The Affordable Care Act

1. The Affordable Care Act The Impact of the Affordable Care Act on Prevention in Wisconsin September 2013 David Riemer, Senior Fellow Michael Bare, Research and Program Coordinator Community Advocates Public Policy Institute

2. Overview • What the ACA Changes: • Changes in Who Gets Insurance Coverage • Changes in How to Obtain Insurance • Changes to What Benefits Are Provided • Implications for Wisconsin • Enrollment Mechanisms • Types of Insurance Coverage • Delivery Systems • Quality of Care • Cost and Inflation

3. 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

4. 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

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. DHS Plans for BadgerCare Member Outreach • September 20 • BadgerCare letters will be sent to: • BadgerCare Basic Plan members • BadgerCare Extension (TMA) members • BadgerCare Plus Core Waitlist • Those projected to be above 100% • October 1 • Individual phone calls • Priority 1: Individuals likely to be losing coverage • Priority 2: Individuals on Core waitlist Health Insurance Exchanges for Individuals and Small Groups Source: Olson, Lisa. Wisconsin Primary Health Care Association

9. 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 FFM Private Coverage SHOP FFM Grand-Fathered Plans Small Groups 1-50 FTEs Self-Insured Employer Large Groups 50+ FTEs

10. How the Marketplace Will Work Source: http://www.washingtonpost.com/blogs/wonkblog/wp/2013/02/14/inside-the-obama-administrations-plan-to-build-25-insurance-markets/

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 (capped at approximately $2,000 for an individual and $4,000 for a family), further “stretch” the value of their insurance. 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 • Subsidies will be provided by U.S. Treasury, as federal tax credits…but paid directly to health plan • Calculator for estimating subsidy: http://kff.org/interactive/subsidy-calculator/

15. 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).

16. 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).

17. 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

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 Employer Penalties At least 50 FTEs? No penalty for small businesses Start No No 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 FFM Private Coverage SHOP FFM 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 FFM SHOP FFM 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 reform of insurance system: • Coverage of children to age 26 on parents’ plans; • Bans lifetime and annual limits on coverage; • Ends rescissions of coverage; • A process for appealing insurance company decisions; and • Ban on discrimination because of pre-existing condition.

24. ACA’s Prevention and Public Health Fund The ACA authorizes $15 billion over 5 years for “expanded and sustained national investment in prevention and public health programs to improve health and help restrain the rate of growth” in health care costs. It has never been fully funded by Congress. Wisconsin has received more than $18.3 million in funding:

25. Medical Health Home Model • Coordinated Care for Medicaid recipients who have: • At least two chronic conditions, • One chronic condition with a risk of a second, or • One serious and persistent mental health condition. Wisconsin has created health homes for HIV/AIDS patients who also have at least one other chronic condition in Brown, Dane, Milwaukee and Kenosha Counties, and may do other health home models for other conditions.

26. In-Person Assistance • Wisconsin Enrollment Directory • E4HealthWI.org • 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. healthcare.gov and cms.marketplace.gov Overview of ACA, timeline of changes, Marketplace information, glossary of terms, brochures and other resources, blog, FAQs, sign up for email updates

28. Timeline September 20, 2013: Letters to BadgerCare enrollees October 1, 2013: Federally-facilitated marketplaces begin operations, DHS calls to BadgerCare enrollees October 1, 2013 to March 2014: Marketplace open enrollment January 1, 2014: Marketplace will be fully operational January 1, 2014: Medicaid changes begin

29. 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 FFM Private Coverage SHOP FFM Grand-Fathered Plans Small Groups 1-50 FTEs Self-Insured Employer Status Quo System Large Groups 50+ FTEs ACA Changes Essential Health Benefits

30. 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

31. Thank you! Please feel free to contact us: David Riemer, Senior Fellow driemermil@yahoo.com, 414.270.2943 Michael Bare, Research and Program Coordinator mbare@communityadvocates.net, 920.242.1639