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The Affordable Care Act of 2010: What is Happening Next What You Need to Know

Training Sections

1. Recent History of Health Care Reform 2. Overview of Changes in Affordable Care Act (ACA) 3. Timeline of Major Changes 4. Resources

Training Section 1: Recent History of Health Care Reform

Recent History March 2010

U.S. Congress passed: • Patient Protection and Affordable Care Act (HR 3590) • Health Care and Education Reconciliation Act of 2010 (HR 4872) 4

Recent History March 2010

President Obama signed into law, creating: • Patient Protection and Affordable Care Act (Public Law 111-148) • Health Care and Education Reconciliation Act of 2010 (Public Law 111-152 ) • Together, commonly known as The Affordable Care Act (ACA) of 2010 5

Training Section 2: Overview of Changes in Affordable Care Act (ACA)

Overview The Affordable Care Act (ACA) of 2010:

• Impacts many areas of health care • Result of many compromises • Does not go into effect all at once • Relies heavily on state and local implementation 7

Overview

Affordable Care Act makes major changes in 4 basic areas: 1. Insurance company accountability 2. Lowering costs and improving quality 3. Increasing access and choice 4. Patient rights and consumer protections 8

Key Strategies in Reform Approach Adapted from Gerben DeJong, PhD, National Rehabilitation Hospital MedStar Health Research Institute

1. Leave “good enough” alone – No drastic changes 2. Share the Responsibility – Everybody in the pool 3. Market-Based Solutions – Shift to competition for price and quality 4. Contain Costs – Focusing on the populations that have the highest health care costs 5. Innovate and Test – Half of ACA text focuses on testing laboratories to avoid implementation mistakes 9

Overview: HealthCare.Gov

Training Section 3: Timeline of Major Changes

Explaining the Timeline How Timeline Works:

• Changes take effect over many years, through 2020 • Timeline shows when major reforms go into effect • Designed to give more detailed information about changes coming soon, summarizes changes down the road

Explaining Timeline: [Date] [Type of Reform]

Who: Population reform impacts Why: Need or problem reform is addressing What: Specifics of what reform does When: When reform goes into effect How: Details of how reform will be implemented or accessed

TIMELINE: IN PROGRESS NOW

Timeline: In Progress Now Pre-existing Condition Insurance Plans Who:

• People who can’t get insurance because of pre-existing medical conditions, including mental health conditions

Why:

• Before ACA, people with pre-existing conditions often couldn’t get any insurance

Timeline: In Progress Now Pre-existing Condition Insurance Plans What:

• People who can’t get insurance because of pre-existing medical conditions can apply for a Pre-Existing Condition Insurance Plan (PCIP) • Law limits premiums to “standard rates” - the average amount private insurers in the state charge for premiums for similar coverage • Limits out-of-pocket expenses – $5,950/year for individual (does not include premiums)

Timeline: In Progress Now Pre-existing Condition Insurance Plans What:

• States can run PCIPs, with federal funding, or use federal PCIP – 29 states chose to run plans themselves – 21 states chose to let the federal government run them • PCIPs in each state operate under ACA standards – But plans may vary from state to state

Timeline: In Progress Now Pre-existing Condition Insurance Plans What:

• For people who live in states where the PCIP is run by the federal government, there are now three options for plans: – Standard plan – Extended plan – Health savings account plan – For more information about these plans, go to: http://www.healthcare.gov/news/factsheets/new_plan_opt ions_2011.html

• The federal PCIP will now offer a special child-only rate for children under 18.

Timeline: In Progress Now Pre-existing Condition Insurance Plans When:

• States letting the federal government run their PCIP: – Can apply online now and get coverage within a month • States running their own PCIP: – Different application and enrollment dates

Timeline: In Progress Now Pre-existing Condition Insurance Plans When:

• PCIPs are meant to be temporary: – End on January 1, 2014, when insurance companies won’t be allowed to deny people coverage because of pre existing conditions – On January 1, 2014, the state-run health insurance Exchanges will be operational.

Timeline: In Progress Now Pre-existing Condition Insurance Plans How:

• To apply for a PCIP you must: – Be a U.S. citizen or lawfully present in the United States – Have had no health coverage for the last 6 months – Have a pre-existing condition, as defined by each PCIP – You can apply no matter what your income is • To find details for your state: www.HealthCare.Gov/law/about/provisions/pcip/index.html

Timeline: In Progress Now Money Follows the Person Grants Who:

• People on Medicaid who need long-term care services

Why:

• In the past, Medicaid’s Money Follows the Person grants have provided flexible funding that lets a person who needs long term care services get services that are most appropriate to what they need and want • MFP funding gives flexibility to move from institutional to community-based services and keep funding

Timeline: In Progress Now Money Follows the Person Grants What:

• ACA extends these grants and adds $2.25 billion in funding • Broadens eligibility standards • Helps states pay for the costs of moving someone from institution to home

When:

• MFP grants have been extended until September 2016

How:

• The program is continuing to operate as before

Timeline: In Progress Now Rescission Outlawed Who:

• Anyone who has insurance and might get sick

Why:

• Before ACA, when someone with insurance got sick with an expensive or chronic illness, insurance companies would often go back and search their application for mistakes, looking for reason to drop their coverage • This is called rescission, and happened to thousands of Americans each year

Timeline: In Progress Now Rescission Outlawed What:

• Under ACA, insurance companies aren’t allowed to drop people’s coverage because they get sick

When:

• Rescission is now illegal

How:

• Department of Health and Human Services is responsible for regulation and enforcement details

Timeline: In Progress Now Ban on Discriminating Against Kids with PEC Who:

• Children under 19 with pre-existing conditions

Why:

• Before ACA, insurance companies could legally deny insurance to children because they had a pre-existing condition

What:

• Under ACA, it is illegal for insurance companies to deny or restrict insurance to children because of pre-existing condition

Timeline: In Progress Now Ban on Discriminating Against Kids with PEC When:

• Applies to health plan years starting after September 23, 2010

How:

• As with any group plan, insurance companies may decide to restrict enrollment to specific enrollment periods • Department of Health and Human Services is responsible for regulation and enforcement details

Timeline: In Progress Now Expanded Coverage for Young Adults Who:

• Adult children up to age 26

Why:

• Before ACA, children were often dropped from parents’ insurance plans when they turned 18 or finished college • Many young people have difficulty finding jobs with employer sponsored coverage and can’t afford to buy individual coverage, so they often would go without insurance

Timeline: In Progress Now Expanded Coverage for Young Adults What:

• Children can stay on (or be added to) their parents’ insurance until they turn 26 – Applies to plans that offer dependent coverage

When:

• Open enrollment for coverage started on September 23, 2010 and was required by law to continue for at least 30 days, with annual open enrollment periods • Finding Insurance Options

Timeline: In Progress Now Ban on Lifetime Coverage Limits Who:

• Anyone who has insurance or will ever use insurance

Why:

• In the past, insurance companies have used lifetime coverage limits to limit amount of money they will pay out for a customer’s health care needs • If someone got sick and reached their lifetime coverage limit during treatment, the insurance company could just stop paying for treatment

Timeline: In Progress Now Ban on Lifetime Coverage Limits What:

• Insurance companies not allowed to put caps on amount they will spend on lifetime coverage costs for essential benefits • Essential benefits include things like hospital stays, doctor visits, and prescription drugs

Timeline: In Progress Now Ban on Lifetime Coverage Limits When:

• Ban started September 23, 2010, for all new individual insurance plans and all group plans • Annual limits are restricted in all group plans and new individual plans, until 2014, when banned completely

How:

• The law includes a detailed list of essential benefits that must be covered without limit

Timeline: In Progress Now Free Preventive Services - Private Coverage Who:

• Anyone who has private insurance

Why:

• Before ACA, many health plans charged for preventive services, so people often chose to skip them • Preventive services can help avoid many costly health problems down the road

Timeline: In Progress Now Free Preventive Services - Private Coverage What:

• Private insurance plans have to cover certain recommended preventive services, like cancer screenings • Insurance companies are required to offer these services free to patient - without deductible, coinsurance, or copayment charges • Law ensures many free preventive health services for children, including many vaccines

Timeline: In Progress Now Free Preventive Services - Private Coverage When:

• All new individual and group plans after September 23, 2010

How:

• Coverage for these services is offered through existing private insurance plans

Timeline: In Progress Now Improvements to Medicaid HCBS Who:

• People who use Medicaid’s Home and Community-Based Services (HCBS)

Why:

• In 2005, 1915(i) was added to Social Security Act • Gave state Medicaid programs option to provide HCBS to people with disabilities before they need institutional care • Many states did not choose to provide these services

Timeline: In Progress Now Improvements to Medicaid HCBS What:

• ACA changes and adds to Section 1915(i) – Removes many barriers to states to offering these services – Allows states to amend their plans instead of having to apply for waiver – Improves quality of services and access to HCBS for people with disabilities • Expands services that state can offer as part of HCBS • Allows states to extend full Medicaid benefits to people using HCBS

Timeline: In Progress Now Improvements to Medicaid HCBS When:

• Changes went into effect on October 1, 2010

How:

• As long as people meet a state’s eligibility requirements, HCBS have to be offered to every eligible person in the state • States can now provide services to people with incomes up to 300% of the Supplemental Security Income (SSI) Federal Benefit Rate ($2,022 per month in 2011)

Timeline: In Progress Now Drug Discounts for People in Donut Hole Who:

• People who fall in Medicare’s donut hole

Timeline: In Progress Now Drug Discounts for People in Donut Hole Why:

• Under Medicare Part D, when person’s prescription drug costs reach a certain amount ($2,840 in 2011): – Medicare stops paying for any prescription drug costs – They have to pay for 100% of their drugs out-of-pocket, until they reach the maximum out-of-pocket amount – Once they reach this maximum ($4,550.00), they are out of the donut hole - Catastrophic Coverage begins, and Medicare starts to help cover the costs again

Timeline: In Progress Now Drug Discounts for People in Donut Hole What:

• People in donut hole get up to 50% discount on brand name drugs, 7% discount on generics for 2011 and 14% for 2012 • People who qualify for Extra Help, and join a Medicare drug plan, will have no coverage gap.

When:

• Discount started January 1, 2011 – Will grow until 2020, when donut hole is closed completely

How:

• Full cost of drugs (rather than discounted amount) still counts towards person’s out-of-pocket maximum

Timeline: In Progress Now More Preventive Services Under Medicare Who:

• Anyone on Medicare

Why:

• Preventive services can help avoid many costly health problems down the road

Timeline: In Progress Now More Preventive Services Under Medicare What:

• People on Medicare can get a free wellness visit and personalized prevention plan each year • Must have had Part B for longer than 12 months • No copayment, deductible, or coinsurance charges for recommended preventive services

Timeline: In Progress Now More Preventive Services Under Medicare When:

• Started January 1, 2011

How:

• Coverage for these services are offered through existing Medicare plans

Timeline: In Progress Now Medicaid Community First Choice Option Who:

• People with disabilities who are on Medicaid with income less than or equal to 150% of Federal Poverty Level, or if greater, meet an institutional level of care

Why:

• People with disabilities have the right to choose to live in and receive services in their homes and communities whenever possible

Timeline: In Progress Now Medicaid Community First Choice Option What:

• Provides HCBS such as attendant services and supports to increase a person’s ability to live in the community • Allows Medicaid plans to choose HCBS as a rule, rather than the exception

When:

• CFC Option will be effective October 1, 2011

Timeline: In Progress Now Medicaid Community First Choice Option How:

• ACA provides a 6 percentage point increase in federal Medicaid match for states that choose the CFC Option

TIMELINE: BY 2012

Timeline: By 2012 CLASS Act Who:

• Everyone

Why:

• Paying for long-term care is expensive – Many people can’t afford it and don’t budget for it • People need options that give them more choice and flexibility about long-term care

Timeline: By 2012 CLASS Act What:

• The Community Living Assistance Services and Support Act (CLASS Act) provides for voluntary, self-funded, long-term care insurance through the workplace • Insurance will help pay for long-term care costs for people with disabilities and elderly people • People will be able to use cash benefit to pay for their choice of variety of long-term care services, including home health care workers, assistive technology, adult day care, transportation, or assisted living

Timeline: By 2012 CLASS Act When:

• Departments of Health and Human Services (HHS) will write rules about how much premiums will cost and what disabilities qualify for the insurance benefits • Rules must be written by October 1, 2012

Timeline: By 2012 CLASS Act How:

• Employers decide whether they want to participate • If employer participates, people are auto-enrolled, can opt out • Premiums taken through payroll deductions – Employers can pay premiums, not required • Will be way for self-employed and employees of companies that don’t participate to choose to enroll

Timeline: By 2012 CLASS Act How:

• People pay premiums for five years before they can collect benefits, which will be a minimum average of $50 a day – Amount of benefit depends on assessment of disability – This benefit will not count as income when determining eligibility for benefit programs like SSI, SSDI • No income or asset limit • There are eligibility criteria, but no screening for pre-existing conditions • No lifetime benefit limit

TIMELINE: BY 2014

Timeline: January 1, 2014 Ban on PEC Discrimination Who:

• Anyone with a pre-existing condition

Why:

• Before ACA, insurance companies could legally deny insurance to people because they had a pre-existing condition

What:

• Under ACA, will be illegal for insurance companies to deny or limit insurance to anyone because of a pre-existing condition

Timeline: January 1, 2014 Ban on PEC Discrimination When:

• Starting on January 1, 2014

How:

• Department of Health and Human Services is responsible for regulation and enforcement details

Timeline: January 1, 2014 Expansion of Medicaid Eligibility Who:

• Low-income people who have previously made too much money to qualify for Medicaid • Low-income adults without children • Low-income adults without a disability

Why:

• Many people who did not qualify for Medicaid did not have access to affordable insurance through their job, and did not make enough to be able to pay for private insurance

Timeline: January 1, 2014 Expansion of Medicaid Eligibility What:

• Medicaid will expand to cover more low-income people including adults without children, and adults without a disability • Anyone below a certain income level will be eligible for Medicaid – Unlike current eligibility that is based on a population or category (such as having a disability) • Will help people with disabilities who did not meet the current Medicaid disability determination requirements

Timeline: January 1, 2014 Expansion of Medicaid Eligibility When:

• Starting January 1, 2014 • States can choose to expand Medicaid eligibility before 2014 • As of March 2011, 2 states (CT, MN) and the District of Columbia have expanded Medicaid eligibility

How:

• Expansion will include most people (age 19 and older)

with incomes up to 133% of Federal Poverty Level

(about $28,000 for family of 4)

Timeline: January 1, 2014 Expansion of Medicaid Eligibility People eligible for this Medicaid category cannot be:

• Age 65 or older • Pregnant • Entitled to or enrolled in benefits under Medicare Part A • Enrolled under Medicare Part B, or: • Part of any of the other “mandatory” groups described in the Medicaid law – Such as certain parents, children, or people who are eligible because they get Supplemental Security Income (SSI) benefits

Timeline: January 1, 2014 Expansion of Medicaid Eligibility

• Most people get benchmark (or benchmark-equivalent) benefits • All rules that apply under the Medicaid program in general apply to this new eligibility group – Including rules related to cost sharing, retroactive coverage, and immigration status • This expansion also gets rid of the asset test for: – New eligibility group – People eligible through Medicare or other programs – People with disabilities

Timeline: January 1, 2014 State Health Insurance Exchanges Who:

• Everyone in private insurance market

Why:

• In the past, it has been complicated for people to compare private insurance plans • People buying individual plans have not been able to negotiate for better prices, the way people buying group coverage can

Timeline: January 1, 2014 State Health Insurance Exchanges What:

• States will create exchanges, a marketplace where people can comparison shop for standardized health packages • Exchanges will provide way for individuals and small businesses to buy more affordable coverage • People will also be able to join together in groups to negotiate more affordable group insurance • Provides subsidies for low-income people on a sliding scale

Timeline: January 1, 2014 State Health Insurance Exchanges What:

• The exchanges inspect policies to make sure they meet standards – Can ask companies to justify rate hikes

When:

• Starts January 1, 2014

Timeline: January 1, 2014 State Health Insurance Exchanges How:

• Exchange packages will include essential health benefits: • Outpatient care • Emergency services • Hospitalization • Maternity and newborn care • Mental health and substance use disorder services • Prescription drugs • Rehabilitative services and devices • Laboratory services • Preventive services and chronic disease management • Pediatric services

Training Section 4: Resources

HealthCare.Gov

• Finding Insurance Options • Timeline • Information for Specific Situations • Comparing Quality of Facilities • Information about Implementation

HealthCare.Gov

• The ACA includes many new regulations • Each new regulation goes through a period known as NPRM: Notice of Proposed RuleMaking • During this period the public can comment, giving input and expertise about the proposed regulation before the final version of the regulation is written • HealthCare.Gov has a section where you can find more information on regulations, including those with “NPRM” periods that are open for comment: http://www.healthcare.gov/center/regulations/index.html