Transcript Virginia Poverty Law Center - Obici Healthcare Foundation

THE AFFORDABLE CARE ACT
PRESENTATION TO
OBICI HEALTHCARE FOUNDATION
BY
JILL HANKEN, STAFF ATTORNEY
VIRGINIA POVERTY LAW CENTER
MAY 2012
700 E Main St. Suite 1410, Richmond, VA 23219
T: 804-782-9430
F: 804-649-0974
Virginia Poverty Law Center
The statewide support center for legal aid in
Virginia providing support in
ADVOCACY
TRAINING
LITIGATION
on the civil justice issues faced by
low-income Virginians
THE AFFORDABLE CARE ACT
 Purpose
 Key Provisions
 Implementation in Virginia
 U.S. Supreme Court
 The Future
PATIENT PROTECTION &
AFFORDABLE CARE ACT (ACA)
Comprehensive care
•
o
Available to all legally in U.S.
o
Affordable
Health Insurers Compete
•
o
On good care and customer service
o
Not by denying care.
Foundation for Better Medical Care
•
o
Effective health care, not just volume
o
Leads to lower health care costs
ACA’S MAJOR CHANGES
 Big changes on January 1, 2014
 Medicaid expansion(+16 million enrolled)
 State health exchanges created (+24 million insured)
 Employer and individual mandates
 But there are many new improvements &
protections in place today.
Private Health Insurance “Patient’s Bill of Rights”
 Allows children to stay on parent’s plan until
26th birthday (even if married).*
 Ends lifetime dollar caps & phases out annual
limits
 Ends arbitrary rescissions of coverage
 Ends denial of coverage for kids with preexisting conditions.*
*Some exceptions apply
“PATIENT’S BILL OF RIGHTS”, cont’d
 Ends co-pays or other out-of-pocket expenses for
Preventive Care*
 Gives choices of primary physician and direct access to
OB/GYN*
 Ends prior authorization for Emergency Care*
 Gives new rights to Insurance Appeals
* Some exceptions apply
ENSURING REASONABLE PREMIUMS
 Rate Review
Federal and state governments
begin annual review of health
insurance premium increases.

 Medical Loss Ratio (MLR)
 Insurers must pay out 80¢ - 85¢
of each $1 premium for medical
benefits -- or pay rebates to consumers.
PRE-EXISTING CONDITION INSURANCE
PLAN (PCIP)
 “Bridge” to 2014
 Uninsured for at least past six months
 Must have Pre-existing condition(s)
 Premiums range from:
 ≈$100 per month (for children 0-18)
 ≈$400 per month (adults over age 55)
 Deductibles for covered benefits (except for
preventive services), & co-pays
 Apply on-line www.pcip.gov;
www.healthcare.gov
MEDICARE REFORMS
 Closing the Rx “Doughnut Hole”
o
$250 Rebate (2010)
o
50% discount brand-name drugs (2011)
o
Doughnut hole ends by 2020
 New preventive benefits
o
adds comprehensive annual check-up, other prevention
benefits
o
no out-of-pocket costs.
 Improves solvency of Medicare Trust Fund
MORE EARLY REFORMS
 Small employer tax credits



Up to 35% of premium cost (up to 50% in 2014-2016)
Small firms with ≤25 full-time equivalent employees
Average annual wages under $50,000
 Grants to states
 Over $182 million to Virginia!
 Planning
 Research
 Workforce
 Community Health Centers
ACTIVITY IN VIRGINIA
 Virginia Health Reform Initiative (VHRI)

Reforming Health Care in Virginia


Planning for Health Benefits Exchange



Report Winter 2010
Report Fall 2011
VHRI meetings scheduled Spring 2012
http://www.hhr.virginia.gov/Initiatives/HealthReform/
 2011 General Assembly adopted Patient Bill of Rights
 2012 General Assembly rejected Exchange
Legislation
LITIGATION
 Numerous constitutional challenges to individual
mandate (and Medicaid expansion)

2 Cases in Virginia
 U.S. Supreme Court heard cases in March and will
decide by June.
JANUARY 1, 2014 is
20 MONTHS AWAY!
What Happens Then?
MEDICAID EXPANSION
 Income limits go up to cover more people <65

133% Federal Poverty Line (FPL)

$14,857 individual; $30,657 for family of 4

Income calculation similar to “adjusted gross income” for
income taxes
 No Asset Limit for newly eligible people

Unless they are over age 65 or receiving long term care
services
 “Benchmark” benefits for newly eligible
OTHER MEDICAID
 Expansion Funded
 100% FFP 2014-2016
 95% FFP 2017
 90% FFP 2020 and after
 Higher RX rebates
 Increase in primary care rates (= Medicare)
in 2013
 Increase CHIP Match
 New Community Based Long-Term Care
Options
 But Hospital DSH payments go down
HEALTH BENEFIT EXCHANGE
 New Marketplace

To compare / purchase private health insurance

For people without affordable job-based coverage and small
employers

Not affordable if it costs ↑9.5% family income; covers ↓60% costs
 Standardized coverage

“Essential Benefits” - hospital, ER, mental health, maternity,
Rx, preventive care, chronic disease management, pediatric
(oral/vision) and more.
 Premium assistance based on income
 Limits on out-of-pocket costs based on income
COVERAGE LEVEL OPTIONS IN THE EXCHANGE
4 standard levels:
Platinum – 90/10
Gold – 80/20
Silver – 70/30
Bronze – 60/40
Options vary by how much
should be covered by the
plan and how much is paid
by enrollee cost sharing
Plus catastrophic plans
for people under age 30 or if
no other coverage is
affordable
90%
80%
70%
60%
0%
20%
40%
60%
10%
20%
30%
40%
80%
100%
MINIMUM COVERAGE REQUIREMENT
 Affordability requires spreading risk over large pool
that includes healthy people
 Who Is Exempt from mandate?
o
Lowest-price Exchange plan costs > 8% of family income
o
Income below tax filing threshold (e.g. $9,500 single/$19,000 couple in
2011)
o
Excused for other financial hardship
o
Religious objectors
o
Native Americans
Undocumented immigrants
o
o
o
Incarcerated persons
Those uninsured for less than 3 months.
TAX PENALTIES FOR NON-EXEMPT WITHOUT
INSURANCE
• Individual / family penalty is much less than cost of
insurance.
2014 - $95 /person or 1% family income
 2015 - $325/person or 2% family income
 2016 - $695/adult; $375/child or 2.5% family income (max.
$2085/family)

• Also penalties on large employers (more than 50 full-time
workers) who don’t offer coverage
Family Income
HEALTH REFORM COVERAGE OPTIONS BY INCOME
>$92,200 for a
family of four;
>400% of federal
poverty line (FPL)
(2012)
 Job-based coverage, or
 Full-cost coverage in the exchange
$69,150-$92,200;
300-400% of FPL
 Job-based coverage, or
 Subsidized exchange coverage: premiums capped
at 9.5% of income
$46,100-$69,150;
200-300% of FPL
 Job-based coverage, or
 Subsidized exchange coverage: premiums capped
at 6.3 – 9.5% of income
$30,657-$46,100;
133-200% of FPL
CHIP
• Job-based coverage, or
• Subsidized exchange coverage:
premiums capped at 3% - 6.3%
of income
<$30,657 for a
family of four;
< 133% FPL
Medicaid
Medicaid
Children
Adults
(non-disabled adults,
not eligible for Medicare)
WHICH VIRGINIANS WILL GAIN COVERAGE?
 Of the over ONE MILLION uninsured Virginians:
 420,000 adults are expected to newly qualify for Medicaid
 106,000 (adults and kids) are expected to get a subsidized
Exchange plan
 100,000 currently eligible but
uninsured children are expected
to enroll in FAMIS/Medicaid
 The rest will remain
uninsured . . .
*Urban Institute Estimates, 2011
WHO WILL STILL BE UNINSURED?
 U.S. Citizens
Exempt from the mandate (no penalty)
 People who choose not to be covered (penalty may apply)

 Low Income Legal Immigrants
 Many are ineligible for Virginia’s Medicaid program
 Can’t afford Exchange products
 Undocumented
 Not covered by Medicaid (except for emergencies),
FAMIS or the Exchange
WEBSITES FOR MORE INFORMATION
 Official Gov’t Website – www.healthcare.gov
 Families USA – www.familiesusa.org
 Kaiser Family Foundation – www.kff.org
Thank You!
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