2006 HEALTH CARE REFORM INITIATIVES—THE DETAILS

 

The 2006 Health Care Affordability Act is a first step toward achieving the goal of quality, affordable health care for all Vermonters. This legislation has one overriding goal: controlling the steeply rising costs of health care. It accomplishes this in two ways: by better managing chronic care and making health care affordable and accessible for all Vermonters.

 

Catamount Health will be offered to eligible Vermonters October 2007.

 

 


Who can purchase Catamount Health?

You may purchase Catamount Health if you are an uninsured Vermont resident and do not have insurance through an employer.

Uninsured means:

Ø      You have insurance which only covers hospital care OR doctor’s visits (but not both)

Ø      You have not had private insurance for the past 12 months

Ø      You had private insurance but lost it because you:

o       Lost your job

o       Got divorced

o       Finished with COBRA coverage

o       Had insurance through someone else who died

o       Are no longer a dependent on your parent’s insurance

o       Graduated, took a leave of absence, or finished college or university and got your insurance through school

Ø      You had VHAP or Medicaid but became ineligible for those programs

 

 

How much will Catamount Health cost?

The cost of Catamount Health will depend on your income and which insurer you sign up with. For the least expensive plan, Catamount Health will cost:

Income by federal poverty level

(1 person/annual in 2006)

Monthly premium cost

Below 200% FPL ($19,600)

$60.00

200-225% ($19,600 – 22,050)

$90.00

225-250% ($22,050 – 24,500)

$110.00

250-275% ($24,500 – 26,950)

$125.00

275-300% ($26,950 – 29,400)

$135.00

Over 300%  ($29,400)

 

Full cost, estimated at $340.00


 

Cost-Sharing Information

Deductibles

In-Network:

$250.00/individual

$500.00/family

 

Out-of-Network:

$500.00/individual

$1,000.00/family

Co-insurance

20%

Co-payment

$10.00 office visit

Prescription Drug Coverage

No deductible

 

Co‑payments:

$10.00 generic drugs

$30.00 drugs on the preferred drug list

$50.00 nonpreferred drugs

Out-of-pocket Maximum

(does not include premium payments; includes deductibles, co-insurance, and co-payments)

In-Network:

$800.00/individual

$1,600.00/family

 

Out-of-Network:

$1,500.00/individual

$3,000.00/family

Preventive Care

$0.

Not subject to deductible, co-insurance, and co-payments.

Chronic Care

$0 for individuals enrolled in the chronic care management program; otherwise, subject to the above amounts.

Text Box: Help for the Underinsured; Cost Shift

  • If you have insurance covering only hospital services OR only doctors visits, you will be eligible for Catamount Health without a wait.
  • People who buy health insurance in the individual market, not through an employer, are paying very high prices for insurance, and their costs go up every year. On July 1, 2007, the state will begin to cover 5% of the claims costs of this kind of insurance. While this may not reduce the premium, it will lower the increase in the premium and provide some relief to these individuals.
  • The act also contains several changes that should help what is called the “cost shift.” The cost shift results when uninsured or underinsured people need health care and cannot afford the bill or when the state or federal government does not pay the full cost of a service. These costs are “shifted” to people with private insurance. By reducing the number of uninsured and underinsured people and by increasing the rates paid by public health insurance programs, the cost shift will be reduced, which in turn will reduce the increases in health care premiums.

 

 


 

WHO CAN RECEIVE FINANCIAL ASSISTANCE

FOR EMPLOYER-SPONSORED insurance?

Individuals enrolled in or eligible for the Vermont Health Access Plan (VHAP).

 

You are eligible for VHAP if you are an uninsured Vermonter with income under 150% of the federal poverty level.

 

150% FPL: $14,700 annual income for an individual

 

Uninsured Vermonters with income under 300% of the federal poverty level.

 

300% FPL: $29,400 annual income for an individual

Uninsured means:

Ø      You have insurance which only covers hospital care OR doctor’s visits (but not both)

Ø      You have not had private insurance for the past 12 months

Ø      You had private insurance but lost it because you:

o       Lost your job

o       Got divorced

o       Finished with COBRA coverage

o       Had insurance through someone else who died

o       Are no longer a dependent on your parent’s insurance

o       Graduated, took a leave of absence, or finished college or university, and got your insurance through school

Ø      You had VHAP or Medicaid but became ineligible for those programs

 


 

How much will I pay for my employer’s plan?

There will be co-payment amounts for emergency room visits as well.

Income by federal poverty level

(One person/annual in 2006)

Monthly premium cost (approximate)

Below 50% FPL ($4,900)

$0.00

50-75% ($4,900 - 7,350)

$7.00

75-100% ($7,350 – 9,800)

$25.00

100-150% ($9,800 – 14,700)

$33.00

150-185% ($14,700 – 18,130)

$49.00

Over 185% ($18,138)

Premiums and cost-sharing to be determined

 

 


 

o       Global Commitment - Requires the Agency of Human Services to seek a global commitment waiver to include Catamount Health assistance and the employer-sponsored insurance premium assistance program in the Medicaid waiver.


 

ADDITIONAL INITIATIVES

 

 

 

 

 

 

 

 

 

 

 

o       The Department of Health will establish a program for the purpose of improving patient safety, eliminating adverse events in hospitals, and supporting hospital quality improvement efforts

o       Hospitals must track adverse events and analyze the causes

o       Rulemaking will define events hospitals must report to the Department of Health, which must include the National Quality Forum 27 “never events”

o       Hospitals must report to patients or family when an adverse event causes death or serious bodily injury

o       Hospitals must give the Department of Health access necessary to evaluate compliance

o       Patient confidentiality and peer review protections are maintained

o       Infection rate reporting is added to hospital community reports  

 

o       Consolidates authority for coordinating and supervising health reform initiatives in the Secretary of Administration’s office; also directs agencies to coordinate efforts  

o       Requires the statewide plan to address issues relating to data ownership, governance, and confidentiality and security of patient information

o       Extends the deadline for the statewide plan by six months