The Affordable Care Act and YOU. Sheldon Weisgrau Presentation to McPherson Healthcare Foundation October 30, 2013

Transcription

1 The Affordable Care Act and YOU Sheldon Weisgrau Presentation to McPherson Healthcare Foundation October 30, 2013

2 Agenda Introduction Health care and health insurance Why do we need health reform? The Affordable Care Act (aka Obamacare ) What s really in the law? How does the ACA affect employers? What s next? 2

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4 Assist in public education and stakeholder engagement related to health reform Provide technical assistance to advocacy organizations and other stakeholders Assist Kansas entities in securing grants and programs available under the Affordable Care 4

5 Supported by Kansas Grantmakers in Health: Kansas Health Foundation Health Care Foundation of Greater KC REACH Healthcare Foundation Sunflower Foundation: Health Care for Kansans United Methodist Health Ministry Fund Wyandotte Health Foundation 5

6 Health Care and Health Insurance 6

7 Why health reform? Access 48 million uninsured in U.S. (18% of pop < age 65) 350,000 uninsured in Kansas (14% of pop <65) 2,900 uninsured in McPherson Co (12% of pop <65)* Millions more underinsured Employment-based health insurance declining 7

8 Why health reform? Access Quality Inconsistent Disparities Infections, medical errors, patients harmed 8

9 Why health reform? Access Quality Cost Highest in the world Increasing faster than salaries and inflation Main driver of long-term budget deficits 9

10 The Affordable Care Act 10

11 Affordable Care Act 906 pages, 10 titles 1. Access to private health insurance 2. Expanded Medicaid coverage 3. Medicare reform 4. Wellness and prevention 5. Health care workforce 6. Fraud and abuse 7. Access to drugs and biologics 8. Voluntary long-term care insurance (CLASS) 11

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13 ACA Linked Goals Make better health insurance coverage more available and affordable for legal residents Reform health care delivery and financing to provide better quality and outcomes, more cost effective care 13

14 ACA Mythbusters What it does Builds on the existing system of coverage What it doesn t do Does not create government-controlled or socialized health care Does not create death panels Does not eliminate (or make big changes to) Medicare 14

15 ACA Snapshot Extends health insurance coverage to million uninsured Expands the Medicaid program Authorizes Medicare financing and delivery reform Restructures markets for individual and small group insurance Health Insurance Marketplace (and SHOP) 15

16 ACA Snapshot Extends health insurance coverage to million uninsured Prohibits insurers from denying coverage to those with pre-existing conditions (guaranteed issue) or charging them more (community rating) Mandates that most people maintain insurance coverage 16

17 How Does the ACA 17

18 Small Business (< 50 employees) No insurance requirements Tax incentives for employers that provide insurance < 25 employees Average annual wages < $50,000/year Employer pays at least 50% of premium cost 18

19 Large Business (50+ employees) DELAYED 19

20 Employer Shared Responsibility Large employers are not required to provide insurance coverage BUT... They may be subject to penalty if: 20

21 Employer Shared Responsibility Large employer may be subject to penalty if: Does not offer coverage to full-time employees and their dependents OR Offers coverage that does not meet affordability or minimum value standards AND At least one full-time employee receives a tax credit 21

22 Employer Shared Responsibility Who does it apply to? Employers with 50 or more full-time and full-time equivalent employees How do we measure full-time employees and FTEs? Full-time employee = Average of 30+ hours/week over course of a month Part-time FTEs: Add hours worked per month, divide by

23 Employer Shared Responsibility What is affordable coverage? Does not exceed 9.5% of employee s W-2 income for the tax year (for individual plan) What is minimum value? Covers at least 60% of costs 23

24 Employer Shared Responsibility If employer does not offer coverage, penalty is $2,000 per full-time employee (minus the first 30 full-time employees) If at least one full-time employee receives a tax credit to purchase in the Marketplace 24

25 Employer Shared Responsibility If employer does not offer coverage, penalty is $2,000 per full-time employee (minus the first 30 full-time employees) Example: Employer with 75 full-time employees: = 45 25

26 Employer Shared Responsibility If employer offers coverage, but it is unaffordable or does not meet minimum value standards, penalty is $3,000 for each affected full-time employee For those employees that receive a tax credit to purchase in the Marketplace 26

27 Employer Shared Responsibility If employer offers coverage, but it is unaffordable or does not meet minimum value standards, penalty is $3,000 for each affected full-time employee Example: Coverage is unaffordable for 10 employees 27

28 Employer Shared Responsibility Multiple businesses with same ownership covered as a single entity Penalties are not deductible Penalties are indexed to inflation after

29 Grandfathered Plans All health plans must End lifetime coverage limits End rescissions Cover children to age 26 Provide Summary of Benefits and Coverage (SBC) Meet MLR requirements Grandfathered plans don t have to Cover preventive care with no out-ofpocket costs Guarantee patient right to appeal Protect choice of doctors and access to emergency care Publicly justify rate increases of more than 10% Provide coverage for pre-existing conditions (individual only) End yearly coverage limits (ind only) 29

30 Information for Businesses

31 The Health Insurance Marketplace 31

32 Health Insurance Marketplaces Established by each state by Oct 1, 2013 Administered by federal govt if state opts out For individual and small group markets Provides web-based one-stop shopping Pooling mechanism for individuals and small businesses 32

33 Essential Health Benefits 1. Ambulatory care services 2. Emergency services 3. Hospitalization 4. Maternity and newborn care 5. Mental health and substance abuse services 6. Prescription drugs 7. Rehabilitative and habilitative services and devices 8. Laboratory services 9. Preventive and wellness services and chronic disease 33

34 Tax Credits Qualify if household income is 100%-400% of Fed Poverty Level and purchase in Marketplace and no affordable employer offer Household 2013 Federal Poverty Guidelines Size 100% 400% 1 $11,490 $45,960 2 $15,510 $62,040 3 $19,530 $78,120 4 $23,550 $94,200 5 $27,570 $110,280 6 $31,590 $126,360 Businesses qualify if they meet size and salary requirements 34

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36 Consumer Assistance Toll-free hotline Agents/brokers Navigators and Certified Application Counselors 36

37 Where do we go from here? 37

38 Important Dates Open Enrollment October 1, 2013 March 31, 2014 Future years: Oct 15-Dec 7 Special enrollment periods If you want insurance on... January 1, enroll by December 15, 2013 If you want to avoid the penalty... 38

39 Where do we go from here? Marketplace opens October 1, 2013 Coverage begins January 1, Individual mandate January 1, 2014 Employer responsibilities Enforcement delayed until

40 Additional information Sheldon Weisgrau, Director 1129 S. Kansas Avenue, Suite B Topeka, KS (785) HealthReformResource@gmail.com 40