The Affordable Care Act Part 1: The Exchanges


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  • The Affordable Care Act Part 1: The Exchanges

    2. 2. O VERVIEW • Affordable Care Act • The Exchange Program • Employer Provided Insurance • Legal Opt-Out Options • Penalties • Key Exchange Implementation DatesPAGE 2
    3. 3. A FFORDABLE C ARE A CT • • Healthcare Insurance Exchanges will allow individuals and employers to shop, compare, and enroll affordable insurance plans • Effective: January 1, 2014PAGE 3
    4. 4. A FFORDABLE C ARE A CT: H IGHLIGHTED C HANGES TO H EALTHCARE C OVERAGE • Individuals with pre-existing conditions are no longer denied coverage, nor can they be dropped when diagnosed with a serious illness/disability • Eligibility requirements and covered healthcare services are expanded • Lifetime insurance limits on essential services are prohibited • Small businesses may qualify for a tax credit • Employers will be penalized for providing inadequate coverage or for not providing coverage at allPAGE 4
    5. 5. A MERICAN H EALTH B ENEFIT E XCHANGE (E XCHANGE ) • ACA §1311 requires each state to have an Exchange program available for consumers to both compare and purchase healthcare coverage • The primary format of an Exchange will be via website o Until all state Exchanges are up and running, consumers can find available healthcare options via the ACA website at • Exchanges will also be available via toll-free hotline, by mail, and through in-person assistance locations o Set up of in-person assistance programs will be optional for statesPAGE 5
    6. 6. E XCHANGE A SSISTANCE • Each Exchange will be required to set up Navigator programs • Navigators are to provide impartial information, assistance to consumers, and help with the appeal process • Navigators can be in the form of different professional or community based organizations o At least one Navigator program within the state must be from the community/consumer non-profit groupPAGE 6
    7. 7. T HE E XCHANGE P ROGRAM : Q UALIFIED H EALTH P LANS (QHP S ) • A Qualified Health Plan is an insurance plan that is certified to operate within an Exchange • QHPs can be offered at four different levels of coverage • QHPs can also be in the form of Child-only or Catastrophic plansPAGE 7
    8. 8. T HE E XCHANGE P ROGRAM Main functions of an Exchange will be to: • Allow for comparison of QHPs • Assist applicants with applications and enrollment • Administer QHP certification process • Monitor QHPs for compliancePAGE 8
    9. 9. T HE E XCHANGE P ROGRAM : Q UALIFIED H EALTH P LANS (QHP S ) A QHP must offer the following 10 essential health benefits, per ACA §1302: 1. Ambulatory patient services 2. Hospitalization 3. Mental health & substance use disorder services 4. Rehabilitative & habilitative services 5. Preventative & wellness services 6. Emergency services 7. Maternity & newborn care 8. Prescription drugs 9. Laboratory services 10. Pediatric servicesPAGE 9
    10. 10. T HE E XCHANGE P ROGRAM : E XCHANGE S ET -U P There are three Exchange types: a State-Based Exchange, a State- Partnership Exchange, and a Federally-Facilitated Exchange To set-up an Exchange, a state must submit a Declaration Letter and Exchange Application to the Centers for Medicare and Medicaid Services (CMS): • Must be submitted November 16, 2012 • If nothing is received, the Department of Health and Human Services (HHS) declare that the state is operating as a Federally-Facilitated ExchangePAGE 10
    11. 11. T HE E XCHANGE P ROGRAM : E XCHANGE T YPES State-Based Exchange • The state conducts all of its Exchange program activities • The state may elect the government to perform tasks such as: o Applicant tax benefits Exemptions o Risk adjustment program o Reinsurance program State-Partnership Exchange • The state partners with HHS to operate Exchange o States perform services for plan management, consumer assistance, or both o HHS performs services for reinsurance programs, eligibility for Medicaid/CHIP and tax credits, and ensures the Exchange meets its required functionsPAGE 11
    12. 12. T HE E XCHANGE P ROGRAM : E XCHANGE T YPES Federally-Facilitated Exchange • HHS performs all Exchange activities for the state • HHS will coordinate with the state to operate a successful Exchange If HHS determines that a state’s Exchange program is non-compliant, it can change the state’s Exchange to a Federally-Facilitated Exchange programPAGE 12
    13. 13. T HE E XCHANGE P ROGRAM : T YPES OF E XCHANGE F UNDING State Planning Grant • Aids state in beginning development of its Exchange program Early Innovator Grant • Awarded to states that developed a working Exchange program that is transferrable to other states to use Level One Establishment Grant • Provides funding for one year to start an Exchange Plan Level Two Establishment Grant • Helps states continue Exchange development after one year,PAGE 13 provided certain criteria is met
    14. 14. T HE E XCHANGE P ROGRAM : E XCHANGE C OMPLIANCE Exchanges are responsible for implementing a compliance monitoring and recertification system for QHPs The Secretary of HHS will conduct annual reviews to ensure the Exchange complies with: • Eligibility verification requirements • Federal funds usage requirements • Quality and performance standardsPAGE 14
    15. 15. L EGAL O PT -O UT O PTIONS States – can opt-out of implementing its Exchange; HHS will then implement a Federally-Facilitated Exchange QHPs – can opt-out of providing abortion related coverage Individuals – can opt-out of automatic enrollment in employer provided insurance plans and individual coverage, if applicablePAGE 15
    16. 16. L EGAL O PT -O UT O PTIONS : I NDIVIDUAL E XEMPTIONS Individuals that fall under the following classifications are exempt from the individual insurance mandate: • Members of religious sects/healthcare sharing ministries • American Indians • Individuals with financial hardships Incarcerated individuals not pending charges and undocumented immigrants are not eligible for coveragePAGE 16
    17. 17. U PCOMING I MPLEMENTATION K EY D ATES The Consumer Operated & Oriented Advisory Board establishes a plan that will allow the creation of non-profit and member-run insurance. Open enrollment period begins ACA Exchanges are in effect.PAGE 17
    18. 18. R EED & A SSOCIATES , CPA S For more information on Reed & Associates, CPAs please contact us at: Phone: 860-395-1996 Or visit our website: reedassociatescpas.comPAGE 18 Quality. Integrity. Experience.