obamacare - the patient protection and affordable care act - aca

Patient Protection and Affordable Care Act Update

Andrew F. Bennett865.712.5711

Setting the Stage...Why the ACA?


“All told, health insurers have been involved in more than four hundred

corporate mergers since 1996, according to antitrust lawyer David Balto, a

former Federal Trade Commission policy chief.”

- Deadly Spin by Wendell Potter p 136

The near total collapse of competitive and dynamic health insurance markets

has not helped patients...an absence of competition in health insurance

markets is clearly not in the best economic interests of patients.”

- 2010 AMA President Dr. J. James Rohack



2000 -2008

Premiums for employer sponsored groups increased 97%

Premiums for individual plans increased 90%

Insurance company payments to providers increased 72%

Medical Inflation only increased 39%

Wages grew 29%

Overall Inflation grew 21%

● Medical inflation only grew a little bit over the regular inflation rate.

● Premiums grew at nearly 2.5 times the rate of medical inflation.



● 2007 - Medical Debt was a key reason for 62% of personal bankruptcy

filings.

● 2008 - Over a million personal bankruptcy filings

● A lack of coverage contributes to about 45,000 people dying prematurely

every year.

● 2000 - 2008 - The top 10 for profit health insurance companies paid their

CEO’s nearly $700 million (combined).

● In 2009 alone WellPoint had 39 executives exceed $1,000,000 in

compensation.

● All from “Deadly Spin” by Wendell Potter

What changed prior to 2014• Some preventative care covered at 100%

– Immunizations / Flu Shots

– Blood Pressure / Cholesterol Screenings

– Mammograms / Colonoscopies

– Type II Diabetes Screening

– Obesity Screening & Counseling

– Tobacco Use Screening


What changed prior to 2014• More Preventative Care for Women

– Annual well woman visits

– Screening for gestational diabetes

– Testing for HPV (human papillomavirus)

– Counseling for sexually transmitted infections

– Counseling and screening for HIV

– Contraception methods and counseling

– Breastfeeding support, supplies, and counseling

– Screening and counseling for interpersonal violence


What has happened so far• Children up to age 26 can remain on their parent’s policies

• Lifetime limits have been eliminated

• Appeals to insurance company decisions are now handled by an independent party outside of the insurance company (no longer an internal appeals board).


As of Jan 1, 2014• Guaranteed Issue – You cannot be refused

• “Pre-Existing” conditions riders can no longer be applied to policies

–You cannot be refused a policy.

–You cannot be rated (i.e. charged more).

–You policy cannot have exclusion riders (i.e. they don’t cover some injuries, illnesses, etc that may be due to the pre-existing condition).


As of Jan 1, 2014• For the same policy an older age group cannot be charged more than three times

the premium of a 21 year old

• Excess premiums charged by companies have to be returned (80% of premiums collected have to go to health care benefits or improving health care, not administrative costs or profit)


As of Jan 1, 2014• The individual mandate – the requirement is to have health insurance. The

requirement is not about purchasing on the marketplace

• The requirement is to have what is called a “Qualified Health Plan.”

• A Qualified Health Plan has 10 “Essential Benefits.”


Your Family Health Insurance AgentAndrew F. Bennett865.712.5711Andrew F. Bennett865.712.5711

Ten Essential Health Benefits (EHB’s)

1. Ambulatory Patient Services

2. Emergency Services

3. Hospitalization

4. Maternity and Newborn Care

5. Mental Health & Substance Abuse Disorder Services

6. Prescription Drugs

7. Rehabilitative Services and Devices

8. Laboratory Services

9. Preventative & Wellness Svcs/Chronic Disease Mgmt

10. Pediatric Services including oral & vision


As of Jan 1, 2014

•Penalties (higher of the two)

– 2014 - $95 per adult and $47.50 per child (maximum of $285) or 1% of income

– 2015 - $325 per adult and $162.50 per child (maximum of $975) or 2% of income

– 2016 - $695 per adult and $347.5 per child (maximum of $2085) or 2.5% of income


As of Jan 1, 2014

Who is eligible for help?

Family size 1 2 3 4

Family Income

$ 11,490 $ 15,510 $ 19,530 $ 23,550

$ 45,960 $ 62,040 $ 78,120 $ 94,200

Anyone is free to purchase outside the online marketplace, but you must purchase inside the marketplace to be eligible for a subsidy.

The household income must be between 100 % - 400% of the federal poverty level.


Financial Assistance Available

Income Level Premium as a Percentage of Income

Up to 133% of FPL 2 % of income

133% - 150% 3-4% of income

150% - 200% 4-6.3% of income

200% - 250% 6.3 - 8.05% of income

250% - 300% 8.05 - 9.5% of income

300% - 400% 9.5% of income


Online Marketplace


• Subsidies

– Income and family sized base

– Premium set on parent(s), up to three children (under 21), and those children between 21 to 26 yrs of age

– Subsidy set on total number of children

• Subsidies will be paid directly to insurer OR can be claimed at end of year on tax return

Financial Assistance Available


Cost Sharing – Provides assistance with:• Deductibles• Co-insurance• Co-Pays

Cost Sharing is ONLY available in Silver Plans

Family Size Maximum Income Allowed

1 $28,725

2 $38,775

3 $48,825

4 $58,875

5 $68,925

6 $78,975

7 $89,025

Your Current Plan• Grandfathered till your renewal date in 2014

–At that point your plan will need to contain all ten essential health benefits in order to qualify as a “Qualified Health Plan.” (QHP)

Information on this slide changed in the fall of 2013 when insurance companies cancelled millions of people’s plans. The insurance companies always cancelled certain policies when they didn’t deliver enough profit, but they used the smoke screen of the ACA to cancel many more than usual. There was a public outcry when the cancellations came out. The President back-pedaled and said people could keep their old plans till 2015, however it was the insurance companies, not the ACA that led to the 2013 cancellations. All those policies could have been grandfathered till 2014.


Online Marketplace• State Based, State & Federal Partnerships, Federally Facilitated

• TN is a Federally Facilitated Marketplace

• Carriers in TN will be BlueCross/BlueShield, Humana, and Cigna (Chattanooga Area only), and CHA (Community Health Alliance). For 2015 Assurant will join the Marketplace in Tennessee (branded as “Time”).


Online Marketplace• CHA (The Community Health Alliance) is a non-profit health insurance company

that was created with low cost government loans. Due to a loss of competition in the health insurance industry (see slide 2) it was expected that each state would create a new non-profit. Lobbying dried up the funding and only 20+ new insurance companies were created to replace the over 400 that had disappeared due to mergers.


Online Marketplace• Policies will be color coded based on “actuarial value” (i.e. mathematically

computed numbers based on national trends, averages, and broadbased data).

– Catostrophic

• Under 30 years old

• Lower Premiums

• Higher Deductibles

• Everything is cost shared except for preventative medicine

– Bronze 60% / 40%

– Silver 70% / 30%

– Gold 80% / 20%

– Platinum 90% / 10%


Online Marketplace● Eligibility

○ Household income must be between 100% and 400% of FPL (federal poverty level)

○ Individual’s must be either Citizens of the United States or have documentation proving they are “legally present.” (permanent resident visa, etc).


Online Marketplace


Your Family Health Insurance Agent

Exemptions

• Religious exemptions (i.e. your religion requires you to abstain from the health insurance system)

• Financial exemption – if private insurance is too expensive, if you do not qualify to purchase in the online marketplace, and you are not eligible for medicaid you will not be fined (i.e. poor people will not be fined for being poor).

• Native American Indian Tribes have separate programs and will be exempted although they are free to participate if they would like.

Online Marketplace


• What is included in income?

– Wages, Salary, Tips

– Net income from self-employment

– Unemployment Compensation

– Social Security income (including disability)

– Alimony

• What is NOT included in income:

– Child Support

– Worker’s Compensation

– Gifts

– SSI (Supplemental Security Income)

– Veteran’s Disability

Employer Mandate• Pushed back till 2015

• Based on the number of full time equivalent employees

– 30 hours a week is one “equivalent” full time employee

• 1 employee equivalent works 30 hours a week

• 2 employees working 15 hours a week = 1 full time equivalents

• 2014 & 15 States can decide if a “small business” has less than 50 employees or less than 100

• 2016 Federal definition 50 or fewer

• Exchanges are not for large businesses


SHOP Exchange• Small Business Health Options Program

– For small business where employer mandate does not apply.

– Tax Credits will apply only if they enroll in 2014.

Group Coverage is nearly always more expensive than individual (many times 20%

more for similar coverage). The shop gives individual pricing with bundled billing.

(restrictions apply). Those savings are without tax credits.


Other Resources• Healthcare.gov

• KFF.org (Kaiser Family Foundation)

• NAHU.org


obamacare - the patient protection and affordable care act - aca

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