The Affordable Care Act Overview of Coverage Provisions
The Affordable Care Act: Overview of Coverage Provisions Dance/USA 2014 Dance Forum New York, NY January 10, 2014 Sarah J. Dash, MPH Georgetown University Health Policy Institute Center on Health Insurance Reforms
About the Georgetown University Center on Health Insurance Reforms Research and analysis of private health insurance markets Monitoring of state and federal health insurance market regulation Analyze impact on affordability, adequacy, and availability of coverage Projects generously funded by The Commonwealth Fund, Robert Wood Johnson Foundation, and others.
Presentation Overview Health Insurance 101 The Affordable Care Act (ACA) Why was it needed and what does it do? How the ACA Expands Coverage Marketplaces (individuals and small businesses) Medicaid Implementation So Far What You Can Do Now Q&A
Health Insurance 101
Health Insurance 101: Where people get their coverage 6% Employer-sponsored coverage 18% Medicaid Uninsured 56% 21% Nongroup 266. 4 Million Non-elderly U. S. : Sources of Coverage for Non-elderly (2011) Source: Kaiser Family Foundation
Health Insurance 101: Fewer Small Businesses Offering Coverage, 2003– 2010 Percent of working adults^ ages 19– 64 Employer offers Employee eligible Covered by own employer 95 90 100 75 85 76 66 58 50 42 61 56 49 80 71 73 94 88 71 55 33 25 0 2003 2010 Small firms (<50 employees) 2003 2010 Midsize firms (50– 99 employees) ^ Workers include both part-time and full-time workers who are not self-employed. Source: The Commonwealth Fund Biennial Health Insurance Surveys (2003 and 2010). 2003 2010 Large firms (>100 employees)
In the Spotlight: Health Insurance for Individuals and Small Businesses
Why the Affordable Care Act?
Why the Affordable Care Act?
Why the Affordable Care Act? (Dysfunctional Insurance Markets) Access Problems – Coverage denied due to pre-existing conditions – Rescissions (retroactive policy cancellations) Affordability Problems – No employer or other subsidy – “Rate ups” for health status, gender, age Adequacy Problems – Pre-existing condition exclusions – Critical benefits not covered – Out-of-pocket costs – Annual/lifetime limits on coverage
Why the Affordable Care Act? Everyone feeling the pain… For individuals: – – Barriers to care: prevention and treatment Financial difficulties “Job lock” Personal anxiety, family stress For businesses: – Skyrocketing health care costs crowd out higher salaries or other business investments For government: – Deficits, budget battles
Why the Affordable Care Act? Many Cooks in the Kitchen… 218 votes in the House 60 votes in the Senate 50 state legislatures, governors, insurance commissioners, and Medicaid directors (plus DC) 17 (ish) directors of state-based Marketplaces 3 federal agencies (HHS, DOL, IRS) Plus… insurers, doctors, businesses, agents/brokers, consumer advocates, and other stakeholders….
The Affordable Care Act: How Does it Help Expand Coverage?
Key ACA Coverage Provisions Availability – New rules of the road for health insurance – Opens new doors for coverage Affordability – More rules of the road for health insurance – Financial help with premiums and cost sharing Adequacy – New standards for benefits and plan design
ACA Coverage Provisions: Availability New rules of the road for health insurance: – Prohibits coverage denials/higher premiums based on health status, gender, occupation New Health Insurance Marketplaces – One stop shop for coverage, in every state) Medicaid expansion – In some states Other coverage provisions: – Enables dependents to stay on their parents’health plan until age 26.
Critical Coverage Provisions: Affordability More “Rules of the Road” for health insurance – – Ends higher premiums based on health status Ban on lifetime and annual dollar limits Limits out-of-pocket costs Insurers must spend at least 80% of premium revenue on health care and quality improvements Financial help for private insurance and Medicaid – Subsidies (premium tax credits) for individuals/families with low to moderate incomes buy health insurance Tax credits for small businesses that provide affordable coverage to their employees
Critical Coverage Provisions: Adequacy Essential health benefits Preventive services covered with no additional cost-sharing NOTE: Health insurance plan choices may still vary based on factors such as cost sharing, networks, and the extent of covered services!
What Does it Mean for Coverage? U. S. Coverage in 2019, With and Without the ACA Uninsured 57 million 20% Nongroup & Other 30 million 11% Medicaid/CHIP 32 million 11% Uninsured 26 million 9% Private Exchanges 23 million 8% Medicaid/CHIP 48 million 17% Nongroup & Other 27 million 10% Employer 161 million 156 million 58% 56% Without Reform - 2019 Under Reform - 2019 280 Million U. S. Residents Under Age 65 Source: Congressional Budget Office, March 2012 Estimate of the Effects of the Affordable Care Act on Health Insurance Coverage
What Else Does the ACA Do? ACA: More than coverage reforms Not discussed today: – Delivery system reform – Quality improvement – Cost containment – Public health/prevention – Medicare
What Does the ACA not Do? It doesn’t fix everything all at once for every person It’s not a “government takeover” – builds on current system It doesn’t make health insurance more fun (but it might make it easier)
Opening the Door to Health Insurance Coverage: Marketplaces and Medicaid
Health Insurance Marketplaces
Marketplace Basics One-stop-shop for coverage – Individuals without other affordable coverage – Small businesses (SHOP marketplace) Compare private insurance plans based on price, benefits, quality, and other features Most people will get a break on costs
Coverage Levels in Marketplace % covered by plan Platinum Gold Silver Bronze % enrollee cost share *All levels have essential health benefits Additional “catastrophic” plan available to individuals under age 30 or if no other coverage is affordable
Who Is Eligible? Marketplace To buy coverage For financial help U. S. citizen or legal resident Not incarcerated Income up to 400% of the poverty level Not eligible for other “minimum essential coverage” SHOP Up to 50 full-time employees (up to 100 in 2016) Self/employed or sole proprietors go to individual marketplace Must offer coverage to all fulltime employees Tax credits up to 50% of employer’s cost Less than 25 FTE employees, <$50 K average wages, and employer pay 50% of premium
Types of Financial Assistance: (Individual Marketplace) Premium Tax Credits (subsidies) – Individuals and families between 100 - 400% of poverty, who aren’t eligible for affordable/adequate job-based insurance, Medicaid, or Medicare Help with Cost-sharing (deductible, copays, and coinsurance) – Individuals/families up to 250% poverty ($28, 725 individual)
2014: ACA Provides Support Fitted to Income Family Income >$45, 960; >400% of FPL Job-based coverage, or Full-cost Marketplace coverage $34, 470 -45, 960; 300 -400% of FPL Job-based coverage, or Marketplace coverage: premiums capped at 9. 5% of income by tax credits $22, 980 -$34, 470; 200 -300% of FPL Job-based coverage, or Marketplace coverage: premiums capped at 6. 3 – 9. 5% of income by tax credits <$15, 856; < 138% FPL Medicaid (depending on state) Family income based on 2013 federal poverty income levels for an individual
Premium Tax Credits Premiums capped at 2 -9. 5% of income, on sliding scale. Value of credit linked to second lowest-cost silver level plan, but can “go shopping” with tax credit and choose any metal tier level of plan. Tax credits can be paid directly to insurer. Enrollee only owes the difference. Insurers must have ways to accept payments from people who lack credit cards and bank accounts. Note! Individuals must report changes in income throughout the year or risk paying back some or all of tax credits to IRS.
Cost Sharing Help No cost-sharing for recommended preventive services Out-of-pocket maximums ($6350 for individual) Cost sharing reductions: deductibles and copays reduced for families under 250% FPL 100 -200% 200 -300% 300 -400%+ % of FPL Annual Out-of individual $2, 017 $3, 025 $4, 033 $6, 050 -pocket $4, 033 $6, 050 $8, 067 $12, 100 family Maximum
SHOP: Features of Note for Small Businesses Ability to more easily compare plans – Online enrollment starts in 2015 for federal SHOP marketplace “Employee choice”: Ability to give employees a choice of plans – Currently available in most state-based marketplaces – Starts in 2015 for federal SHOP marketplace Small Business Tax Credit – Only through SHOP starting in 2014
Timeline for Coverage Individuals: – Initial Open Enrollment: October 1, 2013 – March 31, 2014 – Annual Enrollment: Nov. 15 -Jan. 15, 2015 – Special enrollment periods for qualifying events – First effective date is January 1, 2014 (must enroll by December 15, 2013) Small businesses: continuous enrollment
Medicaid Under the Affordable Care Act
ACA’s Medicaid Expansion Before ACA: – Medicaid generally not available to single (childless) adults – Income eligibility levels vary by state – Federal minimum benefit requirements; states may modify After ACA: – States may choose to make single (childless) adults eligible up to $15, 856 for a single person – Expansion decisions vary by state – Required “benchmark” benefit package must cover Essential Health Benefits; may vary from state to state
Coverage Gap for People in Poverty Source: Kaiser Family Foundation
Implementation So Far
ACA Implementation So Far States of the States: – Insurance Market Reforms: Most (but not all) states are enforcing the market reforms – Health Insurance Marketplaces: 14 states plus DC fully running individual and SHOP marketplaces this year – Medicaid: 26 states expanded to date Some Bumps in the Road to be expected… But Enrollment is Picking Up
States Running Their Own Marketplaces California Colorado Connecticut District of Columbia Hawaii Idaho (in 2015) Kentucky Maryland Massachusetts Minnesota Nevada New Mexico (SHOP only) New York Oregon Rhode Island Utah (SHOP only) Vermont Washington
The Affordable Care Act: What Dance Artists and Companies Need to Know
What Individual Dance Artists Need to Know Responsibility for obtaining coverage (individual mandate) How to access coverage (Marketplaces/Medicaid) Other coverage options What to look for in health insurance coverage How to get assistance
What Small Companies Need to Know No responsibility to provide coverage if <50 full-time employees SHOP Marketplaces Small Business Tax Credits How to get help
What Large Companies Need to Know Employer responsibility to provide affordable, “minimum essential coverage” if > 50 full-time employees (enforcement delayed until 2015) SHOP Marketplaces open to employers up to 100 employees in 2016 Other requirements applying to large employers – Not all requirements apply to self-insured or “grandfathered” plans
What You Can Do Now
How to Get Moving on Finding Coverage Explore current coverage options Visit healthcare. gov Links to Marketplaces in every state Create an account Get personalized help: – Availability of free “assistors” or agents/brokers – “Live talk” through call centers or “live chat” on healthcare. gov
Ways to Enroll In-person Assistance: • Agents/Brokers • Navigators • Certified Application Counselors
Special Considerations for Dance Artists
Some Special Considerations for Dance Artists Know what you are buying – Marketplace vs. non-Marketplace coverage – Understand the tradeoffs (low premiums=higher costsharing) – Understand terminology (deductible, co-pay) – Carefully review benefits in each plan – Tobacco “surcharge” Provider networks and out-of-network benefits Estimating income and reporting changes
Questions?
Thank you! Sarah J. Dash, MPH Georgetown Health Policy Institute Center on Health Insurance Reforms sd 850@georgetown. edu 202 -687 -1405 http: //chir. georgetown. edu/
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