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ACA: Impact on Physician Practices in Kansas


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The Affordable Care Act and it's impact on physician practices in Kansas.

Published in: Health & Medicine, Business
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ACA: Impact on Physician Practices in Kansas

  1. 1. ACA: Impact on Physician Practices in Kansas September 12, 2013
  2. 2. Agenda & Introductions Discussion Topic Presenter Ascension Health’s Role in this Work & SGR Update Mary Ella Payne Senior Vice President Policy & Legislative Leadership Ascension Health What The ACA Means for Physician Practices in Kansas Beth C. Fuchs, Ph.D. Principal Health Policy Alternatives
  3. 3. Our Mission Rooted in the loving ministry of Jesus as healer, we commit ourselves to serving all persons with special attention to those who are poor and vulnerable. Our Catholic health ministry is dedicated to spiritually centered, holistic care which sustains and improves the health of individuals and communities. We are advocates for a compassionate and just society through our actions and our words.
  4. 4. Health Ministry Ascension Participating Entities appoint members of Ascension Health Ministries “Ascension Health Ministries” (PJP composed of up to 12 individuals) Founding Participating Entities Participating Entities Sponsor System Parent Health Ministries Approved by Rome June 30, 2011 Oak Hill Capital Partners Ascension Health Ventures Ascension Health Care Network Management Agreement Leadership Academy Ascension Health Solutions Ascension Health Services Ascension Health (Delivery) Health Ministry Health Ministry Affiliate Organizations Appoint Participating Entities Infrastructure Support Congregation of St. Joseph Sisters of St. Joseph of Carondelet Daughters of Charity Province of St. Louise Alexian Brothers Sisters of the Sorrowful Mother
  5. 5. Ascension Health, part of Ascension, is the largest Catholic health system, the largest private nonprofit system and the third largest system (based on revenues) in the United States, operating in 23 states and the District of Columbia. Our System Daughters of Charity Health System is an affiliate of Ascension Health
  6. 6. Our System Care of Persons Living in Poverty and Community Benefit Programs: $1.3 Billion* *Financial information reflects Ascension Financial Information (FY 12) (in millions) Total Assets $23,776 Operating Revenue $16,611 Operating Income $934 Excess of revenue and gains $968 over expenses and losses, controlling interest
  7. 7. Ascension Health‘s Major Healthcare Delivery Platforms Ambulatory Care and Diagnostics Ambulatory Surgery Centers 70 Employer/Occ Health 44 Free-standing Imaging 83 Retail Lab Collection Sites 256 Primary Care Clinics 491 Specialty Clinics 260 Retail Pharmacies 35 Sleep Centers 28 Telemedicine Programs 59 Inpatient Facilities General Acute Care 100 Long-term Acute Care 3 Rehabilitation 3 Psychiatric 7 Total 113 Prevention & Wellness Programs Alternative Care 13 Community/Social Services 120 Wellness/Fitness 20 Post Acute Service Sites Behavioral Health – Acute units 31 Behavioral Health – Outpatient 76 Cancer Centers 20 Durable Medical Equipment 23 Home Health Agencies 26 Hospice/Palliative Programs 35 Infusion Therapy Programs 23 Private Duty Services 4 Rehabilitation – Outpatient 226 Rehabilitation – Inpatient units 35 Updated May 2013 Long-term Care & Senior Living Sites – 38 communities comprised of the following: Adult Day Care 11 Assisted Living (AL) 7 Independent Living (IL) 3 Skilled Nursing (SNF) 21 CCRC (combined SNF/AL/IL) 9 PACE 3
  8. 8. FY12 Systemwide Statistics* • Discharges 693,544 • Available beds 18,450 • Number of births 72,121 • Total surgical visits 529,341 • Home health visits 534,232 • Clinic visits 1,877,970 • Emergency visits 2,454,455 • Physician office visits 6,974,451 • Total outpatient visits 20,155,034 • Associates 122,000 *FY12 Statistics do not include Ministry Health Care, St. John Health System, or Via Christi Health.
  9. 9. Strategic Direction: ‗Architecture‘ for Realizing our Vision Vital Presence Healthcare That Leaves No One Behind Inspired People Trusted Partnerships Empowering Knowledge Healthcare That Is Safe Healthcare That Works Our outward promise to those we serve Enabled by focused inner strengths
  10. 10. Provider-Centered: transactional model Person-Centered: relationship model Focus  Providers’ delivery of medical services to patients to address a healthcare episode  Trust-based relationship that promotes a spiritually centered, holistic approach to supporting a person’s health and well-being Locus of Control  Primarily providers  Primarily the person and family supported by a trusted ecology of resources Nature of Choices  Healthcare choices are mostly reactive  Health choices are well-understood and frequently proactive Primary Locations  Hospitals and clinics  More care and support in the community, in the home and by virtual means Health Information  Provider-based, episodic, transactional  Coordinated, transparent data managed by well- informed individuals Duration  Episode of care  Lifetime relationships Transformational Path to Realizing our Vision Person- Centered Approach Fostering Continuous, Dynamic Relationships With Those We Serve Moving from Provider-Centered to Person-Centered
  11. 11. Update on Legislation to Repeal and Replace Physician SGR
  12. 12. Medicare SGR Reform • Annual threat of significant reductions in the conversion factor under the Medicare Physician Fee Schedule (PFS)  Estimated 24.4 percent reduction effective January 1, 2014. • Challenges in achieving consensus on a permanent replacement • Challenges in achieving consensus on offsetting savings  CBO estimate of SGR reform 10-year costs at $138 billion BUT this assumes freezing the conversion factor for 10 years, which is not currently what is on the table; costs likely to be much higher 12
  13. 13. SGR Reform Proposals in Congress • House Energy and Commerce Bill, H.R. 2810 – Approved by vote of 51-0 on July 31, 2013 – Repeals SGR and provides for an annual 0.5 percent update to PFS conversion factor for 2014 through 2018 – Beginning in 2019, updates to conversion factor for each physician or physician group would depend upon their performance on certain quality measures and, if applicable, clinical practice improvement activities • House Ways and Means and Senate Finance Committees still need to weigh in • Offsetting savings proposals must be identified and approved • House and Senate must both approve the same reform plan…or approve another short-term fix 13
  14. 14. The ACA: An Overview of Implications for Physician Practices as Small Businesses Beth Fuchs, Ph.D.
  15. 15. Health Care Reform: What Is It? Health Care Reform Quality Enhancement Insurance Coverage Expansion Health Insurance Reforms Patient Protection and Affordable Care Act (ACA) signed on March 23, 2010 Constitutionality Affirmed by Supreme Court on June 28, 2012. The health care reform law makes sweeping changes to our nation’s healthcare system with a vision to provide health coverage to all Americans and promote more efficient care delivery. 15
  16. 16. 16 Overview: Implications for Physicians as Clinicians • Fewer uninsured patients • Insured patients have better coverage, including 100% coverage for recommended preventive services • Insurers can‘t cancel coverage when a patient gets sick, and they can‘t set lifetime benefit limits that leave patients without coverage • Insurers that don‘t spend at least 80% of premium dollars on patient care have to provide rebates to consumers • Medicaid reimbursements increased to match Medicare rates for primary care services (effective January 1, 2013)
  17. 17. 17 Overview: Implications for Physician Practices as Small Businesses • Small physician private practices will be able to join together with other small businesses to purchase health insurance in a new competitive marketplace (SHOP Exchange) – Greater bargaining power when shopping for health insurance for their employees • Small business tax credits may be available to help pay for health insurance for employees
  18. 18. Key Terms • Affordable Care Act = ObamaCare • Health Insurance Exchange = Health Insurance Marketplace – In Kansas – The Health Insurance Marketplace • 18
  19. 19. 19 The ACA and Small Business • Three major provisions in the Affordable Care Act (ACA) for Small Business (small business = fewer than 50 full-time employees) – Exchanges (including SHOP Exchanges) • Premium and cost-sharing subsidies – Insurance Reforms – Small Business Health Insurance Tax Credits
  20. 20. 20 ACA Basics for Small Employers • Small employers (fewer than 50 FTEs) are not required to offer health coverage or pay for coverage for their employees. • Larger employers (50 and more full-time workers) are not required to offer health coverage to their employees. – But if a larger employer does not offer coverage or offers inadequate coverage, and one or more of their employees obtains federally subsidized Exchange insurance, then the employer must pay a penalty. – But, penalty will not be imposed for 2014.
  21. 21. 21 Small Business: Cost of Coverage is a Major Deterrent for Many • Between 1999 and 2012, health insurance premiums increased over 170%* • Because of smaller scale and thinner margins, less able than larger employers to absorb these increasing costs • Small businesses less likely to offer coverage than larger employers *Kaiser Family Foundation and Health Research and Educational Trust, Employer Sponsored Health Coverage 2012,
  22. 22. 22 Cost Equation for Business Owners is Unsustainable Source: Kaiser Family Foundation, 2012 Inflation Health Insurance Premium Increases Over 10 Years Compared to Other Variables Workers‘ Earnings Premiums Worker Contribution to Premiums
  23. 23. 23 Barriers: The Hassle Factor Can‘t be Underestimated Finding insurance, comparing options, and making decisions on renewals can pose a barrier • Searching for affordable options, if any • Comparing them when information is not comparable • Choosing among options • Dealing with renewals • Responding to employee complaints
  24. 24. 24 For Identical Coverage, Small Employers Pay More • Smaller risk pools over which to spread costs • State rating and underwriting rules that permit insurers to price premiums in order to avoid bad risks – In Kansas, insurers have used health status and other factors to vary premiums. Thus, premiums for the same benefits vary widely. • Higher administrative costs • Unlike self-insured employer plans, bear costs of state mandated benefits and insurer premium taxes
  25. 25. Small Group Rating Rules: Premiums Can Vary Significantly 25Source: National Association of Insurance Commissioners and the Center for Insurance Policy and Research
  26. 26. 26 For Identical Coverage, Smaller Employers Pay Higher Costs than Larger Employers for Administration/Overhead Data: Estimates by The Lewin Group for The Commonwealth Fund. Source: Commonwealth Fund Commission on a High Performance Health System, The Path to a High Performance U.S. Health System: A 2020 Vision and the Policies to Pave the Way (New York: The Commonwealth Fund, Feb. 2009). Cost of Administering Health Insurance as a % of Claims, by Group Size
  27. 27. ACA Reforms for Physician Practices as Small Businesses
  28. 28. 28 ACA Insurance Reforms Now In Place • No lifetime limits; limits on use of annual dollar limits on benefits • Insurance companies can‘t renege on promised coverage • No pre-existing conditions exclusions for children under 19 • Children up to age 26 can be covered on their parent‘s plan • Patient cost sharing eliminated for recommended preventive services
  29. 29. 29 More ACA Insurance Reforms Now In Place • Medical Loss Ratio – 80% of insurance premiums must be spent on health care delivery – Insurers must rebate excess premiums • Enhanced rate (premium) review by state regulators • Uniform explanation of coverage documents; standardized definitions
  30. 30. 30 Insurance Reforms as of 2014 • Insurers have to charge small firms in same area for identical coverage more similar premiums regardless of health status of their employees – Within area premiums can only vary for: family size, age, tobacco use • No one can be turned down or cancelled because of health status, pre-existing condition or use of healthcare; no pre-existing condition exclusions – These apply at annual and special enrollment periods
  31. 31. Insurance Reforms in Kansas as of 2014 • For Kansas small businesses-- – Age adjusted community rating (3:1 limits on age variation) – No 90 day pre-existing condition waiting periods for timely enrollment – Insurers must offer Essential Health Benefits • Comparable to largest small business policy in the state • May be more comprehensive than current policy 31
  32. 32. 32 Essential Health Benefits (EHB) • States selected among certain existing option(s) for their EHB benchmark plan. Default is largest small group policy in the state • KS – BCBS Comprehensive Major Medical-Blue Choice luCross Blue Shield of Kansas Comprehensive Plan • EHBs must cover 10 categories of required services: – Ambulatory care, emergency services, hospitalization, maternity/newborn care, mental health and substance use disorder services, including behavioral health treatment, prescription drugs, rehabilitative and habilitative services and devices, laboratory services, preventive and wellness services and chronic disease management
  33. 33. 33 Actuarial Value (AV) and Cost Sharing Plans offering EHB have to meet certain cost-sharing standards: • Limits on maximum out-of-pocket (MOOP) costs for EHB: $6,400 for an individual, $12,800 for a family for 2014 • Certain AV levels (the so-called ―metals‖ levels) – Bronze: 60% AV – Silver: 70% AV – Gold: 80% AV – Platinum: 90% AV Note: The cost-sharing is reduced on sliding scale basis under affordability programs
  34. 34. 34 Actuarial Value (AV) and Cost Sharing Plans offering EHB have to meet certain cost-sharing standards: • Plans in the small group market also have limits on deductibles • Cost-sharing for non-network providers are not taken into account Note: The cost-sharing is reduced on sliding scale basis under affordability programs
  35. 35. 35 Help to Buy Individual Insurance • Self-employed individuals may no longer be denied coverage based on health status • New premium/cost-sharing subsidies for workers in firms that elect not to provide coverage – About 60% of small business owners now buying in individual market have incomes up to 400% of FPL and thus eligible for tax credits in Exchanges or Medicaid – 83% of small business owners who are now uninsured will be eligible for subsidized coverage (split about equally between tax credits and Medicaid)* *Kaiser Family Foundation, How Small Business Owners Get Health Insurance, September 28, 2012.
  36. 36. 36 Health Coverage Options For Individuals In 2014 Source: CCIIO, Insuring America, Presentation, NIHCM Webinar, May 7, 2013 133% FPL for family of 3 -- $25,975 400% FPL for family of 3 -- $78,120 Sliding Scale
  37. 37. 37 Establishment of State Exchanges • Small Business Health Option Program (SHOP) Exchanges − Give small employers some advantages that large employers have in buying private insurance • Exchange for individuals without employer coverage to buy private insurance • States given flexibility in designing and building SHOP and individual market Exchanges, along with federal funding – If a state opts not to create an Exchange, a Federally-Facilitated Exchange/Marketplace is being established
  38. 38. 38 Functions of Exchanges • Approve health plans for participation; ensure adequacy of plan provider networks • Operate annual open enrollment and special enrollment periods • Facilitate plan comparisons (website, call center; standardized comparative info; plan ratings) • Eligibility (including subsidies) and enrollment in plans
  39. 39. 39 Why State Exchanges? • Premiums are reduced by pooling small-business buying power, structure of competition, and economies of scale • More choice of insurance options for small employers and their employees • Comparing and making choices among insurance options is easier • Ultimate goal: drive innovation and improvements in affordability, quality and customer service
  40. 40. 40 Status of the States‘ Exchange Decisions for 2014 State-based Exchange: 16 states + DC have declared Partnership Exchange: 7 states are planning for a Partnership Exchange Federally-Facilitated Exchange: 26 states currently default to the Federally-Facilitated Exchange Kaiser Family Foundation,;
  41. 41. SHOP: Employer Coverage Options • Select among Qualified Health Plans (QHPs) offered by specific insurer for employees • Select a metal tier of Essential Health Benefit coverage – bronze, silver, gold or platinum • Choose plan effective date: enroll for coverage beginning 1/1/2014 or the first of any month thereafter 41Source: In 2014-15, eligible small employers are groups of 2 to 50 employees (increases to 100 by 2016)
  42. 42. 42 SHOP: The Role of the Employer • SHOP is open to firms with up to 50 or fewer full-time employees • The employer must have an office or employee work site within the SHOP's state to use that particular SHOP • Using one online application, employer can (or with help of an agent, broker or assister) compare price, coverage, and quality of plans in a way that's easy to understand the differences • The employer decides how much to pay toward employee premiums • Employees can then enroll in the plan selected by the employer – In 2015, employees will have choice of plans within a tier picked by employer Source:
  43. 43. Which Insurers in Kansas will be Selling through the Individual Exchange? • As of late August – Blue Cross and Blue Shield of Kansas – Blue Cross of Kansas City • Also Multistate Plan Program option in same 103 counties – Coventry Life and Health, and Coventry Health Care of Kansas • PPO and an HMO Source: Wichita Eagle, How will the Affordable Care Act Work? August 28, 2013, act.html 43
  44. 44. Federally Facilitated SHOP-- 44
  45. 45. 45 Sponsored by Kansas Department of Insurance
  46. 46. Outreach Efforts for 2014 for Kansas Exchange (Marketplace) • Help for consumers as they apply for and choose new insurance options – Navigators • Kansas Association for the Medically Underserved, $524,846 – (Consortium of Kansas Hospital Association, the Kansas Association of Local Health Departments, the Association of Community Mental Health Centers of Kansas, the Kansas Area Agencies on Aging Association, and the Kansas Insurance Department). Aim to assist about 48,000 people • Advanced Patient Advocacy, $195,556 • Via Christi Health, Ascension Health, $165,683 – Certified application counselors (e.g., community health centers, hospitals, social service agencies) – Agents and brokers • HHS Call Center; 46
  47. 47. 47 • Many key design decisions left to states, so what exchanges do and how well they do it will vary by state • Exchanges must compete with insurance offered in the outside market, so will need to offer plans that are cost competitive and high quality • Exchanges need to maximize participation to gain scale, avoid adverse selection Will Exchanges Succeed?
  48. 48. Exchanges Projected to Start at 7 million and Reach About 25 million • Exchange enrollment estimated to be about 7 million in 2014, increasing to about 22 million by 2016 and 25 million in 2018 • More than 80 percent of enrollees estimated to be eligible for sliding-scale tax-credits • About 3 million estimated to be in small business (SHOP) Exchange 48
  49. 49. Implications for Physicians and Hospitals • Patients covered under Exchange plans may have better coverage with lower out of pocket maximums than currently • More insured patients but many uninsured likely to be unaware of the Exchanges and subsidies in 2014, so effects of ACA may be limited at first • Plans have to meet network adequacy requirements but Exchange plans may have narrower networks than non-Exchange plans • To keep premiums competitive, insurers may try to negotiate deeper discounts from hospitals; physicians may have to accept lower reimbursement rates to participate in plan networks • In the large group market, some employers may offer ―skinny‖ health plans that lack hospital coverage 49
  50. 50. Small Business Health Insurance Tax Credit
  51. 51. 51 Who Qualifies for the Health Insurance Tax Credit? • Coverage: Do you cover at least 50% of the cost of health care coverage for some of your workers based on the single rate? • Size: Do you have less than the equivalent of 25 full-time workers? (An employer with fewer than 50 half-time workers may be eligible.) – Owner of sole proprietorship is not counted as an employee – Neither is a partner in a partnership • Average annual wage: Do you pay average annual wages below $50,000? • Tax status: Both taxable (for-profit) and tax-exempt firms qualify
  52. 52. 52 How Much Tax Credit Can I Get? Maximum Amount • Up to 35% of a small business' premium costs in 2010-2013 (25% for tax-exempt employers) On January 1, 2014 • Rate increases to 50% (35% for tax-exempt employers)
  53. 53. 53 How Much Tax Credit Can I Get? Phase-out • Credit phases out gradually for firms with average wages between $25,000 and $50,000 and for firms with the equivalent of between 10 and 25 full-time workers Impact of Budget Sequester: Refundable portion of credit is reduced by 8.7 percent (ends 9-30-2013)
  54. 54. 54 Small Business Tax Credit: Two Illustrations Sophie’s Day Care (Non-Profit) Main Street Auto Mechanics Employees: 9 Employees: 10 Wages: $198,000 total or $22,000 per worker Wages: $250,000 total or $25,000 per worker HI costs: $72,000 HI costs: $70,000 2011 Tax Credit: $18,000 (25% credit) 2011 Tax Credit: $24,500 (35% credit) 2014 Tax Credit: $25,200 (35% credit) 2014 Tax Credit: $35,000 (50% credit)
  55. 55. 55 Where Can I Learn More? • Consult your tax preparer or check IRS website at: – • Obtain IRS Form 8941 Small Business Health Insurance Tax Credit and IRS Form 8941 Instructions – –
  56. 56. 56 Medicaid Primary Care Rate Increase for 2013 and 2014 • States required to reimburse qualified Medicaid (including Medicaid CHIP) primary care providers at rate that would be paid for primary care service under Medicare – MD must attest to practicing in Family, General Internal or Pediatric Medicine and also to either being • Board certified in designated specialties/subspecialties or • Having a 60% paid claims history of both certain E&M codes and vaccine administrative codes • Physicians need to complete the attestation form at https://www.kmap- • For forms received after 3/31/2013, the effective date of the rate increase will be the date of the physician's application for attestation
  57. 57. 57 • Now: Tax credit may help some small physician practices that opt to provide coverage to their employees – Can carry the credit back or forward to other tax years – Can claim a business expense deduction for any premium in excess of the credit • 2014: SHOP Exchange, with continuation of outside SHOP market; Exchange for individuals who do not otherwise have access to coverage; small businesses (under 50 FTEs) will not be subject to penalties under shared responsibility requirements Bottom Line for Physician Practices
  58. 58. 58 • Because healthcare costs trends are steadily upwards, even those small physician practices who benefit from new insurance rules may not perceive improvement • Temporary bump up in Medicaid reimbursement for primary care physicians Bottom Line for Physician Practices
  59. 59. ACA‘s Shared Responsibility Requirements
  60. 60. 60 Employer Requirements: ―Shared Responsibility‖ Penalties Applies to employers averaging 50+ full-time employees beginning in 2015 • If employer does not offer minimum essential coverage to FTEs and dependents and at least 1 employee obtains a premium assistance tax credit in an exchange, penalty of $2,000 per full-time employee, with first 30 employees not counted Minimum essential coverage is typical public and private health insurance (excludes accident-only, dental-only, vision-only coverage).
  61. 61. 61 Employer Requirements: ―Shared Responsibility‖ Penalties Applies to employers averaging 50+ full-time employees beginning in 2015 • If employer offers minimum essential coverage and at least 1 employee obtains a premium assistance credit, penalty of $3,000 per subsidized employee (capped at amount of penalty for not offering coverage) – Employees only eligible for premium credit if employer coverage is < 60% actuarial value or employee contribution is at least 9.5% of income Minimum essential coverage is typical public and private health insurance (excludes accident-only, dental-only, vision-only coverage).
  62. 62. 62 Individual Responsibility (―Mandate‖) • Individuals without ―minimum essential coverage‖ pay penalty beginning with tax year 2014 • Exemption for certain religious sects, incarcerated individuals and illegal immigrants • No penalty applies if: income below the tax filing threshold; for hardship; coverage gaps less than 3 months; or if coverage unaffordable (> 8% of income, indexed after 2014) Minimum essential coverage is typical public and private health insurance (excludes accident-only, dental-only, vision-only coverage).
  63. 63. 63 Individual Mandate — Penalty • For 2014, penalty higher of $95 per person (up to 3 per household) or 1% of income above filing threshold (e.g., $9,350 for singles in 2009) • By 2016, penalty increases to $695 or 2.5% of income above threshold ($695 indexed for later years) • Penalty payable on income tax return; pro-rated on monthly basis • No IRS enforcement teeth
  64. 64. More ACA Information
  65. 65. 65 Current Sources of Coverage for Non-Elderly in US and Kansas (2011-2012) Kansas U.S. Employer-Sponsored 60% 56% Individual Insurance 6% 6% Medicaid 14% 18% Other public 4% 3% Uninsured 15% 18% Total 100% 100% Source: Kaiser Family Foundation, Close to 327,000 Kansans are uninsured
  66. 66. Over Time, Number of Uninsured is Projected to Decline by About Half Medicaid and Exchange coverage increases, and the net number of uninsured declines by about 25 million. That still leaves about 30 million uninsured. • The undocumented (cannot get coverage in Exchange or through Medicaid) • Those in States that have not expanded Medicaid • Those can get coverage and opt not to enroll, including those exempt from tax penalty Sources of Coverage, Non-Elderly in Millions Congressional Budget Office, May, 2013 Baseline 66
  67. 67. Medicaid Expansion Decision as of September 3, 2013 67 Kaiser Family Foundation, Status of State Action on the Medicaid Expansion Decision, as of September 3, 2013,
  68. 68. Illustrative Monthly QHP Premiums Cynthia Cox et al., An Early Look at Premiums and Insurer Participation in Health Insurance Marketplaces, 2014, Kaiser Family Foundation, September 2013. participation-in-marketplaces.pdf State Lowest Cost Silver Plan* Lowest Cost Bronze Plan Age 25 Age 40 Age 60 Age 25 Age 40 Age 60 Los Angeles, CA $176 $224 $475 $147 $188 $398 Indianapolis, IN $229 $291 $618 $196 $250 $531 NY, NY $359 $359 $359 $308 $308 $308 Richmond, VA $181 $230 $488 $134 $170 $361 *Lowest cost plan for person age 25. Other insurers may offer lowest cost plans for other age cohorts.
  69. 69. Illustrative QHP Premiums With and Without Subsidies 2014 Monthly Premium for a Single 25-Year-Old at 250% of Poverty ($28,725 per year) Second Lowest Cost Silver plan before subsidies Second Lowest Cost Silver Plan After Subsidies Lowest Cost Bronze Plan Before Subsidies Lowest Cost Bronze Plan After Subsidies Los Angeles, CA $200 $193 $147 $140 Indianapolis, IN $232 $193 $196 $157 NY, NY $390 $193 $308 $111 Richmond, VA $199 $193 $134 $127 Note: Premiums are capped at 8.05% of income for an individual at 250% of poverty. Source: Cynthia Cox et al., An Early Look at Premiums and Insurer Participation in Health Insurance Marketplaces, 2014, Kaiser Family Foundation, September 2013. participation-in-marketplaces.pdf