Greg Matis, Senior Counsel for Intermountain Healthcare, presents information on the Affordable Care Act at the KPCW and Intermountain Park City Medical Center Community Forum on Healthcare Reform. December 2, 2013. These slides are referred to in an accompanying podcast.

1. Affordable Care Act Overview
Park City Community Forum
Jim Santy Auditorium
December 2, 2013

2. Federalism
Florida v. Dept of HHS
“This case is not about whether the Act is wise or unwise
legislation, or whether it will solve or exacerbate the
myriad problems in our health care system. In fact, it is
not really about our health care system at all. It is
principally about our federalist system, and it raises very
important issues regarding the Constitutional role of the
federal government.”
Judge Vinson
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3. “The shepherd drives the
wolf from the sheep's
throat, for which the sheep
thanks the shepherd as his
liberator, while the wolf
denounces him for the
same act as the destroyer
of liberty. Plainly, the
sheep and the wolf are not
agreed upon a definition of
liberty.”
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4. 5 Big Insurance Changes in 2014

5. Five Big Insurance Changes in 2014
1.
2.
3.
4.
5.
Everyone qualifies for coverage
Everyone is required to have coverage
Some people get financial help
Coverage and costs are changing
There are new shopping choices (place and
products)
5

6. 1. Everyone Qualifies for Coverage




Guarantee issue/renewal
No medical underwriting
No Pre-existing condition exclusions
Your coverage can’t be denied or delayed
because of your health or claims experience
 No waiting periods longer than 90 days
 Community rating in the Individual and Small
Employer markets
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7. 2. Everyone is Required to Have Coverage
 Well, mostly everyone. Exceptions to the
mandate may apply to the following:
•
•
•
•
Those with religious objections
Incarcerated individuals
American Indians
Those for whom the lowest-cost health coverage is
more than 8 percent of household income
• Undocumented immigrants
• Those with incomes below the filing threshold
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8. 2. Everyone is Required to Have Coverage
 Penalty starts small
• 2014 - $95 per adult, $47.50 per child
• Max of $285 per household or 1 percent
of the household income
 Penalties increase each year
• 2016 and beyond - Up to $2,085 per
household or 2.5 percent of household
income
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9. 2. Everyone is Required to Have Coverage
Large Employer Mandate
•
Large Employers (>50 FTEs) penalized for not providing
coverage to their full-time employees (30 hrs/week)
 Two kinds of penalty:
• Failure to offer full-time employees minimum essential
coverage; and
• Failure to offer full-time employees affordable coverage or
provide minimum value.
 Delayed a year until 2015
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10. 3. Some Get Financial Help
 Individual Subsidies
•
•
Advanced Premium Tax Credits
Cost-share reductions
 Small Employer Tax Credits
•
•
•
•
Requires low-wage (<$50K), small (<25 employees) workforce
Moves from 35% to 50% in 2014 (two years eligibility)
Employer must pay a uniform percentage of at least 50% of the
premium cost
Employer must purchase a Qualified Health Plan on the
Marketplace
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11. 3. Some Get Financial Help
Individual Subsidies
Available to those who:
•
•
•
•
Don’t get insurance through their work
Aren’t eligible for a public plan like Medicare, Medicaid, or
CHIP
Have an annual income that’s between 100-400 of the
Federal Poverty Level
For a family of four—that goes all the way up to $94,000 a
year
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12. Calculation of Premium Tax Credit
Monthly Maximum Premium
Income as a
Percent of FPL
Max Premium as a Percent of
Income
Up to 133%
2%
$
25
$
51
133-150%
3-4%
$
56
$
115
150-200%
4-6.3%
$
117
$
242
200-250%
6.3-8.05%
$
187
$
387
250-300%
8.05-9.5%
$
265
$
547
300-400%
9.5%
$
310
$
730
Single
Family of 4

13. Cost-sharing Reduction
• Cost-sharing must be reduced for individuals enrolled in a silver plan in the
exchange with incomes up to 400% of the Federal Poverty Level (FPL). For
2014:
Family Income as a % of FPL
AV Level
Maximum Out-of-Pocket
Single/Family
100-150%
94%
$2,250/$4,500
150-200%
87%
$2,250/$4,500
200-250%
73%
$5,200/$10,400
250-400%
70%
$6,350/$12,700 (no reduction)
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14. 4. Coverage and Costs are Changing
Coverage
 Essential Health Benefits (Individual and SE)
•
•
•
Preventive
Maternity
Mental Health and Substance Abuse Treatment
 No annual or lifetime dollar limits
 Deductible and out-of-pocket costs are capped
•
•
Small employer deductible caps: $2000 single/$4000 family
Out-of-pocket maximum: $6350 single/$12700 family
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15. 4. Coverage and Costs are Changing
Costs
 What will cause premiums to rise?
•
•
The coverage changes, e.g., expanded mental health and
maternity benefits, first-dollar preventive, essential health
benefits
More high-risk individuals buying coverage (who were
previously uninsured or covered by a high-risk pool)
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16. 4. Coverage and Costs are Changing
Costs
 What will cause premiums to fall?
16

17. Premiums don’t fall—they only
have a lower rate of increase.
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18. 4. Coverage and Costs are Changing
Typically true. But in this case, costs actually
may be lower for those who:
 Qualify for new federal subsidies available
through the Health Insurance Marketplace
 Previously paid high premiums as a result of their
health condition or age
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19. 5. There are new shopping choices
 Medicaid Expansion
•
•
Up to each state to decide
Utah decision still pending
 Health Insurance Marketplace (fka Exchange)
• Utah’s Marketplace is split: with a Federally Facilitated
Marketplace (FFM) for Individual coverage; and a stateadministered marketplace for small employers (Avenue H)
 New Products
•
Catastrophic plan for <30’s
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20. Federally Facilitated Marketplace:
Update

21. 21

22. 22

23. The FFM: Observations
1. There is still plenty of time:
 December 23—Deadline for enrolling in 2014 coverage
 March 31—Deadline for avoiding a penalty
 March 31—Open enrollment deadline
2. Subsidies should drive enrollment—but the big game-changer
is continuing functionality problems
3. Breaking news: FFM SHOP delayed a year—Doesn’t affect
Utah
4. We are at a critical junction
5. Marketplace has definitely improved
6. Expect more announcements and legislative developments if
the improvements are insufficient
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