What you need to know
Exploring
The Affordable Care Act
Maternal Child Adolescent Health Advisory Board Meeting August 1, 2013
Vanessa Raditz, [email protected]
Why do we need this training?
Many people are confused
April 2013 Kaiser Family Foundation poll: http://kff.org/health-reform/poll-finding/kaiser-health-tracking-poll-april-2013/
Why do we need this training?
Many people are confused
We need to focus on
Wellness not Sickness
The ACA can help us do this
Focus on prevention,
primary care, public health
The Affordable Care Act (ACA) Expand Access
– Health Insurance Exchange
– Expanded Medicaid
Health Center Expansion
Workforce Expansion
Care Delivery Models
Prevention
Subsidized
Unsubsidized
Previously eligible
Newly eligible
Quality Improvements
Improve transparency and accountability & consumer protections
Improve access to medical technologies
Primary Care
Public Health
The Individual Mandate
A federal law requiring most citizens to be enrolled
in a health insurance plan or pay a penalty
Penalty:
2014- $95 per adult,
or 1% of family income
2015- $325 per adult,
or 2% of family income
2016- $695 per adult,
or 2.5% of family income
Mandate Exemptions
Undocumented immigrants
Legal immigrants in U.S. less than 5 years
Income below the threshold for filing a tax return
(In 2013: $10,000 for single, $20,000 for family)
If cheapest policy will still cost more than 8% of their
annual household income
Individuals part of a religion opposed to acceptance of
benefits for a health insurer
Incarcerated individuals
Members of a Native American Tribe
Medicaid Expansion
Currently eligible:
Children, Pregnant women, disabled, elderly, and
some parents of children that meet income guidelines
(Generally <100% FPL)
Newly eligible starting Jan 1st 2014:
Non-disabled, childless adults at or below 138% FPL
Must be US citizen or legal resident >5yrs!
Medicaid Expansion
Medicaid currently covers 1 in 5 Americans
After reform: will cover 1 in 4 Americans o Healthcare for the Homeless, Barbara DiPietro
Medicaid Expansion is a Women’s Health issue:
Women more likely to experience poverty & financial hardship
Women make up more than 2/3 of the Medicaid population
Medicaid finances nearly half of all births in the US
11% of children <100% FPL still uninsured
Medicaid Expansion by State Supreme Court ruled that the ACA is constitutional, but said that states could
choose whether or not they want to expand Medicaid. CA is first to expand!
In CA, we
call Medicaid
“MediCal”
The Exchange
An online marketplace where individuals and
small businesses can compare and enroll in health
insurance plans with support from state and fed. govt.
Plans are regulated:
Essential Health Benefits
Preventive Services
with no co-pay or
deductible
The Exchange
Essential Health Benefits
Previously, only 10% of plans purchased on the
private market covered Maternity & Newborn care.
Now Essential, along with:
Ambulatory patient services;
emergency services;
hospitalization;
maternity and newborn care;
mental health and substance use;
prescription drugs; rehabilitative
and habilitative services and
devices; laboratory services;
preventive and wellness services
and chronic disease management;
and pediatric services, including oral and vision care
The Exchange
Essential Health Benefits
Preventive Services with no co-pay
Yearly physical, well women checks,
routine prenatal care visits,
early detection screenings,
immunizations, breast-
feeding counseling and
support and supplies,
contraceptive methods,
screenings for
domestic violence,
Autism screenings…
…and so much more!
The Exchange
An online marketplace where individuals can
compare and enroll in health insurance plans
Plans are regulated
Essential Health Benefits
Preventive Services
with no co-pay
Cannot be denied for
pre-existing conditions
or charged more
Cannot be charged more
for being a woman!
Covered California
www.coveredca.com
You can go online right now to find out how
much insurance will cost for you and your family
Open Enrollment begins October 1st, 2013
Benefits begin January 1st, 2014
Try using
this calculator
on Covered
California’s
website!
Choosing your Plan
There are four different levels of coverage
They all have same Essential Health Benefits
Pay more monthly or more at time of service?
Choosing your Plan
http://coveredca.com/PDFs/English/CoveredCA-HealthPlanBenefitsComparisonChart.pdf
Upcoming Challenges
Challenge 1: Education and Enrollment Certified Educators and Enrollers in the Community
Online
Challenge 2: What will happen to Safety Net Programs? What will happen to CMSP? How will people roll-over to expanded MediCal?
Healthy Families has rolled over to MediCal with some complications
Hospitals losing some funding to help pay for the ACA- what will happen?
FamPact, Every Women Counts, AIM, etc… what will happen in the long-term?
Challenge 3: The Remaining Uninsured Undocumented, those objecting for political reasons, and many others
Of the 60 million currently uninsured in the US,
30 million will still be uninsured by 2016
Remembering our Goals
Remembering our Goals
High quality, innovative medicine
Increasing access & affordability
Low-cost to insurers, providers, and patients
Keeping people healthy! Focus on Prevention
Long-term impacts on community wellness,
stronger local economies
Long-term decreases to medical costs
For Further Reading FAQ about the exchange:
CA: http://coveredca.com/frequently_asked_questions.html
News and Fact Sheets: Kaiser Family Foundation: http://kff.org/ Know your Care: http://www.knowyourcare.org/aca/ National Exchange Marketplace: http://www.enrollamerica.org/ National Association Of Community Health Centers: http://www.nachc.com/MedicaidExpansion.cfm
Preventive services: http://www.healthcare.gov/news/factsheets/2010/07/preventive-services-list.html
Preventive health for women: http://www.healthcare.gov/news/factsheets/2011/08/womensprevention08012011a.html
Quiz Go through these slides as a Powerpoint, and imagine that a
patient, a community member, or a friend is asking you this
question and try to think of what you would say to them.
Then click to check your answer!
You can also take this quick 10-question quiz online:
http://kff.org/quiz/health-reform-quiz/
Please email me: [email protected] if you have any
questions or want more information or resources
Please refer patients with more questions to Resource Clinic,
Wednesdays from 11am to 1pm.
Question 1
Q: What is the Individual Mandate?
A: A Federal Law requiring most citizens of the United States to
be enrolled in a health insurance plan, or pay a penalty.
Question 2
Q: Will I have to pay a penalty? (Give at least 3 examples of groups who are exempt)
A: Undocumented immigrants
Legal immigrants in U.S. less than 5 years
Income below the threshold for filing a tax return (In 2013: $10,000 for single, $20,000 for family)
If cheapest policy will still cost more than 8% of their annual household income
Individuals part of a religion opposed to acceptance of benefits for a health insurer
Incarcerated individuals
Members of a Native American Tribe
Question 3
Q: I heard that I will be penalized if I don’t get insurance. How bad is it going to be? (What are the tax penalties for being without insurance?)
A:
2014 - $95 per adult and $47.50 per child, up to $285 per family, or 1.0% of family income, whichever is greater
2015- $325 per adult and $162.50 per child, up to $975 per family, or 2.0% of family income, whichever is greater
2014 - $695 per adult and $347.50 per child, up to $2,085 per family, or 2.5% of family income, whichever is greater
Question 4
Q: What was the reason behind the Individual Mandate?
A:
Incentive for buy-in from healthy adults, spreads the risk between the
very healthy and the very sick, which makes the plan feasible for insurers
Without an individual mandate, health care economists project that premiums
would be affected by going up 2 to 40 percent.
Question 5
Q: A friend of mine received an $875 rebate check from his
insurer, what is a rebate check?
A: The health law says that most insurers must spend at least 80 percent
(85 percent for insurers covering large employers) of the premiums you pay
on medical care and quality improvements. If insurers spend too much on
overhead, such as salaries, bonuses, or administrative costs, as opposed to
health care, they must issue premium rebates to consumers each summer.
Question 6 Q: I heard that there are a bunch of free preventive
services now, what does this mean? A: Preventive services help prevent further complications, catch disease at an
earlier stage, or help keep people well.
Not Free – Covered by Insurance with no Share of Cost / Co-pay
Some examples (there are many more!) Blood Pressure screening for all adults
Colorectal Cancer screening for adults over 50
Depression screening for adults
Type 2 Diabetes screening for adults with high bp
Diet counseling for adults at higher risk
HIV screening for all adults at higher risk
Immunization vaccines for adults and children
Obesity screening and counseling for adults and children
Sexually Transmitted Infection (STI) testing and prevention counseling
Alcohol Misuse screening and counseling
Tobacco Use screening and counseling
Lead screening for children at risk of exposure
Well-woman visits to obtain recommended preventive services*
BRCA counseling about genetic testing for women at higher risk
Mammography screenings every 1 to 2 years for women over 40
Cervical Cancer screening for sexually active women
Breastfeeding comprehensive support and counseling from trained providers, as
well as access to breastfeeding supplies, for pregnant and nursing women*
Contraception: Food and Drug Administration-approved contraceptive methods,
sterilization procedures, and patient education and counseling, not including
abortifacient drugs*
Behavioral & Autism screening for children at 18 and 24 months
Oral Health risk assessment for young children
Fluoride Chemoprevention supplements for children
Vision screening for all children
Question 7
Q: I saw that I am still going to have a deductible and have a
bunch of co-pays on top of my premium with the plan I want
on the exchange, but I thought the point was to make sure I
don’t go broke. What’s keeping me from having tens of
thousands of dollars of debt if I get cancer? Or hit by a car?
A: There are “Maximum Out of Pocket” annual limits included in
each plan. This is supposed to keep costs within a reasonable
amount in the event of catastrophic injury or illness.
Question 8
Q: I just turned 27 and am now off my parents’ insurance. I
only make 15,000 dollars a year, which I know is slightly
higher than the Federal Poverty Limit (FPL). What health
insurance options do I have?
A: Medicaid now goes up to 138% for childless adults, if you live in a
state which expands Medicaid. You can also purchase insurance on the
exchange with a government subsidy, if you want.
Question 9
Q: I work with homeless patients who usually have a
really hard time with all the follow-up paperwork to get
MediCal, even though they were already eligible. How
does the ACA make it easier for people to access benefits
they already are entitled to?
A:
No longer have to prove residency/address/citizenship - gets directed straight
to homeland security; you can write in “no fixed address.”
Don’t have to prove income - gets directed straight to IRS
Single access point - can use exchange site to get MediCal
Funds in act for more outreach enrollment workers
Question 10
Q: My family came into the country as undocumented
immigrants, but I just got approved to start my path to
legal residency through the Dream Act. I have been in
the country way more than 5 years. Will I be able to buy
insurance on the exchange with my own money?
A:
No. But this may change depending on current immigration talks
Further reading:
Young Immigrants Shut Out of Health Reform
Lawfully Present Individuals – definition on coveredca
Question 11
Q: Where can I go to find out about the exchange
marketplace in California?
A: Covered California! www.coveredca.com
Question 12
Q: When is the open-enrollment period?
What does that mean?
A: Open enrollment begins October 2013, through March 2014. Future
enrollment will be open only from October through December.
After open enrollment, you are locked into your plan for the coming year,
but you can change during the next open enrollment.
You must purchase health insurance during the open enrollment period in
order to obtain coverage. If you do not enroll during this period, you will
not be assured a health plan will cover you – either through Covered
California or in the private market.
Question 13
Q: Will I be covered once I’ve registered on Covered
California’s exchange during open enrollment?
A: No, benefits will not start until January 1st, 2014
Question 14
Q: How do I choose what plan is best for me?
A: You can compare plans on coveredca.com
Individuals enrolled in a level with higher monthly premiums, will pay less
when coverage is needed. Individuals enrolled in a level with lower monthly
premiums, will pay more when coverage is needed.
All plans are eligible for federal subsidy, but even if a subsidy-eligible
person chooses a Bronze, Gold, or Platinum plan, his or her subsidy amount
is calculated based on the benchmark Silver Plan.
Question 15 Q: The reason that I don’t have health insurance is not that I don’t
want it, it’s just that it’s been too expensive for me. How is shopping online on this exchange thing supposed to make health insurance more affordable for me?
A: You can compare plans more easily instead of having to apply to each company
separately and then comparing prices for different levels of benefits Tax credits: Tax credits are available to lower the cost of health coverage for
individuals and families who meet certain income requirements and do not have health insurance from an employer or a government program. When you enroll in a health plan through Covered California, tax credits can be immediately applied to the insurance premium, which reduces the amount you pay each month.
Cost-sharing subsidies: Cost-sharing subsidies reduce the amount of out-of-pocket health care expenses an individual or family has to pay. These expenses might include the copayments for health care services or other costs.
Expanded MediCal! You may now be covered for free public insurance.