The Affordable Care Act in Texas

Elena M. Marks, JD, MPHHealth Policy Scholar

Initial objective: Expand Access• 50 million uninsured—insurance equals

access• Insurance industry regulations• Mandated coverage for people and

businesses– Insurance exchanges to facilitate purchase– Subsidies for some people and businesses

• Expansion of Medicaid

Predicted Coverage Changes

13%

57%

9%

21%

2013

Medicaid and CHIPEmployerNongroup and OtherUninsured

17%

56%

8%

9%10%

2023

Medicaid and CHIPEmployerNongroup and OtherExchangesUninsured

Feb. 2013, CBO estimates that 30 million will gain insurance by 2023.90% of Americans will be insured.

Insurance Regulatory Changes

In Place Already

• Children < 26 • No pre-X for children• 80% MLR; rebates• No lifetime limits• Preventive services• Rate increase reviews• Temporary pre-X plan

Coming

• No pre-X; guaranteed issue

• Individual mandate• Large employer mandate• Exchanges/subsidies• No annual limits• Essential Health Benefits

Beginning in 2014………

(ALMOST) EVERYONE MUST HAVE INSURANCE

And if you don’t………

YOU (MAY) HAVE TO PAY A TAX

In 2014, the tax is the greater of 1% of total family income or $95 per adult and $47.50 per child up to $285 per family rising to 2.5% of total family income or $695 per adult and $347.50 per child up to $2,085 per family in 2016

Health Insurance Exchanges

• Online marketplace for individuals and small businesses to shop for “qualified” plans

• Texas exchange is operated by the federal government

• Individuals: Citizens, legal residents• Businesses: Up to 50 or 100 employees• Plans: Four levels based on scope of coverage• Essential health benefits in all plans

Essential Health Benefits

Ambulatory patient services Prescription drugs

Emergency services Rehabilitative and habilitative services and devices

Hospitalization Laboratory services

Maternity and newborn care Preventive and wellness services and chronic disease management

Mental health and substance use disorder services, including behavioral health treatment

Pediatric services, including oral and vision care

Plan Levels of Coverage

Levels of Coverage

Plan Pays on Average

Enrollees Pay on Average

(In addition to themonthly plan premium)

Bronze 60 percent 40 percent

Silver 70 percent 30 percent

Gold 80 percent 20 percent

Platinum 90 percent 10 percent

Limited Enrollment Periods

• Initial period is October 1, 2013 to March 31, 2014

• October 1, 2014 to December 24, 2014 for coverage on January 1, 2014

• Limited exceptions include– Loss of coverage– Marriage/birth/adoption– Relocation– Change in eligibility status

Premium SubsidiesIncome as a Percentage of the Federal Poverty Level

Premium as a Percentage of Income

Up to 133% FPL 2%

133-150% 3-4%

150-200% FPL 4-6.3%

200-250% FPL 6.3-8.05%

250-300% FPL 8.05-9.5%

300-400% FPL 9.50%

Federal Poverty Guidelines, 2013

Household Size 100% 200% 300% 400%

1 $11,490 $22,980 $34,470 $45,960 2 15,510 31,020 46,530 62,040 3 19,530 39,060 58,590 78,120 4 23,550 47,100 70,650 94,200

 Household Size

 100% 200%   300% 400% 

 1 $11,490 $22,980 $34,470 $45,960

 2 15,510   31,020 46,530 62,040

 3 19,530   39,060 58,590 78,120

 4 23,550   47,100 70,650 94,200

Sample Premiums and Subsidies

27 Year Old, $25,000 Income Family of 4, $50,000 Income

Tax Credit

$

Lowest Bronze

$

Lowest Bronze

with Tax Credit

Tax Credit$

Lowest Bronze

$

Lowest Bronze with Tax Credit, $

Texas 56 139 83 445 502 57

Houston 57 138 81 446 498 52

Dallas 79 153 74 526 600 74San Antonio 51 138 87 428 510 73

RG Valley 10 109 99 278 395 11736 state average 70 163 93 492 587 95

Texans’ Insurance Coverage, 2010

ESI45%

Individual4%

Medicaid16%

Medicare10%

Other Public1%

Uninsured Total 24%

Source: KFF

24% Uninsured Texans, 2010

201276036%

78274014%

134184024%

83865015%

61501011%

Exchange eligible Medicaid eligible in 2010

Medicaid expansion Undocumented

No ACA plan

Source: HHSC presentation, 7/12/12

Current Texas Medicaid eligibility

Medicaid Expansion

16

Texas Medicaid growth tracks population growth

17

2001 2002 2003 2004 2005 2006 2007 2008 2009 20100

5,000,000

10,000,000

15,000,000

20,000,000

25,000,000

30,000,000

21 million

25 million

35% of population

41%

23%25%

9%14%

Total <200% FPL Uninsured Medicaid

Popu

latio

n (M

illio

ns)

19%

40%

79%

26%

Potential ACA Beneficiaries in Texas

• Insurance Exchange/Subsidy Eligible 2,012,760

• Medicaid Eligible 1,341,850 Expansion population 782,740 “Welcome mat” population

Total: 4,137,350

Source: HHSC presentation, 7/12/12