Learn how you can successfully navigate the Affordable Care Act, "Obama Care".
This easy to read outline will benefit your family and business.
Call (816-224-9466) for more information today.
Health-Care Reform: Replacing Myths with FactsDolf Dunn
Emotions and financial decisions rarely ever go well together, so it is critical to understand how (if any) the new health care program will affect you and your family.
Health-Care Reform: Replacing Myths with FactsDolf Dunn
Emotions and financial decisions rarely ever go well together, so it is critical to understand how (if any) the new health care program will affect you and your family.
The Health Care and Education Affordability Reconciliation Act of 2010 was recently passed by the House and will be signed into law 03/30/2010. NAHU (National Association for Health Underwriters) published a comprehensive timeline of the changes coming over the next few years. Please contact me with any questions.
The Patient Protection and Affordable Care Act (Obama Care) provides opportunities for individuals and very small businesses to obtain affordable health insurance. More people will be covered in states like California which are expanding Medicaid (Medi-Cal) coverage. It is a complicated law but we hope that this presentation can give a suitable overview for the way the law is being implemented in the State of California.
http://www.symbiusmedical.com/ - This article can help you navigate the often misunderstood new world of healthcare - the Affordable Care Act. As of 2014 non-grandfathered individual and small group health plans must provide the essential health benefits (EHBs). EHBs will include items & services in 10 statutory benefit categories. Individuals are able to shop for insurance coverage on state health insurance exchanges, called “marketplaces.” The article is written by Symbius Medical Corporate Compliance Manager, Natalie Franklin.
ReadingsHealth Care Reform and Future PossibilitiesIntroduct.docxsodhi3
Readings
Health Care Reform and Future Possibilities
Introduction
Health care has undergone episodes of major change since the introduction of Medicare in the 1960s. All of these have resulted in fundamental changes in how health care providers were paid for services to Medicare patients and were swiftly followed by matching changes from independent insurance companies. The latest, and some might say the biggest, change since diagnosis-related groups (DRGs) were introduced in 1983 is the signing into law of the Patient Protection and Affordable Care Act (PPACA), on March 23, 2010. This law proposes to change the delivery of health care services by changing how providers are paid and what they are paid for. This module explores some of the key elements of PPACA and how health care providers are planning their changes in delivery processes and systems in response.
Major Elements of PPACA
The most significant elements of the PPACA legislation are scheduled to take place over several years. Congress still has the ability to modify some of these elements, so we will examine them with that in mind.
June 2010
Adults with pre-existing conditions were eligible to join a temporary high-risk insurance pool run by the federal government. This will be replaced by a health care exchange in 2014, which will provide access to insurance at affordable rates. Applicants must have a pre-existing health care condition and have been uninsured in the six months prior to application. Premiums will be set at rates for the general population rather than the high-risk premiums charged by insurance companies. Out-of-pocket costs will be limited to $5,950 for individuals and $11,900 for families.
July 2010
The government established the National Prevention, Health Promotion, and Public Health Council, with the Surgeon General to act as chair of the council. This council will oversee the implementation of many of the PPACA elements and will disseminate recommendations to the health care community at large in regard to best practices in prevention and health promotion. As of fall 2010, little had yet been heard from this entity. However, the National Committee on Quality Assurance, which is a private entity dedicated to improving the quality of health care services, is providing best practices and quality measures for health care providers, especially hospitals.
September 2010
Insurance companies can no longer apply lifetime dollar limits on essential benefits for patients. In addition, children may be covered under their parents' insurance plan until they turn 26 years of age. This includes children not living at home, not listed as dependents on their parents' tax returns, not students, and children who are married. Further, no patients under 19 years of age with pre-existing conditions can be excluded from health care benefits based on the pre-existing conditions, and there can be no deductibles or copayments required for provision of preventive care measures and medic ...
The Health Care and Education Affordability Reconciliation Act of 2010 was recently passed by the House and will be signed into law 03/30/2010. NAHU (National Association for Health Underwriters) published a comprehensive timeline of the changes coming over the next few years. Please contact me with any questions.
The Patient Protection and Affordable Care Act (Obama Care) provides opportunities for individuals and very small businesses to obtain affordable health insurance. More people will be covered in states like California which are expanding Medicaid (Medi-Cal) coverage. It is a complicated law but we hope that this presentation can give a suitable overview for the way the law is being implemented in the State of California.
http://www.symbiusmedical.com/ - This article can help you navigate the often misunderstood new world of healthcare - the Affordable Care Act. As of 2014 non-grandfathered individual and small group health plans must provide the essential health benefits (EHBs). EHBs will include items & services in 10 statutory benefit categories. Individuals are able to shop for insurance coverage on state health insurance exchanges, called “marketplaces.” The article is written by Symbius Medical Corporate Compliance Manager, Natalie Franklin.
ReadingsHealth Care Reform and Future PossibilitiesIntroduct.docxsodhi3
Readings
Health Care Reform and Future Possibilities
Introduction
Health care has undergone episodes of major change since the introduction of Medicare in the 1960s. All of these have resulted in fundamental changes in how health care providers were paid for services to Medicare patients and were swiftly followed by matching changes from independent insurance companies. The latest, and some might say the biggest, change since diagnosis-related groups (DRGs) were introduced in 1983 is the signing into law of the Patient Protection and Affordable Care Act (PPACA), on March 23, 2010. This law proposes to change the delivery of health care services by changing how providers are paid and what they are paid for. This module explores some of the key elements of PPACA and how health care providers are planning their changes in delivery processes and systems in response.
Major Elements of PPACA
The most significant elements of the PPACA legislation are scheduled to take place over several years. Congress still has the ability to modify some of these elements, so we will examine them with that in mind.
June 2010
Adults with pre-existing conditions were eligible to join a temporary high-risk insurance pool run by the federal government. This will be replaced by a health care exchange in 2014, which will provide access to insurance at affordable rates. Applicants must have a pre-existing health care condition and have been uninsured in the six months prior to application. Premiums will be set at rates for the general population rather than the high-risk premiums charged by insurance companies. Out-of-pocket costs will be limited to $5,950 for individuals and $11,900 for families.
July 2010
The government established the National Prevention, Health Promotion, and Public Health Council, with the Surgeon General to act as chair of the council. This council will oversee the implementation of many of the PPACA elements and will disseminate recommendations to the health care community at large in regard to best practices in prevention and health promotion. As of fall 2010, little had yet been heard from this entity. However, the National Committee on Quality Assurance, which is a private entity dedicated to improving the quality of health care services, is providing best practices and quality measures for health care providers, especially hospitals.
September 2010
Insurance companies can no longer apply lifetime dollar limits on essential benefits for patients. In addition, children may be covered under their parents' insurance plan until they turn 26 years of age. This includes children not living at home, not listed as dependents on their parents' tax returns, not students, and children who are married. Further, no patients under 19 years of age with pre-existing conditions can be excluded from health care benefits based on the pre-existing conditions, and there can be no deductibles or copayments required for provision of preventive care measures and medic ...
What Changes to Expect from the new Healthcare Law, presented by The National Federation of Independent Business, the leading small business association.
Health Reform Bulletin 128 | House Passes the American Health Care ActCBIZ, Inc.
On May 4, 2017, the House passed the American Health Care Act of 2017 (“AHCA”, H. R. 1628). Since the initial bill was officially introduced on March 20, 2017 (see The GOP Proposal to Repeal and Replace the Affordable Care Act, HRB 127, 3/10/17), there have been several amendments made to the law’s text. The bill will now progress to the Senate for consideration; its fate in the Senate is unclear at this point. Every indication is that the bill with undergo significant scrutiny and probably substantial change. Following is a brief overview of certain provisions of the bill passed by the House.
What Does Health Reform Mean For You A Consumers Guidekmacaller
A dynamite guide for everything you never wanted to know about Health Care Reform! Did I say "never?" Wish I didn\'t have to deal with this stuff but alas, I do.
The Patient Protection and Affordable Care Act De.docxoreo10
The Patient Protection and Affordable Care Act
Detailed Summary
The Patient Protection and Affordable Care Act will ensure that all Americans have access to quality,
affordable health care and will create the transformation within the health care system necessary to
contain costs. The Congressional Budget Office (CBO) has determined that the Patient Protection and
Affordable Care Act is fully paid for, will provide coverage to more than 94% of Americans while
staying under the $900 billion limit that President Obama established, bending the health care cost
curve, and reducing the deficit over the next ten years and beyond.
The Patient Protection and Affordable Care Act contains nine titles, each addressing an essential
component of reform:
Quality, affordable health care for all Americans
The role of public programs
Improving the quality and efficiency of health care
Prevention of chronic disease and improving public health
Health care workforce
Transparency and program integrity
Improving access to innovative medical therapies
Community living assistance services and supports
Revenue provisions
Title I. Quality, Affordable Health Care for All Americans
The Patient Protection and Affordable Care Act will accomplish a fundamental transformation of
health insurance in the United States through shared responsibility. Systemic insurance market reform
will eliminate discriminatory practices such as pre-existing condition exclusions. Achieving these
reforms without increasing health insurance premiums will mean that all Americans must be part of the
system and must have coverage. Tax credits for individuals and families will ensure that insurance is
affordable for everyone. These three elements are the essential links to achieve reform.
Immediate Improvements: Achieving health insurance reform will take some time to implement. In
the immediate reforms will be implemented in 2010. The Patient Protection and Affordable Care Act
will:
Eliminate lifetime and unreasonable annual limits on benefits
Prohibit rescissions of health insurance policies
Provide assistance for those who are uninsured because of a pre-existing condition
Require coverage of preventive services and immunizations
Extend dependant coverage up to age 26
Develop uniform coverage documents so consumers can make apples-to-apples comparisons
when shopping for health insurance
Cap insurance company non-medical, administrative expenditures
2
Ensure consumers have access to an effective appeals process and provide consumer a place to
turn for assistance navigating the appeals process and accessing their coverage
Create a temporary re-insurance program to support coverage for early retirees
Establish an internet portal to assist Americans in identifying coverage options
Facilitate administrative simplification to lower health system costs
Heal ...
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
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TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
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Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
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Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
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Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
1. Life Guide
The Affordable Care Act (ACA)
The Affordable Care Act,
or ACA, is the nation's
health insurance reform
law, initially enacted in
March 2010 and being
gradually phased in over a
period of years.
Beginning in 2014, most
U.S. citizens and legal
residents must purchase
or be provided by an
employer with minimum
essential health coverage
or be subject to a penalty.
Table of Contents
What Is the Affordable Care Act?.................... 2
Financing the Affordable Care Act ................... 3
ACA Impact on Individuals and
Families...................................................... 4
Health Insurance Recap ................................ 5
The Individual Mandate................................. 7
Where to Get Health Insurance ...................... 8
The Health Insurance Marketplace .................. 9
Qualified Health Plans ................................. 10
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Premium Tax Credit.................................... 12
Federal Tax Subsidies in Action (diagram) ..... 15
Medicaid and the ACA ................................. 16
Employer-Sponsored Health Plans ................ 18
ACA and Individuals (diagram)..................... 20
Tax Impact on Higher-Income Taxpayers ...... 21
ACA and Large Employers ........................... 22
ACA and Small Employers ........................... 25
ACA Employer Penalties (diagram) ............... 26
Additional Information ................................ 27
LG-18
The Affordable Care Act (August 2013)
2. What Is the Affordable Care Act?
The Affordable Care Act, or ACA, is the nation's health insurance reform law,
initially enacted in March 2010 and being gradually phased in over a period of years.
The Patient Protection and Affordable Care Act (PPACA) was signed into law by
President Obama on March 23, 2010. Later that same month, legislation to remove or
modify some provisions of the original PPACA, the Health Care and Education
Reconciliation Act of 2010 (the Reconciliation Act), was passed by Congress and signed
into law by President Obama on March 30, 2010. These two pieces of legislation
have come to collectively be known as the Affordable Care Act (ACA).
Core Principles of the Affordable Care Act
The ACA has five core principles that it is designed to achieve. The degree to which it
achieves these five principles will depend on implementation, compliance with and
enforcement of the law's requirements and, in all probability, future legislation that
addresses flaws that become apparent as the law is implemented:
Impose an Individual Mandate: Most individuals not covered by Medicare or
Medicaid will be required to have health insurance or pay a penalty ("play or pay"). In
addition, insurance companies will no longer be able to deny coverage for pre-existing
conditions, rescind existing health insurance coverage when a person gets sick or
impose annual or lifetime limits on benefits.
Strive to Provide Affordable Coverage:
Lower-income individuals and
families, together with some middle-income individuals and families, will receive
financial assistance to help pay for health insurance. In addition, insurance companies
will have to annually report the share of premium dollars spent on actual medical care
and provide customer rebates for plans that spend a lower percentage of premium
dollars on medical services than that required by the ACA.
Require an Employer Mandate: With the exception of small businesses,
employers that do not provide qualifying health insurance coverage will be subject to
an additional tax. Small employers will be encouraged to provide health care coverage
through a new tax credit.
Cover Preventive Health Services: New group health insurance plans, as
well as individual health insurance policies, will have to provide "first dollar" coverage
for certain preventive services and immunizations.
Transform the Health Care Delivery System: Provide funding for research
and demonstration projects to test payment and service delivery models designed to
reduce health care costs and improve the quality of care provided.
The Affordable Care Act (August 2013 edition)
2
3. Financing the Affordable Care Act
While there are estimates as to what the ACA will cost and how much of that cost will
be offset by new taxes and fees, realistically it's impossible to predict at this point in
time with any accuracy what impact health care reform will have on family budgets.
The hope is that the current legislation, together with possible future changes, will
transform an industry that currently pays doctors and hospitals based on the volume of
services provided to a system that rewards medical providers on the basis of health
care outcomes, resulting in lower health care costs. In reality, however, the legislation
doesn't include any proven strategies for tackling what many consider to be the biggest
concern: health care costs that are rising at twice the rate of inflation.
What we do know, however, is that to help finance the cost of health care reform, the
Affordable Care Act includes a number of taxes and fees that will take effect
over a period of years, including:
Beginning in 2010:
Limits on the deduction of compensation paid by health insurance providers to
high-level executives begin to phase in; and
10% tax on qualified indoor tanning services provided on or after July 1, 2010.
Effective Dates Ranging from 2011 to 2014:
Effective January 1, 2011, the cost of over-the-counter medicines and drugs
cannot be reimbursed from flexible spending arrangements (FSAs) or health savings
accounts (HSAs); and
Annual nondeductible fees imposed on certain health-related industries, such as
medical device manufacturers and importers, sales of brand-name pharmaceuticals and
health insurance providers.
Beginning in 2013:
An increase in Medicare payroll taxes paid by higher-income taxpayers;
An increase in the threshold for the itemized medical expense deduction from
7.5% to 10% of adjusted gross income;
A new 3.8% Medicare contribution tax on certain investment income above
specified income threshold amounts; and
Annual contributions to health flexible spending accounts (FSAs) are limited to
$2,500, indexed for inflation in future years.
Beginning in 2014:
"Shared responsibility payments" will apply to non-exempt individuals who do
not purchase minimum essential health care coverage; and
An annual fee will be assessed on certain health insurance providers.
Beginning in 2015:
"Shared responsibility payments" will apply to certain employers that do not
offer health care coverage to their full-time employees.
Beginning in 2018:
40% excise tax on "high dollar" health insurance plans goes into effect.
The Affordable Care Act (August 2013 edition)
3
4. ACA Impact on Individuals and Families
The impact of the Patient Protection Act on you and your family depends to a
large extent on your age, for whom you work, the amount and sources of your
income and your health status:
Young Adults: Beginning in 2014, young adults will have to purchase health
insurance unless they qualify for an exemption.
Young adults under age 30,
however, will have access to less expensive catastrophic coverage. In addition, since
2010, young adults up to age 26 have been allowed to stay on their parent's health
plans.
Non-Elderly Adults: Unless they qualify for an exemption, beginning in 2014, all
U.S. citizens and legal residents will be required to have qualifying health care
coverage or pay a penalty…the individual mandate. Insurers will no longer be able to
turn down people with pre-existing conditions or charge them higher premiums.
Health insurance plans cannot impose annual limits on the amount of coverage an
individual may receive and premium rating variations can be based only on age,
premium rating area, family composition and tobacco use. Lower-income earners
who earn less than 400% of the federal poverty level will be eligible for subsidies to
help purchase coverage. The lowest-income earners (up to 138% of the federal
poverty level) will become eligible for Medicaid, regardless of whether or not they
have children or a disability, if the state in which they reside has elected to
participate in the ACA Medicaid expansion.
Employees of Large Companies: Participation in an employer's large group health
plan generally will satisfy the individual mandate. Beginning in 2015, companies with
50 or more employees will not be required to provide health care coverage, but those
that don't may have to make "shared responsibility payments." Existing benefit
packages are grandfathered, but must still meet certain requirements. New plans will
have to meet minimum requirements, including limits on out-of-pocket spending.
Employees of Small Companies: A business with fewer than 50 employees is not
required to provide health care coverage. A business with 25 or fewer employees,
however, may qualify for a federal tax credit to help with the cost of providing health
insurance.
Higher-Income Individuals: Beginning in 2013, additional Medicare taxes will be
paid by higher-income individuals on their wages and, for the first time, on net
investment income.
Senior Citizens: Medicare has added free preventive services and the Medicare Part
D prescription drug coverage gap will slowly be closed by 2020. Higher-income
Medicare beneficiaries will pay higher Medicare Part B premiums for medical
insurance. Medicare currently covers about 38 million people and, as a result, has
tremendous clout in the way medical care providers are paid. As a result, expect to
see Medicare pilot programs designed to develop and implement new approaches to
how medical care providers are compensated.
The Affordable Care Act (August 2013 edition)
4
5. Health Insurance Recap
Insurance protects you from high costs when something bad happens. In the case of
health insurance, no one plans to get sick or hurt, but most people need to get treated
for an illness or injury at some point, and health insurance helps pay these costs. You
get health insurance to protect you and your family when you need medical care.
When you understand how health insurance works, it helps you be a better informed
consumer so you can find coverage that fits your needs.
What Is Health Insurance?
Health insurance is a contract between you and your insurance company. You buy a
plan or policy, or one is provided through your employer, and the insurance company
agrees to pay part of your medical expenses when you get sick or hurt. Even when you
need care that costs more than you pay in premiums and deductibles, insurance will
cover the care you need. A standard health insurance policy also gives you access to
preventive care to keep you healthy, like vaccines and check-ups, plus many plans also
cover prescription drugs.
Health Insurance Helps You Pay for Care
Even a brief hospitalization or emergency room visit can cost thousands of dollars.
Having health insurance can help protect you from unexpected costs like these.
Your insurance policy will show what types of care, treatments and services are covered,
including how much the insurance company will pay for different treatments in different
situations. The Affordable Care Act also requires that insurance companies provide
standardized summaries of benefits and coverage so you can easily understand and
compare plans.
What You Pay for Health Insurance
You’ll usually pay a premium every month for health insurance, and you may also have
to meet a deductible once each year before the insurance company starts to pay its
share. How much you pay for your premium and deductible is based on the type of
insurance you have.
While premium cost is important, you also need to evaluate how much you will have to
pay when you receive medical services. Examples include:
►
Deductible: How much you pay before your insurance coverage starts.
►
Coinsurance or copayments: What you pay out-of-pocket for services after you
pay the deductible. For example, you may have to pay 20% of each charge
(coinsurance) or the first $20 for each medical service received (copayment).
►
Out-of-pocket maximum: How much in total you’ll have to pay in a calendar year
before the insurance policy fully pays for your covered medical expenses.
What your policy covers is often directly related to how expensive the health insurance
policy is. The policy with the cheapest premium may not cover as many services and
treatments and/or have higher deductibles, coinsurance and copayments.
The Affordable Care Act (August 2013 edition)
5
6. Health Insurance Recap (continued)
5 Things to Know About Health Insurance
1.
There are many kinds of private health insurance policies. Different kinds of policies
can offer very different kinds of benefits, and some can limit which doctors,
hospitals, or other providers you can use.
2.
You may have to pay coinsurance or a copayment as your share of the cost when
you receive a medical service. Coinsurance is usually a percentage amount (for
example, 20% of the total cost). A copayment is usually a set dollar amount (for
example, you might pay $10 or $20 for a prescription or doctor's visit).
3.
You may have to pay a deductible each plan year before your insurance starts to
pay. For example, let's say you have a $200 deductible. You go to the doctor and
the total cost is $250. You pay the first $200 to cover the deductible, and then your
insurance starts to pay its share.
4.
Many health insurance plans contract with networks of hospitals, doctors,
pharmacies, and health care providers to take care of people in the plan. Depending
on the type of policy you buy, your plan may only pay for your care when you get it
from a provider in the plan’s network, or you may have to pay a bigger share of the
bill if you receive services "out of network."
5.
You may see products that look and sound like health insurance, but don’t give you
the same protection as full health insurance. Some examples are policies that only
cover certain diseases, policies that only cover you if you’re hurt in an accident, or
plans that offer you discounts on health services. Don’t mistake insurance-like
products for full comprehensive insurance protection. Full health insurance usually
covers most medical problems.
The Affordable Care Act (August 2013 edition)
6
7. The Individual Mandate
Beginning January 1, 2014, the Affordable Care Act requires all non-exempt
U.S. citizens and legal residents to have qualifying health coverage or pay a tax
penalty.
The individual mandate makes it possible for everyone, including people with preexisting conditions such as cancer, diabetes and heart disease, to get health insurance.
Without the individual mandate requirement, there is the risk that only people who are
sick and need insurance would purchase it. Healthy people could then wait until they get
sick to purchase coverage, which would make premiums very expensive. By requiring
healthy people to be covered by health insurance or pay a tax penalty, the individual
mandate requirement is predicted to bring down the average health insurance premium
cost for everyone.
"Shared Responsibility" Tax Penalty
Individuals who are not exempt from the individual mandate and are not covered by
qualifying health insurance are subject to a tax penalty:
►
2014: Greater of $95 per adult and $47.50 per child (maximum of $285 for a
family) or 1% of family income.
►
2015: Greater of $325 per adult and $162.50 per child (maximum of $975 for a
family) or 2% of family income.
►
2016: Greater of $695 per adult and $347.50 per child (maximum of $2,085 for a
family) or 2.5% of family income.
►
After 2016: The penalty amounts are increased annually by the cost of living.
For purposes of the "shared responsibility" tax penalty, income is defined as total income
in excess of the income tax return filing threshold ($10,000 for an individual and
$20,000 for a family in 2013). In addition, the penalty is prorated by the number of
months without coverage and there is no penalty for a single gap in coverage of less
than three months in a year. Finally, the penalty is capped at the national average
premium for "Bronze" coverage in a Health Insurance Marketplace (see page 10).
Insurance companies will report to the IRS the names, addresses and tax ID numbers of
individuals with coverage. The IRS will then be able to enforce the penalty on uncovered
individuals by docking tax refunds. Tax liens or levies are not allowed.
Exceptions to the Individual Mandate
The following individuals are exempt from the individual mandate:
►
►
►
►
►
►
members of a religion opposed to acceptance of benefits from a health insurance
policy;
undocumented immigrants;
people who are incarcerated;
members of Indian tribes;
those with family income below the threshold for filing an income tax return
($10,000 for an individual and $20,000 for a family in 2013); and
those who would have to pay more than 8% of their income for health insurance,
after taking into account any employer contributions or premium tax credits.
The Affordable Care Act (August 2013 edition)
7
8. Where to Get Health Insurance
Beginning on January 1, 2014, in order to satisfy the individual mandate,
people will have access to health insurance through the following sources:
From an Employer: The most common way of getting health insurance has been
and will continue to be through an employer-sponsored group plan. Generally
speaking, employers contribute toward the cost of the premiums, with employees
paying the balance of the premiums plus other cost-sharing features such as
deductibles, copayments and coinsurance.
From a Health Insurance Marketplace: The Affordable Care Act creates Health
Insurance Marketplaces in each state through which individuals and small businesses
can purchase qualifying health insurance policies from private insurance companies
and may receive premium tax credits to help pay the cost of the insurance. Open
enrollment in the Marketplaces will begin October 1, 2013, with coverage taking
effect on January 1, 2014.
From a Grandfathered Plan: Many health care plans that existed before the
Affordable Care Act was signed into law do not contain some of the law's consumer
protections and would not be qualifying health care plans under the ACA's individual
mandate. The Act, however, exempts most plans that existed on March 23, 2010,
the day the law was enacted, from some of the law’s consumer protections, which
preserves consumers’ rights to keep the coverage they already had before health
care reform and satisfy the individual mandate. If you have health coverage –
individual or through an employer - from a plan that existed on March 23, 2010 —
and that has covered at least one person continuously from that day forward — your
plan may be considered a “grandfathered” plan.
These plans can lose their
grandfathered status if they make certain significant changes that reduce benefits or
increase costs to consumers.
From Medicaid/CHIP: Medicaid and CHIP are public programs that provide health
care coverage to specific categories of lower-income adults and children. Beginning
January 1, 2014, Medicaid will be expanded to include all U.S. citizens and some legal
residents under age 65 who meet specific income requirements, assuming the state
in which the individual resides does not opt out of the ACA Medicaid expansion. The
Affordable Care Act maintains the Children's Health Insurance Program (CHIP)
eligibility standards currently in place through 2019 and extends CHIP funding until
October 1, 2015, with authority for the program extended through 2019.
From Medicare: Individuals 65 and older, together with some younger individuals
with qualifying disabilities, will continue to receive health care coverage through
Medicare.
From TRICARE/Veterans Health Program: Uniformed Service members, retirees
and their families receive health care benefits through TRICARE. Veterans separated
from the service under any condition other than dishonorable may qualify for VA
health care benefits.
The Affordable Care Act (August 2013 edition)
8
9. The Health Insurance Marketplace
With key parts of the ACA becoming effective in 2014, the Health Insurance
Marketplace will allow individuals and small businesses to compare private
health insurance plans, get answers to questions, find out if they are eligible for
tax credits to purchase private insurance or for health programs like Medicaid
or the Children's Health Insurance Program (CHIP) and, finally, to enroll in a
health plan that meets their needs.
Each state will have its own Health Insurance Marketplace through which
insurance companies compete for your business. States can create and operate
their own Marketplace, use a Marketplace operated by the Department of Health
and Human Services (HHS), or choose to partner with HHS to run some
functions of their Marketplace.
State Health Insurance Marketplaces are currently scheduled to be available for open
enrollment beginning in October 2013, with private health plan coverage purchased
through the Marketplace becoming effective on January 1, 2014. You can also
purchase a health plan outside of your State Marketplace on the "open market" or
through a private insurance exchange.
New Benefits and Protections
If your health plan is subject to ACA requirements, you and your family may be eligible
for some important preventive services at no additional cost to you, services such as:
►
Blood pressure, diabetes, and cholesterol tests
►
Many cancer screenings, including mammograms and colonoscopies
►
Counseling on such topics as quitting smoking, losing weight, eating healthfully,
treating depression, and reducing alcohol use
►
Regular well-baby and well-child visits, from birth to age 21
►
Routine vaccinations against diseases such as measles, polio, or meningitis
►
Counseling, screening, and vaccines to ensure healthy pregnancies
►
Flu and pneumonia shots
Beginning in 2014, a "Patient's Bill of Rights" takes full effect, providing you with certain
protections, including:
►
You cannot be denied health insurance because of a pre-existing condition.
►
Your coverage cannot be cancelled or rescinded if you get sick.
►
Lifetime limits on essential health benefits are banned for all new health insurance
plans.
►
Annual limits on essential health benefits are phased out.
►
Premium rating variations can be based only on age, premium rating area, family
composition and tobacco use and insurers must justify annual premium increases of
10% or more.
►
You can seek emergency care at a hospital outside of your health plan’s network.
The Affordable Care Act (August 2013 edition)
9
10. Qualified Health Plans
Under the Affordable Care Act, starting in 2014, an insurance plan that is
certified by a Health Insurance Marketplace provides essential health benefits,
is a standardized plan, and meets other requirements. A qualified health plan
will have a certification by each Marketplace in which it is sold
Essential Health Benefits
Health plans offered in the individual and small group markets, both inside and outside of
State Marketplaces, must include items and services within at least the following 10
categories:
1.
Ambulatory patient services
2.
Emergency services
3.
Hospitalization
4.
Maternity and newborn care
5.
Mental health and substance use disorder services, including behavioral health
treatment
6.
Prescription drugs
7.
Rehabilitative and habilitative services, such as occupational and speech
therapy, and devices
8.
Laboratory services
9.
Preventive and wellness services and chronic disease management, and
10.
Pediatric services, including oral and vision care
Standardized Plans
It can be difficult to compare health insurance plans that have different benefits and outof-pocket costs. The Affordable Care Act addresses this problem by standardizing the
types of benefits and cost-sharing allowed in health plans offered by private health
insurers through the Health Insurance Marketplace into four levels of coverage.
Each plan level must cover the same minimum essential health benefits, but the amount
of cost-sharing required will vary among the plan levels, as will the premiums charged
(general rule...the higher the percentage of benefit costs paid by the plan, the higher
the premium for that health plan):
►
Bronze plans must cover 60% of the benefit costs of the plan, meaning the
insured is responsible for paying the remaining 40%.
►
Silver plans must cover 70% of the benefit costs of the plan, leaving the insured to
pay the remaining 30%.
►
Gold plans must cover 80% of the benefit costs of the plan, leaving the insured to
pay the remaining 20%.
►
Platinum plans must cover 90% of the benefit costs of the plan, leaving the
insured to pay the remaining 10%.
The Affordable Care Act (August 2013 edition)
10
11. Qualified Health Plans (continued)
Out-of-Pocket Limits (Cost-Sharing Reductions)
All of the standardized qualified health plans must limit your annual out-of-pocket costs,
including deductibles, copayments or coinsurance, to an amount no greater than the
limits for high-deductible Health Savings Account (HSA) plans (in 2014, the HSA limit is
$6,350 for an individual and $12,700 for a family). NOTE: Some group health plans have
been granted a waiver and will not be required to limit annual out-of-pocket costs until
2015.
In addition, out-of-pocket limits must be reduced to the following levels for those with
incomes up to 400% of the Federal Poverty Level (FPL):
►
100% to 200% of the FPL: The annual out-of-pocket limit is reduced to one-third
of the HSA limits ($2,116 for an individual and $4,233 for a family in 2014).
►
200% to 300% of the FPL: The annual out-of-pocket limit is reduced to one-half
of the HSA limits ($3,175 for an individual and $6,350 for a family in 2014).
►
300% to 400% of the FPL: The annual out-of-pocket limit is reduced to twothirds of the HSA limits ($4,234 for an individual and $8,467 for a family in 2014).
The Federal Poverty Level (FPL) is the set minimum amount of gross income that a
family or individual needs for food, clothing, transportation, shelter and other
necessities. The FPL is determined by the Department of Health and Human Services
(HHS) and varies according to family size. The number is adjusted for inflation each
year and reported annually, typically in February. Many public assistance programs
define eligibility income limits as some percentage of FPL. Here are selected 2013 FPL
annual amounts for all states except Alaska and Hawaii:
Percent of Federal Poverty Level (2013)
Family Size
100%
200%
300%
400%
1
$11,490
$22,980
$34,470
$45,960
2
$15,510
$31,020
$46,530
$62,040
3
$19,530
$39,060
$58,590
$78,120
4
$23,550
$47,100
$70,650
$94,200
6
$31,590
$63,180
$94,770
$126,360
7
$35,610
$71,220
$106,830
$142,440
8
$39,630
$79,260
$118,890
$158,520
Catastrophic Plans
Catastrophic plans, which will have lower premiums, can be purchased by young adults
up to age 30, as well as by those who are exempt from the individual mandate. These
plans will cover the essential health benefits, but only after a high deductible is met. The
deductible cannot exceed the limits for high-deductible Health Savings Account (HSA)
plans (in 2014, the HSA limit is $6,350 for an individual and $12,700 for a family).
Preventive benefits and coverage for three primary care visits, however, are exempt
from the deductible.
The Affordable Care Act (August 2013 edition)
11
12. Premium Tax Credit
Starting in 2014, individuals and families can take a new premium tax credit to
help them afford health insurance coverage purchased through a Health
Insurance Marketplace. The premium tax credit is refundable, so taxpayers
who have little or no income tax liability can still benefit. The credit also can
be paid in advance to a taxpayer’s insurance company to help cover the cost of
premiums.
Who Is Eligible for a Premium Tax Credit?
The premium tax credit is generally available to U.S. citizens and legal residents with
incomes between 100% and 400% of the Federal Poverty Level (FPL). This means that
middle-income individuals and families, as well as those in lower-income groups, will
receive financial help in purchasing private health plans through the Health Insurance
Marketplace. The premium tax credit makes up the difference between the amount an
individual is required to pay and the amount the plan charges in premiums. Specific
requirements include:
►
Household income between 100% and 400% of the FPL (see page 11 for
information on the Federal Poverty Level).
►
Covered individuals must enroll in a qualified health plan through a state Health
Insurance Marketplace.
►
Covered individuals must be legally present in the United States and not
incarcerated.
►
Covered individuals must not be eligible for other qualifying coverage, such as
Medicare, Medicaid, or affordable employer-sponsored health coverage.
►
Individuals who are eligible for, but not enrolled in employer-sponsored
health insurance if (a) the insurance is unaffordable (i.e., the self-only premium
exceeds 9.5% of income); or (b) the insurance doesn't provide a minimum
value (i.e., it fails to cover 60% of total allowed costs.
What Is the Premium Tax Credit Amount?
The premium tax credit amount is generally equal to the difference between the
premium for the benchmark plan and the taxpayer's expected contribution:
►
Benchmark Plan: The benchmark plan is the second-lowest-cost plan in the
Marketplace that would cover an individual or family at the "silver" level of coverage
(see Standardized Plans on page 10).
►
Income Eligibility: Income eligibility for the premium tax credit will be based on
the previous year's income tax return. It may also be possible to verify income
through pay stubs or other documentation.
The Affordable Care Act (August 2013 edition)
12
13. Premium Tax Credit (continued)
►
Expected Contribution: The expected contribution is a specified percentage of the
taxpayer's household income...the amount the taxpayer is expected to pay toward
the premium.
The expected contribution will increase as household income
increases:
Income (as a
% of FPL):
Expected
Contribution:
►
Up to
133%
2% of
income
133% to
150%
3-4% of
income
150% to
200%
4-6.3%
of income
200% to
250%
6.3-8.05%
of income
250% to
300%
8.05-9.5%
of income
350% to
400%
9.5% of
income
Limits: If a plan that is less expensive than the benchmark plan is chosen, the
actual amount paid for coverage will be less than the expected contribution (as
illustrated in Example 2 below). Since the premium tax credit is based on a
benchmark plan, older Americans (ages 55 – 64) who face higher premiums will
receive a greater premium tax credit (see Example 3 below). The credit is capped
at the premium for the plan chosen...no one will receive a credit that is larger than
the amount they actually pay for their plan.
Hypothetical Premium Credit Examples
The premium credit amount is generally equal to the difference between the premium for
the benchmark plan and the taxpayer's expected contribution:
Example 1: A family of four with household income of $50,000 purchases the "silver"
level benchmark plan; no tobacco use
Household Income in 2014
209% of FPL
Unsubsidized Benchmark Plan Premium
$9,869
Maximum Expected Contribution %
6.63%
Expected Contribution for the Premium
$3,314 (6.63% of household income;
pays 34% of the premium)
Premium Tax Credit
$6,555 (pays 66% of the premium)
Example 2: A family of four with household income of $50,000 purchases the less
expensive (and less comprehensive) "bronze" level plan; no tobacco use
Household Income in 2014
209% of FPL
Unsubsidized "Bronze" Plan Premium
$8,180
Maximum Expected Contribution %
3.25%
Expected Contribution for the Premium
$1,625 (3.25% of household income;
pays 20% of the premium)
Premium Tax Credit
$6,555 (pays 80% of the premium)
The Affordable Care Act (August 2013 edition)
13
14. Premium Tax Credit (continued)
Example 3: A family of four, two adults between the ages of 55 and 64, with household
income of $50,000 purchases the "silver" level benchmark plan; no tobacco use
Household Income in 2014
209% of FPL
Unsubsidized Benchmark Plan Premium
$14,687
Maximum Expected Contribution %
6.63%
Expected Contribution for the Premium
$3,314 (6.63% of household income;
pays 23% of the premium)
Premium Tax Credit
$11,373 (pays 77% of the premium)
How Is the Premium Tax Credit Paid?
The premium tax credit is advanceable, refundable and subject to reconciliation each
year.
►
Advanceable: An advanceable tax credit allows people to receive the benefit of the
credit at the time they purchase health insurance, rather than paying the premium
out of pocket and waiting to be reimbursed when filing their income tax return. The
premium tax credit will be paid directly to insurance companies by the Department
of the Treasury on a monthly basis. No payments are made directly to consumers.
►
Refundable: The premium tax credit is refundable so taxpayers who have little or
no income tax liability can still benefit.
►
Reconciliation: Taxpayers receiving the premium tax credit must file an income
tax return. Because the premium tax credit is based on the previous year's income,
there is a reconciliation process when taxpayers file their tax returns for the actual
year in which they received the tax credit. If a taxpayer was "under-credited," an
additional credit will be returned to the taxpayer. If there was an excess credit, the
taxpayer is liable for the overpayment, subject to caps ranging from $600 for
married taxpayers ($300 if single) with household income under 200% of FPL to
$2,500 for married taxpayers ($1,250 if single) with household income from 300%
to 400% of FPL. Taxpayers who end the year with household income below 100%
of FPL will not be required to repay any overpayment of the advance credit.
Estimating the Premium Tax Credit
The Henry J. Kaiser Family Foundation has a subsidy calculator that can be used to
estimate the amount of any premium tax credit subsidy to which you might be entitled.
It is located at http://kff.org/interactive/subsidy-calculator/.
The Affordable Care Act (August 2013 edition)
14
15. Federal Tax Subsidies in Action
How Federal Tax Subsides Work to Make Private Health Insurance
Affordable for Low- and Moderate-Income Individuals and Families:
Premium Tax Credit (page 12)
Provides financial help in purchasing
private health plans through a Health
Insurance Marketplace by making up
the difference between the amount
individuals are required to pay and the
amount the plan charges in premiums.
Generally available to U.S. citizens and
legal residents with incomes between
100% and 400% of the Federal
Poverty Level (FPL).
Cost-Sharing Reduction (page 11)
Limits annual out-of-pocket costs to
an amount no greater than the limits
for high-deductible Health Savings
Account (HSA) plans. Further reduces
out-of-pocket limits for those with
incomes up to 400% of the Federal
Poverty Level (FPL).
Application
Individual uses a Health Insurance Marketplace to select a health
plan and applies for premium tax credit and cost-sharing reduction
at the Health Insurance Marketplace during open enrollment
periods (beginning in October 2013).
Premium Payment
Cost-Sharing Reduction
If the individual qualifies, a premium
tax credit is paid in advance on a
monthly basis directly to the health
plan. Individual pays the balance of
the premium due to the health plan.
People with income from 100% to
400% of the FPL pay two-thirds, onehalf or one-third of the maximum
annual out-of-pocket cost for the plan
in which they enroll.
Reconciliation
When the individual files an income
tax return for the actual year in which
he/she received the premium tax
credit, underpayments and
overpayments are reconciled.
The Affordable Care Act (August 2013 edition)
15
16. Medicaid and the ACA
Medicaid is the nation's health insurance program available to some lowerincome U.S. citizens and jointly funded by the federal and state government.
Current Medicaid rules require coverage for certain groups of individuals, such
as low-income children and some of their parents, poor pregnant women,
certain low-income seniors and some individuals with disabilities who are under
age 65. Other groups are excluded, such as low-income, able-bodied parents,
low-income adults without children and low-income individuals with chronic
illness who do not meet Medicaid disability standards.
The Affordable Care Act essentially divides the uninsured into three groups:
1. Those whose income is high enough to afford to purchase private health insurance
without financial assistance (income above 400% of FPL);
2. Those who can afford to purchase private health insurance with financial assistance in
the form of the premium tax credit (income from 100% to 400% of FPL); and
3. Those who can't afford to purchase private health insurance (income up to 138% of
FPL).
As originally written, it was the intention of the ACA to cover this last group
through Medicaid by redefining Medicaid eligibility according to income and age
alone, instead of a combination of income, age and participation in an eligible
group. Beginning in 2014, states were going to be required to extend Medicaid to all
individuals between the ages of 19 and 65 with incomes up to 138% of the Federal
Poverty Level (FPL), with the federal government paying 100% of the cost of the
expansion until 2017, 95% in 2017, 94% in 2018, 93% in 2019 and 90% in 2020 and
beyond. A state that didn't comply with Medicaid expansion risked losing all of its
federal Medicaid funding.
Legal challenges to the ACA eventually made their way to the Supreme Court which, in
2012, upheld the Affordable Care Act, but gave the states the option to opt out of
Medicaid expansion without risk to their current federal Medicaid funding. As a
result, individuals with incomes below 138% of the FPL who are not currently covered by
Medicaid will need to check with their state's health and human services department to
see if their state is participating in the Medicaid expansion.
States Participating in the Medicaid Expansion
If your state is participating in the Medicaid expansion, all newly eligible adults will be
guaranteed a benchmark benefit package that meets the essential health benefits
requirement of policies available through the Health Insurance Marketplaces.
Beginning no later than 2014, U.S. citizens and certain legal noncitizens with incomes
up to 138% of FPL will be eligible for Medicaid. Anyone who applies for premium
credits through a Health Insurance Marketplace and is determined to be eligible for
Medicaid will be enrolled by the Marketplace in Medicaid.
Any lawfully-present
noncitizens who have incomes below 100% of FPL and are ineligible for Medicaid due to
their alien status will be deemed to have income at 100% of FPL and will be eligible for
premium credits through a Health Insurance Marketplace.
The Affordable Care Act (August 2013 edition)
16
17. Medicaid and the ACA (continued)
Note: Some states are participating in the Medicaid expansion, but adapting it in such a
way as to meet their unique needs. This might even include providing funding to enable
newly-eligible Medicaid recipients to purchase private insurance through the state's
Health Insurance Marketplace.
Percent of Federal Poverty Level (2013)
Family Size
100%
138%
1
$11,490
$15,856
2
$15,510
$21,404
3
$19,530
$26,951
4
$23,550
$32,499
6
$31,590
$43,594
7
$35,610
$49,142
8
$39,630
$54,689
States Opting Out of the Medicaid Expansion
If a state opts out of participating in the Medicaid expansion and an individual is not
already eligible for Medicaid, that individual will not be eligible for Medicaid in 2014.
►
Income up to 100% of the FPL: Since the original ACA legislation assumed that
individuals with incomes up to 100% of the FPL would be covered by Medicaid, the
law expressly disallows premium credits for these individuals.
As a result,
individuals who would be newly-eligible for Medicaid coverage in 2014 will not
receive that coverage if the state in which they reside opts out of the Medicaid
expansion and they will not be eligible for premium credits to use in purchasing
private insurance.
►
Income from 100% to 138% of FPL: Individuals with income from 100% to
138% of the FPL who would be newly-eligible for Medicaid coverage in 2014 will not
receive Medicaid coverage if the state in which they reside opted out of the Medicaid
expansion. They are, however, eligible to use the premium tax credit to purchase
private insurance through their state Health Insurance Marketplace.
Note: Beginning in 2015, the Affordable Care Act will tax larger employers that do not
provide health benefits to lower-income employees who then receive a premium tax
credit. In those states that opt out of the Medicaid expansion, companies with 50 or
more employees may be liable for tax penalties if they do not provide health benefits to
their employees who make between 100% and 138% of the FPL and those employees
then sign up for premium tax credits through a Health Insurance Marketplace.
The Affordable Care Act (August 2013 edition)
17
18. Employer-Sponsored Health Plans
Prior to passage of the Affordable Care Act, most Americans under age 65 with
health care insurance received it through an employer- or union-sponsored
health plan, either as an employee or as a dependant of a covered worker, and
that's likely to continue once the ACA is fully implemented.
"Play-or-Pay" Provision
While no employer is forced by the Affordable Care Act to provide health insurance, there
is a "play-or-pay" provision that requires employers with 50 or more full-time employees
to offer employer-sponsored health care coverage to their full-time employees or pay a
"shared responsibility" penalty. Employers with fewer than 50 full-time employees are
not subject to the penalty.
Employer-Sponsored Health Plan Requirements
The Affordable Care Act contains a variety of new requirements that may impact the
employer-sponsored heath care coverage provided to employees. All of the following
provisions will be in effect by 2014:
►
Adult children under age 26 must be allowed to enroll in a parent's plan;
►
Waiting periods of more than 90 calendar days before coverage begins are banned;
►
Medical underwriting is prohibited and premium rating variation is only allowed
based on age, tobacco use, family composition and geography.
►
Prohibition against lifetime and annual limits on the dollar value of coverage (some
group health plans, however, have been granted a waiver and will not be required
to limit annual out-of-pocket costs until 2015);
►
Availability of specified preventive services without cost sharing;
►
Out-of-pocket costs cannot exceed the Health Savings Account limit ($6,350 for an
individual and $12,700 for a family in 2014);
►
Plans must limit deductibles, generally to $2,000 for single coverage and $4,000 for
family coverage in 2014;
►
Plans must include a package of essential health benefits; and
►
Employer-sponsored health insurance must be "affordable."
Under the Affordable Care Act, "affordable" employer-sponsored health insurance
requires an employee contribution of less than 9.5% of household income for an
employee-only plan that covers at least 60% of medical costs on average. Any
employees who must contribute more than 9.5% of household income can decline the
employer-sponsored coverage and apply for premium tax credits through a Health
Insurance Marketplace (see page 12).
If, however, employer-sponsored self-only
coverage costs less than 9.5% of household income, then both employees and their
family members are not eligible for subsidies through a Marketplace, regardless of
whether or not family coverage is "affordable."
The Affordable Care Act (August 2013 edition)
18
19. Employer-Sponsored Health Plans (continued)
Grandfathered Plans
Employer-sponsored health care plans in existence as of March 23, 2010, the date the
Affordable Care Act was signed into law, are grandfathered in regard to many of the
requirements outlined on the previous page.
DO Apply to Grandfathered Plans:
►
Adult children under age 26 must be
allowed to enroll in a parent's plan;
and
►
Prohibition against lifetime limits and,
in group plans, annual limits on the
dollar value of coverage.
DO NOT Apply to Grandfathered Plans:
►
Preventive health benefits with no cost
sharing;
►
Stronger appeals processes; and
►
Letting insureds choose their primary
doctor.
If an Employer-Sponsored Health Plan Is Grandfathered…
Grandfathered plans must provide a statement to all enrollees, notifying them that the
plan is grandfathered and outlining the benefits provided.
In order to maintain its grandfathered status, a health care plan cannot:
►
Eliminate all or almost all benefits to diagnose and treat certain health conditions;
►
Increase the plan's coinsurance percentage;
►
Increase the plan deductible by more than 15% plus medical inflation;
►
Increase co-payments by more than $5 adjusted for medical inflation or 15% plus
medical inflation, whichever is greater; or
►
Increase the employees' share of the premium by more than 5%.
A health care plan that loses its grandfathered status must then comply with all the
consumer protections that apply to new health care plans, as outlined on page 18. It is
anticipated that, over time, most plans will make changes and lose their grandfathered
status.
If You Have Employer-Sponsored Health Plan Coverage…
Chances are that you will meet the individual mandate requirements through your
employer-sponsored health care plan. Expect to receive additional information from your
employer and employer-sponsored plan about the Affordable Care Act and your health
care coverage by October 1, 2013.
The Affordable Care Act (August 2013 edition)
19
20. ACA and Individuals (2014)
Step 1:
Do any of the following apply to you?:
►
Member of a religion opposed to acceptance
of benefits from a health insurance policy;
►
An undocumented immigrant;
►
Incarcerated;
►
Member of an Indian tribe;
►
Family income below the threshold for filing
an income tax return ($10,000 for an
individual and $20,000 for a family in
2013); or
►
Someone who would have to pay more than
8% of your income for health insurance,
after taking into account any employer
contributions or premium tax credits.
YES
You are exempt
from the
individual
mandate. There
is no penalty for
being without
health insurance.
YES
The requirement
to have health
insurance is
satisfied and no
penalty is
payable.
YES
The requirement
to have health
insurance is
satisfied and no
penalty is
payable.
NO
Step 2:
Are you insured through any of the
following sources?:
►
Medicare;
►
Medicaid or CHIP;
►
TRICARE;
►
The veteran's health program;
►
A plan offered by an employer;
►
A qualified health plan that you purchased
on your own that is at least at the Bronze
level (see page 10); or
A grandfathered plan in existence before
the ACA was enacted (March 23, 2010).
►
NO
Step 3:
Are you planning to purchase a
qualified health plan, possibly with
federal tax subsidies, through a Health
Insurance Marketplace (page 9), or
through another source?
NO
Step 4:
There is a "shared responsibility" tax
penalty for being without health
insurance…see page 7.
The Affordable Care Act (August 2013 edition)
20
21. Tax Impact on Higher-Income Taxpayers
The Affordable Care Act includes two Medicare-related tax increases that took
effect in 2013, impacting higher-income taxpayers.
Medicare Payroll Tax Increase
Prior to 2013, the Medicare Part A payroll tax was 2.9% of all wages, with the
employee and the employer each paying 1.45%.
Effective January 1, 2013, the Medicare Part A payroll tax on wages increased by 0.9%
on wages over $200,000 for single taxpayers and over $250,000 for married taxpayers
filing jointly. The increase applies only to the employee portion of the Medicare Part
A payroll tax. For example:
►
A single person making $300,000 in wages in 2013 will pay a total of $5,250 into
Medicare...1.45% of the first $200,000 ($2,900) plus 2.35% of the next $100,000
($2,350)...an increase of $900 from 2012. The employer will continue paying
1.45% of $300,000 or $4,350.
►
A married couple making $500,000 in wages in 2013 will pay a total of $9,500
into Medicare...1.45% of the first $250,000 ($3,625) plus 2.35% of the next
$250,000 ($5,875)...an increase of $2,250 from 2012. The employer will continue
paying 1.45% of $500,000 or $7,250.
Medicare Contribution Tax on Unearned Income
Beginning in 2013, higher-income taxpayers are subject to a new 3.8% Medicare
contribution tax on unearned or net investment income, which includes interest,
dividends, rents, royalties, gain from disposing of property, and income earned from a
trade or business that is a passive activity. Self-employed individuals, as well as estates
and trusts, are also liable for this tax. While distributions from qualified retirement
plans are exempt from paying the new tax, income from non-qualified annuities is
subject to the tax.
The tax applies to single taxpayers with modified adjusted gross income (MAGI) in
excess of $200,000 and to married taxpayers filing jointly with a MAGI in excess of
$250,000. MAGI includes wages, salaries, tips and other compensation, dividend and
interest income, business and farm income, realized capital gains, and income from a
variety of other passive activities and certain foreign earned income.
Taxpayers with modified adjusted gross income below the $200,000 single/$250,000
married filing jointly thresholds are not subject to the 3.8% unearned income Medicare
contribution tax.
For taxpayers whose MAGI exceeds the thresholds, the amount of tax owed is equal to
3.8% multiplied by the lesser of (1) net investment income or (2) the amount by
which their MAGI exceeds the thresholds:
Tax = 3.8% X [lesser of (MAGI - $200,000/$250,000 or net investment income)]
The Affordable Care Act (August 2013 edition)
21
22. ACA and Large Employers
While the Affordable Care Act does not require employers to provide their
employees with access to employer-sponsored health care plans, the ACA does
include incentives and penalties intended to (1) minimize disruptions of the
existing employer-provided health care system and (2) to encourage smaller
employers to provide their employees with access to employer-sponsored
health care plans.
"Play-or-Pay" System (Employer Mandate)
Under the Affordable Care Act's "play-or-pay" or "shared responsibility" system, larger
employers – those with 50 or more full-time equivalent non-seasonal employees
– are subject to two basic rules, now scheduled to take effect on January 1, 2015:
►
If an employer does not offer health care coverage meeting certain
standards to all full-time employees and any one full-time employee receives
tax-subsidized coverage through a Health Insurance Marketplace, the employer
must pay a $2,000 penalty for every full-time employee over 30.
►
If an employer does offer health care coverage, but a full-time employee
obtains tax-subsidized coverage through a Health Insurance Marketplace,
the employer must pay a $3,000 penalty for that employee. While any employee
is free to decline to participate in an employer-sponsored health care plan and,
instead, purchase coverage through a Health Insurance Marketplace, a premium
tax credit (tax-subsidized coverage) is available only if the employee's
required contribution to the employer's plan for single coverage is more than 9.5%
of the employee's income or the employer-sponsored plan pays less than 60% of
the cost of covered services.
Full-Time Equivalent Employees (FTEs)
According to the Affordable Care Act, only "large" employers are subject to the "playor-pay" requirements, with a large employer defined as an employer who employed
an average of at least 50 full-time equivalent employees (FTEs) during the
previous calendar year.
While the penalties associated with the "play-or-pay"
requirements do not take effect until January 1, 2015, employers are advised to record
employee hours in 2014 in order to determine if they will be subject to the employer
mandate in 2015. FTEs are calculated as follows:
►
Full-time employees are defined as having worked on average at least 30 hours
per week, with full-time seasonal employees who work under 120 days during
the year excluded from the calculation.
►
Part-time employees (i.e., those working less than 30 hours per week) are not
excluded from the calculation.
Instead, the hours worked by part-time
employees are converted into FTEs and used in the calculation to determine if
an employer is a large employer for ACA purposes. This is done by adding up the
total hours worked by part-time employees during a month and dividing the total by
120. The result is added to the number of full-time employees to arrive at the
number of FTE employees for Affordable Care Act large employer requirements.
The Affordable Care Act (August 2013 edition)
22
23. ACA and Large Employers (continued)
FTE Example
Let's say we have a business with 42 full-time employees (30 or more hours per week)
that also has 15 part-time employees who all work 20 hours a week (or 80 hours a
month). The hours worked by part-time employees are equivalent to 10 FTEs:
15 part-time employees X 80 hours = 1,200 hours / 120 = 10 FTEs
In our example, the business would be considered a "large" employer for ACA purposes,
with 52 FTEs (42 full-time employees plus 10 FTEs based on the number of part-time
hours worked).
Owner of Multiple Entities
The owner of multiple entities, such as a franchise owner with several restaurants, is
treated as a controlled group for ACA purposes. This means that if one individual or
entity owns, or has a substantial ownership interest in, several franchises, all of those
franchises are essentially considered as one entity and the employees in each of the
franchises must be aggregated for purposes of determining large employer "play-orpay" status.
Application of Penalties
The calculation of FTEs as described above serves one purpose only...to determine if
an employer is considered a "large" employer for purposes of the Affordable Care Act
"play-or-pay" requirements.
Any penalties actually assessed apply only to full-time employees.
The
employer in our earlier example would be considered a large employer for the "play-orpay" requirements, but would be liable for a penalty only if at least one of its full-time
employees – individuals working on average 30 or more hours per week - obtains
coverage through a Health Insurance Marketplace and receives a premium tax credit.
Part-time employees are not included in actual penalty calculations and an
employer will not pay a penalty for any part-time worker who receives a
premium tax credit through a Health Insurance Marketplace.
Employer-Sponsored Health Plan Requirements
Beginning in 2014, new employer-sponsored health care plans must meet the
qualified health plan requirements outlined on page 18. These include extension of
family coverage to adult children under age 26, prohibition of annual and lifetime limits
on the dollar value of coverage, required coverage of preventive services without cost
sharing, a waiting period no longer than 90 days and certain consumer protections.
Other considerations faced by large employers that offer employer-sponsored health
care plans include:
The Affordable Care Act (August 2013 edition)
23
24. ACA and Large Employers (continued)
►
Employers will need to decide whether to adjust plan benefit or contribution
amounts in order to pass the affordability test and, beginning in 2015, to avoid the
potential $3,000 per employee penalty (see page 22).
►
Some employer-sponsored health care plans are discriminatory, providing "richer"
benefits to more highly-compensated employees. Plans that do not remove such
discriminatory coverage face penalties beginning in 2015: $100 per day for each
non-highly compensated employee who is not eligible for the "richer" benefits, with
a maximum penalty of $500,000.
►
It is not unusual for employer-sponsored health care plans to exclude some fulltime employees, typically those with lower incomes. These employees will have to
be included beginning in 2015.
"Grandfathered" Plans
Some of the new rules do not apply to "grandfathered" health care plans...those in
existence when the Affordable Care Act was signed into law on March 23, 2010. Since
there are very tight limits on changes that can be made to a plan and have it retain its
grandfathered status, expectations are that not very many plans will remain
grandfathered in the coming years.
See page 19 for more information on grandfathered plans.
"Cadillac" Plans
Beginning in 2018, employer-sponsored health care plans with a plan cost per enrollee
that exceeds a cap will face a 40% excise tax. The 40% excise tax is initially set at the
amount by which the costs of the plan per enrollee exceed $10,200 for single workers
and $27,500 for family coverage. These caps may end up being higher if health care
costs rise faster than currently projected.
While insurers or plan administrators will have to pay the 40% excise tax, the reality is
that the cost will probably be passed through to employers. Employers offering socalled "Cadillac" plans may begin revising them prior to 2018 when the excise tax first
becomes payable.
Finally, the $10,200/$27,500 thresholds will be increased by $1,650/$3,450 for retiree
health plans (age 55 and over who are not Medicare-eligible) and for certain high-risk
jobs.
The Affordable Care Act (August 2013 edition)
24
25. ACA and Small Employers
The Affordable Care Act defines "small" employers as those with fewer than
50 full-time equivalent employees (FTEs). Small employers are exempt from
the ACA "play-or-pay" penalties. There are, however, incentives to some
small employers to offer health care coverage to their employees.
Small Business Health Options Program (SHOP)
While the initial availability date may vary by state, a Small Business Health Options
Program – or SHOP – that offers small businesses and their employees new choices will
become available in each state. Through the SHOP, employers will be able to offer
employees a variety of Qualified Health Plans (see page 10), and their employees can
choose the plans that fit their needs and their budget.
Starting in 2014, SHOP or a merged SHOP and individual Health Insurance
Marketplace (see page 9) may be offered in your State. Businesses with up to 100
employees will be eligible, although States can limit participation to businesses with up
to 50 employees until 2016.
When fully implemented, SHOPs are intended to help small businesses by:
►
Simplifying Choices: SHOPs will provide side-by-side comparisons of Qualified
Health Plans, their benefits, premiums, and quality.
►
Expanding Employee Options: SHOPs will enable small businesses to offer their
employees a choice of Qualified Health Plans from several insurers, much as large
employers can.
►
Preserving Employer Control: Small businesses will be able to decide whether
and when to participate in SHOP. It will be possible to choose how much the
business will contribute toward employees’ coverage, and make a single monthly
payment via SHOP rather than to multiple plans.
►
Lowering Costs: SHOP has the potential to save money by spreading insurers’
administrative costs across more employers. In addition, a small business may be
eligible for small business tax credits when it offers health coverage for its
employees through a SHOP.
Small Business Tax Credit
Small businesses with 25 or fewer full-time equivalent employees (see page 22) and
average annual wages below $50,000 may receive a tax credit for offering health
insurance to their employees and contributing at least 50% of the cost of the
premiums. Beginning in 2014, the credit is up to 50% of employer contributions
(35% for tax-exempt businesses) and is available for two consecutive years for
employers that purchase the coverage through a SHOP/Health Insurance Marketplace.
The credit varies by employer size and average wage...employers with 10 or fewer FTEs
and average wages of $25,000 or less receive the full 50% credit (35% if tax exempt),
with the credit gradually phasing out as number of employees and average wages
increase.
The Affordable Care Act (August 2013 edition)
25
26. ACA Employer Penalties (2015)
Does the employer
have at least 50 fulltime equivalent
employees (page 22)?
Small employers are
exempt from
penalties. Employers
with 25 or fewer
employees may be
eligible for a health
insurance tax credit.
See page 25.
NO
YES
Does the
employer offer
health care
coverage to its
employees?
NO
Did at least one
employee receive
a premium tax
credit or cost
sharing subsidy in
a Marketplace?
YES
The employer must
pay a penalty for not
offering health
insurance coverage to
its employees. See
page 22.
YES
Does the health
care coverage pay
for at least 60%
of covered health
care expenses?
NO
Employees have
the option to buy
health care
coverage in a
Marketplace and
receive a
premium tax
credit.
YES
Do any employees
have to pay more
than 9.5% of
their family
income for the
employersponsored health
care coverage?
The employer must
pay a penalty for not
offering affordable
health insurance
coverage to its
YES
Employees have
the option to buy
health care
coverage in a
Marketplace and
receive a
premium tax
credit.
employees. See page
22.
NO
There is no penalty
since the employer (a)
offers health care
coverage and (b) that
coverage is considered
affordable.
The Affordable Care Act (August 2013 edition)
26