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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. Health Insurance in Wisconsin Today. TRICARE Military. Providers Doctors Specialists

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The affordable care act

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


The affordable care act

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


The affordable care act

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


The affordable care act

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


The affordable care act

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


Badgercare today

BadgerCare Today

Health Insurance Exchanges for Individuals and Small Groups


Governor s plan badgercare in 2014

Governor’s Plan: BadgerCare in 2014

Health Insurance Exchanges for Individuals and Small Groups


The affordable care act

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


The affordable care act

Marketplace Functions

  • Traffic Cop

  • Competition Manager

  • Subsidy Delivery

Individual

Marketplace

SHOP

Marketplace


The affordable care act

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


Levels of coverage available

Levels of Coverage Available

Source: Community Catalyst & Georgetown University Health Policy Institute


Low income cost sharing subsidies

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


Premiums based on income

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


Subsidies for low income people

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


How subsidies are delivered

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


Estimated premiums for individuals

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).


Estimated premiums for a family

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).


The affordable care act

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.


The affordable care act

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


The affordable care act

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


The affordable care act

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


The affordable care act

Free Preventive Care

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


The affordable care act

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.


Healthcare gov

healthcare.gov

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


E4healthwi org

e4healthwi.org


In person assistance

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


The affordable care act

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


The affordable care act

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


The affordable care act

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


The affordable care act

Thank you!

Please feel free to contact us:

Mike Bare, Research and Program Coordinator [email protected], 920.242.1639


Statewide outreach and enrollment efforts

Statewide Outreach and Enrollment Efforts

Updates from the

Wisconsin Primary Health Care Association


Overview

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!


Enrollment assistance today

Enrollment Assistance Today

A few examples:

  • Income Maintenance Agencies

  • Agents and Brokers

  • Hospital/Clinic enrollment staff

  • CAP Agencies

  • ADRCs

  • Public Health

  • Veterans

  • Insurance Companies


New categories of enrollment assisters created by aca

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


Mobilizers

Mobilizers!

Mobilizers


Overview1

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!


Regional enrollment network strategy

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.


Overview2

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!


Four key messages to reach most uninsured

Four Key Messages to Reach Most Uninsured

One of these = top message for 89% of population

Source: Enroll America


1 message

#1 Message

HEALTHCARE.GOV


Overview3

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!


The affordable care act

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


Overview4

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!


Tools and resources

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


In person assistance1

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


Questions follow up

Questions/Follow-Up

Lisa Olson

[email protected]

608-277-7477


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