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Implementation of the Affordable Care Act (ACA) and Health Insurance Marketplaces and Implications for Public Health and Federal
Collaboration
Presented by:CDR Jennifer MoonLCDR Jacquelyne Ivery
AMSUS Presentation November 2013
This continuing education activity is managed and accredited by Profession Education Services Group (PESG) in cooperation with AMSUS. Neither PESG, AMSUS or any accrediting organization support of endorse and product or service mentioned in this activity.PESG and AMSUS staff have no financial interest to disclose.Commercial support was not received for this activity.
Disclosures
AMSUS Presentation November 2013
CDR Jennifer Moon nor LCDR Jacquelyne Ivery have any financial interest to disclose.
Disclosures Cont.
AMSUS Presentation November 2013
At the conclusion of this activity, the participant will be able to: Describe the ACA federal and state
exchange/marketplace infrastructure Explain the public health implications for
underserved and vulnerable population Discuss current, future and potential federal
interagency collaboration
Objectives
AMSUS Presentation November 2013
• 3.1 million young adults have gained insurance through their parent’s plans
• 6.1 million people with Medicare through 2012 received $5.7 billion in prescription drug discounts
• 34 million people with Medicare received a free preventive service
• 71 million privately insured people gained improved coverage for preventive services
• 105 million Americans have had lifetime limits removed from their insurance
ACA Accomplishments
AMSUS Presentation November 2013
On October 1, 2013, the Health Insurance Marketplace (Affordable Insurance Exchange) opened in each state, providing a new, simplified way to compare individual market health insurance plans.
In 36 states the Department of Health and Human Services (HHS) will support or fully run the Health Insurance Marketplace
Individuals will have an average of 53 qualified health plan choices in states where HHS will fully or partially run the Marketplace
Premiums before tax credits will be more than 16 percent lower than projected
Marketplace Specific Accomplishments
AMSUS Presentation November 2013
Section 1311(b) (1) of the ACA and implementing regulations (45 CFR§ C.F.R §155.410(c) (i)) requires Marketplaces to offer coverage in every state starting on January 1, 2014.
Section 1321(c)(1) of the Affordable Care Act directs the Secretary of The Department of Health & Human Services (HHS) to establish and operate a Federally-Facilitated Marketplace (FFM) in any state that does not elect to operate a State Based Marketplace (SBM), or in one that will not have an operable Marketplace for the 2014 coverage year.
The Marketplace (or Exchange) - Place for individuals and small employers to directly compare private health insurance options known as Qualified Health Plans (QHPs)
Introduction to The Marketplace
AMSUS Presentation November 2013
Market Reforms
AMSUS Presentation November 2013
Each state had the option to choose between:• State Based Marketplace (SBM) – State creates and runs
its own Marketplace• State Partnership Marketplace (SPM) – State partners
with Federal government to run some Marketplace functions
• Federally Facilitated Marketplace (FFM) – State has a Marketplace established and operated by the Federal government
Marketplace Establishment
AMSUS Presentation November 2013
The FFM and SPM have two components: Individual Market – governs eligibility and enrollment
for consumers seeking coverage not connected to job-based coverage.
Small Business Health Options Program (SHOP) Market – governs eligibility and enrollment for employers seeking coverage for their employees.
Individual Market and SHOP
AMSUS Presentation November 2013
Implementation of the Marketplace
AMSUS Presentation November 2013
Helps enhance competition in the health insurance market Increases affordability through premium tax credits, cost
sharing reductions, or public insurance programs Ensures quality through QHPs that must meet basic
standards, including quality standards, consumer protections, and access to an adequate range of clinicians
Makes costs clear by providing information about prices and benefits in simple terms consumers can understand, so they don’t have to guess about costs
Advantages of the Marketplace
AMSUS Presentation November 2013
Marketplace initial open enrollment period began October 1, 2013 and ends March 31, 2014
Marketplace eligibility requires consumers to• Live in its service area, and• Be a U.S. citizen or national, or• Be a non-citizen who is lawfully present in the U.S. for the
entire period for which enrollment is sought• Not be incarcerated
Eligibility and Enrollment
AMSUS Presentation November 2013
Application and Eligibility
Submit single,
streamlined
application to the Marketpla
ce
Verify and
determine eligibility
• Online• Phone• Mail• In Person
Supported by Data Services Hub
Eligible for Marketplace or Medicaid/CHIP
Enroll(Marketplace)
Enroll(Medicaid/CHIP)
AMSUS Presentation November 2013
Health plans offered in the Exchanges/Marketplaces must be certified as Qualified Health Plans (QHP)
Through the QHP certification process, FFMs will check that health plans meet basic standards, as established in the Exchange final rule (45 CFR 156 Subpart C: QHP Minimum Certification Standards)
Issuers will need to ensure each QHP complies with the minimum certification standards on an ongoing basis
Examples of QHP Certification Requirements include:• Network Adequacy, Essential Community Providers, Service Area and
Benefit Design
Requirements for QHPs Offered in theFFMs
AMSUS Presentation November 2013
A Qualified Health Plan (QHP)• Is offered by an issuer that is licensed by the state and in
good standing• Covers Essential Health Benefits (EHBs)• Offers at least one plan at the “silver” level and one at the
“gold” level of cost sharing• Agrees to charge the same premium rate whether offered
directly through Marketplace or outside the Marketplace (except stand alone dental plans/SADPs)
Qualified Health Plan (QHP)
AMSUS Presentation November 2013
1. Ambulatory patient services2. Emergency services3. Hospitalization4. Maternity and newborn care5. Mental health and
substance use disorder services, including behavioral health treatment
6. Prescription drugs
7. Rehabilitative and habilitative services and devices
8. Laboratory services9. Preventive and wellness
services and chronic disease management
10. Pediatric services, including oral and vision care
All Qualified Health Plans Will Cover These Essential Health Benefits
AMSUS Presentation November 2013
Who is eligible?• Young adults under 30 years of age• Those who can not afford coverage and obtain a hardship
waiver from the Marketplace What is catastrophic coverage?
• Plans with high-deductibles and lower premiums• Includes coverage of 3 primary care visits and preventive
services with no out-of-pocket costs• Protects consumers from high out-of-pocket costs
Catastrophic Plans
AMSUS Presentation November 2013
Grant program sponsored by each Marketplace• Navigators will
Raise awareness about the Marketplace Provide unbiased information about enrollment Help consumers understand health plan differences
And help submit consumers’ selections to the Marketplace Provide culturally/linguistically appropriate information Give referrals May be an agent or a broker if standards are met
Can’t be paid by issuer for enrolling people in QHPs/non-QHPs Other assistance also may be available beyond Navigators
Navigator Program
AMSUS Presentation November 2013
SHOP is a Marketplace for small businesses and their employees (fewer than 100 employees)• States may limit participation to those with 50 or fewer
employees for the first 2 years• Employer will access the SHOP where its principle business
office is located• Employer must offer coverage to all full-time employees• Sole proprietors may buy through the Marketplace rather
than the SHOP
Small Business Health Options Program (SHOP)- Employees
AMSUS Presentation November 2013
The Marketplace is a new way to find and buy health insurance
Individuals and small businesses can shop for health insurance that fits their budget
States have flexibility to establish their own Marketplace There is financial help for working families and other
people with limited income There is assistance available to help consumers get the
best coverage for their needs
Marketplaces: Key Points to Remember
State # of Uninsured
California 5,560,000
Colorado 656,000
Connecticut 243,000
Washington, DC 42,000
Idaho 223,000
Hawaii 90,000
Kentucky 622,000
Maryland 481,000
Consumer Impact: Number of Uninsured (SBMs)
22
State # of Uninsured
Massachusetts 240,000Minnesota 423,000Nevada 474,000New York 1,915,000New Mexico 360,000Oregon 520,000Rhode Island 101,000Washington 835,000Vermont 44,000
AMSUS Presentation November 2013
Individuals and families with household incomes between 100 percent and 400 percent of the Federal Poverty Level (FPL) who are not eligible for certain other types of coverage may qualify for tax credits to make premiums more affordable
Tax credits will make premiums even more affordable for individuals and families
After taking tax credits into account, fifty-six percent of uninsured Americans (nearly 6 in 10) may qualify for health coverage in the Marketplace for less than $100 per person per month, including Medicaid and CHIP in states expanding Medicaid
Implications for Underserved and Vulnerable Populations
AMSUS Presentation November 2013
Underserved and vulnerable populations often have limited access to relevant health information
Vulnerable populations are subject to serious disparities in health care
Insurance alone does not constitute affordable, quality care, or improved long-term health and equity
Provider shortages, particularly relating to primary care, impact vulnerable populations
Public Health Challenges
AMSUS Presentation November 2013
ACA Provisions with Direct References to “Health Literacy” Sect 3501. Health Care Delivery System Research; Quality
Improvement Technical Assistance Sect 3506. Program to Facilitate Shared Decision-making Sect 3507. Presentation of Prescription Drug Benefit and
Risk Information Sect 5301. Training in Family Medicine, General Internal
Medicine, General Pediatrics, and Physician Assistantship
Health Literacy
AMSUS Presentation November 2013
HRSA• Essential Community Provider (ECP)• National Health Service Corps (NHSC)• Federally Qualified Health Centers (FQHC)
AHRQ • Funding is used to develop research, reports, practical
tools, and other resources to improve the quality, safety, effectiveness, and efficiency of health care.
CDC• HAI prevention
Examples of Interagency Collaboration
AMSUS Presentation November 2013
Tricare and most VA medical coverage meets the minimum essential coverage requirement
Tricare Young Adult (TYA) signed in 2011• your dependent must be under age 26, unmarried, and not
eligible for their own employer-sponsored health insurance plan
Separation from service (not retirement) is a special enrollment period
How does this impact you as an Uniformed Service Member?
AMSUS Presentation November 2013
1. The Marketplace is a new way to shop for health coverage. 2. Each state will have a Marketplace, run either by the state,
through a state-federal partnership, or by the federal government. 3. Open Enrollment begins on October 1, 2013, and ends on March
31, 2014. Coverage can begin as soon as January 1, 2014. 4. Health plans offered in a Marketplace will generally offer
comprehensive coverage, including a set of “essential health benefits”.
5. Individuals can buy insurance through a Marketplace if they live in the United States, are U.S. citizens or U.S. nationals (or are lawfully present), and aren’t currently incarcerated.
10 Things Providers Need to Know
AMSUS Presentation November 2013
6. Nobody can be turned away or charged more because of their gender or a pre-existing condition.
7. Depending on household income and family size, many individuals may qualify for tax credits to help lower their share of monthly premiums, or help that reduces deductible, copayment or other cost-sharing amounts.
8. Individuals will be able to choose a Marketplace plan by health plan category (bronze, silver, gold, or platinum).
9. Consumers can apply on the web, over the phone or with 1-on-1 assistance in person.
10 Things Providers Need to Know (continued)
AMSUS Presentation November 2013
10. Resources are available now.• Marketplace.cms.gov: Where organizations and individuals looking to
help can get the latest resources and learn more about the Marketplace
• HealthCare.gov: Where individuals can learn about the Marketplace and the upcoming benefits (including where they can find local assistance), or be connected to appropriate resources in states that are running their own Marketplace.
• Health Insurance Marketplace Call Center: If you have questions, call 1-800 318 2596. TTY users should call 1-855-889-4325‑ ‑ .
10 Things Providers Need to Know (continued)
AMSUS Presentation November 2013
AMSUS Presentation November 2013
Training Materials for Stakeholders• marketplace.cms.gov
Educational Materials for Consumers• healthcare.gov
CMS/CCIIO Resource website• http://www.cms.gov/cciio/index.html
The full text of the ACA is available at: • http://www.healthcare.gov/law/full/index.html
Resources
AMSUS Presentation November 2013
Congressional Refresher Briefing (May 16, 2013) ASPE Issue Brief (Sept 25, 2013) Health Literacy Implications of the ACA (IOM, Nov
2010) “Closing Racial And Ethnic Disparity Gaps:
Implications Of The Affordable Care Act”, www.forbes.com (5/28/13)
References
AMSUS Presentation November 2013
If you would like to receive continuing education credit for attending this activity, please visit:
http://amsus.cds.pesgce.com
Obtaining CME/CE Credit