The Affordable Care Act of 2010: What is Happening Next What You Need to Know.

The Affordable Care Act of 2010: What is Happening NextWhat You Need to Know

Training Sections

1. Recent History of Health Care Reform

2. Overview of Changes in Affordable Care Act (ACA)

3. Timeline of Major Changes

4. Resources

Training Section 1:Recent History of Health Care

Reform

4

Recent History

March 2010

U.S. Congress passed:

• Patient Protection and Affordable Care Act (HR 3590)

• Health Care and Education Reconciliation Act of 2010 (HR 4872)

5

Recent History

March 2010

President Obama signed into law, creating: • Patient Protection and Affordable Care Act

(Public Law 111-148)

• Health Care and Education Reconciliation Act of 2010 (Public Law 111-152 )

• Together, commonly known as The Affordable Care Act (ACA) of 2010

Training Section 2:Overview of Changes in

Affordable Care Act (ACA)

7

Overview

The Affordable Care Act (ACA) of 2010:

• Impacts many areas of health care

• Result of many compromises

• Does not go into effect all at once

• Relies heavily on state and local implementation

Overview

Affordable Care Act makes major changes in 4 basic areas:

1. Insurance company accountability

2. Lowering costs and improving quality

3. Increasing access and choice

4. Patient rights and consumer protections8

Key Strategies in Reform Approach

Adapted from Gerben DeJong, PhD, National Rehabilitation Hospital MedStar Health Research

Institute1. Leave “good enough” alone

– No drastic changes

2. Share the Responsibility– Everybody in the pool

3. Market-Based Solutions– Shift to competition for price and quality

4. Contain Costs– Focusing on the populations that have the highest health

care costs

5. Innovate and Test– Half of ACA text focuses on testing laboratories to avoid

implementation mistakes9

Overview: HealthCare.Gov

Training Section 3:Timeline of Major Changes

12

Explaining the Timeline

How Timeline Works:• Changes take effect over many years, through 2020

• Timeline shows when major reforms go into effect

• Designed to give more detailed information about changes coming soon, summarizes changes down the road

13

Explaining Timeline: [Date] [Type of Reform]

Who: Population reform impacts

Why: Need or problem reform is addressing

What: Specifics of what reform does

When: When reform goes into effect

How: Details of how reform will be implemented or accessed

TIMELINE: IN PROGRESS NOW

14

15

Timeline: In Progress Now Pre-existing Condition Insurance

Plans

Who: • People who can’t get insurance because of pre-

existing medical conditions, including mental health conditions

Why: • Before ACA, people with pre-existing conditions

often couldn’t get any insurance

16


Plans What:• People who can’t get insurance because of pre-

existing medical conditions can apply for a Pre-Existing Condition Insurance Plan (PCIP)

• Law limits premiums to “standard rates” - the average amount private insurers in the state charge for premiums for similar coverage

• Limits out-of-pocket expenses

– $5,950/year for individual (does not include premiums)

17


PlansWhat:• States can run PCIPs, with federal funding, or use

federal PCIP– 29 states chose to run plans themselves– 21 states chose to let the federal government run

them

• PCIPs in each state operate under ACA standards– But plans may vary from state to state

18


Plans What:• For people who live in states where the PCIP is run

by the federal government, there are now three options for plans: – Standard plan– Extended plan– Health savings account plan– For more information about these plans, go to:

http://www.healthcare.gov/news/factsheets/new_plan_options_2011.html

• The federal PCIP will now offer a special child-only rate for children under 18.

19


PlansWhen:• States letting the federal government run their PCIP:

– Can apply online now and get coverage within a month

• States running their own PCIP: – Different application and enrollment dates

20


PlansWhen:• PCIPs are meant to be temporary:

– End on January 1, 2014, when insurance companies won’t be allowed to deny people coverage because of pre-existing conditions

– On January 1, 2014, the state-run health insurance Exchanges will be operational.

21


PlansHow:• To apply for a PCIP you must:

– Be a U.S. citizen or lawfully present in the United States

– Have had no health coverage for the last 6 months – Have a pre-existing condition, as defined by each

PCIP

– You can apply no matter what your income is • To find details for your state:

www.HealthCare.Gov/law/about/provisions/pcip/index.html

22

Timeline: In Progress Now Money Follows the Person Grants

Who:• People on Medicaid who need long-term care services

Why:• In the past, Medicaid’s Money Follows the Person

grants have provided flexible funding that lets a person who needs long-term care services get services that are most appropriate to what they need and want

• MFP funding gives flexibility to move from institutional to community-based services and keep funding

23

Timeline: In Progress Now Money Follows the Person Grants

What:• ACA extends these grants and adds $2.25 billion in

funding• Broadens eligibility standards • Helps states pay for the costs of moving someone

from institution to home

When:• MFP grants have been extended until September 2016

How:• The program is continuing to operate as before

24

Timeline: In Progress NowRescission Outlawed

Who:• Anyone who has insurance and might get sick

Why:• Before ACA, when someone with insurance got sick

with an expensive or chronic illness, insurance companies would often go back and search their application for mistakes, looking for reason to drop their coverage

• This is called rescission, and happened to thousands of Americans each year

25

Timeline: In Progress Now Rescission Outlawed

What:• Under ACA, insurance companies aren’t allowed to

drop people’s coverage because they get sick

When:• Rescission is now illegal

How:• Department of Health and Human Services is

responsible for regulation and enforcement details

26

Timeline: In Progress Now Ban on Discriminating Against

Kids with PECWho:• Children under 19 with pre-existing conditions

Why:• Before ACA, insurance companies could legally deny

insurance to children because they had a pre-existing condition

What:• Under ACA, it is illegal for insurance companies to

deny or restrict insurance to children because of pre-existing condition

27

Timeline: In Progress Now Ban on Discriminating Against

Kids with PECWhen:• Applies to health plan years starting after

September 23, 2010

How:• As with any group plan, insurance companies may

decide to restrict enrollment to specific enrollment periods

• Department of Health and Human Services is responsible for regulation and enforcement details

28

Timeline: In Progress Now Expanded Coverage for Young

AdultsWho:• Adult children up to age 26

Why:• Before ACA, children were often dropped from

parents’ insurance plans when they turned 18 or finished college

• Many young people have difficulty finding jobs with employer-sponsored coverage and can’t afford to buy individual coverage, so they often would go without insurance

29

Timeline: In Progress Now Expanded Coverage for Young

AdultsWhat:• Children can stay on (or be added to) their parents’

insurance until they turn 26– Applies to plans that offer dependent coverage

When: • Open enrollment for coverage started on September

23, 2010 and was required by law to continue for at least 30 days, with annual open enrollment periods

• Finding Insurance Options

30

Timeline: In Progress Now Ban on Lifetime Coverage Limits

Who:• Anyone who has insurance or will ever use insurance

Why:• In the past, insurance companies have used lifetime

coverage limits to limit amount of money they will pay out for a customer’s health care needs

• If someone got sick and reached their lifetime coverage limit during treatment, the insurance company could just stop paying for treatment

31


What:• Insurance companies not allowed to put caps on

amount they will spend on lifetime coverage costs for essential benefits

• Essential benefits include things like hospital stays, doctor visits, and prescription drugs

32


When:• Ban started September 23, 2010, for all new

individual insurance plans and all group plans • Annual limits are restricted in all group plans and

new individual plans, until 2014, when banned completely

How:• The law includes a detailed list of essential benefits

that must be covered without limit

33

Timeline: In Progress Now Free Preventive Services - Private

CoverageWho:• Anyone who has private insurance

Why:• Before ACA, many health plans charged for

preventive services, so people often chose to skip them

• Preventive services can help avoid many costly health problems down the road

34


CoverageWhat:• Private insurance plans have to cover certain

recommended preventive services, like cancer screenings

• Insurance companies are required to offer these services free to patient - without deductible, coinsurance, or copayment charges

• Law ensures many free preventive health services for children, including many vaccines

35


CoverageWhen:• All new individual and group plans after September

23, 2010

How:• Coverage for these services is offered through

existing private insurance plans

36

Timeline: In Progress Now Improvements to Medicaid HCBS

Who:• People who use Medicaid’s Home and Community-Based

Services (HCBS)

Why:• In 2005, 1915(i) was added to Social Security Act

• Gave state Medicaid programs option to provide HCBS to people with disabilities before they need institutional care

• Many states did not choose to provide these services

37


What:• ACA changes and adds to Section 1915(i)

– Removes many barriers to states to offering these services

– Allows states to amend their plans instead of having to apply for waiver

– Improves quality of services and access to HCBS for people with disabilities

• Expands services that state can offer as part of HCBS

• Allows states to extend full Medicaid benefits to people using HCBS

38


When:• Changes went into effect on October 1, 2010

How:• As long as people meet a state’s eligibility

requirements, HCBS have to be offered to every eligible person in the state

• States can now provide services to people with incomes up to 300% of the Supplemental Security Income (SSI) Federal Benefit Rate ($2,022 per month in 2011)

39

Timeline: In Progress Now Drug Discounts for People in

Donut Hole

Who:• People who fall in Medicare’s donut hole

40


Donut Hole Why:• Under Medicare Part D, when person’s prescription drug

costs reach a certain amount ($2,840 in 2011): – Medicare stops paying for any prescription drug costs

– They have to pay for 100% of their drugs out-of-pocket, until they reach the maximum out-of-pocket amount

– Once they reach this maximum ($4,550.00), they are out of the donut hole - Catastrophic Coverage begins, and Medicare starts to help cover the costs again

41


Donut HoleWhat:• People in donut hole get up to 50% discount on brand

name drugs, 7% discount on generics for 2011 and 14% for 2012

• People who qualify for Extra Help, and join a Medicare drug plan, will have no coverage gap.

When:• Discount started January 1, 2011

– Will grow until 2020, when donut hole is closed completely

How:• Full cost of drugs (rather than discounted amount) still

counts towards person’s out-of-pocket maximum

42

Timeline: In Progress Now More Preventive Services Under

Medicare

Who:• Anyone on Medicare

Why:• Preventive services can help avoid many costly

health problems down the road

43


MedicareWhat: • People on Medicare can get a free wellness visit and

personalized prevention plan each year

• Must have had Part B for longer than 12 months

• No copayment, deductible, or coinsurance charges for recommended preventive services

44


MedicareWhen:• Started January 1, 2011

How:• Coverage for these services are offered through

existing Medicare plans

45

Timeline: In Progress Now Medicaid Community First Choice

OptionWho:• People with disabilities who are on Medicaid with

income less than or equal to 150% of Federal Poverty Level, or if greater, meet an institutional level of care

Why:• People with disabilities have the right to choose to

live in and receive services in their homes and communities whenever possible

46


Option

What:• Provides HCBS such as attendant services and

supports to increase a person’s ability to live in the community

• Allows Medicaid plans to choose HCBS as a rule, rather than the exception

When:• CFC Option will be effective October 1, 2011

47


Option

How:• ACA provides a 6 percentage point increase in

federal Medicaid match for states that choose the CFC Option

TIMELINE: BY 2012

48

49

Timeline: By 2012CLASS Act

Who:• Everyone

Why:• Paying for long-term care is expensive

– Many people can’t afford it and don’t budget for it

• People need options that give them more choice and flexibility about long-term care

50


What:• The Community Living Assistance Services and Support

Act (CLASS Act) provides for voluntary, self-funded, long-term care insurance through the workplace

• Insurance will help pay for long-term care costs for people with disabilities and elderly people

• People will be able to use cash benefit to pay for their choice of variety of long-term care services, including home health care workers, assistive technology, adult day care, transportation, or assisted living

51


When:• Departments of Health and Human Services (HHS)

will write rules about how much premiums will cost and what disabilities qualify for the insurance benefits

• Rules must be written by October 1, 2012

52


How:• Employers decide whether they want to participate

• If employer participates, people are auto-enrolled, can opt out

• Premiums taken through payroll deductions– Employers can pay premiums, not required

• Will be way for self-employed and employees of companies that don’t participate to choose to enroll

53


How:• People pay premiums for five years before they can

collect benefits, which will be a minimum average of $50 a day– Amount of benefit depends on assessment of disability– This benefit will not count as income when determining eligibility for

benefit programs like SSI, SSDI

• No income or asset limit

• There are eligibility criteria, but no screening for pre-existing conditions

• No lifetime benefit limit

TIMELINE: BY 2014

54

55

Timeline: January 1, 2014Ban on PEC Discrimination

Who:• Anyone with a pre-existing condition

Why:• Before ACA, insurance companies could legally deny

insurance to people because they had a pre-existing condition

What:• Under ACA, will be illegal for insurance companies to

deny or limit insurance to anyone because of a pre-existing condition

56

Timeline: January 1, 2014 Ban on PEC Discrimination

When:• Starting on January 1, 2014

How:• Department of Health and Human Services is

responsible for regulation and enforcement details

57

Timeline: January 1, 2014Expansion of Medicaid Eligibility

Who:• Low-income people who have previously made too

much money to qualify for Medicaid

• Low-income adults without children

• Low-income adults without a disability

Why:• Many people who did not qualify for Medicaid did

not have access to affordable insurance through their job, and did not make enough to be able to pay for private insurance

58


What:• Medicaid will expand to cover more low-income people

including adults without children, and adults without a disability

• Anyone below a certain income level will be eligible for Medicaid– Unlike current eligibility that is based on a

population or category (such as having a disability)

• Will help people with disabilities who did not meet the current Medicaid disability determination requirements

59


When:• Starting January 1, 2014• States can choose to expand Medicaid eligibility before

2014 • As of March 2011, 2 states (CT, MN) and the District of

Columbia have expanded Medicaid eligibility

How:• Expansion will include most people (age 19 and older)

with incomes up to 133% of Federal Poverty Level

(about $28,000 for family of 4)

60


People eligible for this Medicaid category cannot be:• Age 65 or older• Pregnant• Entitled to or enrolled in benefits under Medicare Part A• Enrolled under Medicare Part B, or:

• Part of any of the other “mandatory” groups described in the Medicaid law– Such as certain parents, children, or

people who are eligible because they get Supplemental Security Income (SSI) benefits

61


• Most people get benchmark (or benchmark-equivalent) benefits

• All rules that apply under the Medicaid program in general apply to this new eligibility group– Including rules related to cost sharing, retroactive

coverage, and immigration status

• This expansion also gets rid of the asset test for:– New eligibility group– People eligible through Medicare or other

programs– People with disabilities

62

Timeline: January 1, 2014State Health Insurance Exchanges

Who:• Everyone in private insurance market

Why:• In the past, it has been complicated for people to

compare private insurance plans

• People buying individual plans have not been able to negotiate for better prices, the way people buying group coverage can

63


What:• States will create exchanges, a marketplace where

people can comparison shop for standardized health packages

• Exchanges will provide way for individuals and small businesses to buy more affordable coverage

• People will also be able to join together in groups to negotiate more affordable group insurance

• Provides subsidies for low-income people on a sliding scale

64


What:• The exchanges inspect policies to make sure they

meet standards– Can ask companies to justify rate hikes

When:• Starts January 1, 2014

65


How:• Exchange packages will include essential health

benefits:• Outpatient care• Emergency services• Hospitalization• Maternity and newborn care• Mental health and substance use disorder services• Prescription drugs• Rehabilitative services and devices• Laboratory services• Preventive services and chronic disease management• Pediatric services

Training Section 4:Resources

67

HealthCare.Gov

• Finding Insurance Options

• Timeline

• Information for Specific Situations

• Comparing Quality of Facilities

• Information about Implementation

68

HealthCare.Gov• The ACA includes many new regulations

• Each new regulation goes through a period known as NPRM: Notice of Proposed RuleMaking

• During this period the public can comment, giving input and expertise about the proposed regulation before the final version of the regulation is written

• HealthCare.Gov has a section where you can find more information on regulations, including those with “NPRM” periods that are open for comment: http://www.healthcare.gov/center/regulations/index.html

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