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Affordable Care Act: Find Your Way Around the Health Care Law . Educational Series-Promoting Good Health . David Parra Associate State Director- Multicultural Outreach , AARP Arizona . Agenda People with health insurance People who are uninsured or buy their own coverage

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affordable care act find your way around the health care law

Affordable Care Act: Find Your Way Around the Health Care Law

Educational Series-Promoting Good Health

David Parra

Associate State Director- Multicultural Outreach, AARP Arizona

slide2

Agenda

    • People with health insurance
    • People who are uninsured or buy their own coverage
    • People with Medicare
    • Small business owners
slide4

Adds More Consumer Protections

    • Premium increases of 10% or more must be justified.
    • 80% to 85% of health insurance premiums must be spent on care; otherwise, refunds will be given to policyholders.
    • No excessive premiums can be charged (ratios allowed: 3 to 1 and 1.5 to 1).
  • (continues)
slide5

Adds More Consumer Protections

    • Coverage can’t be dropped if you get sick or for making an honest mistake on the application.
    • Pre-existing conditions can’t be used to deny coverage or charge more.
    • No limits can be placed on coverage – lifetime (now), annual (2014).
  • (continues)
slide6

Adds More Consumer Protections

    • More free preventive services must be offered, such as immunizations, and screenings for diabetes and certain cancers (including mammograms and colonoscopies). Women’s services are also included.
    • Young adults can remain on family policy until age 26.
slide7

People Who Are Uninsured

Or Buy Their Own Coverage

slide8

Creates a Health Insurance Marketplace

Initial

Open Enrollment Period

Oct. 1, 2013 – Mar. 31, 2014

Coverage Begins

as Early as

January 1, 2014

four levels of coverage
Four Levels of Coverage

* Based on average cost of an individual under the plan. Figures may not be the same for every enrolled person.

CATASTROPHIC & DENTAL PLANS will also be offered.

slide10

10 Essential Health Benefits

Doctor visits

Emergency services

Hospital care

Maternity and newborn care

Mental health and substance use disorder services, including behavioral health treatment

Prescription drugs

Rehabilitative services and habilitative services and devices

Laboratory services

Preventive and wellness services, and chronic disease management

Pediatric services, including oral and vision care

slide11

Out-of-Pocket Limits and SHOP

  • Plans will have out-of-pocket limits equal to those on Health Savings Accounts ($6,250 for individual and $12,500 for couple in 2013) – starts in 2015.
  • Marketplace will include a Small Business Health Options Program (SHOP).
slide12

Expands Medicaid (Optional for States)

  • States may receive 100% federal funding for 2014 through 2016, 95% in 2017, 94% in 2018, 93% in 2019, and 90% for 2020 and beyond.
  • Participating states provide a benchmark benefits package which must include the 10 essential health benefits.
  • Marketplace will screen for Medicaid and CHIP eligibility, but will refer, not process applications.
slide13

Insurance, Subsidies, and Penalties

  • Must be a citizen or national, lawfully present, not incarcerated, and live in the service area.
  • Advanced Premium Tax Credits will be available (help to pay for monthly premium).
  • Cost-sharing subsidies will be offered (help to reduce the out-of-pocket limits).

(continues)

slide14

Insurance, Subsidies, and Penalties

  • 0% to 133% (additional 5% of income not counted) - eligible for Medicaid in States that expand Medicaid (new resident 5-year rule applies).
  • 100% to 400% - eligible for advanced premium tax credit.
  • 100% to 250% - eligible for cost-sharing subsidy.

(continues)

slide15

Insurance, Subsidies, and Penalties

  • Employees with employer-based coverage are eligible for subsidies in the Marketplace only if their plan has an actuarial value of less than 60% or their premium share (individual) exceeds 9.5% of income.
  • Employers with more than 200 employees will be required to automatically enroll employees in their health plan. Employees may opt out if so choose.

(continues)

slide16

Insurance, Subsidies, and Penalties

  • Penalties for individual adults: $95 in 2014, $325 in 2015, and $695 in 2016 or1.0% of taxable income in 2014, 2.0% in 2015, and 2.5% in 2016 – whichever is greater. After 2016, increase will follow cost-of-living adjustment.

(continues)

slide17

Insurance, Subsidies, and Penalties

  • Penalty exemptions: financial hardship, religious objections, American Indians, no coverage for less than three months, undocumented immigrants, incarcerated individuals, those for whom the lowest cost plan option exceeds 8% of an individual’s income, and those with incomes below the tax filing threshold (in 2012 the threshold for taxpayers under age 65 is $9,750 for singles and $19,500 for couples).
slide19

Strengthens Medicare by:

  • Protectingand improving guaranteed benefits.
  • Cracking down on waste and fraud.
  • Identifying savings that extend its financial stability.
slide20

Closes the Doughnut Hole by 2020

2014:

52.5% discount on brand name drugs

28% discount

on generics

2020:

Coverage gap will disappear

Part D cost sharing will remain

slide21

Part D: 2014 Drug Coverage

Stage 1

Initial

Coverage

Stage 2

No Coverage

“Doughnut Hole”

Stage 3

Catastrophic Coverage

52.5% disc. - brand

You pay: 5% of drug costs

$0 - $2,850

$2,850 - $4,550

$4,550+

Out-of-Pockets:

Deductible

Copayment

Coinsurance

Premium - not counted

28% disc. - generic

Closes by 2020

Coinsurance

0% - Insurance

100% - You

Coinsurance

95% - Insurance

5% - You

Coinsurance

75% - Insurance

25% - You

slide22

www.aarp.org/doughnuthole

You pay: 5% of drug costs

slide23

Adds Free Preventive Services

  • An annual wellness visit.
  • Screenings for diabetes and certain cancers (mammograms and colonoscopies).
  • Certain vaccines.
  • Applies also to Advantage plans.

Call Medicare at 1-800-633-4227

www.medicare.gov

slide24

Other Important Items

Offers bonus and extra payments to promote quality care and encourage doctors and nurses to serve under-served communities.

Improves home care coordination: face-to-face visits from certain health practitioners (certification of home health services) - visits must occur within 90 days before you receive home health care or 30 days after you start care. (continues)

slide25

Other Important Items

Higher Part D premium for higher income earners (applies also to Part B) - $85K for individuals/$170K for couples.

Higher Part A contribution (FICA) for higher income earners - $200K-individuals/$250K-couples (0.9% increase) *not applicable to employer.

More information about

nursing homes required.

tax credits to offset insurance costs
Tax Credits to Offset Insurance Costs
  • Phase I: 35% of contribution (25% for Tax-Exempt) / 2010-2013 / three requirements:
    • Fewer than 25 full-time employees (30 hours).
    • Under $50K average annual wages.
    • Pay at least 50% of employee premiums.
    • Phase II: 50% of contribution (35% for Tax-Exempt) / 2014 and beyond / same requirements.
    • Full credit if fewer than 10 full-time employees, with under $25K average annual wages.
insurance options and penalties
Insurance Options and Penalties
  • Companies with under 50 full-time equivalent employees – no requirement, no penalty.
  • Companies with 50 or more full-time equivalent employeeswho do not offer health insurance and have at least one employee receiving a premium tax credit in the Insurance Marketplace will pay $2K a year per employee – first 30 are exempt.

(continues)

insurance options and penalties1
Insurance Options and Penalties
  • Companies with 50 or more full-time equivalent employees who do offer health insurance but have at least one employee receiving a premium tax credit in the Insurance Marketplace will pay the lesser of $3K a year per employee receiving the credit or $2K per full-time employee – first 30 are exempt. (continues)
insurance options and penalties2
Insurance Options and Penalties
  • Companies with up to 100 employees will be able to obtain health insurance for their employees at the health insurance marketplace – SHOP.
  • Penalty implementation for businesses will start in 2015.
resources
Resources

www.healthcare.gov

www.healthlawanswers.org

www.healthlawfacts.org

www.healthlawresources.org

www.marketplace.cms.gov

www.hhs.gov/healthcare

www.azahcccs.gov

www.healthearizonaplus.gov

www.sba.gov/healthcare

(continues)

resources1
Resources

www.id.state.az.us/healthcarereform

www.irs.gov/sbhtc

www.smallbusinessmajority.org

www.kff.org

www.coveraz.org

www.aachc.org

www.medicare.gov

www.ssa.gov