The document provides information about the Affordable Care Act (ACA) including its goals of expanding health coverage eligibility, making it easier to obtain coverage, and improving existing coverage. It discusses provisions such as the individual and employer mandates, Medicaid expansion, health insurance marketplace options, and subsidies available to help people obtain coverage. The summary also mentions key points in Indiana's approach, including using a federally run marketplace and not expanding Medicaid through pursuing the Healthy Indiana Plan instead.

1. Indiana State Nurses Association
• www.indiananurses.org
– CNE, Career Center, Advocacy Tools
– Legislative Conferences: 2/5, 2/20
• ISNAbler
• bmiley@indiananurses.org
@IndianaNurses
Indiana State Nurses Association

2. Why Learn About the Affordable Care Act?
• Join the Policy Discussion
• Only 31% of those eligible for Medicaid and 35%
of those eligible for subsidies know they qualify
– KFF & Urban Institute survey using data from 9/2013
• 70% of WSJ/NBC News Poll respondents don’t
understand the ACA
• Nurses – Gallup’s most trusted profession for 12
consecutive years

3. Affordable Care Act Goals
• Expand Health Coverage Eligibility
– Employer Mandate (2015)
– Medicaid Expansion (optional)
• Easier to Obtain Coverage – Marketplaces
• Improve Coverage
– Insurers Must Be Nicer to Sick People
– Medicare
– Provider Incentives/Penalties

4. Make Insurers Be Nicer to Sick
People
Insurers Dropping Coverage, Charging High
Fees
• Regulate Insurance Rates & Offerings
– More Sick People Have Insurance, Not Enough
Healthy People Buy Insurance to Offset
• Individual Mandate
– Children can stay on parents’ policies up to age 26

5. Supreme Court Decision
• Individual Mandate Constitutional
– Walks like a Tax, Quacks like a Tax
• Mandatory Medicaid Expansion
Unconstitutional
– Taking Away All Medicaid Funds if State’s Don’t
Expand is Unduly Coercive
• Remedy Makes Expansion Optional

6. Medicaid Expansion
• Up to 138%* of the Federal Poverty Level
• Federal Funding of New Enrollees
– 100% for 2014-2016; scales down to 90% in 2020
• Would Apply to Approximately 348,900 Hoosiers
• 100% Federal Poverty Level
– Individual: $11,490
– Family of 4: $23,550

7. Mandates
• Businesses Over 50 Employees (FTE)
– Provide Affordable Health Coverage or Pay Penalty
• Affordable = contribution < 9.5% of household income
• 30 hour/week employees over 3, 6, or 12 months
– Penalty = (# of workers – 30) x $2,000
• Individual: greater of $95 or 1% income
– Must Have Health Coverage or Pay Tax
• Exemptions if coverage gap < 3 months, low income, etc.
– Enforcement limited to future refunds

8. Indiana’s Approach
• Federally Run Marketplace
• No Medicaid Expansion
• Lawsuit by Schools Seeking to Prevent
Employer Mandate Penalty
– DC Court Rejected Similar Challenge
• Seeking Repeal of 2.3% Medical Device Tax
• Healthy Indiana Plan (HIP)
– Federal Waiver Program, Expansion Possible

9. HIP Differences from Medicaid
• Eligibility
– Medicaid: pregnant, child, families, disability, 65+
– HIP: ages 19-64, not eligible for Medicaid
• Reimbursement at Medicare Levels (higher)
• Annual & Lifetime Caps on Benefits
– $300,000 per year/$1 million lifetime
• 45,000 Cap on Enrollment

10. HIP Differences from Medicaid
• POWER Account
– Contributions by Participants
• Sliding Scale: Max 5% of annual income, Min $160/year
• Unused Rollover
– Contributions by State
• $1,100 minus Individual Contribution
• Unused Rollover Only if Preventive Services Utilized

11. Marketplaces
• Healthcare.gov - Open Enrollment 10/1/13 – 3/31/14
• Individuals Receive Federal Tax Credits if Income is
100-400% FPL and Employer Doesn’t Offer
Coverage
• Prospective then reconciled or just at tax time
• Amount scaled to second-cheapest silver plan
• Determine eligibility for Tax Credits, Medicaid, CHIP
• In.gov/healthcarereform
• SHOP: Small Business Tax Credits Available Now,

12. Marketplace Plans
• Metallic Categories By % of Costs Covered
– Bronze: 60%, Silver: 70%, Gold: 80%,
Platinum: 90%
• Catastrophic Coverage: high deductible,
low premium
– Eligible if under 30 or hardship (including prior
insurance plan canceled)
• Regulated by State Dept. of Insurance

13. Indiana Marketplace Options
4 Providers, 241 Plans
• Anthem – Community Health Network, Wishard
Health Services, Suburban Health Organization
• MDwise – IU Health, St. Vincent Health,
Franciscan Alliance
• Physicians Health Plan of Northern Indiana
(north central & northwest)
• Coordinated Care-Celtic (northeast)

14. Helping People with Marketplace
• Navigators
– No Fees to Consumers or Commission
– Federal certification: 30 hours of training, exam,
annual recertification &
• Separate Indiana certification requirements
– Cannot recommend specific plan
• Application Counselors

15. Medicare
• Beneficiaries do not use Marketplaces
• Increases Preventive Services
• Reduces Prescription Drug Costs in Part D Coverage
Gap
Deductible
Initial
Coverage
Coverage
Gap
Catastrophic
Coverage

16. Insurers
• Minimum Required Medical Loss Ratio
– % of Premiums Spent on Claims & Wellness
– Small Group = 80%, Large Group = 85%
– $22.6 million in rebates in Indiana for 2012
– Includes Medicare Advantage plans
• No Lifetime or Annual Limits on Coverage

17. Insurers
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Can’t Disqualify Based on Pre-existing Conditions
Premiums Can’t Vary Based on Gender
Premium Variance Based on Age < 300%
Can’t Penalize for Clinical Trial Participation
Non-grandfathered plans must cover Essential
Health Benefits
• Total Out-of-Pocket Expenses Capped in 2015
– $6,350 for individual; $12,700 for family (includes
copays, deductibles, not premiums)

18. EHB Categories
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Ambulatory Patient Services
Emergency Services
Hospitalization
Maternity & Newborn Care
Mental Health & Substance Use Disorder Services
Prescription Drugs
Rehabilitative and Habilitative Services
Laboratory Services
Preventive & Wellness Services
Pediatric Services, including Dental & Vision

19. Supreme Court 2014 Contraceptives
• Preventive services for women include
prescription contraceptives
• Religiously affiliated nonprofits may request an
accommodation requiring the insurer to bear the
cost of the contraceptives
• Supreme Court will decide whether for-profit
companies can be required to cover
contraceptives

20. Hospital Value Based
Purchasing
• Medicare Bonuses or Penalties
– Inpatient Prospective Payment System
• Process Measures
• Patient Surveys
• Readmission & Mortality Rates
– Myocardial Infarction, Heart Failure,
Pneumonia

21. CMS Innovation Center
• Accountable Care Organizations
• Bundled Payments for Care
– Different Models for Episode of Care
• Medical Home Approach

22. Nurse Programs
• National Health Service Corps
– Nurse Practitioner or Certified Nurse Midwife
– Service Commitment to Health Professional
Shortage Area
• Nurse Corps Loan Repayment Program
– Registered Nurse or Nurse Faculty
– Service Commitment to Critical Shortage Area
• Nurse Managed Health Clinics

23. ACA Takeaways
• Goals
– Expand Health Coverage Eligibility
– Easier Access to Coverage
– Efforts to Improve Coverage
• Access to Coverage Does Not Equate to
Access to Care

24. ACA Timeline
• Oct. 1, 2013 – Marketplaces Open
• Dec. 15, 2013 – Deadline to Obtain Coverage
Starting Jan. 1, 2014
• Jan. 1, 2014 – Individual Mandate Begins
• Mar. 31, 2014 – Open Enrollment Closes
• Oct. 15 to Dec. 7, 2014 – Open Enrollment
• Nov. 1, 2013 – SHOP Available on Marketplaces
• Jan. 1, 2015 – Employer Mandate Begins, Out-ofPocket Cap

25. Info Resources
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healthcare.gov - US Dept. of Health/Human Serv.
Marketplace Help Line: 1-800-318-2596
Marketplace.cms.gov – Provider info by CMS
hrsa.gov – Grant programs from HRSA
in.gov/fssa/healthcarereform – Program Table
rwjf.org - Robert Wood Johnson Foundation
kff.org - Kaiser Family Foundation
Indiananurses.org – Indiana State Nurses Association