the affordable care act and you

The Affordable Care Actand YOU

Sheldon WeisgrauPresentation to Via Christi 50+, Wichita

October 23, 2013

Health Reform Resource Project 2

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


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)

Health Reform Resource Project


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



Health Care and Health Insurance


Why health reform?


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?


Access Quality

◦ Inconsistent◦ Disparities◦ Infections, medical errors, patients harmed

Why health reform?


Access Quality Cost

◦ Highest in the world◦ Increasing faster than salaries and inflation◦ Main driver of long-term budget deficits

Why health reform?


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?


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


The Affordable Care Act


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


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


What it does◦ Builds on the existing system of coverage

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ACA Mythbusters



What it does not do◦ Does not create “government-controlled” or

“socialized” health care

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ACA Mythbusters




“socialized” health care◦ Does not create “death panels”

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ACA Mythbusters




“socialized” health care◦ Does not create “death panels”◦ Does not eliminate (or make big changes to)

Medicare

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ACA Mythbusters


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


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




◦ Mandates that most people maintain insurance coverage

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ACA Snapshot




◦ Mandates that most people maintain insurance coverage

◦ Provides tax credits to help individuals and small businesses purchase insurance

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ACA Snapshot


The ACA and Medicare


Enhances benefit package◦ Covers annual wellness visit




Reduces out-of-pocket costs◦ No deductibles or coinsurance for preventive

services




Reduces out-of-pocket costs◦ No deductibles or coinsurance for preventive

services◦ Phases out Part D donut hole



Reduces rate of cost growth



Reduces rate of cost growth◦ Phases out overpayment to Medicare Advantage

plans




plans◦ Enables provider payment and delivery system

reforms From “volume-based” to “value-based”




plans◦ Enables provider payment and delivery system

reforms From “volume-based” to “value-based”

◦ Expands fraud and abuse prevention



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


The Health Insurance Marketplace


Established by each state by Oct 1, 2013

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Health Insurance Marketplaces(aka Exchanges)


Established by each state by Oct 1, 2013◦ Administered by federal govt if state opts out

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For individual and small group markets

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Provides web-based one-stop shopping◦ Pooling mechanism for individuals and small

businesses

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Provides web-based one-stop shopping◦ Pooling mechanism for individuals and small businesses

Plans must offer “essential health benefits” package

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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


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


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


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

http://www.healthcare.gov/

http://www.cuidadodesalud.gov/

http://www.insureks.org/


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

http://www.medicare.gov/


Where do we go from here?


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


Where do we go from here?

http://www.healthcare.gov/

http://www.cuidadodesalud.gov/


Sheldon Weisgrau, DirectorHealth Reform Resource Project1129 S. Kansas Avenue, Suite BTopeka, KS 66612(785) [email protected]

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Additional information

mailto:[email protected]

the affordable care act and you

Health & Medicine