the affordable care act: what you need to know -...
TRANSCRIPT
The Affordable Care Act:
What You Need To Know
Yolonda Campbell, J.D., M.P.H.
Health Policy Analyst
Health Resources and Services Administration
Michelle Chuk Zamperetti, MPH
Senior Advisor
National Association of County and City Health
Officials
James M. Galloway, M.D. F.A.C.P., F.A.C.C.
Director of the Office of Health System
Collaboration
Centers for Disease Control and Prevention
Sarah R. Linde, M.D.
Chief Public Health Officer
Health Resources and Services Administration
Andrew Rein
Associate Director for Policy
Centers for Disease Control and Prevention
Rita Vandivort-Warren, M.S.W.
Senior Public Health Analyst
Health Resources and Services Administration
Sarah R. Linde, M.D.
Chief Public Health Officer
Health Resources and Services Administration
Andrew Rein
Associate Director for Policy
Centers for Disease Control and Prevention
Yolonda Campbell, J.D., M.P.H.
Health Policy Analyst
Health Resources and Services Administration
Rita Vandivort-Warren, M.S.W.
Senior Public Health Analyst
Health Resources and Services Administration
Working Together to Achieve Better Care, Better Health,
Lower Costs through Care Improvements
Affordable Care Act
Setting the Stage
• More than 1-in-5 uninsured men
aged 18-45 end up in the
emergency room each year.
• More than 1-in-3 Americans
without insurance have problems
paying medical bills.
• People with health coverage get
more preventive care.
Making it Easier to Get Coverage
The Affordable Care Act:
• New rules strengthen private insurance for consumers.
• Creates a Marketplace in each state where individuals
and small businesses can shop for insurance.
• Provides financial help for some persons to get insurance
through the Marketplace.
• Gives states the opportunity to expand Medicaid coverage
to low-income adults.
Insurance Reforms
New rules affecting how insurance
companies do business phased in
from 2010 to 2014:
• Free Preventive Care: 71 million
privately insured people gained
improved coverage for preventive
services
• No Dollar Limits on Coverage: 105
million Americans have had lifetime
limits removed from their insurance
• Dependent Coverage: 3.1 million
young adults gained insurance
through their parents’ plans
More Insurance Reforms
(effective in 2014)
• Guaranteed Issue: Insurers cannot deny people
coverage because they have pre-existing
conditions or cancel it when they get sick.
• Community rating: Premiums can only vary
based on a person’s age, geographic area, family
size, and tobacco use (not their health status.)
Payments with Your Tax
Returns
• In 2014
– If individuals don’t have a certain level of health
coverage (employer coverage, Medicare,
Medicaid, CHIP, TRICARE, certain VA
coverage, an individual policy, or a plan in the
Marketplace) they may have to make a
payment with their tax return
Starting when the individual files their 2014
Federal tax return in 2015
– Some people may qualify for an exemption
Health Insurance Marketplace
• Every state will have a Marketplace (aka Exchange)
where individuals and small businesses can shop for and
purchase private health insurance.
• All options will be in one place, with clear language and
apples-to-apples comparisons about prices and benefits.
• Plans offered through the Marketplace are called
Qualified Health Plans (QHPs).
Enrollment starts October 1, 2013 Coverage starts January 1, 2014
Enrollment starts October 1, 2013
Coverage begins as early as January 1, 2014
Advantages of the Marketplace
• Helps enhance competition in the health insurance market
• Increases Affordability through premium tax credits, cost sharing reductions, or public insurance programs
• Ensures Quality through QHPs that must meet basic standards, including quality standards, consumer protections, and access to an adequate range of clinicians
• Makes Costs Clear by providing information about prices and benefits in simple terms consumers can understand, so they don’t have to guess about costs
State-Based: 17 States &
DC (royal blue) are setting
up & managing their own
Marketplaces
Partnership: 7 States
(aqua blue) are working in
partnership with the
federal government
Federally-Facilitated: In
27 States (light blue) the
federal government is
setting up the
Marketplace.
Marketplace Establishment
Source: Kaiser Family Foundation. Status of State Health Insurance Exchange Decision, as of July 1,
2013, http://kff.org/health-reform/state-indicator/state-decisions-for-creating-health-insurance-exchanges-
and-expanding-medicaid/#
Qualified Health Plans cover Essential Health Benefits
which include at least these 10 categories
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 (pediatric
oral services may be
provided by stand-alone plan)
Essential Health Benefits
Marketplace plans will be
similar & different
All Marketplace plans will:
• Cover essential health benefits
• Adhere to all the new insurance rules
Plans can vary based on:
• Premiums, copays, coinsurance
• Some may cover additional benefits
• Many will cover only providers in their network
Many People Can Get Help to
Pay for a QHP
• 90% of people who are currently uninsured will qualify
for discounted or free health insurance
• Eligible persons can get premium tax credits and/or
purchase plans with lower cost-sharing (e.g., co-pays
and deductibles)
% of Federal Poverty Level (FPL)
Individuals household income*
Family of 4 household income*
– Discounted Premiums
– 100-400%
– $11,490 - $45,960
– $23,550 - $94,200
– Reduced Cost-sharing
– 100-250%
– $11,490 - $28,725
– $23,550-$58,875
% of Federal Poverty Level (FPL)
Individuals household income*
Family of 4 household income*
Discounted Premiums
100-400% $11,490 - $45,960
$23,550 - $94,200
Reduced Cost-sharing
100-250% $11,490 - $28,725
$23,550-$58,875
*Based on 2013 Federal Poverty Guidelines
Medicaid Expansion
• States may expand Medicaid to non-elderly
adults with incomes up to 133% of the Federal
Poverty Level ($15,282/year for an individual,
$31,322/year for a family of 4)
• One streamlined application for Medicaid or
private health plans
• Shifts to simplified way of calculating income
(MAGI)to determine Medicaid/CHIP eligibility
• 100% federal funding for newly Medicaid eligible
• States have no deadline to decide if they are
going to expand
Expanding Medicaid
Source: Kaiser Family Foundation. Status of State Medicaid Expansion Decision, as of July 1, 2013,
http://kff.org/medicaid/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/#
What If a State Does Not
Expand Medicaid?
• Individuals whose income is more than $11,500 per year as a single
person (about $23,500 for a family of 4, or 100% of the federal poverty
level) will be able to buy health insurance in the Marketplace and get
lower costs based on household size and income.
• Individuals whose income is less than $11,500 per year as a single
person (about $23,500 for a family of 4, or 100% of the federal poverty
level) will be able to get insurance in the Marketplace, but are not eligible
for financial assistance.
– These individuals can get an exemption from having to pay a fee for
not having health insurance coverage
• Even if a state is not expanding Medicaid, individuals should apply for
coverage to see if they qualify.
• Find out if your state is expanding Medicaid at HealthCare.gov.
Eligibility Cheat Sheet
Income level % FPL
Eligible :
For Medicaid?
To purchase insurance through Market-places?
For insurance purchased through the Marketplace:
Premium Tax Credits
Reduced cost-sharing
0 to 100%: Currently eligible people will generally remain eligible. Individuals with incomes up to 138% FPL will be able to enroll in Medicaid in states that implement Medicaid expansion; Yes; No (Exception:
legal immigrants)
100% - 138%: %: Currently eligible people will generally remain eligible. Individuals with incomes up to 138% FPL will be able to enroll in Medicaid in states that implement Medicaid expansion; Yes;
Yes*
138% - 250%: Generally not (although some States cover some individuals); Yes; Yes*
250% - 400%; No; Yes; Yes*; No
Above 400%; No; Yes; No; No
Not lawfully present; No (except emergency Medicaid); No; No; No
* unless eligible for other minimum essential coverage as defined in IRC 5000A(f)
Income level
% FPL
Eligible :
For Medicaid?
To purchase
insurance
through
Market-
places?
For insurance purchased
through the Marketplace:
Premium
Tax Credits
Reduced
cost-
sharing
0 to 100%
Currently eligible people will generally
remain eligible. Individuals with
incomes up to 138% FPL will be able
to enroll in Medicaid in states that
implement Medicaid expansion
Yes No (Exception:
legal immigrants)
100% - 138% Yes
Yes* 138% - 250%
Generally not (although some States
cover some individuals) Yes
250% - 400% No Yes Yes* No
Above 400% No Yes No No
Not lawfully present No (except emergency Medicaid) No No No
* unless eligible for other minimum essential coverage as defined in IRC 5000A(f)
Who will Remain Uninsured?
After these new options are implemented, there may still be up
to 31 million uninsured persons in the U.S in 2023, including:
• Citizens under 100% FPL in states that don’t expand
Medicaid.
• Individuals who are not “lawfully present”
• Persons who are exempt from the Individual Responsibility
Payment (e.g., members of Indian Tribes, those with
religious objections)
• Persons who choose to pay the Individual Responsibility
Payment
Timelines for Enrolling
• Initial Open Enrollment starts October 1, 2013 and ends March
31, 2014 with QHP coverage effective as early as January 1,
2014.
• Annual Open Enrollment: October 15, 20xx-December 7, 20xx
• Special Enrollment Periods
• Medicaid enrollment will continue to occur throughout the year
Where Consumers Can Get Help
• Healthcare.gov
• Toll-free call center - 24/7
• 800-318-2596
(150 languages)
• Website chat 24/7
(English and Spanish)
• In-Person Help (Assisters &
Educators)
Then Direct to
Customer Service
Website
Call Center
Assister
Provide basic awareness and education about the Marketplace and serve to refer people to customer service channels for assistance
Help consumers through the application, plan comparison, and enrolling in coverage and may be able to provide additional education about health insurance & program options
Are not displayed in Find Local Help & are not
consumer referral points – educators refer
consumers
In Find Local Help &
Customer Service Referrals
Find Local Help shows all organizations that have been
trained & are available to help with application &
enrollment. Trained state/local government employees will
not be displayed.
Application & Plan Compare Assistance
• See individuals’ personal
information & data (PII)
• Help consumers fill out the
application
• Help consumers compare plans &
make an enrollment selection
• Provide education about the
application and plan compare
process
• Some may offer additional education
about health insurance basics,
program options, and plan offerings
• May conduct local outreach to bring
consumers in the door for
assistance
Outreach about the Marketplace
• Create awareness of the
Marketplace
• Drive consumers to Customer
Service channels (website &
assisters)
• Conduct outreach events & activities
• Provide basic information about the
Marketplace and where to get help
• Partners &
Stakeholders
• Local government
branches &
employees
• School
administration &
staff
• Navigators
• Enrollment Assisters
(FFM only)
• In-person Assisters
(SPM only)
• Certified Application
Counselors (hospitals, doctors
offices, libraries,
existing trusted
business partners)
• Agents/Brokers
• Call Center
Representatives
Educators
Assisters
Consumer Assistance Framework
Key Points to Remember
• The Marketplace is a new way to find and buy health
insurance
• Consumers in all 50 states will have better health
insurance choices when open enrollment begins on Oct.
1, 2013
• There is financial help for working families and other
people with limited income
• There is assistance available to help consumers get the
best coverage for their needs
• HHS re-launched HealthCare.gov and opened a 24/7 call
center to begin helping consumers get ready for open
enrollment.
Opportunities for Public Health
Covering more people with health insurance improves
population health.
People can get care they need to stay healthy.
Many preventive care services are free for new health
plans.
People with health coverage get more preventive care
and report better physical and mental health.
coverage for clinical preventive
services
community disease prevention & health promotion
research on prevention
services & models
employer wellness programs
ACA Preventive
Activities
Many Faces of
Prevention Strategies
Mechanisms Implementing Public Health
Prevention and Wellness Strategies
o National Prevention Strategy- a national roadmap o Prevention and Public Health Fund o Preventive and early intervention services o Expanded research on preventive services and
greater incorporation of evidenced based services o Childhood obesity research o Emphasis on wellness, such as employer wellness
programs o Workforce
General Resources
NACCHO: http://www.naccho.org/
HealthCare.gov: http://www.healthcare.gov
Stay Connected:
Sign up to get email and text alerts at signup.healthcare.gov
Updates and resources for partner organizations are available at
Marketplace.cms.gov
Twitter: @HealthCareGov, @CuidadoDeSalud
Facebook: facebook.com/Healthcare.gov,
facebook.com/CuidadoDeSaludgov
James M. Galloway, M.D. F.A.C.P., F.A.C.C.
Director of the Office of Health System Collaboration
Centers for Disease Control and Prevention
Questions?
Yolonda Campbell, J.D., M.P.H.
Health Policy Analyst, HRSA
Michelle Chuk Zamperetti, MPH
Senior Adviser, NACCHO
James M. Galloway, M.D. F.A.C.P., F.A.C.C.
Director of the Office of Health System Collaboration, CDC
Contacts
Sarah R. Linde, M.D.
Chief Public Health Officer, HRSA
Andrew Rein
Associate Director for Policy, CDC
Rita Vandivort-Warren, M.S.W.
Senior Public Health Analyst, HRSA