What Tribal Leaders Need to Know About the Affordable Care Act (ACA)

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What Tribal Leaders Need to Know About the Affordable Care Act (ACA) National Indian Health Outreach & Education Initiative March 11, 2014. Learn more about. Impact of the ACA on American Indians and Alaska Natives (AI/ANs) Medicaid Expansion Benefits AI/ANs - PowerPoint PPT Presentation

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  • What Tribal Leaders Need to Know About theAffordable Care Act (ACA) National Indian Health Outreach & Education InitiativeMarch 11, 2014

  • Impact of the ACA on American Indians and Alaska Natives (AI/ANs)Medicaid Expansion Benefits AI/ANs AI/ANs Can Enroll in Health Plans through the Marketplace or local I/T/UIncreased Resources for I/T/Us and CHS SavingsTribal Sponsorship Exemptions for AI/ANsImpact on Tribal Employers

    Learn more about

  • Impact of the ACA on American Indians and Alaska Natives

  • On March 23, 2010, President Obama signed into law the Patient Protection and Affordable Care Act (ACA)

    The ACA protects the rights of all Americans, including American Indians and Alaska Natives (AI/ANs), to access affordable health care

    More than 32 million people in this country who would otherwise not have health insurance will have access to health coverage

    The Health Care Law

  • Health Care & Federal Trust Responsibility

  • Permanent reauthorization of the Indian Health Care Improvement Act

    Strengthens the Indian Health Service and ensures that AI/ANs will be able to continue to receive services from I/T/UsProvides special protections for Indians to gain greater access to health coverage

    Impact of the ACA on American Indians and Alaska Natives (AI/ANs)

  • Expanded Authority for IHS: Reauthorization of the IHCIA allows IHS to modernize its health care delivery systems & permit tribal governments to make technical changes in the future

    Greater Workforce: New resources to increase the number of doctors, nurses and other health care providers in AI/AN communities

    Strengthening the Indian Health Service

    Increased Revenue: Third party billing increases funding to IHS that supports both direct care and contract health care services

  • Medicaid Expansion Benefits American Indians and Alaska Natives

  • Medicaid Expansion for Indian Country

  • Tribal Leaders must continue to advocate for Medicaid Expansion if their state has not opted to expandStates have the option to expand Medicaid eligibility to adults ages 19 - 64 with income up to $31,322/yr. for a family of 4, or $39,155/yr. in Alaska* Average income of AI/AN households is $35,192**Modified Adjusted Gross Income used to determine eligibilityNo premiums or deductibles for AI/ANs who are eligible to and do receive IHS, tribal 638, or urban Indian health services

    No copays for services received from an Indian health care provider or through referral under contract health services

    AI/AN Benefit from Medicaid Expansion*2013 Federal Poverty Level**US Census Bureau, 2012

  • AI/ANs Can Enroll in Health Plans through the Marketplace or Local I/T/U

  • AI/ANs May Apply for Medicaid, Childrens Health Insurance Program (CHIP), or Marketplace plans Enrollment assistance is available through the Marketplace or local I/T/UTax Credits for health plans lower the monthly premiums qualified individuals pay (up to 400% FPL)Family of four with annual income $23,550* - $94,200*Zero and Limited Cost Sharing Plan Variations available to members of federally recognized tribes or ANCSA Corporations

    AI/AN Can Enroll In Health Plans through the Marketplace or Local I/T/U

    *2013 Federal Poverty Level

  • Members of federally recognized tribes or ANCSA Corporations:

    No out of pocket costs if enrolled in a Zero Cost Sharing Plan Variation (300%FPL) for services provided by an I/T/U or through referral by contract health services.

    Special Monthly Enrollment Period and can change their enrollment status in any plan through the Marketplace once a month.

    Eligible for an Exemption from the Shared Responsibility Payment. Note: Exemption is not automatic, application required.

    Protections for Indian Country in the Marketplace

    300% FPL = individual income of $34,470/yr. and family of four $70,650/yr.

  • The Application Process

    OnlinePhoneMailIn PersonSupported by Data Services HubFind out more about the Marketplace in your state by visiting healthcare.gov.

  • Increased Resources forI/T/Us

  • Increased Resources for I/T/Us and CHS Savings through AI/AN Enrollment

  • Tribal Sponsorship of Marketplace Plans

  • Some tribes are purchasing health insurance (Qualified Health Plans) for some or all of its citizens through the Marketplace. Zero cost sharing plan variation and limited cost sharing plan variation available at different metallic levels.

    Tribal Sponsorship of Health Insurance Plans

    Plan levels in Marketplace: Bronze, Silver, Gold & Platinum

    Plans will vary by: the cost of premium & out of pocket costs.

    Lower Premium Higher PremiumHigher AV Means Less Cost Sharing

  • All insurance plans certified by the Marketplace must:

    Include 10 Essential Health Benefits (EHB)

    Limit cost-sharing deductibles, copayments, and out-of-pocket maximum amounts

    Offer zero cost sharing plan variation and limited cost sharing plan variations for AI/AN

    What are Qualified Health Plans (QHPs)

  • 10 Essential Health BenefitsAmbulatory Patient ServicesPrescription DrugsEmergency servicesRehabilitative & Habilitative Services and DevicesHospitalizationLaboratory ServicesMaternity & Newborn CarePreventive & Wellness Services and Chronic Disease ManagementMental Health & Substance Use Disorder Services, Including Behavioral Health TreatmentPediatric Services, including Oral & Vision Care

  • Benefits of Tribal Sponsorship

    Tribe could purchase the bronze plan (lowest premium) for Tribal citizens. Many Tribal citizens will qualify for tax credits (lowers monthly premium) and cost sharing reductions. Tax credits available up 400% FPL. Family of four with annual income $23,550* - $94,200*Members of federally recognized tribes and ANCSA Corporations may enroll in zero cost sharing plan variation (300% FPL)Individuals not eligible for plan variations could qualify for cost sharing reductions if

  • Exemptions for American Indians and Alaska Natives

  • Individuals who can afford health insurance but choose not to buy it, must pay a fine known as an individual shared responsibility payment.

    In 2014, the fine is $95 per person ($47.50 per child under 18) with maximum of up to $285 per family using this method OR up to 1% of yearly household income, whichever is higher. For 2014, the payment is made through 2014 tax return filing in April 2015.

    In 2015, it is $325 per person or 2% of income; and in 2016, it is $695 per person or 2.5% of income.

    How Much is the Fine for Not Having Insurance?

  • Who Qualifies for an Exemption from the Fine?

    Members of federally recognized tribes or ANCSA Corporations; or individuals eligible for services from an Indian health care provider.

    Individuals/families where the lowest-priced coverage available would cost more than 8% of the household income. Individuals uninsured for less than 3 months of the year.

    Individuals who do not have to file a tax return because their income is too low.

    If other other circumstances apply. See healthcare.gov/exemptions/ for other exemptions.

  • Members of federally recognized tribes and ANCSA Corporations May apply for the exemption through the Marketplace; ORMay claim the exemption when they file their 2014 taxes (due April 15, 2015). Individuals eligible to receive services through an Indian health care providerMay only apply for the exemption through the Marketplace. Once you receive the exemption, you dont have to apply again unless your circumstances change (i.e., no longer enrolled or not eligible for services).

    How do AI/ANs Claim the Exemption?

  • AI/AN Exemption Application

    Available at: http://marketplace.cms.gov/getofficialresources/publications-and-articles/tribal-exemption.pdfCovers both types of AI/AN exemptions.One application can be used for the tax household.Instructions for the Application will be available soon.

  • What is Needed to Apply?

    Required documentation to apply:Documents showing tribal membership or eligibility for services from the I.H.S., a tribal health care provider or an urban Indian health care provider. Social security numbersInformation about people in your tax household

  • Application Process

    Complete and sign the application. Mail the application with the required documents to address provided. Per application, applicant will receive a response within 1-2 weeks if more information is needed. If exemption is approved, applicant will receive a certificate of exemption number for filing of tax return.

  • Impact of ACA on Tribal Employers

  • Tribal Employer Opportunities & Requirements

  • ACA Employer Provisions At-A-Glance

    ACA Provisions Number of employees 1 to 2425 to 4950 to 99100-200> 200Small Business Health Care Tax CreditX

    Small Business Health Options Program (SHOP)XX(up to 50)

    IRS Assessable Payments & ReportingX(transition relief in 2015)XX

  • Why is this Important for Tribes?If a Tribe is considered a large employer, it may incur an assessable payment for not offering health insurance.Tribes may be eligible to purchase health insurance through the Small Business Health Options Program (SHOP). Tribes can strategize to meet ACA employer requirements in a cost effective manner.

  • Small Tribal Employer Opportunity

  • What is SHOP?SHOP = Small Business Health Options Program Designed to help small businesses purchase health insurance for employees.Allows an employer to compare plans based on price, coverage and quality.Employers eligible if 50 employees (see next slide).In 2016, will increase to 100 employees.Tribes and Tribal entities are eligible to participate.To find our more about the Marketplace in your State, visit: https://www.healthcare.gov/marketplace/shop/.

  • Employer Eligibility CriteriaGenerally, an employer is eligible to participate in SHOP if the employer: Is a small employer on business days during the prior calendar year and who employs at least one employee on first day of the plan year; Elects to offer all full-time employees coverage in a plan through a SHOP; andHas its principal place of business address in the Exchange and offers coverage to all full-time employees through that SHOP; OR offers coverage to each eligible employee through the SHOP serving that employees primary worksite (in this case, the employer participates in multiple SHOPs).

  • Small Tribal Non-Profit Employer Opportunity

  • Small Business Health Care Tax Credit

    Qualify if 1 to 24 full-time equivalent employees. Per IRS Guidance, an agency or instrumentality of an Indian tribal government is not eligible for the tax credit unless it is a 501(c)(3).Other Tribally owned entities may be eligible for the tax credit (e.g., an entity organized under State law).

  • Eligibility for the Tax CreditA small employer may qualify for a tax credit if the small employer meets all of these requirements:1. Fewer than 25 full-time equivalent employees (FTEs); 2. Pays an average annual wage of less than $50,000 per year per FTE; and3. Pays for at least 50% of the cost of health insurance coverage for each of its employees.

  • About the Tax CreditThe tax credit is a percentage of premiums paid by employer.Percent is sliding scale based on employer size and average wage.Beginning January 1, 2014, maximum credit is:50% for small business employers 35% for small tax-exempt employersThe maximum credit is available to employers with 10 FTE employees and average annual wages of $25,000.In 2014, the credit will only be available for employers that purchase insurance coverage through a SHOP.The employer can only receive the credit for 2 consecutive years (beginning in 2014).

  • Large Tribal Employer Requirement

  • Employer Shared Responsibility MandateEmployer Shared Responsibility Mandate provisions (i.e., assessable payments): Applicable to employers with > 50 full-time employees, including full-time equivalent employees. In 2015, transition relief for employers with 50 to 99 full-time employees (certification required).Final regulations issued on February 12, 2014.Delayed to 2015 (IRS Notice 2013-45).

  • What is the Mandate?The Employer Shared Responsibility mandate means that an employer will be subject to an Assessable Payment or Shared Responsibility Payment for not offering health insurance coverage that is affordable or that does not provide minimum value to its full-time employees and their dependents.

  • How the Mandate Applies to TribesTribal governments and subdivisions of Tribal governments are not exempt.The rules specific to governmental entities (which includes Tribal governments and subdivisions of Tribal governments) have not been issued by the IRS.All Tribal entities will have to comply with these provisions to avoid Assessable Payments.Tribal businesses, organizations and all other entities such as casinos, retail businesses, health centers, nursing homes and non-profit organizations.See 26 U.S.C. 4980H, 78 Fed. Reg. 218, and 79 Fed Reg. 8544.

  • Determining Large Employer StatusMany employers will know they are a large employer without having to count their full-time employees. Number of full-time employees (average of 30 hours of service per week) and full-time equivalent employees (FTEs) are counted. A specific method must be used to count hours of service for hourly and non-hourly employees. Large employer status determined in current year for following calendar year. Transition Relief in 2015: Employers close to threshold may use a one-time period of six consecutive months to determine large employer status.

  • Steps to Determine Large Employer StatusCalculate the number of full-time employees (including seasonal workers) for each calendar month in the prior year.Calculate the number of full-time equivalent employees (including seasonal workers) for each calendar month in the prior year.Full-time equivalent employees = Add the total number of hours of service of part-time employees in a calendar month and divide by 120.Add the number of full-time employees and full-time equivalent employees for each month of the calendar year.Add up the 12 monthly numbers and divide by 12.

    *

  • Steps to Determine Large Employer Status (continued)The ResultIf the result is less than 50, the employer is not a large employer. If the result is 50 or more, the employer is a large employer. Employer may not be considered a large employer if the Seasonal Worker Exception applies.

  • Seasonal Worker ExceptionAn employer may not be considered a large employer if:The employers work force only exceeds 50 full-time employees for 120 days or less during the calendar year; andThe employees in excess of 50 who were employed during that 120 day period or less were seasonal workers.

  • Definition of Seasonal WorkerSeasonal worker = a worker who performs labor or services on a seasonal basis as defined by the Secretary of Labor, including (but not limited to) workers covered by 29 CFR 500.20(s)(1), and retail workers employed exclusively during holiday seasons. 79 Fed. Reg. 8581.Employers may use a good faith interpretation of seasonal worker under DOL Regulations 29 CFR 500.20(s)(1). Per IRS guidance:The 120-period may be applied using four calendar months (whether or not consecutive) or a period of 120 days (whether or not consecutive).Not limited to agricu...

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