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Affordable Care Act and Ryan White Program


The effects on insurance coverage for people living with HIV/AIDS in the Philadelphia EMA (including Philadelphia, Montgomery, Delaware, Chester, and Bucks Counties in PA and Salem, Gloucester, …

The effects on insurance coverage for people living with HIV/AIDS in the Philadelphia EMA (including Philadelphia, Montgomery, Delaware, Chester, and Bucks Counties in PA and Salem, Gloucester, Camden, and Burlington Counties in NJ)

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  • People will come to the exchanges and fill out one application and receive a determination of eligibility depending on their income for Medicaid, CHIP, Basic Health Plan, or premium tax credits for private plans known as qualified health plans in the exchanges. In genearl people with incomes under 133% of poverty will be eligible for Medicaid, but if you are a legal immigratn in the five year waiting period for Medicaid, eligible for tax credits. Under the law, taxpayers eligible for tax credits are required to make contributions to their premiums as a share of their income from 2 percent to 9.5 percent. Those Eligible will have a choice of private, qualified health plans sold through the exchanges that offer a comprehensive set of benefits, also known as the essential benefit package, which is to be defined in regulations due out this fall. Insurers will offer these plans at four levels of cost-sharing: bronze plans (covering on average 60% of someone's annual medical costs), silver (70% of costs), gold (80% of costs), and platinum (90% of costs). However, for people with low incomes, the average costs covered by the silver plan will be increased to 94 percent (for those with incomes up to 149% FPL), 87 percent (150%–199% FPL), and 73 percent (200%–249% FPL).


  • 1. Affordable Care Act and Ryan White ProgramThe effects on insurance coverage for people living with HIV in the Philadelphia EMA
  • 2. Universal Coverage Medicaid Eligibility 133% FPL Premium Subsidies 133% - 400% FPLInsurance Market EmployerReforms & SponsoredIndividual Insurance Mandate
  • 3. Summary of Patient Protection andAffordable Care Act Most individuals will be required to have health insurance starting in 2014 Employers will be required to pay penalties for employees who receive tax credits for health insurance Individuals who do not have access to employer- offered insurance will be able to purchase insurance through state exchanges  Premium and cost-saving credits/subsidies will be available for some people
  • 4. Summary of Patient Protection andAffordable Care Act All (non-grandfathered) plans will be:  required to provide a minimum benefits package  prevented from denying coverage for any reasons  prevented from charging higher premiums based on health status and gender  prevented from imposing annual or lifetime spending caps  Required to include prevention services with no cost- sharing
  • 5. Individual Mandate U.S. citizens and legal residents required to have health coverage Those without coverage pay tax penalty of $695/person, up to $2085 a year Those exempt from mandate:  Demonstrated financial hardship  Religious objections  Undocumented immigrants  Incarcerated individuals  Those for whom the lowest cost plan option exceeds 8% of the individual’s income  Those who do not file federal income tax returns
  • 6. America Health Benefit Exchanges Access to exchanges limited to US citizens and legal immigrants Exchange plans will be required to offer a minimum benefits package at four different levels  Platinum – covers 90% of benefits cost  Gold – covers 80% of benefits costs  Silver – covers 70% of the benefits costs  Bronze – covers 60% of the benefits costs  Catastrophic –  Available to those under 30 years old and to those who are exempt from the mandate.  Provides catastrophic coverage only with the coverage level set at the HSA current level laws except for prevention benefits and coverage for 3 primary care visits would be exempt from deductible.  Only available on individual market.
  • 7. Essential Health Benefits Plans on Exchanges and newly eligible Medicaid must include these services:  Ambulatory patient 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, and  Pediatric services, including oral and vision care
  • 8. Essential Health Benefits States will have the flexibility to select a benchmark plan that reflects the scope of services offered by a “typical employer plan If states choose not to select a benchmark, HHS intends to propose that the default benchmark will be the small group plan with the largest enrollment in the state. Plans could modify coverage within a benefit category so long as they do not reduce the value of coverage. States will choose one of the following benchmark health insurance plans:  One of the three largest small group plans in the state by enrollment;  One of the three largest state employee health plans by enrollment;  One of the three largest federal employee health plan options by enrollment;  The largest HMO plan offered in the state’s commercial market by enrollment.
  • 9. Cost-sharing SubsidiesIn order to help individuals and families purchase plan on the exchanges: Cost-sharing subsidies will also be available for those with incomes between 100%-250% FPL to limit out-of- pocket spending Premium subsidies will be provided to families with incomes of up to 400% FPL ($29,327 to $88,200 for family of four)  Subsidies on a sliding scale  Subsidies will limit the cost of premiums to between 2% and 9.5% of income
  • 10. Premiums as Share of IncomeHousehold Income as a Percent of Premium Range as a Percent of FPL Income Up to 133% 2% 133 - 150% 3-4% 150 – 200% 4 – 6.3% 200 – 250% 6.3 – 8.05% 250 – 300% 8.05 – 9.5% 300 – 400% 9.5% Premium tax credits are advanceable – recipients immediately receive the credit (directly to insurer) Recipients will have to reconcile the tax credit received with actual income and repay any excess credit
  • 11. Cost-sharing Subsidies Reduced cost-sharing for people up to 250% of FPL Subsidies increase actuarial value of coverage  Actuarial value is the average percentage of anticipated costs that an insurer will pay towards care for people insured in a given plan  In other words, it is the percent of costs paid for by the insurer, the individual is responsible for the remaining percent Household Income as Actuarial Value of Percent of FPL Coverage 100 – 150% 94% 150 – 200% 87% 200 – 250% 73% 250 – 400% 70%
  • 12. Employer-Offered Health Plans Employers with more than 50 employees who do not offer coverage and have at least one full-time employee receiving a premium subsidy will be fined $2000 per full-time employee Employees who are offered coverage by employer are not eligible for premium tax credits unless the premium exceeds 9.5% of income
  • 13. Expanded Medicaid Eligibility Many low income individuals will be covered under Medicaid  All adults with income at or below 133% FPL will be eligible for Medicaid regardless of health/disability  133% FPL = $14,404 for individual and $29,327 for family of 4 in 2009  For most Medicaid enrollees, income will be based on modified adjusted gross income without an assets test or resource test.  Newly-eligibles may have different package of services based on essential services under exchanges
  • 14. ACA Medicaid Changes Minimum Support for Floor for Health Coverage Care 133% FPL System Additional Long Term Federal Care/ Financing for Coordination for Newly Eligible Duals Coverage
  • 15. Private Health Insurance Health premiums will be allowed to vary based on age (by a 3 to 1 ratio), geographic location, tobacco use and the number of family members No lifetime/annual limits on coverage Increases in premiums will be subject to review by the state No cost sharing for preventative services Existing plans will be allowed to remain the same except:  Required to extend coverage to dependents up to age 26  Prohibited from rescissions of coverage  Eliminate waiting periods for coverage to over 90 days
  • 16. Premium and Cost Sharing Limits for Individuals upto 400% FPL (non- Employer Coverage) Income % FPL Coverage Premiums and Cost Sharing < 138% Medicaid •No Premiums •Cost sharing limited to nominal amounts for most services 139 – 250% Exchange •Sliding scale tax credits limit premium costs to 3- 8.05% •Sliding scale cost- sharing credits 251 – 400% Exchange •Sliding scale tax credits limit premium costs to 8.05 – 9.5% •No cost-sharing credits
  • 17. Exhibit 15. Distribution of Uninsured Nonelderly Individuals in 2010, by Income Level and Provisions of the Affordable Care Act 133%–249% FPL Subsidized private 11.7 million coverage with Medicaid 24% consumer <133% FPL protections 21.3 million 250%–399% FPL 43% 6.3 million 13% >400% FPL 5 million Nonsubsidized private 10% coverage with consumer Undocumented protections or parents’ 4.9 million policies 10% 49.1 million uninsured individuals, ages 0–64Note: FPL refers to federal poverty level.Source: Analysis of the March 2011 Current Population Survey by N. Tilipman and B. Sampatof Columbia University for The Commonwealth Fund.
  • 18. Exhibit 18. Source of Insurance Coverage Pre-Reform and Under the Affordable Care Act, 2020 23M (8%) 24M (8%) Uninsured Exchanges (Private Plans) 56M (20%) 15M (5%) Uninsured Other 15M (5%) Other 163M (57%) 8M (3%) 162M (57%) ESI Nongroup ESI 14M (5%) Nongroup 52M (18%) 36M (13%) Medicaid Medicaid Under Prior Law Affordable Care Act Among 284 million people under age 65Notes: Employees whose employers provide coverage through the exchange are shown as covered by their employers.ESI refers to employer-sponsored insurance. “Other” includes Medicare.Source: Testimony Statement of Douglas W. Elmendorf, Director, before the Subcommittee on Health Committee onEnergy and Commerce U.S. House of Representatives, CBO’s Analysis of the Major Health Care Legislation Enactedin March 2010, March 30, 2011, http://www.cbo.gov/ftpdocs/121xx/doc12119/03-30-HealthCareLegislation.pdf.
  • 19. Exhibit 17. Annual Premium and Tax Credits for a Single Adult Under the Affordable Care Act, 2014Annual premium amount paid by policy holder and premium tax credit*$6,000 Premium tax credit Full Required premium payment by policy holder premium =$5,000 $4,500$4,000 1,221 Contribution capped at 2,185 9.5% of$3,000 income 3,050 Contribution 3,810 capped at 3,977 8.05% of Contribution income 4,500$2,000 capped at 6.3% of 3,279 Contribution income Contribution 2,315$1,000 capped at capped at 4.0% of 1,450 3.3% of income 523 income 690 $0 138% FPL 150% FPL 200% FPL 250% FPL 300% FPL 500% FPL $15,877 $17,258 $23,011 $28,763 $34,516 $57,527* For a single adult, age 40, in a medium-cost area in 2014. Premium estimates are based on an actuarial value of 0.70.Actuarial value is the average percent of medical costs covered by a health plan. FPL refers to federal poverty level.Source: Premium estimates are from Kaiser Family Foundation Health Reform Subsidy Calculator,http://healthreform.kff.org/Subsidycalculator.aspx.
  • 20. Exhibit 14. Premium Tax Credits and Cost-Sharing Protections Under the Affordable Care Act Federal Premium contribution Out-of-pocket Actuarial value: Income poverty level as a share of income limits Silver plan S: <$14,484 <133% 2% (or Medicaid) 94% F: <$29,726 S: $16,335 S: $1,983 133%–149% 3.0%–4.0% 94% F: $33,525 F: $3,967 S: $21,780 150%–199% 4.0%–6.3% 87% F: $44,700 S: $27,225 200%–249% 6.3%–8.05% 73% F: $55,875 S: $2,975 S: $32,670 F: $5,950 250%–299% 8.05%–9.5% 70% F: $67,050 S: $43,560 S: $3,967 300%–399% 9.5% 70% F: $89,400 F: $7,933 S: >$43,560 S: $5,950 >400% — — F: >$89,400 F: $11,900Four levels of cost-sharing: 1st tier (Bronze) actuarial value: 60% Catastrophic policy with essential benefits 2nd tier (Silver) actuarial value: 70% package available to young adults and 3rd tier (Gold) actuarial value: 80% people who cannot find plan with premium 4th tier (Platinum) actuarial value: 90% <=8% of incomeNotes: In the income and out-of-pocket limits columns, S refers to single and F refers to family. Actuarial values arethe average percent of medical costs covered by a health plan. Premium and cost-sharing credits are for silver plan.Source: Federal poverty levels are for 2011; Commonwealth Fund Health Reform Resource Center: What’s in theAffordable Care Act? http://www.commonwealthfund.org/Health-Reform/Health-Reform-Resource.aspx.
  • 21. Exhibit 2. Premium Tax Credit Amount for a Family of Four Annual family Annual family Annual family income: $50,000 income: $30,000 income: $50,000 older parents Income as a percentage of FPL 133% 224% 224% Expected family contribution As a percent of income: 3.0% 7.1% 7.1% Dollar amount: $900 $3,570 $3,570 Premium for benchmark plan $9,000 $9,000 $14,000 $8,100 $5,430 $10,430 Premium tax credit ($9,000 – $900) ($9,000 – $3,570) ($14,000 – $3,570) Premium for plan family $9,000 $9,000 $14,000 chooses Actual family contribution $900 $3,570 $3,570Note: FPL refers to Federal Poverty Level.Source: Federal Register, Vol. 76, No. 159, Aug. 17, 2011, pp. 50931–50949, Commonwealth Fund analysis.
  • 22. No Wrong Door  Individuals should be screened for eligibility for Medicaid, Medicare, Exchange, subsidies, etc. at any point of enrollment  One form/method of enrollment for Exchanges, Medicaid, etc. will be developed by HHS Secretary  Application form will be available for submission by web, fax, mail, telephone or in-person  States will rely on trusted third party sources for data matches, if accurate, no additional documentation can be required from individual  Easy to understand and navigate websites/information
  • 23. Total Population Insurance Type for NJ, PA and US, 200970.0 59.060.0 55.0 US30.0 PA20.0 NJ 16.0 17.0 14.0 15.0 15.0 12.0 12.0 11.0 10.010.0 5.0 5.0 3.0 1.0 0.0 0.0 0.0 Employment Based Nongroup Other Individual/ Medicaid Medicare Other Public Uninsured
  • 24. EMA General Population Income100.00% 90.00% 80.00% 70.00% 65.06% 60.00% 50.00% 42.71% 42.33% 40.41% 38.52% 41.88% 40.00% 27.02% 32.00% 30.47%27.42% 28.09% 30.00% 20.00% 10.00% 0.00% Total Population under 150% FPL Total Population between 150% and 300% FPL Total Population Below 300% FPL
  • 25. RW Clients Income Level, 2009 437, 4% 675, 5% 78% of RW Clients earn less than $10,890/year1548, 13% <100% FPL 100-199% 200-299% 9595, 78% >300%
  • 26. RW Client Insurance Status By Type, 2009 Unknown 1% Many uninsured will be eligible None Private for Medicaid and subsidies.Other Public 17% 17% 1% Medicare 13% NO CHANGE Medicaid in 51% COVERAGE for about 64% of RW Clients
  • 27. Office of HIV Planning Coverage Estimates NOW 2014 estimates Medicaid 51% >78% Private 17% 12% insurance Uninsured 17% 4-7% Medicare 13% 13% • Estimate for Private Insurance and Uninsured are probably too large, because they are based on General Population estimates. • 78% Medicaid coverage is based on eligibility by income (133% FPL) alone.
  • 28. Resources HIV Health Reform  http://www.hivhealthreform.org/ Kaiser Family Foundation Health Reform Gateway:  http://www.healthreform.kff.org/ Commonwealth Fund  http://www.commonwealthfund.org/Health-Reform.aspx