the affordable care act and you
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The Affordable Care Actand YOU
Sheldon WeisgrauPresentation to Via Christi 50+, Wichita
October 23, 2013
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Introduction
Health care and health insurance◦ Why do we need health reform?
The Affordable Care Act (aka “Obamacare”)◦ What’s really in the law?◦ The ACA and Medicare ◦ The Health Insurance Marketplace
Q&A
Agenda
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Assist in public education and stakeholder engagement related to health reform
Provide technical assistance to advocacy organizations and other stakeholders
Assist Kansas entities in securing grants and programs available under the Affordable Care Act (ACA)
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Supported by Kansas Grantmakers in Health:◦ Kansas Health Foundation◦ Health Care Foundation of Greater Kansas City◦ REACH Healthcare Foundation◦ Sunflower Foundation: Health Care for Kansans◦ United Methodist Health Ministry Fund◦ Wyandotte Health Foundation
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Health Care and Health Insurance
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Why health reform?
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Access◦ 48 million uninsured in U.S. (18% of pop < age
65) 360,000 uninsured in Kansas (14% of pop <65) 67,000 uninsured in Sedgwick Co (15.5% of pop <65)
◦ Millions more underinsured◦ Employment-based health insurance declining
Why health reform?
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Access Quality
◦ Inconsistent◦ Disparities◦ Infections, medical errors, patients harmed
Why health reform?
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Access Quality Cost
◦ Highest in the world◦ Increasing faster than salaries and inflation◦ Main driver of long-term budget deficits
Why health reform?
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The uninsured:◦ Receive less preventive and prenatal care◦ Go without medical care and prescription drugs
due to cost◦ Diagnosed at later stage of illness◦ Hospitalized for avoidable conditions◦ Less healthy◦ Earn less (and have less financial protection)◦ Have higher death rates
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What difference does health insurance make?
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Communities with high rates of uninsurance◦ More difficulty recruiting and retaining physicians
◦ ER crowding and diversion
◦ Insured patients have lower access, quality, and satisfaction
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Community Consequences of Uninsurance
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The Affordable Care Act
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906 pages, 10 titles1. Access to private health insurance2. Expanded Medicaid coverage3. Medicare reform4. Wellness and prevention5. Health care workforce6. Fraud and abuse7. Access to drugs and biologics8. Voluntary long-term care insurance (CLASS)9. Revenue measures10. Manager’s amendment and reconciliation
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Affordable Care Act
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Make better health insurance coverage more available and affordable for legal residents
Reform health care delivery and financing to provide better quality and outcomes, more cost effective care
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ACA – Intertwined Goals
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What it does◦ Builds on the existing system of coverage
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ACA Mythbusters
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What it does◦ Builds on the existing system of coverage
What it does not do◦ Does not create “government-controlled” or
“socialized” health care
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ACA Mythbusters
Health Reform Resource Project
What it does◦ Builds on the existing system of coverage
What it does not do◦ Does not create “government-controlled” or
“socialized” health care◦ Does not create “death panels”
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ACA Mythbusters
Health Reform Resource Project
What it does◦ Builds on the existing system of coverage
What it does not do◦ Does not create “government-controlled” or
“socialized” health care◦ Does not create “death panels”◦ Does not eliminate (or make big changes to)
Medicare
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ACA Mythbusters
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Extends health insurance coverage to 25-30 million uninsured ◦ Expands the Medicaid program
◦ Authorizes Medicare financing and delivery reform
◦ Restructures markets for individual and small group insurance Health Insurance Marketplace
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ACA Snapshot
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Extends health insurance coverage to 25-30 million uninsured ◦ Prohibits insurers from denying coverage to those
with pre-existing conditions (guaranteed issue) or charging them more (community rating)
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ACA Snapshot
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Extends health insurance coverage to 25-30 million uninsured ◦ Prohibits insurers from denying coverage to those
with pre-existing conditions (guaranteed issue) or charging them more (community rating)
◦ Mandates that most people maintain insurance coverage
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ACA Snapshot
Health Reform Resource Project
Extends health insurance coverage to 25-30 million uninsured ◦ Prohibits insurers from denying coverage to those
with pre-existing conditions (guaranteed issue) or charging them more (community rating)
◦ Mandates that most people maintain insurance coverage
◦ Provides tax credits to help individuals and small businesses purchase insurance
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ACA Snapshot
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The ACA and Medicare
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Enhances benefit package◦ Covers annual wellness visit
The ACA and Medicare
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Enhances benefit package◦ Covers annual wellness visit
Reduces out-of-pocket costs◦ No deductibles or coinsurance for preventive
services
The ACA and Medicare
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Enhances benefit package◦ Covers annual wellness visit
Reduces out-of-pocket costs◦ No deductibles or coinsurance for preventive
services◦ Phases out Part D donut hole
The ACA and Medicare
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Reduces rate of cost growth
The ACA and Medicare
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Reduces rate of cost growth◦ Phases out overpayment to Medicare Advantage
plans
The ACA and Medicare
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Reduces rate of cost growth◦ Phases out overpayment to Medicare Advantage
plans◦ Enables provider payment and delivery system
reforms From “volume-based” to “value-based”
The ACA and Medicare
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Reduces rate of cost growth◦ Phases out overpayment to Medicare Advantage
plans◦ Enables provider payment and delivery system
reforms From “volume-based” to “value-based”
◦ Expands fraud and abuse prevention
The ACA and Medicare
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Expansion of home and community-based services
More funding for Aging and Disability Resource Centers (ADRCs)
Programs to enhance quality and patient safety, reduce readmissions
Programs to expand primary care, nursing, geriatric care workforce
Other ACA Provisions Affecting Seniors
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The Health Insurance Marketplace
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Established by each state by Oct 1, 2013
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Health Insurance Marketplaces(aka Exchanges)
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Established by each state by Oct 1, 2013◦ Administered by federal govt if state opts out
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Health Insurance Marketplaces(aka Exchanges)
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Established by each state by Oct 1, 2013◦ Administered by federal govt if state opts out
For individual and small group markets
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Health Insurance Marketplaces(aka Exchanges)
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Established by each state by Oct 1, 2013◦ Administered by federal govt if state opts out
For individual and small group markets
Provides web-based one-stop shopping◦ Pooling mechanism for individuals and small
businesses
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Health Insurance Marketplaces(aka Exchanges)
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Established by each state by Oct 1, 2013◦ Administered by federal govt if state opts out
For individual and small group markets
Provides web-based one-stop shopping◦ Pooling mechanism for individuals and small businesses
Plans must offer “essential health benefits” package
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Health Insurance Marketplaces(aka Exchanges)
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1. Ambulatory care services2. Emergency services3. Hospitalization4. Maternity and newborn care5. Mental health and substance abuse services6. Prescription drugs7. Rehabilitative and habilitative services and devices8. Laboratory services9. Preventive and wellness services and chronic
disease management10. Pediatric services, including oral and vision care
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Essential Health Benefits
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Qualify if household income is 100%-400% of Fed Poverty Level and purchase in Marketplace and no affordable employer offer
Businesses qualify if they meet size and salary requirements
Most Kansans who would have been covered by Medicaid expansion will be too poor to qualify for tax credits
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Tax Credits
Household Size
2013 Federal Poverty Guidelines
100% 400%
1 $11,490 $45,960
2 $15,510 $62,040 3 $19,530 $78,120 4 $23,550 $94,200 5 $27,570 $110,280 6 $31,590 $126,360
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No lifetime or annual coverage limits
Children up to age 26 on parent’s policy
Plan standardization◦ Catastrophic, Bronze, Silver, Gold, Platinum ◦ Limits on out-of-pocket costs◦ Standard language and definitions
Helpful Consumer Provisions
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Toll-free hotline◦ 1-800-318-2596◦ http://www.healthcare.gov◦ http://www.cuidadodesalud.gov
Agents/brokers
Navigators and Certified Application Counselors◦ Clinics, health departments, Area Agencies on Aging,
community mental health centers, hospitals, etc.
Kansas Insurance Department◦ http://www.insureKS.org
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Consumer Assistance
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Senior Health Insurance Counseling For Kansas (SHICK)◦ Area Agencies on Aging◦ 1-800-860-5260
1-800-MEDICARE
http://www.medicare.gov
Consumer Assistance: Medicare Beneficiaries
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Where do we go from here?
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Open Enrollment ◦ October 1, 2013 – March 31, 2014
Future years: Oct 15-Dec 7◦ Special enrollment periods
If you want insurance on . . .◦ January 1, enroll by December 15, 2013
If you want to avoid the penalty . . .◦ Enroll by February 15, 2014
Important Dates
Marketplace opened October 1, 2013◦ Coverage begins January 1, 2014 ◦ www.healthcare.gov ◦ http://www.cuidadodesalud.gov
Individual mandate – January 1, 2014
Employer responsibilities ◦ Enforcement delayed until 2015
Medicaid expansion
OUTREACH / EDUCATION / ENROLLMENT
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Where do we go from here?
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Sheldon Weisgrau, DirectorHealth Reform Resource Project1129 S. Kansas Avenue, Suite BTopeka, KS 66612(785) 408-8008HealthReformResource@gmail.com
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Additional information
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