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The Affordable Care Act:Overview of Coverage
ProvisionsDance/USA
2014 Dance ForumNew York, NY
January 10, 2014
Sarah J. Dash, MPHGeorgetown University Health Policy Institute
Center on Health Insurance Reforms
About the Georgetown University Center on Health Insurance Reforms
Research and analysis of private health insurance markets
Monitoring of state and federal health insurance market regulation
Analyze impact on affordability, adequacy, and availability of coverage
Projects generously funded by The Commonwealth Fund, Robert Wood Johnson Foundation, and others.
Presentation Overview
Health Insurance 101
The Affordable Care Act (ACA)Why was it needed and what does it do?
How the ACA Expands CoverageMarketplaces (individuals and small businesses)
Medicaid
Implementation So Far
What You Can Do Now
Q&A
Health Insurance 101: Where people get their coverage
Employer-sponsored coverageMedicaidUninsuredNongroup
56%21%
18%
6%
266.4 Million Non-elderly
Source: Kaiser Family Foundation
U.S.: Sources of Coverage for Non-elderly (2011)
2003 2010 2003 2010 2003 20100
25
50
75
100
6661
8580
95 94
5849
7671
90 88
42
33
56 55
73 71
Employer offers Employee eligible Covered by own employer
Health Insurance 101: Fewer Small Businesses Offering Coverage, 2003–2010
^ Workers include both part-time and full-time workers who are not self-employed.Source: The Commonwealth Fund Biennial Health Insurance Surveys (2003 and 2010).
Percent of working adults^ ages 19–64
Small firms(<50 employees)
Large firms(>100 employees)
Midsize firms(50–99 employees)
Why the Affordable Care Act? (Dysfunctional Insurance Markets)
Access Problems– Coverage denied due to pre-existing conditions– Rescissions (retroactive policy cancellations)
Affordability Problems– No employer or other subsidy– “Rate ups” for health status, gender, age
Adequacy Problems– Pre-existing condition exclusions– Critical benefits not covered– Out-of-pocket costs– Annual/lifetime limits on coverage
Why the Affordable Care Act? Everyone feeling the pain…
For individuals:– Barriers to care: prevention and treatment– Financial difficulties– “Job lock”– Personal anxiety, family stress
For businesses:– Skyrocketing health care costs crowd out higher
salaries or other business investments
For government:– Deficits, budget battles
Why the Affordable Care Act?Many Cooks in the Kitchen…
218 votes in the House
60 votes in the Senate
50 state legislatures, governors, insurance commissioners, and Medicaid directors (plus DC)
17 (ish) directors of state-based Marketplaces
3 federal agencies (HHS, DOL, IRS)
Plus… insurers, doctors, businesses, agents/brokers, consumer advocates, and other stakeholders….
Key ACA Coverage Provisions
Availability– New rules of the road for health insurance– Opens new doors for coverage
Affordability– More rules of the road for health insurance– Financial help with premiums and cost sharing
Adequacy– New standards for benefits and plan design
ACA Coverage Provisions: Availability
New rules of the road for health insurance:– Prohibits coverage denials/higher premiums based on health
status, gender, occupation
New Health Insurance Marketplaces– One stop shop for coverage, in every state)
Medicaid expansion – In some states
Other coverage provisions:– Enables dependents to stay on their parents’health plan
until age 26.
Critical Coverage Provisions: Affordability
More “Rules of the Road” for health insurance– Ends higher premiums based on health status– Ban on lifetime and annual dollar limits– Limits out-of-pocket costs– Insurers must spend at least 80% of premium revenue on
health care and quality improvements
Financial help for private insurance and Medicaid– Subsidies (premium tax credits) for individuals/families with low
to moderate incomes buy health insurance
Tax credits for small businesses that provide affordable coverage to their employees
Critical Coverage Provisions:Adequacy
Essential health benefits
Preventive services covered with no additional cost-sharing
NOTE: Health insurance plan choices may still vary based on factors such as cost sharing, networks,
and the extent of covered services!
Under Reform - 2019
Employer
156 million
56%
Medicaid/CHIP48 million
17%
Nongroup & Other
27 million 10%
Private Exchanges23 million
8%
Uninsured26 million
9%
Employer
161 million
58%
Medicaid/CHIP32 million
11%
Uninsured57 million
20%
Nongroup & Other
30 million 11%
Without Reform - 2019
280 Million U.S. Residents Under Age 65
What Does it Mean for Coverage?U.S. Coverage in 2019, With and Without the ACA
Source: Congressional Budget Office, March 2012 Estimate of the Effects of the Affordable Care Act on Health Insurance Coverage
What Else Does the ACA Do?
ACA: More than coverage reforms
Not discussed today:– Delivery system reform– Quality improvement– Cost containment– Public health/prevention– Medicare
What Does the ACA not Do?
It doesn’t fix everything all at once for every person
It’s not a “government takeover” – builds on current system
It doesn’t make health insurance more fun (but it might make it easier)
Marketplace Basics
One-stop-shop for coverage– Individuals without other affordable coverage– Small businesses (SHOP marketplace)
Compare private insurance plans based on price, benefits, quality, and other features
Most people will get a break on costs
Coverage Levels in Marketplace
40%
30%
20%
90%
80%
70%
60%
10%
0% 20% 40% 60% 80% 100%
% covered by plan% enrollee cost share
Platinum
Bronze
Gold
Silver
Additional “catastrophic” plan available to individuals under age 30 or if no other coverage is affordable
*All levels have essential health benefits
Who Is Eligible?
Marketplace SHOP
To buy coverage
U.S. citizen or legal residentNot incarcerated
Up to 50 full-time employees (up to 100 in 2016)Self/employed or sole proprietors go to individual marketplaceMust offer coverage to all full-time employees
For financial help
Income up to 400% of the poverty levelNot eligible for other “minimum essential coverage”
Tax credits up to 50% of employer’s costLess than 25 FTE employees, <$50K average wages, and employer pay 50% of premium
Types of Financial Assistance:(Individual Marketplace)
Premium Tax Credits (subsidies)– Individuals and families between 100 - 400% of
poverty, who aren’t eligible for affordable/adequate job-based insurance, Medicaid, or Medicare
Help with Cost-sharing (deductible, copays, and coinsurance)– Individuals/families up to 250% poverty ($28,725
individual)
>$45,960;>400% of FPL
Job-based coverage, or Full-cost Marketplace coverage
$34,470-45,960; 300-400% of FPL
Job-based coverage, or Marketplace coverage: premiums capped at 9.5% of
income by tax credits
$22,980-$34,470;200-300% of FPL
Job-based coverage, or Marketplace coverage: premiums capped at 6.3 –
9.5% of income by tax credits
<$15,856; < 138% FPL
Medicaid (depending on state)
Fam
ily
Inco
me
2014: ACA Provides Support Fitted to Income
Family income based on 2013 federal poverty income levels for an individual
Premium Tax CreditsPremiums capped at 2-9.5% of income, on sliding scale.
Value of credit linked to second lowest-cost silver level plan, but can “go shopping” with tax credit and choose any metal tier level of plan.
Tax credits can be paid directly to insurer. Enrollee only owes the difference. Insurers must have ways to accept payments from people who lack credit cards and bank accounts.
Note! Individuals must report changes in income throughout the year or risk
paying back some or all of tax credits to IRS.
Cost Sharing Help
No cost-sharing for recommended preventive services
Out-of-pocket maximums ($6350 for individual)
Cost sharing reductions: deductibles and copays reduced for families under 250% FPL
% of FPL 100-200% 200-300% 300-400% 400%+Annual Out-
of-pocket Maximum
individual $2,017 $3,025 $4,033 $6,050
family $4,033 $6,050 $8,067 $12,100
SHOP: Features of Note for Small Businesses
Ability to more easily compare plans– Online enrollment starts in 2015 for federal SHOP
marketplace
“Employee choice”: Ability to give employees a choice of plans – Currently available in most state-based marketplaces– Starts in 2015 for federal SHOP marketplace
Small Business Tax Credit– Only through SHOP starting in 2014
Timeline for Coverage
Individuals:– Initial Open Enrollment: October 1, 2013 –
March 31, 2014– Annual Enrollment: Nov. 15-Jan. 15, 2015– Special enrollment periods for qualifying
events– First effective date is January 1, 2014 (must
enroll by December 15, 2013)
Small businesses: continuous enrollment
ACA’s Medicaid Expansion
Before ACA:– Medicaid generally not
available to single (childless) adults
– Income eligibility levels vary by state
– Federal minimum benefit requirements; states may modify
After ACA:– States may choose to
make single (childless) adults eligible up to $15,856 for a single person
– Expansion decisions vary by state
– Required “benchmark” benefit package must cover Essential Health Benefits; may vary from state to state
ACA Implementation So Far
States of the States:– Insurance Market Reforms: Most (but not all) states
are enforcing the market reforms– Health Insurance Marketplaces: 14 states plus DC
fully running individual and SHOP marketplaces this year
– Medicaid: 26 states expanded to date
Some Bumps in the Road to be expected…
But Enrollment is Picking Up
States Running Their Own Marketplaces
California
Colorado
Connecticut
District of Columbia
Hawaii
Idaho (in 2015)
Kentucky
Maryland
Massachusetts
Minnesota
Nevada
New Mexico (SHOP only)
New York
Oregon
Rhode Island
Utah (SHOP only)
Vermont
Washington
What Individual Dance Artists Need to Know
Responsibility for obtaining coverage (individual mandate)
How to access coverage (Marketplaces/Medicaid)
Other coverage options
What to look for in health insurance coverage
How to get assistance
What Small Companies Need to Know
No responsibility to provide coverage if <50 full-time employees
SHOP Marketplaces
Small Business Tax Credits
How to get help
What Large Companies Need to Know
Employer responsibility to provide affordable, “minimum essential coverage” if > 50 full-time employees (enforcement delayed until 2015)
SHOP Marketplaces open to employers up to 100 employees in 2016
Other requirements applying to large employers– Not all requirements apply to self-insured or
“grandfathered” plans
How to Get Moving on Finding Coverage
Explore current coverage options
Visit healthcare.gov
Links to Marketplaces in every state
Create an account
Get personalized help:–Availability of free “assistors” or
agents/brokers–“Live talk” through call centers or “live
chat” on healthcare.gov
Ways to Enroll
In-person Assistance:
• Agents/Brokers
• Navigators
• Certified Application
Counselors
Some Special Considerations for Dance Artists
Know what you are buying– Marketplace vs. non-Marketplace coverage– Understand the tradeoffs (low premiums=higher cost-
sharing)– Understand terminology (deductible, co-pay)– Carefully review benefits in each plan– Tobacco “surcharge”
Provider networks and out-of-network benefits
Estimating income and reporting changes
Thank you!
Sarah J. Dash, MPHGeorgetown Health Policy Institute
Center on Health Insurance Reforms [email protected]
202-687-1405
http://chir.georgetown.edu/