Transcript Document

Washington Health Benefit Exchange
AFFORDABLE CARE ACT 101
SUMMER 2013
Navigator/In-person Assister Program
Today’s Agenda
▪ History of the Affordable Care Act (ACA)
▪ Highlights of the Affordable Care Act
▪ Impact of the Affordable Care Act
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PURPOSE AND OBJECTIVES
Purpose
This webinar is to provide an overview of the Affordable Care
Act (ACA)
Objectives
Upon completion of this presentation you will:
▪ Understand how the Affordable Care Act applies to you and
others
▪ Understand how the Affordable Care Act is being
implemented in Washington State
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WHAT IS THE ACA?
▪ Patient Protection and Affordable Care Act (PPACA)
▪ Affordable Care Act (ACA)
▪ Health Care Reform Law
▪ Obamacare
▪ Health Care and Education Reconciliation Act of 2010
(HCERA)
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WHY THE RUSH TO REFORM HEALTH
CARE?
▪ 1912 – President Theodore “Teddy” Roosevelt - Proposal
▪ 1935 – President Franklin Roosevelt - Social Security
▪ 1942 – President Franklin Roosevelt - Established Price
Controls
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WHY THE RUSH TO REFORM HEALTH
CARE?
▪ 1945 – President Harry Truman – Proposal
▪ 1965 – President Lyndon Johnson – Medicare
▪ 1974 - President Richard Nixon - Proposal
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WHY THE RUSH TO REFORM HEALTH
CARE?
▪ 1993 – President Bill Clinton - Proposal
▪ 2005 – President George W. Bush - Medicare Part D
▪ 2010 – President Barack Obama - Health Care Reform
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AFTER 100+ YEARS, WHY NOW?
Consumer can't afford
doctor
Consumer drops policy
due to high price and is
now uninsured
Consumer delays care,
goes to ER
Insurers shift cost to
consumer
Consumer can't pay
Providers shift cost to
Insurers
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HIGHLIGHTS OF THE ACA
 Expand health care coverage to 32 million Americans who
are uninsured.
 Slow down the rising cost of health care which accounted for
almost 18% of the Gross Domestic Product (GDP) in 2010.
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Impact Of The Affordable Care Act
▪ Changes to private insurance, e.g.,
 Kids can’t be denied health coverage if they are sick
 Young adults on parents’ policies to age 26
 Prohibit lifetime monetary caps
 Minimum medical loss ratio
▪ Closes the Medicare prescription “doughnut hole”
▪ Expands coverage + imposes individual mandate in 2014
 Expands Medicaid to 138%* of FPL
 Exchanges
*ACA 133% = 138% due to across the board income disregards
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TEN ESSENTIAL HEALTH BENEFITS
1. Ambulatory services
6. Prescription drugs
2. Emergency services
7. Rehabilitative and habilitative services and
devices
3. Hospitalization
8. Laboratory services
4. Maternity and newborn care
9. Preventive and wellness services and chronic
disease management
5. Mental health and substance use
disorder services, including behavioral
health treatment
10. Pediatric services, including oral and vision
care
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HOW WILL PEOPLE GET HEALTH CARE
COVERAGE?
The ACA will expand health care coverage in the following ways:
▪ Individual Mandate
▪ Small Business Tax Incentives
▪ Medicaid Expansion
▪ Premium Subsidies
▪ Large Employer Mandate
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INDIVIDUAL MANDATE
▪ Require all citizens and legal residents (there are some
exceptions) to have health coverage in 2014.
▪ What happens if someone does not meet this deadline?
▪ Will they go to jail?
NO!
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THE MANDATE DOES NOT APPLY FOR
SOME
When any of the following apply:
▪ Religious objections
• Undocumented immigrant
• Incarcerated
• American Indians and Alaskan Natives
No penalty
for being
without
health
insurance.
• Income below the tax filing threshold
• The lowest cost plan option exceeds 9.5 percent of an individual’s
income
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THE MANDATE IS SATISFIED WHEN
You were insured for the whole year through a combination of
any of the following sources:
▪ Medicare
▪ TRICARE
▪ The veteran’s health program
No Penalty. The
requirement to
have health
insurance is
satisfied
▪ A plan offered by an employer
▪ Medicaid or the Children’s Health Insurance Program (CHIP)
▪ Insurance bought on your own that is at least at the Bronze
level
▪ A grandfathered health plan in existence before the health
reform law was enacted
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WHAT IS THE PENALTY?
2014: $95 per adult
and $47.50 per child
(up to $285 for a
family) or 1% of
income, whichever is
greater
2015: $325 per adult
and $162.50 per child
(up to $975 for a
family) or 2%,
whichever is greater
2016: $695 per adult
and $347.50 per child
(up to $2,085 for a
family) or 2.5% of
family income,
whichever is greater
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HEALTH INSURANCE PREMIUM TAX
CREDITS
▪ Designed to make premiums affordable for individuals and
families with lower incomes
▪ Only available to individuals and families with income up to
400% Federal Poverty Level (FPL)
▪ Can be used to reduce monthly premiums
▪ Can be claimed as a credit on annual tax return
▪ Must apply through Washington Healthplanfinder
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2013 FEDERAL POVERTY LEVELS
BY ANNUAL INCOME
Federal Poverty Level
Annual Income:
Individual
Annual Income:
Family of 3
100%
$11,496
$19,536
133%
$15,288
$25,980
138%
$15,864
$26,952
200%
$22,980
$39,060
300%
$34,476
$58,596
400%
$45,960
$78,120
Source: http://aspe.hhs.gov/poverty/13poverty.cfm
Per HHS directive, after inflation adjustment, the guidelines are rounded and adjusted
to standardize the differences between family sizes.
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Health Insurance Premium Tax Credit and
Cost Sharing Reductions
Cost Sharing Reductions:
Premium Tax Credits:
Income Level
Up to 133%
FPL
Premium as Percent of
Income
2% of income
133-150% FPL
3-4% of income
150-200% FPL
4-6.3% of income
200-250% FPL
6.3-8.05% of income
250-300% FPL
8.05-9.5% of income
300-400% FPL
9.5% of income
*Of the second lowest cost Silver plan
Income Level
Reduction in Out-ofPocket Liability
100-150%
FPL
94% of the actuarial
value*
150-200%
FPL
87% of the actuarial
value
200-250%
FPL
73% of the actuarial
value
A Silver Metal Level plan must be purchased to
qualify for Cost Sharing Reductions
http://www.wahealthplanfinder.org/
EXAMPLE
▪ Family of 3
▪ Annual Income = 200% of FPL
▪ Health Insurance Premium Tax Credit? YES
▪ Cost Sharing Reduction? YES
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HOW WILL PEOPLE GET THESE
SUBSIDIES?
▪ The ACA requires all states to create a new marketplace
website where consumers can go to search, compare and
enroll in an affordable health coverage plan.
▪ The one in our state is the:
▪ Open enrollment is October 1, 2013 for coverage effective
January 1, 2014.
▪ After answering a few questions including income, consumers
will be notified about their health care coverage eligibility.
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MEDICAID EXPANSION
▪ Medicaid and Medicaid Expansion populations
▪ Adults (without children) up to 138% of FPL*
▪ Parents 40% to 138% of FPL
▪ Modified Adjusted Gross Income (MAGI)
▪
The ACA’s “133% of the FPL” is effectively 138% of the FPL because of a 5% across-the-board income
disregard
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2014 Large Employer Requirements
▪ Large employers with over 50 FTE’s are required to offer a minimum level of
health insurance
▪ Larger Employers offering non-qualifying coverage:
o May be assessed the lesser of up to $3,000 per year for each FTE receiving incomebased assistance, or, up to $2,000 for every FTE.
▪ Large Employers not offering minimum essential coverage:
o May be assessed $2,000 per FTE (first 30 full-time employees excluded) if at least one
full-time employee receives income-based assistance to buy coverage in the Exchange.
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WHAT ABOUT SMALL BUSINESSES?
▪ Up to 50 Employees (these employers are exempt
from the mandate)
▪ Small Business Health Insurance Tax credits
available
▪ Washington Healthplanfinder can be used to
manage employee health care benefits
▪ Options are available
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HOW WILL PEOPLE GET HEALTH CARE COVERAGE?
Agent
Broker
Navigator
In-person
Assister
Customer
Support
Center
Website
Partner
SelfDirected
STREAMLINED APPLICATION
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ON-THE-SPOT ELIGIBILITY RESULTS
▪ Single portal for Medicaid, tax subsidies and Qualified
Health Plans
▪ Use of electronic data to verify eligibility
▪ Real-time eligibility determination
▪ Interfaces to federal and state systems
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SUMMARY
▪ Historic significance of the Affordable Care Act
▪ Reforms to Health Care already in place
▪ Reforms effective January 1, 2014
▪ Benefits to Individuals
▪ Benefits to Families
▪ Benefits to Employers
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KNOWLEDGE CHECK
What is the Affordable Care Act?
A. Health Care Insurance Reform
B. Affordable Car Insurance
C.
Gun Control
D. Animal Case Adaptation
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KNOWLEDGE CHECK
Open Enrollment begins on…
A. March 23, 2010
B. January 2, 2014
C.
October 1, 2013
D. December 7, 2013
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KNOWLEDGE CHECK
What are the two key goals of the Affordable Care Act?
A. Increase the cost of health care and decrease the number
of Americans that are uninsured.
B. Slow down the rising cost of health care and expand health
care coverage to uninsured Americans.
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KNOWLEDGE CHECK
The soonest coverage in a Qualified Health Plan can be effective
is….
A. November 1, 2013
B. December 1, 2013
C.
January 1, 2014
D. April 1, 2014
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KNOWLEDGE CHECK
Washington State is implementing Medicaid Expansion. Which
of the following statements is not true?
A. Washington State Medicaid is going to include the state of
Idaho.
B. Washington State Medicaid will include adults (without
children) up to 138% of FPL.
C.
Washington State Medicaid will include Parents with
income up to 138% of FPL
D. Washington State Medicaid will use Modified Adjusted
Gross Income to determine applicant’s income.
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KNOWLEDGE CHECK
One way the Affordable Care Act will expand health care
coverage is…
A. By requiring all citizens be given pay raises.
B. By requiring everyone to purchase health care coverage
with no exceptions.
C.
By requiring all employers to provide health care coverage
to all of their employees as well as their dependents.
D. Through premium subsidies.
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KNOWLEDGE CHECK
Which of the following statements is not true regarding Health
Insurance Premium Tax Credits?
A. These credits are designed to make premiums affordable
for individuals and families with lower incomes.
B. Enrollment through the Healthplanfinder is not required to
receive these credits.
C.
Tax credits can be used to reduce monthly premiums.
D. Tax credits can be claimed on your annual tax return.
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KNOWLEDGE CHECK
Cost sharing reductions…
A. Are a way to reduce consumer out of pocket health care
expenses.
B. Lower monthly premiums.
C.
Lower annual premiums.
D. Lower grocery bills.
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KNOWLEDGE CHECK
The Individual mandate…
A. Requires all citizens and legal residents to have health care
coverage for their dogs and cats in 2014.
B. Requires incarcerated individuals to purchase healthcare coverage
through the Washington Healthplanfinder.
C.
Requires all citizens and legal residents to have health care
coverage in 2013.
D. Requires all citizens and legal residents to have health care
coverage in 2014.
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KNOWLEDGE CHECK
Washington Apple Health (Medicaid) is administered by…
A. The Washington Health Benefit Exchange.
B. The Washington State Health Care Authority.
C.
The Washington Healthplanfinder.
D. The assister the customer is working with.
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KNOWLEDGE CHECK
A person that does not obtain health insurance coverage
through a Qualified Health Plan may owe a penalty to…
A. The Washington Health Care Authority (HCA).
B. Centers for Medicare and Medicaid Services (CMS).
C.
Internal Revenue Service (IRS).
D. The Washington Healthplanfinder
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QUESTIONS
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Congratulations! You have completed the Affordable
Care Act Course!
THANK YOU!
More on the Exchange
http://wahbexchange.org/
Includes information about:
▪ Exchange Board
▪ Legislation and grants
▪ Policy discussion
▪ Technical Advisory Committees and stakeholder involvement
▪ IT systems development
▪ HHS guidance
▪ Listserv registration
▪ Healthplanfinder Calculator: http://www.wahealthplanfinder.org/
▪ Contact the Exchange at: [email protected]
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APPENDIX: GLOSSARY OF TERMS
▪ Actuarial Value: The percentage of total average costs for covered benefits that a plan will cover. For
example, if a plan has an actuarial value of 70%, on average, you would be responsible for 30% of the costs of all
covered benefits. However, you could be responsible for a higher or lower percentage of the total costs of
covered services for the year, depending on your actual health care needs and the terms of your insurance policy.
▪ Affordable Care Act: The comprehensive health care reform law enacted in March 2010. The law
was enacted in two parts: The Patient Protection and Affordable Care Act was signed into law on March 23, 2010
and was amended by the Health Care and Education Reconciliation Act on March 30, 2010. The name “Affordable
Care Act” is used to refer to the final, amended version of the law.
▪ Catastrophic Plan: Currently, some insurers describe these plans as those that only cover certain
types of expensive care, like hospitalizations. Other times insurers mean plans that have a high deductible, so
that your plan begins to pay only after you've first paid up to a certain amount for covered services.
▪ Cost Sharing: The share of costs covered by your insurance that you pay out of your own pocket. This
term generally includes deductibles, coinsurance and copayments, or similar charges, but it doesn't include
premiums, balance billing amounts for non-network providers, or the cost of non-covered services. Cost sharing
in Medicaid and CHIP also includes premiums.
▪ Deductible: The amount you owe for health care services your health insurance or plan covers before
your health insurance or plan begins to pay. For example, if your deductible is $1000, your plan won’t pay
anything until you’ve met your $1000 deductible for covered health care services subject to the deductible. The
deductible may not apply to all services.
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GLOSSARY OF TERMS CONT.
▪ Donut Hole, Medicare Prescription Drug: Most plans with Medicare prescription
drug coverage (Part D) have a coverage gap (called a "donut hole"). This means that after you and your drug
plan have spent a certain amount of money for covered drugs, you have to pay all costs out-of-pocket for your
prescriptions up to a yearly limit. Once you have spent up to the yearly limit, your coverage gap ends and your
drug plan helps pay for covered drugs again.
▪ Federal Poverty Level (FPL): A measure of income level issued annually by the Department
of Health and Human Services. Federal poverty levels are used to determine your eligibility for certain
programs and benefits.
▪ Grandfathered Health Plan: As used in connection with the Affordable Care Act: A group
health plan that was created—or an individual health insurance policy that was purchased—on or before
March 23, 2010. Grandfathered plans are exempted from many changes required under the Affordable Care
Act. Plans or policies may lose their “grandfathered” status if they make certain significant changes that reduce
benefits or increase costs to consumers. A health plan must disclose in its plan materials whether it considers
itself to be a grandfathered plan and must also advise consumers how to contact the U.S. Department of Labor
or the U.S. Department of Health and Human Services with questions. (Note: If you are in a group health plan,
the date you joined may not reflect the date the plan was created. New employees and new family members
may be added to grandfathered group plans after March 23, 2010).
▪ Modified Adjusted Gross Income: MAGI is the new methodology for calculation of
income for certain Medicaid programs which closely mirrors how the IRS determines adjusted gross income
and household composition for tax purposes. This simplified income calculation will be used to determine
Medicaid eligibility and also by the Exchange to determine Health Insurance Premium Tax Credits.
▪ Open Enrollment Period: The period of time set up to allow you to choose from available
plans, usually once a year.
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GLOSSARY OF TERMS (CONT.)
▪ Out-of-Pocket Costs: Your expenses for medical care that aren't reimbursed by insurance. Out-ofpocket costs include deductibles, coinsurance, and copayments for covered services plus all costs for services that
aren't covered.
▪ Premium: The amount that must be paid for your health insurance or plan. You and/or your employer
usually pay it monthly, quarterly or yearly.
▪ Prescription Drug Coverage: Health insurance or plan that helps pay for prescription drugs and
medications.
▪ Primary Care Physician: A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic
Medicine) who directly provides or coordinates a range of health care services for a patient.
▪ Provider:
A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine), health care
professional or health care facility licensed, certified or accredited as required by state law.
▪ Qualified Health Plan: Under the Affordable Care Act, starting in 2014, an insurance plan that is
certified by an Exchange, provides essential health benefits, follows established limits on cost-sharing (like
deductibles, copayments, and out-of-pocket maximum amounts), and meets other requirements. A qualified health
plan will have a certification by each Exchange in which it is sold.
▪
Source: Health and Human Services For more terms please visit:
http://www.healthcare.gov/glossary/a/index.html
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