Some notes about the affordable care act


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A presentation covering questions about the Affordable Care Act (also known as Obamacare) by the Public Health Organization of Chicago (PHO).

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Some notes about the affordable care act

  1. 1. Some notes on the Affordable Care Act
  2. 2. Almost Universal Health Insurance Coverage• Improve health care access, decrease costs, improve service quality and outcomes• Health Insurance Reforms• Individual Mandate• Employer Mandate (Employer-sponsored Insurance Coverage)• Marketplace purchased coverage• Public Insurance Coverage Expansion
  3. 3. Health Insurance Reforms• Pre-existing conditions - temporary plan - March 1, 2013 Illinois closing its doors to new applicants, early.• In most cases, insurers are prohibited from excluding pre-existing medical conditions for children under the age of 19• Pre-existing conditions restrictions eliminated for all in 2014
  4. 4. Health Insurance Reforms• Bans discrimination based on health status, medical condition (mental or physical illness), disability• Guaranteed issue and renewability• Small group and Individual plans must accept every employer and individual who applies.• should reduce delayed and more expensive care and bankruptcy due to inability to afford chronic care
  5. 5. Dependents under age 26• Plans must allow adult children under age 26 to enroll in a parent’s plan. Children do not have to live with parents, nor be students May be married, but spouses and children not eligible• provides for care in time for early intervention in mental illness and access to reproductive care, early HIV care. and chronic illness care
  6. 6. No lifetime or annual limits• Plans are prohibited from limiting the lifetime dollar value of benefits• Eliminates lifetime limits on most care (essential health benefits) and by 2014 eliminates annual limit cost of care• Elimination of caps on service coverage• Beneficial for individuals experiencing traumatic injuries (accidents, gun violence) or long-term medical conditions and some developmental disabilities
  7. 7. Funds should pay for health care• Requires 80-85% of premiums to be spent on health care services and health care quality improvements• Plans must provide rebates to consumers if the percentage of premiums spent on medical services and quality improvement activities falls below 85 percent for large group plans or 80 percent for small group and individual plans
  8. 8. Health Insurance Reforms• Direct Access to Obstetrician Gynecologist (already in IL)• Plans are prohibited from requiring a referral to see an OB-GYN• No prior authorization or higher cost sharing for out-of-network emergency services• Choice of doctor
  9. 9. Out of Pocket Spending Caps• Plans must limit out-of-pocket costs to $6,050 for single coverage and $12,100 for family coverage (2012 dollars) effective in 2014.• Limits on cost sharing: deductibles, coinsurance, co- payments 100-200% FPL: $1,983/individual; $3,967/family 200-300% FPL: $2,975/individual; $5,950/family 300-400% FPL: $3,987/individual; $7,973/family• Small group market plans are prohibited from deductibles greater than $2,000 for individuals and $4,000 for families
  10. 10. Reduce “Job Lock”• Insurance rate variation is only allowed based on age, tobacco use, family composition and geography• No gender or illness based discrimination• No jacking up premiums by up to 200 percent because an employee got sick or older.• Reduces the fear of switching jobs due to concerns over losing health
  11. 11. Minimum Coverage – Essential Health Benefits• Establishes a core set of benefits that are “essential” for every health insurance plan offered in Illinois• Ambulatory Patient Services• Emergency Services• Hospitalization• Maternity & Newborn Care• Mental Health & Substance Use Disorder Services• Prescription Drugs• Rehabilitative & Habilitative Services and Devices• Laboratory Services• Preventive, Wellness Services & Chronic Disease Management• Pediatric Services (Including Oral & Vision Care)• [Missing oral and vision care for adults]
  12. 12. Preventive services – no co-pays• Plans must offer without co-pays or cost-sharing (first dollar coverage) for certain preventive services.• All new insurance plans must cover• recommended childhood immunizations and adult vaccinations• certain preventive services (such as mammograms and colonoscopies)• Womens Preventive Services (including well-woman visits, support for breastfeeding equipment, contraception and domestic violence screening)• Annual wellness visit for Medicare enrollees
  13. 13. Insurance Reforms• Insurance rate change transparency – most provide public justification• Gradually Closes Medicare Part D Coverage Gap
  14. 14. Individual Mandate• Who must have health insurance?• Citizens and documented or legal residents
  15. 15. Coverage Options under the Individual Mandate• Expands Medicaid to all individuals under age 65 with incomes up to 133% (138%) of the poverty level ($$15,282/individual or $ 31,322/family of 4)• Includes adults without dependent children• No asset test for new eligibility category• Disability – financial eligibility versus medically needy• CountyCare• Federal Share (FMAP):• 100% for newly eligible first 3 years (2014 – 2016)• Phases down to 90% for 2020 and subsequent years
  16. 16. Options for Coverage• Health Insurance Marketplaces where individuals and small employers can purchase coverage• Provide premium subsidies to eligible individuals and families with incomes up to 400% of the poverty level ($45,960/individual or $94,200 /family of 4) through the Exchanges Metal Levels:  Bronze = 60%  Silver = 70%  Gold = 80%  Platinum =90%
  17. 17. Marketplace Requirements• No wrong door approach• Certify qualified health plans• Establish toll free telephone access• Web portal development with standardized, comparative information on health plan options• Choice of plan options• Electronic calculator to determine cost of plan and premium tax credit• Seamless with Medicaid enrollment/eligibility
  18. 18. Health Insurance Marketplace• Illinois is partnering with the federal government to run the marketplace• Navigators and In-Person Assisters• Is there an advisory body?• What will the exchange look like?   
  19. 19. Marketplace• Why purchase insurance on the marketplace?• It is the only way to access subsidies and tax credits if you are eligible for them• Small employers may only claim federal tax credit if they offer insurance to employees on the exchange
  20. 20. Individual Mandate• Penalties for not having insurance• Tax penalties for no coverage - IRS: 2014: $95 2015: $325 2016: $695 OR• Percent of household income: 1% in 2014, 2% in 2015, 2.5% - 2016 and after• Exempts individuals with incomes too low to pay taxes ($9,350) or if premiums exceed 8% of income
  21. 21. Business Tax Credits or Penalties• Under ACA, small employers with fewer than 25 full-time equivalent employees and average annual wages of less than $50,000 that purchase health insurance for employees are eligible for a tax credit.• For 2014 Health Insurance Exchanges can receive a tax credit for two years of up to 50 percent of their contribution.• In 2014, the Affordable Care Act requires large employers to pay a shared responsibility fee only if they do not provide affordable coverage• Employers with 50 or more full time employees (FTEs) who do not offer coverage must pay penalty: for every full-time employee that receives a premium credit for the Exchange
  22. 22. Not everyone will be covered• Immigrants without required documents• Individuals eligible for public coverage that don’t apply• Individuals that choose not to apply and pay the penalty instead• People without an affordable insurance option• Network adequacy
  23. 23. Other related concerns• CountyCare• Expansion of Federally Qualified Health Centers• Centers for Medicare and Medicaid Innovations Programs• Illinois Medicaid – Care Coordination and expansion of managed care• SMART Act• SB 26• H.R. 676 The Expanded & Improved Medicare• H.R. 261 Public Option
  24. 24. Thank you