The Affordable Care Act: Overview of Coverage Provisions

1. The Affordable Care Act: Overview of Coverage Provisions Dance/USA 2014 Dance Forum New York, NY January 10, 2014 Sarah J. Dash, MPH Georgetown University Health Policy Institute Center on Health Insurance Reforms

2. 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.

3. Presentation Overview • Health Insurance 101 • The Affordable Care Act (ACA) • Why was it needed and what does it do? • How the ACA Expands Coverage • Marketplaces (individuals and small businesses) • Medicaid • Implementation So Far • What You Can Do Now • Q&A

4. Health Insurance 101

5. Health Insurance 101: Where people get their coverage 266.4 Million Non-elderly U.S.: Sources of Coverage for Non-elderly (2011) Source: Kaiser Family Foundation

6. Health Insurance 101: Fewer Small Businesses Offering Coverage, 2003–2010 Percent of working adults^ ages 19–64 Large firms (>100 employees) Small firms (<50 employees) Midsize firms (50–99 employees) ^ 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).

7. In the Spotlight: Health Insurance for Individuals and Small Businesses

8. Why the Affordable Care Act?

9. Why the Affordable Care Act?

10. 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

11. 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

12. 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….

13. The Affordable Care Act: How Does it Help Expand Coverage?

14. 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

15. 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.

16. 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

17. 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!

18. What Does it Mean for Coverage? U.S. Coverage in 2019, With and Without the ACA Private Exchanges 23 million 8% Medicaid/CHIP 32 million 11% Uninsured 26 million 9% Uninsured 57 million 20% Medicaid/CHIP 48 million 17% Nongroup & Other 27 million 10% Nongroup & Other 30 million 11% Employer 161 million 58% Employer 156 million 56% Without Reform - 2019 Under Reform - 2019 280 Million U.S. Residents Under Age 65 Source: Congressional Budget Office, March 2012 Estimate of the Effects of the Affordable Care Act on Health Insurance Coverage

19. 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

20. 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)

21. Opening the Door to Health Insurance Coverage: Marketplaces and Medicaid

22. Health Insurance Marketplaces

23. 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

24. Coverage Levels in Marketplace % enrollee cost share % covered by plan Additional “catastrophic” plan available to individuals under age 30 or if no other coverage is affordable Platinum *All levels have essential health benefits Gold Silver Bronze

25. Who Is Eligible?

26. 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)

27. 2014: ACA Provides Support Fitted to Income Family Income Family income based on 2013 federal poverty income levels for an individual

28. Premium Tax Credits • Premiums 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 yearor risk paying back some or all of tax credits to IRS.

29. 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

30. 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

31. 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

32. Medicaid Under the Affordable Care Act

33. 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

34. Coverage Gap for People in Poverty Source: Kaiser Family Foundation

35. Implementation So Far

36. 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

37. 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

38. The Affordable Care Act: What Dance Artists and Companies Need to Know

39. 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

40. 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

41. 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

42. What You Can Do Now

43. 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

44. Ways to Enroll • In-person Assistance: • Agents/Brokers • Navigators • Certified Application • Counselors

45. Special Considerations for Dance Artists

46. 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

47. Questions?

48. Thank you! Sarah J. Dash, MPHGeorgetown Health Policy Institute Center on Health Insurance Reforms sd850@georgetown.edu 202-687-1405 http://chir.georgetown.edu/