Washington Health Benefit Exchange

AFFORDABLE CARE ACT 101SUMMER 2013

Navigator/In-person Assister Program

Today’s Agenda

▪ History of the Affordable Care Act (ACA)

▪ Highlights of the Affordable Care Act

▪ Impact of the Affordable Care Act

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PURPOSE AND OBJECTIVESPurpose

This webinar is to provide an overview of the Affordable Care Act (ACA)

Objectives

Upon completion of this presentation you will:

▪ Understand how the Affordable Care Act applies to you and others

▪ Understand how the Affordable Care Act is being implemented in Washington State

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WHAT IS THE ACA?

▪ Patient Protection and Affordable Care Act (PPACA) ▪ Affordable Care Act (ACA)▪ Health Care Reform Law ▪ Obamacare

▪ Health Care and Education Reconciliation Act of 2010 (HCERA)

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WHY THE RUSH TO REFORM HEALTH CARE?

▪ 1912 – President Theodore “Teddy” Roosevelt - Proposal

▪ 1935 – President Franklin Roosevelt - Social Security

▪ 1942 – President Franklin Roosevelt - Established Price Controls

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WHY THE RUSH TO REFORM HEALTH CARE?

▪ 1945 – President Harry Truman – Proposal

▪ 1965 – President Lyndon Johnson – Medicare

▪ 1974 - President Richard Nixon - Proposal

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WHY THE RUSH TO REFORM HEALTH CARE?

▪ 1993 – President Bill Clinton - Proposal

▪ 2005 – President George W. Bush - Medicare Part D

▪ 2010 – President Barack Obama - Health Care Reform

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AFTER 100+ YEARS, WHY NOW?

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Consumer can't afford doctor

Consumer delays care, goes to ER

Consumer can't pay

Providers shift cost to Insurers

Insurers shift cost to consumer

Consumer drops policy due to high price and is

now uninsured

HIGHLIGHTS OF THE ACA

Expand health care coverage to 32 million Americans who are uninsured.

Slow down the rising cost of health care which accounted for almost 18% of the Gross Domestic Product (GDP) in 2010.

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Impact Of The Affordable Care Act

▪ Changes to private insurance, e.g., Kids can’t be denied health coverage if they are sickYoung adults on parents’ policies to age 26Prohibit lifetime monetary capsMinimum medical loss ratio

▪ Closes the Medicare prescription “doughnut hole”

▪ Expands coverage + imposes individual mandate in 2014Expands Medicaid to 138%* of FPLExchanges

10*ACA 133% = 138% due to across the board income disregards

TEN ESSENTIAL HEALTH BENEFITS

1. Ambulatory services 6. Prescription drugs

2. Emergency services 7. Rehabilitative and habilitative services and devices

3. Hospitalization 8. Laboratory services

4. Maternity and newborn care 9. Preventive and wellness services and chronic disease management

5. Mental health and substance use disorder services, including behavioral health treatment

10. Pediatric services, including oral and vision care

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HOW WILL PEOPLE GET HEALTH CARE COVERAGE?

The ACA will expand health care coverage in the following ways:

▪ Individual Mandate

▪ Small Business Tax Incentives

▪ Medicaid Expansion

▪ Premium Subsidies

▪ Large Employer Mandate

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INDIVIDUAL MANDATE

▪ Require all citizens and legal residents (there are some exceptions) to have health coverage in 2014.

▪ What happens if someone does not meet this deadline?

▪ Will they go to jail? NO!

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THE MANDATE DOES NOT APPLY FOR SOME

When any of the following apply:

▪ Religious objections

• Undocumented immigrant

• Incarcerated

• American Indians and Alaskan Natives

• Income below the tax filing threshold

• The lowest cost plan option exceeds 9.5 percent of an individual’s income

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No penalty for being without health

insurance.

THE MANDATE IS SATISFIED WHEN

You were insured for the whole year through a combination of any of the following sources:

▪ Medicare

▪ TRICARE

▪ The veteran’s health program

▪ A plan offered by an employer

▪ Medicaid or the Children’s Health Insurance Program (CHIP)

▪ Insurance bought on your own that is at least at the Bronze level

▪ A grandfathered health plan in existence before the health reform law was enacted

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No Penalty. The requirement to

have health insurance is

satisfied

WHAT IS THE PENALTY?2014: $95 per adult and $47.50 per child (up to $285 for a family) or 1% of income, whichever is greater

2015: $325 per adult and $162.50 per child (up to $975 for a family) or 2%, whichever is greater

2016: $695 per adult and $347.50 per child (up to $2,085 for a family) or 2.5% of family income, whichever is greater

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HEALTH INSURANCE PREMIUM TAX CREDITS

▪ Designed to make premiums affordable for individuals and families with lower incomes

▪ Only available to individuals and families with income up to 400% Federal Poverty Level (FPL)▪ Can be used to reduce monthly premiums▪ Can be claimed as a credit on annual tax return

▪ Must apply through Washington Healthplanfinder

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2013 FEDERAL POVERTY LEVELS BY ANNUAL INCOME

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Federal Poverty Level Annual Income: Individual

Annual Income:Family of 3

100% $11,496 $19,536

133% $15,288 $25,980

138% $15,864 $26,952

200% $22,980 $39,060

300% $34,476 $58,596

400% $45,960 $78,120

Source: http://aspe.hhs.gov/poverty/13poverty.cfmPer HHS directive, after inflation adjustment, the guidelines are rounded and adjusted to standardize the differences between family sizes.

Health Insurance Premium Tax Credit andCost Sharing Reductions

Income Level Premium as Percent of Income

Up to 133% FPL

2% of income

133-150% FPL 3-4% of income

150-200% FPL 4-6.3% of income

200-250% FPL 6.3-8.05% of income

250-300% FPL 8.05-9.5% of income

300-400% FPL 9.5% of income

Income Level Reduction in Out-of-Pocket Liability

100-150% FPL

94% of the actuarial value*

150-200% FPL

87% of the actuarial value

200-250% FPL

73% of the actuarial value

Premium Tax Credits: Cost Sharing Reductions:

*Of the second lowest cost Silver plan http://www.wahealthplanfinder.org/

A Silver Metal Level plan must be purchased to qualify for Cost Sharing Reductions

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EXAMPLE

▪ Family of 3

▪ Annual Income = 200% of FPL

▪ Health Insurance Premium Tax Credit? YES

▪ Cost Sharing Reduction? YES

HOW WILL PEOPLE GET THESE SUBSIDIES?

▪ The ACA requires all states to create a new marketplace website where consumers can go to search, compare and enroll in an affordable health coverage plan.

▪ The one in our state is the:

▪ Open enrollment is October 1, 2013 for coverage effective January 1, 2014.

▪ After answering a few questions including income, consumers will be notified about their health care coverage eligibility.

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MEDICAID EXPANSION

▪ Medicaid and Medicaid Expansion populations

▪ Adults (without children) up to 138% of FPL*

▪ Parents 40% to 138% of FPL

▪ Modified Adjusted Gross Income (MAGI)

▪ The ACA’s “133% of the FPL” is effectively 138% of the FPL because of a 5% across-the-board income disregard

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2014 Large Employer Requirements

▪ Large employers with over 50 FTE’s are required to offer a minimum level of health insurance

▪ Larger Employers offering non-qualifying coverage:o May be assessed the lesser of up to $3,000 per year for each FTE

receiving income-based assistance, or, up to $2,000 for every FTE.

▪ Large Employers not offering minimum essential coverage:o May be assessed $2,000 per FTE (first 30 full-time employees

excluded) if at least one full-time employee receives income-based assistance to buy coverage in the Exchange.

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WHAT ABOUT SMALL BUSINESSES?

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▪ Up to 50 Employees (these employers are exempt from the mandate)

▪ Small Business Health Insurance Tax credits available

▪ Washington Healthplanfinder can be used to manage employee health care benefits

▪ Options are available

Website

HOW WILL PEOPLE GET HEALTH CARE COVERAGE?

STREAMLINED APPLICATION

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ON-THE-SPOT ELIGIBILITY RESULTS

▪ Single portal for Medicaid, tax subsidies and Qualified Health Plans

▪ Use of electronic data to verify eligibility

▪ Real-time eligibility determination

▪ Interfaces to federal and state systems

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SUMMARY

▪ Historic significance of the Affordable Care Act

▪ Reforms to Health Care already in place

▪ Reforms effective January 1, 2014▪ Benefits to Individuals▪ Benefits to Families▪ Benefits to Employers

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KNOWLEDGE CHECK

What is the Affordable Care Act?

A. Health Care Insurance Reform

B. Affordable Car Insurance

C. Gun Control

D. Animal Case Adaptation

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KNOWLEDGE CHECK

Open Enrollment begins on…

A. March 23, 2010

B. January 2, 2014

C. October 1, 2013

D. December 7, 2013

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KNOWLEDGE CHECK

What are the two key goals of the Affordable Care Act?

A. Increase the cost of health care and decrease the number of Americans that are uninsured.

B. Slow down the rising cost of health care and expand health care coverage to uninsured Americans.

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KNOWLEDGE CHECK

The soonest coverage in a Qualified Health Plan can be effective is….

A. November 1, 2013

B. December 1, 2013

C. January 1, 2014

D. April 1, 2014

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KNOWLEDGE CHECK

Washington State is implementing Medicaid Expansion. Which of the following statements is not true?

A. Washington State Medicaid is going to include the state of Idaho.

B. Washington State Medicaid will include adults (without children) up to 138% of FPL.

C. Washington State Medicaid will include Parents with income up to 138% of FPL

D. Washington State Medicaid will use Modified Adjusted Gross Income to determine applicant’s income.

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KNOWLEDGE CHECK

One way the Affordable Care Act will expand health care coverage is…

A. By requiring all citizens be given pay raises.

B. By requiring everyone to purchase health care coverage with no exceptions.

C. By requiring all employers to provide health care coverage to all of their employees as well as their dependents.

D. Through premium subsidies.

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KNOWLEDGE CHECK

Which of the following statements is not true regarding Health Insurance Premium Tax Credits?

A. These credits are designed to make premiums affordable for individuals and families with lower incomes.

B. Enrollment through the Healthplanfinder is not required to receive these credits.

C. Tax credits can be used to reduce monthly premiums.

D. Tax credits can be claimed on your annual tax return.

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KNOWLEDGE CHECK

Cost sharing reductions…

A. Are a way to reduce consumer out of pocket health care expenses.

B. Lower monthly premiums.

C. Lower annual premiums.

D. Lower grocery bills.

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KNOWLEDGE CHECKThe Individual mandate…

A. Requires all citizens and legal residents to have health care coverage for their dogs and cats in 2014.

B. Requires incarcerated individuals to purchase healthcare coverage through the Washington Healthplanfinder.

C. Requires all citizens and legal residents to have health care coverage in 2013.

D. Requires all citizens and legal residents to have health care coverage in 2014.

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KNOWLEDGE CHECK

Washington Apple Health (Medicaid) is administered by…

A. The Washington Health Benefit Exchange.

B. The Washington State Health Care Authority.

C. The Washington Healthplanfinder.

D. The assister the customer is working with.

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KNOWLEDGE CHECK

A person that does not obtain health insurance coverage through a Qualified Health Plan may owe a penalty to…

A. The Washington Health Care Authority (HCA).

B. Centers for Medicare and Medicaid Services (CMS).

C. Internal Revenue Service (IRS).

D. The Washington Healthplanfinder

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QUESTIONS

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THANK YOU!

Congratulations! You have completed the Affordable Care Act Course!

http://wahbexchange.org/

Includes information about:▪ Exchange Board

▪ Legislation and grants

▪ Policy discussion

▪ Technical Advisory Committees and stakeholder involvement

▪ IT systems development

▪ HHS guidance

▪ Listserv registration

▪ Healthplanfinder Calculator: http://www.wahealthplanfinder.org/

▪ Contact the Exchange at: info@wahbexchange.org

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More on the Exchange

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APPENDIX: GLOSSARY OF TERMS▪ Actuarial Value: The percentage of total average costs for covered benefits that a plan will cover. For

example, if a plan has an actuarial value of 70%, on average, you would be responsible for 30% of the costs of all covered benefits. However, you could be responsible for a higher or lower percentage of the total costs of covered services for the year, depending on your actual health care needs and the terms of your insurance policy.

▪ Affordable Care Act: The comprehensive health care reform law enacted in March 2010. The law was enacted in two parts: The Patient Protection and Affordable Care Act was signed into law on March 23, 2010 and was amended by the Health Care and Education Reconciliation Act on March 30, 2010. The name “Affordable Care Act” is used to refer to the final, amended version of the law.

▪ Catastrophic Plan: Currently, some insurers describe these plans as those that only cover certain types of expensive care, like hospitalizations. Other times insurers mean plans that have a high deductible, so that your plan begins to pay only after you've first paid up to a certain amount for covered services.

▪ Cost Sharing: The share of costs covered by your insurance that you pay out of your own pocket. This term generally includes deductibles, coinsurance and copayments, or similar charges, but it doesn't include premiums, balance billing amounts for non-network providers, or the cost of non-covered services. Cost sharing in Medicaid and CHIP also includes premiums.

▪ Deductible: The amount you owe for health care services your health insurance or plan covers before your health insurance or plan begins to pay. For example, if your deductible is $1000, your plan won’t pay anything until you’ve met your $1000 deductible for covered health care services subject to the deductible. The deductible may not apply to all services.

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GLOSSARY OF TERMS CONT. ▪ Donut Hole, Medicare Prescription Drug: Most plans with Medicare prescription

drug coverage (Part D) have a coverage gap (called a "donut hole"). This means that after you and your drug plan have spent a certain amount of money for covered drugs, you have to pay all costs out-of-pocket for your prescriptions up to a yearly limit. Once you have spent up to the yearly limit, your coverage gap ends and your drug plan helps pay for covered drugs again.

▪ Federal Poverty Level (FPL): A measure of income level issued annually by the Department of Health and Human Services. Federal poverty levels are used to determine your eligibility for certain programs and benefits.

▪ Grandfathered Health Plan: As used in connection with the Affordable Care Act: A group health plan that was created—or an individual health insurance policy that was purchased—on or before March 23, 2010. Grandfathered plans are exempted from many changes required under the Affordable Care Act. Plans or policies may lose their “grandfathered” status if they make certain significant changes that reduce benefits or increase costs to consumers. A health plan must disclose in its plan materials whether it considers itself to be a grandfathered plan and must also advise consumers how to contact the U.S. Department of Labor or the U.S. Department of Health and Human Services with questions. (Note: If you are in a group health plan, the date you joined may not reflect the date the plan was created. New employees and new family members may be added to grandfathered group plans after March 23, 2010).

▪ Modified Adjusted Gross Income: MAGI is the new methodology for calculation of income for certain Medicaid programs which closely mirrors how the IRS determines adjusted gross income and household composition for tax purposes. This simplified income calculation will be used to determine Medicaid eligibility and also by the Exchange to determine Health Insurance Premium Tax Credits.

▪ Open Enrollment Period: The period of time set up to allow you to choose from available plans, usually once a year.

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GLOSSARY OF TERMS (CONT.)

▪ Out-of-Pocket Costs: Your expenses for medical care that aren't reimbursed by insurance. Out-of-pocket costs include deductibles, coinsurance, and copayments for covered services plus all costs for services that aren't covered.

▪ Premium: The amount that must be paid for your health insurance or plan. You and/or your employer usually pay it monthly, quarterly or yearly.

▪ Prescription Drug Coverage: Health insurance or plan that helps pay for prescription drugs and medications.

▪ Primary Care Physician: A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine) who directly provides or coordinates a range of health care services for a patient.

▪ Provider: A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine), health care professional or health care facility licensed, certified or accredited as required by state law.

▪ Qualified Health Plan: Under the Affordable Care Act, starting in 2014, an insurance plan that is certified by an Exchange, provides essential health benefits, follows established limits on cost-sharing (like deductibles, copayments, and out-of-pocket maximum amounts), and meets other requirements. A qualified health plan will have a certification by each Exchange in which it is sold.

▪ Source: Health and Human Services For more terms please visit: http://www.healthcare.gov/glossary/a/index.html

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