15,001 and $44,680 and do NOT have insurance:
This is a quite a bit more complicated. You will be required to purchase insurance on an exchange. You will be able to buy a Qualified Health Plan through Covered California, the new state insurance marketplace. You will also be able to get help from the Office of AIDS to pay for your insurance premiums if you meet the income criteria for ADAP. OA-HIPP will be continuing to pay insurance premiums and you are still eligible if you meet the above income requirements. They will still pay insurance premiums for newly enrolled people with HIV and possibly help out with some co-pays in the future.

Important to note: Make SURE your doctors and specialists are covered under the plan you choose. You can ask them which ones they plan to join. Enrollment period is October 1, 2013 and ends January 1, 2014. It is important you enroll during this time. There are basically four different tiers of coverage: Bronze: 60% coverage, (you pay 40% of costs) Silver: 70% coverage, (you pay 30%) Gold: 80% coverage, (you pay 20%) Platinum: 90% coverage, (you pay 10%) You also pay according to your age, your county and income level. Yup, its complicated. (See Covered California FAQs on page 16) Take your time and make sure you understand what youre getting into. Dont be afraid to ask for help. Contact an independent insurance agent or someone you trust such as an insurance counselor with AARP or another knowledgeable organization to help explain it to you (See resource numbers page 12). Its recommended for people with HIV who qualify for OA-HIPP to get the platinum plan, to keep their out-of-pocket costs down. The most they will pay for premiums is $1,938 a month most premiums should be far below that For more information on your specific city and plans that are available there, go to www.coveredca.com, or call them, and they will walk you through a worksheet with your best options. They have on line counselors available to help you determine your best coverage options. ADAP will still take care of co-pays and costs of your HIV meds not covered by your insurance. Note to OA-PCIP enrollees: Yes you will have to choose insurance through the Covered California Plan by January 1, 2014. Again, the Office of AIDS will be offering assistance with premiums, but any other assistance is yet to be determined.

If you are Medi-Medi, or Dual Eligible You will be required to enroll in a Medi-Cal HMO. They are also going to ask (if you have no share of cost) to enroll in a program called Cal MediConnect. Enrollment start is expected to be April 1, 2014.
The state of California is getting out of the single-payer Medi-Cal theyve done in the past. There are five HMOs to choose from in the county of San Diego, which I will outline later on. MediConnect plans are HMOs, basically a trial roll-out of a Medicare/Medi-Cal merger in an effort to cut down on redundancy and consolidate billings.

HOWEVER: Beneficiaries who have a Medicare Advantage plan will not be asked to join. This
means they can continue to see the same Medicare doctors and providers they see today.
,

*If you are enrolled in a Medicare Advantage plan, they will not ask you to enroll,

though you may choose to join at any time, if you qualify. For others enrolled in Medi-Medi with no share of cost, you also have the option of Opting out (*this includes those enrolled in the 250% working disabled program that have no share of cost.)
Opting out is when an eligible beneficiary chooses not to join a Cal Medi-Connect health plan and keep his or her Medicare benefits separate and out of the Medi-Connect health plan. Beneficiaries who enroll in a Cal Medi-Connect health plan may opt out or change health plans at any time.

Note: Opting out applies only to Medicare benefits. Beneficiaries must still get their Medi-Cal benefits through a health plan, as described below. For people with both Medicare and Medi-Cal who do not enroll in a Cal Medi-Connect Health Plan: The state will require enrollment in a Medi-Cal plan for all Medi-Cal long-term services and supports and any Medicare deductibles or costs, and if you do not, they will choose one for you. For dual eligible beneficiaries, enrolling in a Medi-Cal health plan does not change your Medicare benefits. You can still go to your Medicare doctors, hospitals, and providers.

Some Reasons to Opt Out: o Your doctor or specialists that you see are not enrolled in or choose not to enroll in one of the 4 HMOs. o You have special prescription(s) that are covered under your Part D prescription drug plan that are not covered under any other plan. o You wish to keep seeing all of your current doctors and specialists who take Medicare, and dont want to make any changes right now. .

Some Reasons to Opt in: There may be Doctors in the network who youd really prefer to be with, but they dont take Medi/Medi They often have a wider range of other services, such as vision and transportation services. They often have educational and support groups, i.e. pain management, smoking cessation, etc.

For Kaiser Subscribers:

Individuals enrolled in a Kaiser plan will not receive notices regarding Cal MediConnect and will not be passively enrolled into Cal MediConnect. However, individuals enrolled in Kaiser will still have to enroll in a Medi-Cal managed care plan for their Medi-Cal benefit. (It will probably be mandatory that they enroll in a Kaiser Medi-Cal HMO, which to me is a no-brainer since theyre probably going to require you enroll in the same company , but it hasnt been specifically defined yet, but probably will be.) If a beneficiary enrolled in Kaiser would like to enroll in Cal MediConnect, they would have to dis-enroll from Kaiser and choose a Cal MediConnect plan. This exception applies to both Medicare and Medi-Cal Kaiser plans.

Continuing to see your current providers and the Medi-Connect Plans:

After enrolling in a Cal Medi-Connect health plan, beneficiaries may continue seeing their existing Medicare doctors for up to six months and their Medi-Cal providers for up to 12 months, even if the providers do not join the health plans network. During this time, the health plans may try to bring many of these doctors into their networks to ensure people dont have disruptions in their care. Most likely this will not happen. Additionally, Cal Medi-Connect enrollees may at any time change plans or go back to original Medicare.

What happens if I decide to stay in her Medicare Advantage plan, but there is no matching Medi-Cal plan?
Normally, individuals who are in Medicare Advantage cannot enroll in Medi-Cal managed care for their Medi-Cal benefit unless the Medi-Cal managed care plan is operated by the same company that operates their Medicare Advantage plan. This is called a matching plan. Instead, the beneficiary would remain in Medi-Cal. This matching policy will not apply. For example, an individual who is enrolled in United Healthcare for Medicare Advantage will still have to enroll in a Medi-Cal managed care plan despite the fact that United Healthcare does not offer a Medi-Cal managed care plan. (Me: sounds really messed up hopefully theyll fix that before
April. Theres a lot of stuff thats still up in the air, so stay tuned! )

***Should you decide to keep your current doctor and opt out, Make SURE that they have accepted something that Medicare calls assignment, here is the explanation taken from the Medicare Web site: http://www.medicare.gov/your-medicare-costs/part-a-costs/assignment/costs-andassignment.html ***

Assignment means that your doctor, provider, or supplier agrees (or is required by law) to accept the Medicare-approved amount as full payment for covered services
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*IMPORTANT* If you choose to keep your Medicare, make sure your doctor, provider, or supplier accepts assignment! Otherwise you may get a bill!
Most doctors, providers, and suppliers accept assignment, but you should always check to make sure. Participating providers have signed an agreement to accept assignment for all Medicarecovered services.

What happens if your doctor, provider, or supplier accepts assignment:

Your out-of-pocket costs may be less. They agree to charge you only the Medicare deductible and coinsurance amount and usually wait for Medicare to pay its share before asking you to pay your share. They have to submit your claim directly to Medicare and can't charge you for submitting the claim. Ask your Doctor. If the Doctor doesnt know, ask to speak with his insurance person /office manager! Many times the office will not bother to bill for the additional 20% of the balance because its a lot of work for very little reimbursement. Non-participating providers are ones that haven't signed an agreement to accept assignment for all Medicare-covered services, but they can still choose to accept assignment for individual services. These providers are called "non-participating." (You will most likely not encounter this situation, but I have presented it here in case you do run into it.)

If your doctor, provider, or supplier doesnt accept assignment:

You might have to pay the entire charge at the time of service. Your doctor, provider, or supplier is supposed to submit a claim to Medicare for any Medicare-covered services they provide to you. They can't charge you for submitting a claim. If they don't submit the Medicare claim once you ask them to, call 1-800-MEDICARE. In some cases, you might have to submit your own claim to Medicare using Form CMS-1490S to get paid back. They can charge you more than the Medicare-approved amount, but there's a limit called "the limiting charge." The provider can only charge you up to 15% over the amount that nonparticipating providers are paid. Non-participating providers are paid 95% of the fee schedule amount.

The limiting charge applies only to certain Medicare-covered services and doesn't apply to some supplies and durable medical equipment. Not sure if your doctor is covered by Medicare or one of the plans you are choosing? Ask!!! The Doctor may be covered under your Medi-Cal plan, even though youve opted out to keep your Medicare Doctors. Dont be afraid to ask questions!!!! Your Health depends on it!!!!

THE DIFFERENCE BETWEEN MEDICARE AND MEDI-CAL

(Medicare pays 80% of the billing, less deductibles and co-pays, Medi-Cal is billed the other 20%)
(*note Denti-Cal dental benefits are returning May 1, 2014 YAY!)

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If you make less than $$15,856 a year, or 138% of the FPL (Federal Poverty Level):
You are eligible for full scope Medi-Cal and must choose one of these five listed HMOs. Enrollment starts October 1, 2013. Coverage will not begin until January 1, 2014. These are the four HMOs that will be choices in San Diego. Note only one; Community Health Group is a non-profit. Care 1st Health Plan o New Members: 1-855-905-3825 (TTY: 1-800-735-2929) Community Health Group CommuniCare Advantage o New Members: 1-800-224-7766 (TTY: 1-800-735-2929) Health Net o New Members: 1-888-788-5395 (TTY: 1-888-788-6383) Molina Dual Options o New Members: 1-855-665-4627 (TTY: 1-800-479-3310; CRS: 711) Kaiser Permanente (Not Available under Medi-Connect) o New Members: 1-877-258-8951 or TTY 711

If you are going to choose one of these, I suggest you read reviews of them on line, and ask other people you know about them. Most importantly ASK YOUR DOCTOR!!! They are going to be the one whos going to be making referrals for services, specialists etc. They will give you the best advice. Make sure any promises for services that these HMOs make that seem too good to be true arent limited in some way, or involve an extra cost or catch! *Read the fine print or better yet ASK!!!!!! I have been informed that people with HIV/AIDS can dis-enroll from a Medi-Cal HMO and go back to regular Medi-Cal. To do this, you have to have your Doctor fill out what they call a MER or Medical Exception Report. I have also been informed that it will not be easy and you may have to appeal their decision. The final decision will be made by the Department of Health Care Services (DHCS)s Med-Cal Managed Care Division. It is also recommended that you have an experienced health care counselor guide you through this process. Remember that these are all (but one) are for profit: companies that means despite the intentions and regulations of the Affordable Care Act, they are still worried about the bottom line If you choose one of these, keep that in the back of your mind. Some of these I havent heard of before, and others Ive heard good and bad. Get as much information as you can to make the best decision possible! *(My personal experience has been that for example the dental plans really arent worth it, and have REALLY high
deductibles! But Gov. Jerry Brown just signed a Bill re-instating Denti-Cal, effective May 1 2014, and will require ALL plans to cover full dental services!)

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Veterans Health Care and the Affordable Care act:

The health care law does not change VA health benefits or Veterans out-of-pocket costs. Your TRICARE coverage makes you exempt from the Affordable Care Act. However, you may supplement your care with other coverage.

Three things you should know:

VA wants all Veterans to receive health care that improves their health and well-being. 2. If you are enrolled in VA health care, you dont need to take additional steps to meet the health care law coverage standards. The health care law does not change VA health benefits or Veterans out-of-pocket costs. 3. If you are not enrolled in VA health care, you can apply at any time. Here is more information I pulled from the US Dept. of Veterans affairs website:
1.

Veterans Enrolled in VA Health Care

The good news is that Veterans enrolled in VA health care programs have health coverage that meets the new health care laws standard. You do not have to take any additional steps to have health coverage.

Veterans Not Enrolled in VA Health Care

Veterans not currently enrolled in VA health care program can apply for enrollment at any time.

Family Members
VA offers health care benefits for certain family members of Veterans through programs such as the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) and the Spina Bifida program. ***Your family members who are not enrolled in a VA health care program should use the Health Care marketplace to get coverage.

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Additional Health Care Law Information We understand you may have questions about the health care law and how it might affect you and your family. We compiled a list of Frequently Asked Questions http://www.va.gov/health/aca/FAQ.asp to help you make informed decisions about your health care. Let them know if you have questions regarding the health care law and your VA health care at 1-877-222-VETS (8387).

Can I continue to use VA health care with other programs, like private insurance or federal health care programs?
Yes. You can continue to use VA for all your health care needs, or complement your VA care with private health insurance or coverage by other federal health care programs, including private insurance, Medicare, Medicaid, and TRICARE.

Canceling Your EnrollmentA Word of Caution

If you choose to cancel your VA health care enrollment, you may reapply for enrollment at any time; however, acceptance for future VA health care enrollment will be based on eligibility factors at the time of application, which may result in a denial of enrollment.

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IN CONCLUSION..
The final decision for health care should be made between you, and your health care practitioner, Period. Dont feel pushed or pressured by aggressive agents or salesmen who have an agenda and get a commission from the companies for signing people up. Go on line and do research. Take notes. Seek out impartial advice. Go to panel discussions. Ask as many questions as you feel necessary. If its not clear to you, ask them to explain it until you do. If it doesnt feel right, dont do it Its your body and health, OWN it! Your life REALLY does depend on it!!

IMPORTANT PHONE NUMBERS:

Being Alive San Diego Peer Advocacy 4070 Centre St. San Diego CA 92103 619.291.1400 www.beingalive.org Health Insurance Counseling and Advocacy Program/HICAP 1-800-434-0222 http://www.cahealthadvocates.org/HICAP/ Covered California 1-800-300-1506 www.coveredca.com AARP www.aarp.org 1-888-687-2277 Medi-Cal www.medi-cal.gov 1-866-262-9881 Medicare 1-800-633-4227 or www.medicare.gov Social Security Administration 1-800-772-1213 www.socialsecurity.gov The Consumer Center for Health Education and Advocacy -

Disability Help Center http://www.ssdhelpcenter.org/ 1833 4th Ave. San Diego, CA 92101 619.282.1761

Elder Law and Advocacy

http://www.seniorlaw-sd.org/programs/hicap.php
Can answer questions about your Medicare and Medi-Cal coverage. 5151 Murphy Canyon Road, Suite 110 San Diego CA 92123 (858) 565-8772 California Office of AIDS

http://www.lassd.org/CCHEA%20broc%20Ap22%20 08.pdf
619-744-0935

http://www.cdph.ca.gov/programs/AIDS/Pages/Defaul t.aspx
1-916-449-5900

Veterans administration http://www.va.gov/ 1-877-222-VETS (8387).

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Source Material & Affordable Care Act information Websites:

http://www.nsclc.org/index.php/health/aca/ California State Insurance Exchange AAHIVM Essential Health Benefits Qualified Health Plans Search Results opting out | Cal Duals Californias Duals Demonstration Cal MediConnect | Cal Duals Frequently Asked Questions | Cal Duals www.sfhiv.org/wp-content/uploads/Planning-considerations_providers_4-16-13.pdf Health Care Reform Transition | SFHIV.ORG Task Force Releases Recommendations to Help San Franciscans Living with HIV Navigate Health Care Reform | SFHIV.ORG www.cdph.ca.gov/pubsforms/fiscalrep/Documents/ADAP May Revise FY2013-14 FINAL.pdf www.cdph.ca.gov/programs/aids/Documents/IntegratedPlan.pdf Search Results: Cal MediConnect California Health Insurance | Covered California Download and customize: Health Reform Q & A for Ryan White Program Clients : HIV Health Reform www.hivhealthreform.org/wp-content/uploads/2013/07/NC-Client-Brochure-all-states.pdf Health Insurance Counseling and Advocacy Program Elder Law Advocacy - Programs - HICAP Home | AARP Health Law Answers Resources for Consumers & Providers : HIV Health Reform State Resources for ACA Implementation : HIV Health Reform 66.147.244.246/~aidsconn/hivhealthreformorg/wp-content/uploads/2013/03/California-Modeling-Final.pdf NASTAD Health Reform Watch - February 12, 2013 Ryan White & the Affordable Care Act: What You Need to Know HIV Care and the Affordable Care Act - TheBodyPRO.com What does Marketplace health insurance cover, Essential Health Benefits | HealthCare.gov www.hivhealthreform.org/wp-content/uploads/2013/09/Assessment-Workbook-Final-eForm-Enabled.pdf Ryan White HIV/AIDS Program Information and Resources in San Diego County Veterans Health Today - Summer 2013

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Affordable Care Act -- VA, Affordable Care Act and You ACA Frequently Asked Questions -- VA, Affordable Care Act and You Target Center | Supporting HIV care through education and innovation Ryan White HIV/AIDS Program Information and Resources in San Diego County www.coveredca.com/news/PDFs/CC_Health_Plans_Booklet-rev1-8-6.pdf www.nastad.org/Docs/Public/Resource/2007918_ADAP Glossary_Final_Sept_2007.pdf health-law.com/wp-content/uploads/2013/05/042213-MediConnect-Whitepaper-FINAL-For-DISTRIBUTION.pdf Ryan White & the Affordable Care Act: What You Need to Know No need to juggle health reform info! One-stop info from NASTAD : HIV Health Reform Costs & assignment | Medicare.gov Get Covered Calculator | Covered California Affordable Health Insurance | Covered California http://www.va.gov/health/aca/

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Covered California FAQs

Thanks to Arin McNeese

What is Covered California? Covered California will make it simple and affordable for you to purchase high-quality health insurance and access financial assistance to pay for coverage. You can shop online, over the phone or in person to find the right health care insurance option for you. Through Covered California, both individuals and small businesses can compare different health insurance plans. Individuals can learn if they qualify for federal financial assistance that can lower the cost of health insurance. Individuals also will be able to find out if they are eligible for health programs like Medi-Cal. In addition, employers with fewer than 25 full-time workers will be able to find out if they qualify for a small business tax credit that can help cover the cost of providing employee health care. When can I purchase coverage through Covered California? Enrollment in health plans through Covered California will begin later this year and continue until March 31, 2014. You must purchase health insurance during this open-enrollment period in order to obtain coverage in 2014. If you do not enroll during this period, you will not be assured a health plan will cover you either through Covered California or in the private market. If you have a life-changing event such as the loss of a job, death of a spouse or birth of a child, you are eligible for special enrollment within 60 days of the event. The next open-enrollment period begins in October 2014 for coverage in 2015. What kind of health insurance will be offered through Covered California? Covered California will offer Qualified Health Plans that are the same high-quality health plans available on the private market today. These Qualified Health Plans are guaranteed to provide essential levels of coverage and consumer protections required by the Affordable Care Act. These plans will be offered in categories based on the percentage of covered expenses paid by the health plan. The health plan choices offered by Covered California will be as good as you can get anywhere even if you are not eligible for a subsidy. Health insurance companies must offer the same products at an identified price whether they are offered through Covered California or in the open market. In addition to these traditional health plans, Covered California will offer what is called "catastrophic coverage," which helps protect a person from financial disaster in the event of a serious and expensive medical emergency. Catastrophic coverage is not designed for day-to-day medical expense such as doctor visits, prescription medicines or even emergency room visits. It is designed to cover excessive medical bills that occur above the limit that you would be able to manage financially. Covered California will provide catastrophic coverage those up to age 30, or those individuals who can provide a certification that they are without affordable coverage or are experiencing hardship.

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How will Covered California make it easier for me to compare different plans? There will be four basic levels of coverage: Platinum, Gold, Silver and Bronze. This ranking system will make it easy to compare different health plans. As the metal category increases in value, so does the percent of medical expenses that a health plan will cover. These expenses are usually incurred at the time of health care services when you visit the doctor or the emergency room, for example. The health plans that cover more of your medical expenses usually have a higher monthly payment but you will pay less whenever you receive medical care. You can choose to pay a higher monthly cost so that when you need medical care, you pay less. Or you can choose to pay a lower monthly cost so that when you need medical care, you pay more. You can choose the level of coverage that best meets your health needs and budget. What kind of help is available to help lower the cost of insurance? Starting in 2014, individuals seeking health coverage will be helped to afford coverage in three ways: 1. Tax credits: Tax credits are available to lower the cost of health coverage for individuals and families who meet certain income requirements and do not have health insurance from an employer or a government program. When you enroll in a health plan through Covered California, tax credits can be immediately applied to the insurance premium, which reduces the amount you pay each month. Cost-sharing subsidies: Cost-sharing subsidies reduce the amount of out-of-pocket health care expenses an individual or family has to pay. These expenses might include the copayment for health care services or other costs. Medi-Cal assistance: Starting in 2014, the State of California is planning to expand the Medicaid program (called Medi-Cal in California) to cover people under age 65, including people with disabilities, with income of less than $15,000 for a single individual and $31,180 for a family of four. The coverage is free for those who qualify and part of the provisions of the Affordable Care Act.

2. 3.

Am I eligible for tax credits? Tax credits are available for individuals and families who meet certain income requirements and do not have access to affordable health insurance through their employer that also meets minimum coverage requirements. Eligibility for tax credits is based on a standard, called the federal poverty level, that looks at the family income and the number of people in the family. The size of the tax credit is based on a sliding scale, with those who make less money getting a larger financial assistance to lower the cost of their insurance coverage. Individuals and families who make between 138 percent and 400 percent of the federal poverty level may be eligible for a tax credit. This means that an individual making up to $44,680 and a family of four earning up to $92,200 may be eligible for a tax credit. There are some key facts about tax credits.

Tax credits lower the cost of your premium. Tax credits reduce the amount of the premium amount you will pay for insurance. Tax credits help low- and middle-income individuals and families. Tax credits are available to individuals and families who meet certain income requirements. Tax credits can be used when you enroll. Tax credits can be applied to the cost of your health plan when you enroll you do not need to wait until file a tax return at the end of the year.

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Tax credits are only available through Covered California. You must enroll in a health plan through Covered California if you want to use your tax credits. Tax credits are paid directly to your health plan. These tax credits are paid by Covered California to your health plan to keep your costs low. Tax credits will be adjusted at the end of the year based on your actual income. At the end of the year, the tax credits may be adjusted if your income is different than you anticipated. This means that you will want to notify Covered California if your income changes.

Small businesses with 25 or fewer full-time equivalent are also eligible for tax credits if they meet certain criteria. Do I have to buy health insurance? If you don't have health insurance, you should. Health insurance is an important way to make sure we have access to medical care when we need it. Starting in January 2014, most people will be required to have health insurance or pay a penalty if they don't. Coverage may include employer-provided insurance, coverage someone buys on their own, Medicare or Medi-Cal The penalty phases in for three years and becomes increasingly more costly. In 2014, the penalty will be 1 percent of annual income or $95, whichever is greater. By 2016, the penalty will be 2.5 percent of your annual income or $695. This means that if you do not have coverage in 2014, you will be required to pay a penalty when you file your taxes at the end of the year. Some people do not have to pay a penalty, including:

People who would have to pay more than 8 percent of their income for health insurance People with incomes below the threshold required for filing taxes (in 2012, $9,750 for a single person and $27,100 for a married couple with two children) People who qualify for religious exemptions Undocumented immigrants People who are incarcerated

Members of Native American tribes There will be a penalty for people who are not covered and do not fall into one of these categories Businesses with 50 or more full-time equivalent employees may be subject to a penalty beginning in 2014 if it does not offer health insurance to employees (and their dependents)

So far the Health Care companies to choose from in the San Diego market place are:
Anthem/Blue Cross www.anthem.com/ca 1 (866) 721 1387 Health Net www.healthnet.com Individual & Family Plans (IFP) Customer Service1-800-839-2172 Sales 1-800-909-3447 Kaiser kp.kaiser.org/ 1-800-539-0691 Blue Shield - www.blueshieldcaplans.com 1 (877) 646 1825 Molina www.molinahealthcare.com Main Number: 1-562-435-3666 Toll Free: 1-888-562-5442

Sharp www.sharp.com 1-800-82-SHARP (1-800-827-4277)

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DEFINITION OF TERMS
AARP: Formerly known as the American Association of Retired Persons, AARP is the nation's leading
organization for people age fifty and older. Founded in 1958 by retired educator Dr. Ethel Percy Andrus, it is a nonprofit, nonpartisan association with a membership of 40 million. It provides information, education, research, advocacy and community services through a nationwide network of local chapters and experienced volunteers. It focuses its work on consumer issues, economic security, work, health and independent living issues, and engages in legislative, judicial and consumer advocacy in these areas.

ADAP: ADAP stands for the AIDS Drug Assistance Program. A state administered program
authorized under Part B (formerly Title II) of the Title XXVI of the Public Health Service Act as amended by the Ryan White HIV/AIDS Treatment Modernization Act of 2006 (Ryan White Program) that provides Food and Drug Administration (FDA) approved medications to low income individuals with HIV disease who have limited or no coverage from private insurance or Medi-Cal.

Affordable Care Act: also known as the PPACA or The Patient Protection and Affordable Care Act
also known as the Affordable Care Act, Obamacare or ACA is the landmark health reform legislation passed by the 111th Congress and signed into law by President Barack Obama in March 2010. The legislation includes a long list of health-related provisions that began taking effect in 2010, and come into full force January 1, 2014 Key provisions are intended to extend coverage to millions of uninsured Americans, to implement measures that will lower health care costs and improve system efficiency, and to eliminate industry practices that include rescission and denial of coverage due to pre-existing conditions.

Assignment: means that your doctor, provider, or supplier agrees (or is required by law) to accept
the Medicare-approved amount as full payment for covered services.

California Office of AIDS: The Office of AIDS has lead responsibility for coordinating Federal Ryan
White Care Act funds to California state programs, services, and activities relating to HIV/AIDS.

Co-insurance:

A percentage of the cost of prescription drugs that a client must pay when enrolled in some

health plans (i.e., Medicare Part D Plans). ADAP will pay the co-insurance for ADAP formulary drugs.

Co-Pays: A set amount an individual must pay upon receiving medical services or prescriptions. For
example, there may be a $10 co-payment required each time a prescription is purchased at a retail pharmacy. California ADAP will pay the co-payments for ADAP formulary drugs.
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Covered California: The health Coverage Marketplace in California where uninsured persons can
buy insurance under the Affordable Care Act.

Deductible: - A fixed dollar amount during the benefit period - usually a year - that an insured
person pays before the insurer starts to make payments for covered medical services. Plans may have both per individual and family deductibles. Some plans may have separate deductibles for specific services. For example, a plan may have a hospitalization deductible per admission. Deductibles may differ if services are received from an approved provider or if received from providers not on the approved list.

Dual-Eligible: Individuals who are eligible for both Medicare and Medicaid/Medi-Cal Federal Poverty Level: The set minimum amount of gross income that a family needs for food,
clothing, transportation, shelter and other necessities. In the United States, this level is determined by the Department of Health and Human Services. FPL varies according to family size. The number is adjusted for inflation and reported annually in the form of poverty guidelines. Public assistance programs, such as Medicaid in the U.S., define eligibility income limits as some percentage of FPL.

Formulary: A list of prescription drugs, both generic and brand name that are available through
your health plan. Your health plan may only pay for medications that are on the formulary.

Health Plan Network: A large group of physicians, hospitals, and other health care providers that
have agreed to provide medical services to a health insurance plan's members at discounted costs.

HMO (Health Maintenance Organization): An organization that provides health coverage

with providers under contract. A Health Maintenance Organization (HMO) differs from traditional health insurance by the contracts it has with its providers. These contracts allow for premiums to be lower, because the health providers has the advantage of having patients directed to them; but these contracts also add additional restrictions to the HMO's members.

Medicaid: A joint federal and state program that helps low-income individuals or families pay for
the costs associated with long-term medical and custodial care provided they qualify. Although largely funded by the federal government, Medicaid is run by the state where coverage may vary.

Medi-Cal: The California Medical Assistance Program (Medi-Cal or MediCal) is the name of
the California Medicaid welfare program serving low-income families, seniors, persons with disabilities, children in foster care, pregnant women, and certain low-income adults. It is jointly administered by the California Department of Health Care Services (DHCS) and the Centers for

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Medicare and Medicaid Services (CMS), with many services implemented at the local level mainly by the counties of California. Under the Affordable Care Act, it will be extended to all with incomes of $15k or less.

Medicare Advantage plan (Also known as Medicare Part C): A Medicare Advantage Plan is
a type of Medicare health plan offered by a private company that contracts with Medicare to provide you with all your Part A and Part B benefits. Medicare Advantage Plans include Health Maintenance Organizations, Preferred Provider Organizations, Private Fee-for-Service Plans, Special Needs Plans, and Medicare Medical Savings Account Plans. If you're enrolled in a Medicare Advantage Plan, Medicare services are covered through the plan and aren't paid for under Original Medicare. Most Medicare Advantage Plans offer prescription drug coverage.

Medicare Part A: Medicare Part A covers services (like lab tests, surgeries, and doctor visits) and
supplies (like wheelchairs and walkers) considered necessary to treat a disease or condition. In general, Part A covers: Hospital care, Skilled nursing facility care, Nursing home care (as long as custodial care isn't the only care you need), Hospice, and Home Health Care.

Medicare Part B: Part B covers Medically necessary services: Services or supplies that are needed
to diagnose or treat your medical condition and that meet accepted standards of medical practice and Preventive services: Health care to prevent illness (like the flu) or detect it at an early stage, when treatment is most likely to work best. Part B covers things like: Clinical research, Ambulance services, Durable medical equipment (DME), Mental health, (Inpatient, Outpatient, and Partial hospitalization), Getting a second opinion before surgery, Limited outpatient prescription drugs.

Medicare Part B Premium: You pay a premium each month for Medicare Part B (Medical
Insurance). Most people will pay the standard premium amount. However, if your modified adjusted gross income as reported on your IRS tax return from 2 years ago is above a certain amount, you may be charged an Income Related Monthly Adjustment Amount (IRMAA). IRMAA is an extra charge added to your premium. Most people pay the Part B premium of $104.90 each month in 2013. If you have Medi-Cal without a share of cost they will pay your Part B premium.

Medicare Part C: Also known as Medicare Advantage are plans offered by a private company
that contracts with Medicare to provide Part A and Part B benefits to people with Medicare who enroll in the plan. Medicare health plans include all Medicare Advantage Plans, Medicare Cost Plans, Demonstration/Pilot Programs, and Programs of All-inclusive Care for the Elderly (PACE). In all types of Medicare Advantage Plans, there is coverage for emergency and urgently needed care. Medicare
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Advantage Plans must cover all of the services that Original Medicare covers except hospice care. Original Medicare covers hospice care even if you're in a Medicare Advantage Plan. The plan can choose not to cover the costs of services that aren't medically necessary under Medicare. Medicare Advantage Plans may offer extra coverage, like vision, hearing, dental, and/or health and wellness programs. Most include Medicare prescription drug coverage (Part D). In addition to your Part B premium, you usually pay a monthly premium for the Medicare Advantage Plan. Most people pay the Part B premium of $104.90 each month in 2013. Most of the time it is deducted from your Social Security Benefit.

Medicare Part D: Pays for Prescription Medications. There are many Part D Plans. Each Medicare
Prescription Drug Plan has its own list of covered drugs (called a formulary). Many Medicare drug plans place drugs into different "tiers" on their formularies. Drugs in each tier have a different cost. A drug in a lower tier will generally cost you less than a drug in a higher tier. In some cases, if your drug is on a higher tier and your prescriber thinks you need that drug instead of a similar drug on a lower tier, you or your prescriber can ask your plan for an exception to get a lower copayment

Medi-Connect: The state Medi-Cal program and the federal Medicare program are partnering to
launch a three-year demonstration to promote coordinated health care delivery to seniors and people with disabilities who are dually eligible for both of the public health insurance programs, dual eligible beneficiaries. The program will be called Cal-MediConnect. It will be implemented no sooner than January 2014 in eight counties: Alameda, San Mateo, Santa Clara, Los Angeles, Orange, San Diego, Riverside and San Bernardino. The Cal MediConnect program aims to improve care coordination for dual eligible beneficiaries and drive high quality care that helps people stay health and in their homes for as long as possible. Additionally, shifting services out of institutional settings and into the home and community will help create a person-centered health care system that is also sustainable.

Medi-Medi: See Dual Eligible OA-HIPP: Stands for Office of AIDS Health Insurance Premium Payment. OA-HIPP is a program
that pays the monthly health insurance premiums for eligible Californian residents with an HIV/AIDS diagnosis. This program is available to individuals with health insurance who are at risk of losing it, as well as to individuals currently without health insurance who would like to purchase it.

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OA-PCIP: Similar to OA-HIPP, but Paid for a program called Pre-existing Condition Insurance Plan
this program has been phased out in favor of the Health Care exchange.

Obamacare: See Affordable Care Act Opt-Out: In this context, when a person decides not to enroll in a Cal MediConnect program. Share Of Cost: in addition to covering individuals who receive cash assistance from the
government, Medi-Cal offers health care coverage to individuals and families who have incomes too high to qualify for welfare, but too low to cover health care costs. Medi-Cal requires some of these recipients to contribute to their health care by paying a share of the cost of the services they receive. Once a recipient's health care expenses reach a predetermined amount (the "share of cost"), MediCal will pay for any additional covered expenses for that month. Share of cost is an amount owed to the health care provider, not to the state.

Single-Payer: Single-payer health care is the financing of the costs of delivering universal health
care for an entire population through a single insurance pool out of which costs are met. There may be many contributors to the single pool (insured persons, employers, government, etc.)

TRICARE: TRI-CARE, formerly known as the Civilian Health and Medical Program of the Uniformed
Services (CHAMPUS), is a health care program of the United States Department of Defense Military Health System.

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