The Affordable Care Act

1. The Affordable Care Act The Impact of the Affordable Care Act on Prevention in Wisconsin October 2013 Mike Bare, Research and Program Coordinator Community Advocates Public Policy Institute

2. Health Insurance in Wisconsin Today TRICARE Military Providers Doctors Specialists Hospitals Clinics Rx Drugs Etc. Government Coverage VA Some Veterans Uninsured Medicare Seniors and SSDI Insured Products HMOs PPOs FFS Etc. Insured Medicaid Low-Income, EBD, SSI, Pregnant Women & Children Individuals and Self-Employed Private Coverage Small Groups 1-50 FTEs Self-Insured Employer Large Groups 50+ FTEs

3. ACA’s Individual Mandate TRICARE Military Providers Doctors Specialists Hospitals Clinics Rx Drugs Etc. Exempt Government Coverage VA Some Veterans Uninsured Medicare Seniors and SSDI Insured Products HMOs PPOs FFS Etc. Insured Medicaid Low-Income, EBD, SSI, Pregnant Women & Children Individuals and Self-Employed Private Coverage Small Groups 1-50 FTEs Self-Insured Employer Large Groups 50+ FTEs

4. ACA and Medicare Medicare Seniors and SSDI • The ACA does not affect eligibility • Expands preventive care benefits with no copays or deductibles • Fills “Donut Hole” • Open enrollment is Oct. 15-Dec. 7 Questions? www.medicare.gov or 1-800-633-4227

5. ACA Changes BadgerCare for Adults TRICARE Military Providers Doctors Specialists Hospitals Clinics Rx Drugs Etc. Exempt Government Coverage VA Some Veterans Uninsured Medicare Seniors and SSDI Insured Products HMOs PPOs FFS Etc. Insured Medicaid < 100% of FPL, EBD, SSI, Pregnant Women & Children Individuals and Self-Employed Private Coverage Small Groups 1-50 FTEs Self-Insured Employer Large Groups 50+ FTEs

6. BadgerCare Today Health Insurance Exchanges for Individuals and Small Groups

7. Governor’s Plan: BadgerCare in 2014 Health Insurance Exchanges for Individuals and Small Groups

8. ACA Creates New Marketplaces TRICARE Military Providers Doctors Specialists Hospitals Clinics Rx Drugs Etc. Exempt Government Coverage VA Some Veterans Uninsured Medicare Seniors and SSDI Insured Products HMOs PPOs FFS Etc. Insured Medicaid < 100% of FPL, EBD, SSI, Pregnant Women & Children Individuals and Self-Employed Individual Marketplace Private Coverage SHOP Marketplace Grand-Fathered Plans Small Groups 1-50 FTEs Self-Insured Employer Large Groups 50+ FTEs

9. Marketplace Functions • Traffic Cop • Competition Manager • Subsidy Delivery Individual Marketplace SHOP Marketplace

10. How the Marketplace Works October 1, 2013 to March 31, 2014 and “Special Enrollment Periods” www.healthcare.gov 1-800-318-2596 By Mail In person

11. Levels of Coverage Available Source: Community Catalyst & Georgetown University Health Policy Institute

12. Low-Income Cost-Sharing Subsidies ACA cost-sharing subsidies, which reduce what low income people must pay for deductibles and co-pays, further “stretch” the value of their silver-level qualified health plan. Source: Adapted from Kaiser Family Foundation, http://kaiserfamilyfoundation.files.wordpress.com/2013/01/7962-02.pdf

13. Premiums Based on Income • Individuals who use Marketplace to buy insurance must pay premiums = % of their income based on the Federal Poverty Level. Source: Adapted from Kaiser Family Foundation, http://kaiserfamilyfoundation.files.wordpress.com/2013/01/7962-02.pdf

14. Subsidies for Low-Income People • People between 100-400% of the FPL will get subsidies if buying coverage in the Marketplace • Subsidy = Cost of 2nd lowest Silver Plan minusPremium based on income/poverty

15. How Subsidies Are Delivered • Subsidies will be provided by U.S. Treasury, as federal tax credits…but paid directly to health plan • Reconciled at the end of the year on tax returns • Calculator for estimating subsidy: http://kff.org/interactive/subsidy-calculator

16. Estimated Premiums for Individuals ACA Estimated Premium Payments: Individuals: 2013 Angeles, January. “Making Health Care More Affordable: The New Premium and Cost-Sharing Assistance.” Center on Budget and Policy Priorities. Updated April 3, 2013. http://www.cbpp.org/cms/?fa=view&id=3190. (These amounts assume the coverage provisions in health reform were in effect in 2013. The 2014 FPL has not yet been calculated).

17. Estimated Premiums For a Family ACA Estimated Premium Payments: Family of Four: 2013 Angeles, January. “Making Health Care More Affordable: The New Premium and Cost-Sharing Assistance.” Center on Budget and Policy Priorities. Updated April 3, 2013. http://www.cbpp.org/cms/?fa=view&id=3190. (These amounts assume the coverage provisions in health reform were in effect in 2013. The 2014 FPL has not yet been calculated).

18. Tax Credits for Small Businesses within SHOP Exchange Businesses with up to 25 employees (50 employees beginning in 2014) that offer insurance and pay wages below $50,000 can claim a tax credit of up to 35% of the cost of insurance.

19. ACA’s Large Employer Penalties At least 50 FTEs? No penalty for small businesses Start No Yes Those employees can buy FFM coverage and receive a subsidy. Did that occur? $2,000 penalty* per FTE (minus first 30) No Yes Coverage offered? Yes Does the coverage pay for at least 60% of health expenses AND does every employee pay less than 9.5% of family income for the coverage? Those employees can buy FFM coverage and receive a subsidy. Did that occur? $3,000 penalty* for each receiving a subsidy (up to a maximum of $2,000 per employee minus first 30) Yes No No penalty Yes * The penalty is annual and increases with the growth in insurance premiums. Source: ACA, and adapted from Kaiser Family Foundation

20. Essential Health Benefits TRICARE Military Providers Doctors Specialists Hospitals Clinics Rx Drugs Etc. Exempt Government Coverage VA Some Veterans Uninsured Medicare Seniors and SSDI Insured Products HMOs PPOs FFS Etc. Insured Medicaid < 100% of FPL, EBD, SSI, Pregnant Women & Children Individuals and Self-Employed Individual Marketplace Private Coverage SHOP Marketplace Grand-Fathered Plans Small Groups 1-50 FTEs Self-Insured Employer Status Quo System Large Groups 50+ FTEs ACA Changes Essential Health Benefits

21. Expanded Coverage Package •  Ambulatory patient services • Emergency services • Hospitalization • Maternity and newborn care • Mental health and substance use disorder services, • including behavioral health treatment • Prescription drugs • Rehabilitative and habilitative services and devices • Laboratory services • Preventive and wellness services and chronic • disease management • Pediatric services, including oral and vision care Medicaid < 100% of FPL, EBD, SSI, Pregnant Women & Children Individual Marketplace SHOP Marketplace Individuals and Self-Employed Small Groups 1-50 FTEs

22. Free Preventive Care The ACA provides first dollar coverage of all preventive care in Medicaid, Medicare and new plans.

23. ACA Insurance Reforms Several across-the-board reforms of insurance system: • Coverage of children up to age 26 on parents’ plans; • Bans lifetime and annual limits on coverage; • Ends rescissions of coverage; • A process for appealing insurance company decisions; • Medical Loss Ratio (MLR) rule (80% of premium must go • towards care and not admin costs); and • Ban on discrimination because of pre-existing condition.

24. healthcare.gov Overview of ACA, timeline of changes, Marketplace information, glossary of terms, brochures and other resources, blog, FAQs, sign up for email updates

25. e4healthwi.org

26. In-Person Assistance • Wisconsin Enrollment Assistance Directory • Navigator awardees: • Partners for Community Development • Northwest CEP • Legal Action of Wisconsin/Senior LAW • National Council of Urban Indian Health • National Healthy Start Association • R&B Solutions • Community Health Centers Source: Olson, Lisa. Wisconsin Primary Health Care Association

27. Timeline • October 1 • Open Enrollment Begins • DHS begins phone calls • March 31 • Open enrollment ends • December 15 • Last day to apply and pay premium for coverage beginning on 1/14 • September 20 • DHS sent BC letters • November 18 • DHS will begin to send official notifications of BC coverage ending • January 1 • Marketplace coverage may begin • BC changes begin • Individual mandate takes effect

28. Health Insurance in Wisconsin in 2014 TRICARE Military Providers Doctors Specialists Hospitals Clinics Rx Drugs Etc. Exempt Government Coverage VA Some Veterans Uninsured Medicare Seniors and SSDI Insured Products HMOs PPOs FFS Etc. Insured Medicaid < 100% of FPL, EBD, SSI, Pregnant Women & Children Individuals and Self-Employed Individual Marketplace Private Coverage SHOP Marketplace Grand-Fathered Plans Small Groups 1-50 FTEs Self-Insured Employer Status Quo System Large Groups 50+ FTEs ACA Changes Essential Health Benefits

29. Health Insurance Options in Wisconsin Beginning January 1, 2014 (With a Premium) (After Spend Down) (After Spend Down) BadgerCare Plus for 18-64 % of FPL 0% 100% 133% 150% 200% 250% 300% 400% FFM-facilitated QHP for legal aliens, no subsidy Individual FFM-Facilitated QHP QHP Actuarial Value with Cost-Sharing Subsidies 94% 87% 73% Percent of Income Paid Towards Premium Small Employer-Sponsored Insurance in the Private Insurance Market with No Tax Credits Large Employer-Sponsored Insurance in the Private Insurance Market or Self-Insured with No Tax Credits FF-SHOP-Facilitated Small Employer-Sponsored Insurance with Tax Credits for the Business TRICARE for some active members of the military and their dependents Medicare for 65+ and SSDI Recipients VA for some veterans and their dependents 9.5% 3% 2% 4% 6.3% 8.1% BadgerCare Plus for Children BadgerCare Plus for Pregnant Women

30. Thank you! Please feel free to contact us: Mike Bare, Research and Program Coordinator mbare@communityadvocates.net, 920.242.1639

31. Statewide Outreach and Enrollment Efforts Updates from the Wisconsin Primary Health Care Association

32. Overview • Enrollment Assistance today and in the future • Wisconsin’s coordinated approach to outreach and enrollment • Key outreach messages to share • Key dates • Coming Soon!

33. Enrollment Assistance Today A few examples: • Income Maintenance Agencies • Agents and Brokers • Hospital/Clinic enrollment staff • CAP Agencies • ADRCs • Public Health • Veterans • Insurance Companies

34. New categories of “Enrollment Assisters” created by ACA Certified Application Counselors and Navigators • Funding • Training & Certification (State and Federal) • Outreach • Additional Standards • Conflict of Interest

35. Mobilizers! Mobilizers

36. Overview • Enrollment Assistance today and in the future • Wisconsin’s coordinated approach to outreach and enrollment • Key outreach messages to share • Key dates • Coming Soon!

37. Regional Enrollment Network Strategy • Asset-Based Community Development model • Determine how every interested organization in Wisconsin can play a role in getting people covered • Coordinate training and education needs • Determine roles, responsibilities and capacity for each partner organization. • Determine education and training needs for each partner organization.

39. Overview • Enrollment Assistance today and in the future • Wisconsin’s coordinated approach to outreach and enrollment • Key outreach messages to share • Key dates • Coming Soon!

40. Four Key Messages to Reach Most Uninsured One of these = top message for 89% of population Source: Enroll America

41. #1 Message HEALTHCARE.GOV

42. Overview • Enrollment Assistance today and in the future • Wisconsin’s coordinated approach to outreach and enrollment • Key outreach messages to share • Key dates • Coming Soon!

43. Timeline • October • Open Enrollment Begins • DHS phone calls begin • December • 12/15: Last day to apply and pay premium for coverage beginning on 1/4 • March • 3/31: Open enrollment ends • September • REN Kick-Offs • DHS Sends BC letters • E4Health Website live • November • 11/18: DHS systems updated • DHS official notifications of coverage ending • January • Marketplace coverage begins • BC changes take effect • Individual mandate takes effect

44. Overview • Enrollment Assistance today and in the future • Wisconsin’s coordinated approach to outreach and enrollment • Key outreach messages to share • Key dates • Coming Soon!

45. Tools and Resources • www.dhs.wisconsin.gov/health-care/ • www.e4healthwi.org • www.marketplace.cms.gov • What can you do if you’re not certified? • Flowchart for making patient referrals • Q&As

46. In-Person Assistance • Wisconsin Enrollment Directory • Including: • Navigator awardees: • Partners for Community Development • Northwest CEP • Legal Action of Wisconsin/Senior LAW • National Council of Urban Indian Health • National Healthy Start Association • R&B Solutions • Certified Application Counselors • Agents and Brokers

47. Questions/Follow-Up Lisa Olson lolson@wphca.org 608-277-7477