Why did we need a new law?• Working people can’t find good affordable coverage can t – 2.6 million New Yorkers currently lack health insurance (47 million in US). – 50% of uninsured adults in New York work full-time jobs. – 1 in 3 New Yorkers say they or someone in their family has postponed getting medical care or a prescription in the past year because of a lack of money or insurance.•I Insurance prices have outpaced wages i h t d – Between 2000 and 2009, health insurance premiums in NY grew by 92%, while median earnings only rose by 14%. – The average annual cost of insurance in the individual market in NY is over $12,000 for an individual, or $24,000 for a family. – Employers are cutting back health care benefits, or dropping them altogether. 4
Distribution o health insurance o of coverage in New York New York Uninsured 15% Public 23% Employer- Sponsored 58% Directly Purchased 4%Source: United Hospital Fund, “Health Insurance Coverage in New York: 2008,” June 2010. Data 5includes all people below age 65.
1 Million more young adults are covered • Young adults less than 26 years old can get covered through parents’ parents their parents’ job-based insurance. – Don’t have to be in college – Can be married – In NY, people between 26 and 29 can pay more and keep coverage through their parents’ employer (will cost slightly more). • Since passage of the ACA, 1 Million more young adults gained coverage ‒ Rates of young adults with coverage increased from 66% to 69% in 2010 . ‒ Yo ng adults were the onl Young ad lts ere only group to gain coverage last year 7Source: ACA § 1001 (dependent coverage), codified at PHSA §2714; ACA § 1302(e) (catastrophic plans).
The NY Bridge Plan • NY Bridge Plan offers coverage to state residents who: • are a US citizen or lawful immigrant; • have one or more pre-existing medical conditions; and • h have b been uninsured f th l t six months. i d for the last i th • Bridge plan will offer affordable coverage until the Exchange kicks in in 2014 2014. • Since 2010, 2,000 New Yorkers have joined the Bridge Plan 8
Consumer Assistance Programs Community Comm nit Health Ad ocates Advocates ‒ Served over 30,000 New Yorkers between October 2010 and September 2011 ‒ Network of 32 Community Based groups ‒ 3 Specialists (Empire Justice, Legal Aid, Medicare Rights Center) ‒ Serving 62 counties ‒ Identified problems and trends • Super high rate increases, led to rate appeals and new transparency on rate filings • Identified in correct drug caps in commercial plans • Identified Medicaid application delays in upstate counties 1-888-614-5400 1 888 614 5400 9
Profile: ACA Triple Play Megan Schley, Circleville New York • B id Pl Bridge Plan • Dependent (up to age 26) Coverage g ) g • Consumer Assistance Program 10
New rules make insurance more secure secure, easier to keep and use • No more co‐payments or deductibles for preventive services • No lifetime or unreasonable annual caps on benefits, no rescissions, new appeals rules l l • No more insurance discrimination: No “pre-existing condition” exclusions St t d for kids i 2010 Started f kid in Will start for adults in 2014 • New rules on how much of your premium must be spent on your care. (85% f l for large group/80% f small or non-group). /80% for ll )Source: PHSA §§ 2711 (lifetime/annual limits); 2712 (rescissions); 2714 (dependent coverage); 2701-05 (rating); 2718 (MLR limits); ACA §§1301 et 11seq (qualified health plans, essential benefits.). §§ 1311-1313; 1312(d)(3)(D) (Members of Congress must use Exchange)
For seniors who have Medicare • In 2011, there will be no co-payments and annual deductibles for preventive services. • By 2014, Medicare Advantage plans will be required to spend at 2014 least 85¢ of every $1 on health care for seniors. • Seniors who hit the coverage gap (or the “donut hole”) will get a rebate of $ $250 in 2010, and a 50% discount on brand name drugs and biologics in 2011. • By 2020, the Medicare donut hole will be closed. 12Source: ACA § 3301; Recon. Act § 1101 (closing donut hole, $250 rebate, and drug discounts); ACA § 4103 (no cost sharing onpreventive care); Recon. Act § 1103 (85¢ from every $1).
For Small Businesses: Tax Credits• T credits of up t 35% of th cost of offering h lth coverage f Tax dit f to f the t f ff i health for • Employers with <25 employees and average annual wages of <$50K • Must pay at least 50% of the health premiums • Tax credit amounts phase-in based on the number of employees and their average earnings (To qualify for the full credit amount, an employer must have 10 or fewer employees and average wages of $25K or less• Increases to 50% in 2014 • The tax credit may be claimed for up to 6 years total.For ProfitFor-Profit Businesses Non Profit Non-Profit BusinessesGet a general business credit based on Credit will be in the form of a reduction intheir actual tax liability. Unused credits income and Medicare tax withheld fromcan be carried forward up to 20 years. employee wages and the employer share of Medicare tax on employee wages. 13 Source: ACA § 1421 (all). .
Profile: Small Business Tax Credits Matt Grove Utica, Utica New York • Runs a bagel bakery • The ACA’s 35% tax credit allows Matt to increase his contribution for his e p oyees ea t employees health coverage from 50% to 65%. 14
Prior approval of premiumincreases• ACA requires states or federal government to review rates before they take effect.• In June 2010 New York State restored authority to review and approve health insurance premium rate increases before any changes take effect. MLR for a particular policy must be at least 82% (85% for large employers in 2012). Process – notices requirements, DFS posts notices, consumers have 30 day comment period.• For January 2011 rate increases, DFS approved average 8.2% increase, increase and reduced proposed increases by 4 5% 4.5%.• Recent rebates – 11 insurance companies will refund $114.5 million to 573,748 people• Consumer victory – insurance companies agreed to allow state to post rate increase requests 15
What does theAffordable Care Act do in i 2014? 16
The ACA will provide affordable quality coverage t 810 000 1 16 million New Yorkers to 810,000-1.16 illi N Y k Currently % of Total Newly Insured Post- Remaining Uninsured Uninsured Uninsured Reform Post-ReformEligible for Medicaid but unenrolled 1,000,000 42% 110,000-440,000 660,000–1,000,000Newly eligible for Medicaid 90,000 3% 50,000-70,000 20,000-40,000(Childless adults 100-133% FPL)Access to Exchange & Eligible for 700,000 27% 570,000 130,000Subsidies (0-400% FPL)Access to Exchange & Not Eligible 340,000 13% 80,000 260,000for Subsidies (>400% FPL)Affordability Exemption Takers 200,000 Penalty Payers Our Challenge! 60,000 Undocumented Immigrants 390,000 15% 0 390,000TOTAL 2,620,000 100% 810,000-1,160,000 1,460,000-1,820,000 Source: NYS Health Foundation, “Implementing Federal Health Care Reform: A Roadmap for New 17 York State,” August 2010.
Health Insurance Exchanges make insurance easier to get • St ti 2014 there will b H lth I Starting 2014, th ill be Health Insurance E h Exchanges: – Like a health insurance “Costco” where people can get wholesale prices for insurance; pools risk and improves bargaining power for individuals and small businesses – Website & telephone hotline to help individuals and small businesses buy and enroll into “qualified health plans” qualified plans – Allows shoppers to compare plans on an “apples to apples” basis – Eligibility to purchase insurance on Exchange is limited to individuals, families, members of Congress, small businesses, and immigrants who are lawfully p g y present.Source: PHSA §§ 2711 (lifetime/annual limits); 2712 (rescissions); 2714 (dependent coverage); 2701-05 (rating); 2718 18(MLR limits); ACA §§1301 et seq (qualified health plans, essential benefits.). §§ 1311-1313; 1312(d)(3)(D) (Members ofCongress must use Exchange)
The ACA makes insurance more affordable • Expands Medicaid eligibility to 133% of the Federal Poverty Level (FPL) ($24,300 for a family of th ) ($24 300 f f il f three). ‒ Will be able to access Medicaid and CHP through the Exchange • People ineligible for Medicaid and earning between 0 - 400% FPL ($73,200 for a family of three) will get subsidies to help them pay for insurance through the Exchange. – Subsidies may only be used for private insurance purchased on the Exchange. – Can’t use the Exchange if you have an offer of j job-based coverage ( g (unless y p y more than you pay 8% of your income for it).Source: ACA §§1401-02, 1411-12 (subsidies/tax credits and eligibility). 19
You can get subsidies if you use the Exchange If you earn less than 400% of the federal poverty level may be eligible for subsidies -- advanceable and refundable “tax credits” -- to buy insurance through the Exchange. – Refundable payments will be issued to the enrollee via tax returns, advanceable payments will be issued directly to the health plan. – Subsidies may only be used for private insurance purchased on the Exchange. Annual Income Range Maximum annual premium Maximum annual co-pays (for a family of three) costs and deductibles < 133% FPL < $24,352 $487 $3,867 134%-150% FPL $24,352 - $27,465 $730 - $1,098 $3,867 151%-250% FPL $27,465 - $45,775 $1,098 - $2,883 $3,867 - $5,800 251%-300% FPL $45,775 - $54,930 $2,883 - $4,421 $5,800 301%-400% FPL $54,930 - $73,240 $4,421 - $6,957 $7,733 20Source: ACA §§1401-02, 1411-12 (subsidies/tax credits and eligibility).
MostM t employers must provide coverage l t id• Employers with 200+ employees must automatically enroll employees in health plans (employees can opt out).• Employers with 50 + employees o Who do offer coverage, but who still have at least one full-time employee getting premium credits, o Who do not offer health insurance, must pay a insurance penalty if at least one full-time employee uses premium credits.• Employers with less than 50 employees are exempt from requirements and penalties. Source: ACA §§ 1511 (auto enrollment); 1513 (employer penalties). 21
The Mandate: Individuals (that’s You!) must have coverage • Starting in 2014, you must have insurance – Must meet minimum standard of quality – Exemptions based on financial hardship, undocumented immigrants, religion, etc. • If you are uninsured for more than 3 months you must pay a tax penalty. p y – $95 per person in 2014. – Max. of $695 per person per year, or $2,085 per family in 2016 family, 2016. 23Source: ACA §1501 (individual mandate, exemptions and penalties); § 1511 (employer responsibility).
If you have job-based coverage • If you like your insurance, you can keep it. - Employers offering health insurance on the date on which the law was enacted – March 23, 2010 – may continue to offer that y insurance, and continue to enroll new employees into it. • If you don’t like your insurance, you can buy different insurance on the Exchange or elsewhere at full price. • If you pay more than 9.5% of your income on your share of your employer’s health insurance plan, then you can buy insurance on the Exchange and get a subsidy. 24Source: ACA §§ 1251 (grandfathered plans); 1401 (eligibility if pay more than 9.5% of income; 1411 (eligibility to access exchange and subsidies);§10108 (free choice vouchers).
If you buy health insurance o you o o if you ea su a ce on your own orare uninsured• If you like your plan, and were enrolled in the plan on or before March 23, 2010, then you can keep it.• In 2014 if you don’t like your plan or are uninsured you can 2014, don t uninsured, purchase insurance through the Exchange. – If you earn between 133% - 400% of FPL ($24,350 - $73,240 annually for a family of three) you can get a subsidy to buy insurance on the Exchange. 25Source: ACA §§ 1251 (grandfathered plans); 1401 (eligibility if pay more than 9.5% of income; 1411 (eligibility to access exchange and subsidies);§10108 (free choice vouchers).; § 1101 (high risk pool).
For women • New anti discrimination rules: anti-discrimination – “Gender rating” banned in 2014, age-rating limited. – Bans denials of pre-existing conditions, such as breast cancer, c-sections, domestic violence. • No co-pays for preventive services and screenings (such as mammograms, Pap smears), maternity mandated, starting August 2012 2012. • Around 6.4 million women of reproductive health age (15 to 44) will get Medicaid and 4.8 million will get federal subsidies to buy private coverage coverage. • But abortion restrictions remain in Medicaid: 2 checks required in the Exchange, and general concern that most insurers will drop abortion benefit altogether. 26Source: ACA § 1201 (rating), codified at PHSA 2701; ACA § 1201 (pre-existing condition exclusions), codified at PHSA § 2704; ACA § 1001(preventive services), codified at PHSA § 2713; ACA §§ 1303, 10104 (abortion).
For kids • Kids under 19 in families that earn less than 133% FPL ($24,300 for a family of 3) will be eligible for free Medicaid coverage. Kids (and everyone else) with Medicaid will have more doctors to choose from because the new law raises pediatrician and primary care payment rates to match Medicare rates. • Child Health Plus (SCHIP) will continue until 2019. All kids up to 400% FPL ($73,240 for a family of 3) have access to affordable, comprehensive health insurance. p • Kids will no longer be subject to a pre-existing condition exclusion (2010).Source: ACA § § 2001(a)(5) (coverage of kids up to 133% FPL); 2101 (SCHIP); 1201 (pre-existingcondition exclusions), codified at PHSA § 2704; ACA § 10103 (pre-existing exclusion rule for children 27applies to grandfathered plans); Recon Act § 1203 (primary care rates).
For immigrants • If you are an immigrant with insurance, and you like it, you may keep it. • If you are a lawfully present immigrant and don’t don t like your insurance, or do not have insurance, starting in 2014 you may purchase insurance on the Exchange and get subsidies if you meet the standard eligibility requirements. • If you are an undocumented immigrant you cannot buy insurance or get subsidies for yourself on the Exchange. – But, you can get it for your family members who may b citizens or l f ll present. h be iti lawfully t Source: ACA § 1411 (eligibility for exchange). 28
The bottom line: Health Security• 32 million people will b illi l ill become covered d• Insurance industry will be regulated strictly• The cost of insurance will likely go down due to more people paying into the system. It is estimated that the premiums on the direct-pay market will go down by as much as 20%. Job-based coverage will go down by about 3%. Fewer health-related bankruptcies, Fe er health related bankr ptcies more job and health sec rit security• People will be able to use the new insurance Exchange as a simplified way to enroll into both public insurance programs and private health plans. plans The new law sets aside grants to states to establish consumer assistance programs to help people enroll in plans, file complaints and appeals, and solve problems. Source: whitehouse.gov (effect on premiums)., ACA § § 1311-1313, 10104, 10203 (exchanges); 1002 (consumer assistance), codified at PHSA § 2793; ACA § 1001 (appeals process); codified at PHSA § 2719 30
Implementation• Ph Phase-in over th next 3 years; f ll i l i the t fully implemented b t d by January, 2014• State policymakers are working on implementation – NY is getting federal funding to implement ACA Early Innovator, Consumer Assistance, Exchange y g Planning, Exchange Establishment grants State is conducting a lot of studies• Federal policymakers are issuing technical regulations and guidance.• Exchange 32
Regulations• The federal government will continue to issue proposed regulations and finalize regulations that have received comments. comments• Here are some regulations that SHARE members will be interested in: i t t di • Essential Health Benefits – watch for regulations • Summary of Benefits and Coverage – ongoing battle • Exchange regulations – in progress • Medicaid eligibility – in progress 33
What should the NYS Exchange looklike? HCFANY standards: t d d – One statewide Exchange for all. g – An Exchange that offers quality and affordable benefit packages. – An Exchange that is easy to navigate and represents consumers. Good consumer information and representation will ensure maximum enrollment and improve everyone’s health care outcomes. – An Exchange that builds on the success of New York’s public programs. Building on existing public programs and a new public option will give consumers a real alternative to private insurance plans. – An Exchange that supports principles of Health Equity. 34
NYS falling behind • Senate failed to pass agreed-upon legislation for a New York Exchange bill in June Old bill is obsolete Possible that Exchange authorization will be in budget g 35
What about theSupreme Court?• The Supreme Court announced that it will hear the case on whether the ACA is constitutional. – Oral argument will be in March 2012 – The decision will be out as early as June – The court will consider Whether the individual mandate is constitutional Whether it can answer this question before anyone has had to pay the tax Whether the Medicaid expansion is unconstitutional• What does it mean? – Recent decisions in favor of the ACA’s constitutionality by conservative judges – Political considerations and timing 36
Resources• Health Care For All New York: www.hcfany.org – Check out our website to find out more about the law and to keep posted on what’s going on with health reform implementation or call: (212) 614-5337.• Community Health Advocates: www.communityhealthadvocates.org – For help enrolling and using insurance or health care, call toll free: 1-888-614-5400.• Find coverage: www.healthcare.gov• Congressional Budget Office: http://www.cbo.gov/publications/collections/health.cfm• Kaiser Family Foundation: http://healthreform.kff.org/• Community Catalyst: http://www.communitycatalyst.org/• ACA h // ACA: http://www.ncsl.org/documents/health/ppaca-consolidated.pdf l /d /h l h/ lid d df 37