Transcript Affordable Care Act: The Basics

Affordable Care Act: The Basics
Jon Bailey, Director
Rural Public Policy Program
Center for Rural Affairs
Disclaimer
The Center for Rural Affairs does not offer or
provide legal advice. CFRA is not an insurance
agency, broker, or consultant; does not
recommend any health insurance product or
policy or provide any advice on the purchasing
of health insurance; and does not accept any
compensation or consideration from an
insurance company, insurance broker, or
insurance consultant.
Health Care Reform Law
Actually two bills adopted by Congress
• Patient Protection and Affordable Care Act” –
Public Law 111-148, signed by President
Obama on March 23, 2010
• “Health Care and Education Reconciliation Act
of 2010” – Public Law 111-152, signed by
President Obama on March 30, 2010
Health Insurance Reforms
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Under the law, a new “Patient’s Bill of Rights” reforms key
aspects of health insurance
Provides Coverage to Americans with Pre-existing
Conditions
Keeps Young Adults Covered -- If you are under 26, you
may be eligible to be covered under your parent’s health
plan
Ends Lifetime Limits on Coverage
Ends Pre-Existing Condition Exclusions for children under
19
Ends Arbitrary Withdrawals of Insurance Coverage -Insurers can no longer cancel your coverage without
evidence of fraud
Health Insurance Reforms
• Reviews Premium Increases -- Insurance companies must now publicly
justify any double-digit rate hikes
• Helps You Get the Most from Your Premium Dollars – 80% or 85% of
premium dollars must be spent on direct health care costs or consumers
get a rebate
• Restricts Annual Dollar Limits on Coverage -- Annual limits on your health
benefits will be phased out by 2014
• Removes Insurance Company Barriers to Emergency Services -- You can
seek emergency care at a hospital outside of your health plan’s network
• Covers Preventive Care at No Cost to You -- You may be eligible for
recommended preventive health services with no copayment
• Guarantees Your Right to Appeal
All apply to most health insurance plans beginning January 1, 2014
Health Insurance Requirements
Individuals
• Starting January 1, 2014, all U.S. citizens and legal
residents are required to have some form of health
insurance
• Exemptions – financial hardship, religious objections
• Penalty – Phased in starting in 2014 ($95 or 1% of
taxable income) to 2016 ($695 or 2.5% of taxable
income)
• MARCH 31, 2014 – Deadline for 2014 insurance to
avoid penalty
Health Insurance Requirements
Employers
• Employers with fewer than 50 employees (FTEs) –
No requirement to offer health insurance (9698% of all US businesses)
• Employers with 50 or more employees (FTEs) –
Required to offer health insurance
• Employers with more than 200 employees (FTEs)
– Required to automatically enroll employees into
health plans offered by the employer. Employees
may opt out.
Health Insurance Marketplaces
• ACA = Exchanges
• Now = Marketplaces
• Will be the new way health insurance is
purchased on the individual and small group
markets
• Focus = Those who purchase their own insurance,
small businesses and small groups
Health Insurance Marketplaces
Choice of plans in Exchange
• Platinum – 90% cost of care coverage
• Gold – 80% cost of care coverage
• Silver – 70% cost of care coverage
• Bronze – 60% cost of care coverage
• Catastrophic – limited to those under 30,
exempt from individual mandate due to
affordability
Nebraska Marketplace
Insurance companies participating:
• Blue Cross and Blue Shield of Nebraska
• Coventry Health Care
• CoOportunity
• Health Alliance Midwest, Inc.
Nebraska Marketplace
Find estimated insurance plan premium information at:
https://www.healthcare.gov/find-premium-estimates
Provides up you all estimated premiums for all plans in
your county for individual and small business plans
Actual premiums will be based on individual factors
and choices
Nebraska Marketplace
Nebraska Marketplace
How to apply for health insurance coverage:
https://www.healthcare.gov/how-do-i-applyfor-marketplace-coverage/
• By Phone – 1-800-318-2596; TTY: 1-855-8894325
• By Paper
• By Personal Help
• Online – healthcare.gov
Nebraska Marketplace
• Purchasers through the Marketplace will
receive premium assistance tax credits
• Those up to 400% of federal poverty level
eligible for tax credits (approximately $94,200
for family of 4 in 2013 guidelines)
• Tax credit is a percentage of individual/family
modified adjusted gross income
• May still purchase insurance outside of
Exchange – generally not eligible for tax credit
Nebraska Marketplace
• Tax credit reduces the amount of your health
insurance premium
• Specific amount of credit difficult to determine –
depends on too many individual factors
• Credit can go directly to insurance company or can
be claimed later on tax return
• Subsidy Calculators
http://kff.org/interactive/subsidy-calculator/
http://www.getcoveredamerica.org/calculator/
Nebraska Marketplace
Cost-Sharing Assistance – Out-of-Pocket Expenses
• Incomes below 250 percent of the federal poverty level
(about $59,000 for a family of four, about $29,000 for an
individual under the 2013 guidelines)
• Eligible for cost-sharing assistance for out-of-pocket
expenses
• Compared to 30 percent for all other individuals and families
purchasing a Silver plan – Must purchase Silver plan
• Out –of-pocket expense limit:
100-150% = 6%
150-200% = 13%
200-250% = 27%
ACA and Insurance Coverage
Essential Health Benefits
• Ambulatory patient services, such as doctor's visits and outpatient
services
• Emergency services
• Hospitalization
• Maternity and newborn care
• Mental health and substance use disorder services, including behavioral
health treatment
• Prescription drugs
• Rehabilitative and habilitative services and devices
• Laboratory services
• Preventive and wellness services and chronic disease management
• Pediatric services, including oral and vision care
ACA and Insurance Coverage
Essential Health Benefits
• Apply only to individual market and small group market (less
than 50 employees)
• The essential health benefits are intended to mirror those
provided under a typical employer-sponsored health plan.
Insurance plans must provide a package that includes those
benefits, at a minimum.
• The law does not define the specific services that must be
covered or the amount, duration, or scope of services. HHS
will define the specific benefits within each of these
categories.
• All plans sold on the Marketplace will provide Essential Health
Benefits
Small Businesses and Marketplace
• Small businesses may currently purchase insurance plans on
marketplace
• For employers and employees
• Shopping feature on healthcare.gov provides information on
available plans
• SHOP exchange – special small business on marketplace; available
November 1, 2014
• For businesses with 50 or fewer employees
• May apply by paper for SHOP plans and tax credits
• Small business tax credits are available only for Small Business
Health Options Program (SHOP) coverage that begins in 2014
• Self-employed and no employees = purchase through individual
Marketplace not SHOP
• SHOP information = 1-800-706-7893
Marketplace Open Enrollment
• You will be able to enroll and purchase insurance in the
Marketplace during certain times – open enrollment periods.
• You will be unable to purchase insurance in the Marketplace
outside of these dates.
• Initial enrollment period – October 1, 2013 to March 31, 2014
• Subsequent years – October 15 to December 7 (same as
Medicare D)
• Exceptions to open enrollment period – changes in life
circumstances – child, married, move, lose a job, etc.
Choosing Insurance in the Marketplace
Key Decision Points
• #1 = How much coverage do you want? May depend on
subsidies you receive
• #2 = Qualify for cost-sharing subsidies? Must buy Silver plan
to receive
• #3 = How to apply subsidy
• #4 = Weighing risk vs. coverage – higher premium is more
coverage; lower premium is more risk
• #5 = Weighing out-of-pocket costs – tolerance for risk
• #6 = Provider choice – Doctors/hospitals in network?
• Finally = Ask for Summary of Benefits and Coverage
• Buy!
Marketplace Help
There will be people trained and certified to help
you understand your health coverage options and
enroll in a plan.
• Navigators
• Application assistors
• Certified application counselors
Insurance agents and brokers can also help you with
your application and choices.
Marketplace Help
Need More Information?
• Website: https://www.healthcare.gov
• https://www.cuidadodesalud.gov.es
• By phone: 1-800-318-2596 (24 hours)
• 1-800-706-7893 (small businesses)
• TTY: 1-855-889-4325
• Live chat: https://www.healthcare.gov/chat/
Medicaid Expansion
• U.S. Supreme Court = ACA constitutional, expanding
Medicaid a state option
• ACA Medicaid expansion – anyone up to 138% of poverty
level eligible for Medicaid
• Adds childless adults as Medicaid eligible population
• 138% poverty level = $32,500 for household of 4; full-time
minimum wage for single person (2013 levels)
• Governor Heineman = Nebraska won’t expand Medicaid
• LB 577 filibustered in Legislature in 2013
• Could be a big thing for small businesses
• LB 887 in 2014 Legislature
• Coverage Gap
For more information
Jon Bailey
Center for Rural Affairs
402-687-2100
[email protected]
http://www.cfra.org/policy/healthcare/research
http://www.cfra.org/policy/health-care
Questions
?