Washington Health Benefit Exchange

Transcription

1 Washington Health Benefit Exchange AFFORDABLE CARE ACT 101 APRIL 26, 2013 Christine Brown Navigator/In-person Assister Program

2 Today s Agenda History of the Affordable Care Act (ACA) Highlights of the Affordable Care Act Impact of the Affordable Care Act 2

3 PURPOSE AND OBJECTIVES Purpose 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 3

4 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) 4

5 WHY THE RUSH TO REFORM HEALTH CARE? 1912 Teddy Roosevelt - Proposal 1935 President Franklin Roosevelt - Social Security 1942 President Franklin Roosevelt - Established Price Controls 5

6 WHY THE RUSH TO REFORM HEALTH CARE? 1945 President Harry Truman Proposal 1965 President Lyndon Johnson Medicare President Richard Nixon - Proposal 6

7 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 7

8 AFTER 100+ YEARS, WHY NOW? Consumer can't afford doctor Consumer becomes uninsured Consumer delays care, goes to ER Insurers shift cost to consumer Consumer can't pay Providers shift cost to Insurers 8

9 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

10 Impact Of The Affordable Care Act Changes to private insurance, e.g., Kids can t be denied health coverage if they are sick Young adults on parents policies to age 26 Prohibit lifetime monetary caps Minimum medical loss ratio Closes the Medicare prescription doughnut hole Expands coverage + imposes individual mandate in 2014 Expands Medicaid to 138%* of FPL Exchanges *ACA 133% = 138% due to across the board income disregards 10

11 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 11

12 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 12

13 INDIVIDUAL MANDATE Require all citizens and legal residents (there are some exceptions) to have health coverage in What happens if someone does not meet this deadline? Will they go to jail? NO! 13

14 THE MANDATE DOES NOT APPLY FOR SOME When any of the following apply: Religious objections Undocumented immigrant Incarcerated American Indians and Alaskan Natives No penalty for being without health insurance. Income below the tax filing threshold The lowest cost plan option exceeds 9.5 percent of an individual s income 14

15 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 No Penalty. The requirement to have health insurance is satisfied 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 15

16 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 $ per child (up to $975 for a family) or 2%, whichever is greater 2016: $695 per adult and $ per child (up to $2,085 for a family) or 2.5% of family income, whichever is greater 16

17 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 17

18 2013 FEDERAL POVERTY LEVELS BY ANNUAL INCOME Federal Poverty Level Annual Income: Individual Annual Income: Family of 3 100% $11,496 $19, % $15,288 $25, % $15,864 $26, % $22,980 $39, % $34,476 $58, % $45,960 $78,120 Source: Per HHS directive, after inflation adjustment, the guidelines are rounded and adjusted to standardize the differences between family sizes. 18

19 Health Insurance Premium Tax Credit and Cost Sharing Reductions Premium Tax Credits: Income Level Up to 133% FPL Premium as Percent of Income 2% of income % FPL 3-4% of income % FPL 4-6.3% of income Cost Sharing Reductions: Income Level % FPL % FPL Reduction in Out-of- Pocket Liability 94% of the actuarial value* 87% of the actuarial value % FPL % of income % FPL % of income % FPL 9.5% of income % FPL 73% of the actuarial value *Of the second lowest cost Silver plan

20 EXAMPLE Family of 3 Annual Income = 200% of FPL Health Insurance Premium Tax Credit? YES Cost Sharing Reduction? YES 20

21 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, After answering a few questions including income, consumers will be notified about their health care coverage eligibility. 21

22 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 22

23 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. 23

24 WHAT ABOUT SMALL BUSINESSES? 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 24

25 HOW WILL PEOPLE GET HEALTH CARE COVERAGE? Agent Broker Customer Support Center Website Navigator In-person Assister Partner Self- Directed

26 STREAMLINED APPLICATION 26

27 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 27

28 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 28

29 More on the Exchange 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: Contact the Exchange at: 29

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31 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 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, 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. 31

32 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, 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. 32

33 GLOSSARY OF TERMS (CONT.) Out-of-Pocket Costs: Your expenses for medical care that aren't reimbursed by insurance. Out-ofpocket 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: 33