Understanding ACA and What It Means For You

1. Understanding ACA and What It Means For You George L. Askew, MD, FAAP Chief Medical Officer Administration for Children and Families HPOG Annual Grantee Meeting November 6, 2013

2. Things You Should Know from the Start • The ACA is law • In most cases if you like your insurance you do NOT have to change • Upheld (legality confirmed) by the Supreme Court • However expansion of Medicaid became a state option – therefore varies by state • The requirement that all be insured was confirmed • Important upcoming activity – opening of Marketplaces • Who runs Marketplaces also varies by state

3. Resources • To find an up-to-date ACA training module from CMS visit http://www.cms.gov/Outreach-and-Education/Training/CMSNationalTrainingProgram/index.html • To check for updates on the new health care legislation, visit https://www.healthcare.gov/ • To view the Affordable Care Act, visit http://www.hhs.gov/healthcare/rights/law/index.html

4. Training Objectives • Review the Affordable Care Act (ACA) • Explain the Health Insurance Marketplace, Quality Health Plans, Medicaid • SHOP and Employer Mandate • Enrollment period, Enrollment Assistance and Review Timelines

5. Why I Think This is so Important? • The next step into the social justice frontier • “Of all forms of inequality, injustice in health care is the most shocking and inhumane.” Dr. Martin Luther King • The most significant social justice investment in my lifetime • Groundbreaking legislative change is not enacted often or easily

6. The Law and You

7. The Health Care Law In March 2010, President Obama signed into law theAffordable Care Act.

8. ACF and the Affordable Care Act (ACA) • Responsible for administering 4 ACA provisions: • Maternal, Infant and Early Childhood Home Visiting Program (Tribal only) (CB) • Personal Responsibility Education Program (FYSB) • State Abstinence Education (FYSB) • Health Profession Opportunity Grants (OFA)

9. The Health Care Law and You • Insurance companies could turn away the 129 million Americanswith pre-existing conditions • Premiums had more than doubled over the last decade, while insurance company profits were soaring • Tens of millions were underinsured, and many whohad coverage were afraid of losing it • 50 million Americans had no insurance at all

10. The Law Stops Insurance Companiesfrom Taking Advantage of You TODAY, it is illegal for insurance companies to: • Deny coverage to children because of a pre-existing condition like asthma or diabetes. • Put a lifetime cap on how much care they will pay for if you get sick. • Cancel your coverage when you get sick by finding a mistake on your paperwork. • And more…

11. The Law Strengthens Medicare • Free preventive services such as mammograms, colonoscopies and an annual wellness visit. • A 50% discount on covered brand-name medications for those in the prescription drug donut hole – an average savings of more than $650 per person. • Strong anti-fraud measures, including tougher penalties for criminals. https://www.healthcare.gov/if-i-have-medicare-do-i-need-to-do-anything/

12. The Law Provides Better Options for Getting Coverage • For millions of Americans who buy their own coverage, lose their coverage, or have no coverage at all, the law provides better options. • Young adults under the age of 26 can now stay on their parents’ health plans even if they’re: • Married • Attending school • Not living with their parents • Not financially dependent on them

13. What the Law Means: 7 Things to Know • Ends the worst insurance company abuses • Makes health insurance more affordable • Strengthens Medicare • Improves how care is delivered • Improves access to care • Provides better options for coverage • Numerous independent experts have confirmed that the law will not add a dime to the deficit

14. The Health Insurance Marketplace

15. The Health Insurance Marketplace • A new way to get health insurance • Enrollment starts October 1, 2013 • Coverage begins January 2014 • About 25 million Americans will have access to quality health insurance • Up to 20 million may qualify for help to make it more affordable • Working families can get help through the Marketplace https://www.healthcare.gov/marketplace/individual/

16. 3 Things to Know about the Marketplace… 1. It’s an easier way to shop for health insurance • Simplifies the search for health insurance • All options in one place • One application, one time, and an individual or family can explore every qualified insurance plan in the area 2. Most people will be able to get a break on costs • 90% of people who are currently uninsured will qualify for discounted or free health insurance 3. Clear options with apples-to-apples comparisons • All health insurance plans in the Marketplace present their price and benefit information in plain language

17. Marketplace Establishment • Each state can choose between: • State Based Marketplace – State creates and runs its own Marketplace • State Partnership Marketplace – State partners with Federal government to run some Marketplace functions • Federally Facilitated Marketplace – State has a Marketplace established and operated by the Federal government

18. Marketplaces Learn how the Affordable Care Act is helping people in your state http://www.hhs.gov/healthcare/facts/bystate/statebystate.html

19. Quality Coverage in the Marketplace https://www.healthcare.gov/what-does-marketplace-health-insurance-cover/

20. Catastrophic Plans • Who is eligible? • Young adults under 30 years of age • Those who obtain a hardship waiver from the Marketplace • What is catastrophic coverage? • Plans with high deductibles and lower premiums • Includes coverage of 3 primary care visits and preventive services with no out-of-pocket costs • Protects consumers from high out-of-pocket costs https://www.healthcare.gov/can-i-buy-a-catastrophic-plan/

21. Medicaid and CHIP • Medicaid and the Children’s Health Insurance Program (CHIP) • Eligibility for health coverage extended under the new law • Simplifies eligibility • Coordinated with new Qualified Health Plan coverage • No wrong door if you apply through the Marketplace • Streamlined application for affordability programs • New website with program information and option to enroll

22. Medicaid Eligibility in 2014 • Creates new opportunities for states to expand Medicaid eligibility to • Adults ages 19 – 64 with incomes up to 133% of the Federal Poverty Level (FPL) ($15,282/year for an individual, $31,322/year for a family of 4 (2013 amounts)) • Ensures Medicaid coverage for all children • With incomes up to 133% of the FPL • Shifts to simplified way of calculating income to determine Medicaid/CHIP eligibility • Known as Modified Adjusted Gross Income (MAGI)-based method

23. Medicaid Expansion: As of September 3, 2013 • 26 Moving forward • AZ, AR, CA, CO, CT, DE, D.C., HI, IL, IA, KY, MD, MA, MI, MN, NV, NJ, NM, NY, ND, OH, OR, RI, VT, WA, WV • 22 Not moving forward at this time • AL, AK, FL, GA, ID, IN, KS, LA, ME, MS, MO, MT, NE, NC, OK, SC, SD, TX, UT, VA, WI, WY • 3 States in an ongoing debate • NH, PA, TN Sept 3: Source: http://kff.org/medicaid/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/

24. Small Business Health Option Program (SHOP) • 50 or fewer full-time equivalent (FTE) employees is considered a small business under the health care law (full time is 30 hours per week) • Small business employers may get employee insurance through the SHOP Marketplace—applies to non-profit organizations too • Beginning in 2016, the Small Business Health Options Programs (SHOP) will be open to employers with 100 or fewer FTEs

25. Small Business Health Option Program (SHOP)-Benefits • SHOP helps level the playing field for small employers • Employers can pool risk and gain the leverage enjoyed by their larger competitors • Small-business owners have already taken advantage of tax credits up to 35 percent of their premium contribution, which increases to 50 percent next year

26. Large Business • 50 or more employees are considered a "large business" under the health care law. • Important parts of the law apply: • Most large employers can’t use the SHOP Marketplace • SHOPs will be open to employers with up to 100 FTEs in 2016 • The Employer Shared Responsibility Payment for 2015 applies to some larger employers in 2015 • May have to make a payment if you have 50 FTE and at least one of them gets lower costs through the Marketplace • New reporting responsibilities • Payments if affordable coverage not offered to FTE

28. Key Points to Remember • You have choices • Employer-based coverage will continue • Insurance will continue to be sold outside of the Marketplace • Purchase from Marketplace not required • The Marketplace is the only place to get the • New premium tax credits • Cost-sharing reductions

29. Who Can Enroll and How?

30. Eligibility and Enrollment • Marketplace eligibility requires you to • Live in its service area, and • Be a U.S. citizen or national, or • Be a non-citizen who is lawfully present in the U.S. for the entire period for which enrollment is sought • Not be incarcerated • Can apply for Marketplace if pending disposition of charge • Can apply for Medicaid/CHIP at any time https://www.healthcare.gov/am-i-eligible-for-coverage-in-the-marketplace/

31. Timelines

32. When You Can Enroll in the Individual Market • Marketplace Initial Open Enrollment Period Starts October 1, 2013 and ends March 31, 2014 • Annual Open Enrollment Periods after that start on October 15 and end on December 7 • Special Enrollment Periods available in certain circumstances during the year

33. Enrollment Assistance • Toll Free Call Center • 1-800-318-2596 (TTY 1-855-889-4325) • Customer service representatives - 24/7 • English and Spanish • Language line for 150 additional languages • Certified Assisters • Navigators program • Non-Navigator in-person assisters • http://marketplace.cms.gov/help-us/cac.html • Agents and brokers • HealthCare.gov and state Marketplace websites https://www.healthcare.gov/how-do-i-get-help-enrolling-in-the-marketplace/

34. Want More Information About the Marketplace? • Stay Connected • Sign up to get email and text alerts at signup.healthcare.gov • Updates and resources for partner organizations are available at Marketplace.cms.gov • Twitter@HealthCareGov • facebook.com/Healthcare.gov • Twitter@ACFHHS_GAskewmd

35. The Health Care Law and You Not “The End” but “The Beginning”