1 the affordable care act the impact of the affordable care act on prevention in wisconsin october...

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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

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Health Insurance in Wisconsin Today

TRICAREMilitary

TRICAREMilitary

VASome Veterans

VASome Veterans

MedicareSeniors and

SSDI

MedicareSeniors and

SSDI

Individuals and Self-EmployedIndividuals and Self-Employed

Small Groups1-50 FTEs


Large Groups50+ FTEs


Insured Products

HMOsPPOsFFSEtc.

Insured Products

HMOsPPOsFFSEtc.

ProvidersDoctors

SpecialistsHospitals

ClinicsRx Drugs

Etc.

ProvidersDoctors


ClinicsRx Drugs

Etc.

UninsuredUninsured

InsuredInsured

Government Coverage

Government Coverage

Private Coverage

Private Coverage

Self-Insured

Employer

Self-Insured

Employer

MedicaidLow-Income, EBD,

SSI, Pregnant Women & Children

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ACA’s Individual Mandate

TRICAREMilitary

TRICAREMilitary

VASome Veterans

VASome Veterans

MedicareSeniors and

SSDI

MedicareSeniors and

SSDI






Insured Products

HMOsPPOsFFSEtc.

Insured Products

HMOsPPOsFFSEtc.

ProvidersDoctors


ClinicsRx Drugs

Etc.

ProvidersDoctors


ClinicsRx Drugs

Etc.

UninsuredUninsured

InsuredInsured

Government Coverage

Government Coverage

Private Coverage

Private Coverage

Self-Insured

Employer

Self-Insured

Employer

MedicaidLow-Income, EBD,

SSI, Pregnant Women & Children

Exempt

Exempt

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ACA and Medicare

MedicareSeniors and SSDIMedicare

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

http://www.medicare.gov/

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ACA Changes BadgerCare for Adults

TRICAREMilitary

VASome Veterans

MedicareSeniors and

SSDI

Medicaid< 100% of FPL,

EBD, SSI, Pregnant Women & Children

Individuals and Self-Employed



Insured Products

HMOsPPOsFFSEtc.

ProvidersDoctors


ClinicsRx Drugs

Etc.

Insured

Government Coverage

Private Coverage

Self-Insured

Employer

UninsuredUninsured

Exempt

Exempt

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BadgerCare Today

Health Insurance Exchanges for Individuals and Small Groups

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Governor’s Plan: BadgerCare in 2014

Health Insurance Exchanges for Individuals and Small Groups

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ACA Creates New Marketplaces

TRICAREMilitary

TRICAREMilitary

VASome Veterans

VASome Veterans

MedicareSeniors and

SSDI

MedicareSeniors and

SSDI






Insured Products

HMOsPPOsFFSEtc.

Insured Products

HMOsPPOsFFSEtc.

ProvidersDoctors


ClinicsRx Drugs

Etc.

ProvidersDoctors


ClinicsRx Drugs

Etc.

InsuredInsured

Government Coverage

Government Coverage

Private Coverage

Private Coverage

Self-Insured

Employer

Self-Insured

Employer

IndividualMarketplace

SHOPMarketplace

Grand-Fathered Plans




UninsuredUninsured

Exempt

Exempt

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Marketplace Functions


SHOPMarketplace

• Traffic Cop

• Competition Manager

• Subsidy Delivery

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How the Marketplace Works

www.healthcare.gov1-800-318-2596

By MailIn person

October 1, 2013 to March 31, 2014 and“Special Enrollment Periods”

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Source: Community Catalyst & Georgetown University Health Policy Institute

Levels of Coverage Available

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Source: Adapted from Kaiser Family Foundation, http://kaiserfamilyfoundation.files.wordpress.com/2013/01/7962-02.pdf

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.

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Individuals who use Marketplace to buy insurance must pay premiums = % of their income based on the Federal Poverty Level.

Premiums Based on Income

Source: Adapted from Kaiser Family Foundation, http://kaiserfamilyfoundation.files.wordpress.com/2013/01/7962-02.pdf

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• People between 100-400% of the FPL will get subsidies if buying coverage in the Marketplace

• Subsidy = Cost of 2nd lowest Silver Plan minus Premium based on income/poverty

Subsidies for Low-Income People

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• 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

How Subsidies Are Delivered

http://kff.org/interactive/subsidy-calculator/

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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).

Individuals Percentage of Poverty Line

Annual Income Percentage of Income Towards

Premiums

Annual Premium

100% $11,490 2.0% $228 150% $17,235 4.0% $684 200% $22,980 6.3% $1,452 250% $28,725 8.1% $2,316 300% $34,470 9.5% $3,264 350% $40,215 9.5% $3,816 400% $45,960 9.5% $4,368

http://www.cbpp.org/cms/?fa=view&id=3190

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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).

Family of Four Percentage of Poverty Line

Annual Income Percentage of Income Towards

Premiums

Annual Premium

100% $23,550 2.0% $468 150% $35,322 4.0% $1,416 200% $47,100 6.3% $2,964 250% $58,875 8.1% $4,470 300% $70,650 9.5% $6,708 350% $82,425 9.5% $7,824 400% $94,200 9.5% $8,940

http://www.cbpp.org/cms/?fa=view&id=3190

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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.

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ACA’s Large Employer Penalties

Start

At least

50 FTEs?

No penalty for small

businesses

No

Yes

Coverage offered?

No $2,000 penalty* per FTE (minus

first 30)

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?

Yes

Those employees can buy FFM coverage and

receive a subsidy. Did that occur?

No

No penalty

$3,000 penalty* for each receiving

a subsidy (up to a maximum of $2,000 per employee minus first 30)

Yes

Yes

Source: ACA, and adapted from Kaiser Family Foundation* The penalty is annual and increases with the growth in insurance premiums.

Those employees can buy FFM coverage and

receive a subsidy. Did that occur?

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Essential Health Benefits

TRICAREMilitary

TRICAREMilitary

VASome Veterans

VASome Veterans

MedicareSeniors and

SSDI

MedicareSeniors and

SSDI






Insured Products

HMOsPPOsFFSEtc.

Insured Products

HMOsPPOsFFSEtc.

ProvidersDoctors


ClinicsRx Drugs

Etc.

ProvidersDoctors


ClinicsRx Drugs

Etc.

InsuredInsured

Government Coverage

Government Coverage

Private Coverage

Private Coverage

Self-Insured

Employer

Self-Insured

Employer


SHOPMarketplace






ACA Changes

Status Quo System

UninsuredUninsured

Exempt

Exempt

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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


SHOPMarketplace






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Free Preventive Care

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

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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.

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

healthcare.gov

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e4healthwi.org

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• 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

In-Person Assistance

Source: Olson, Lisa. Wisconsin Primary Health Care Association

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Timeline

September 20•DHS sent BC letters

October 1•Open Enrollment Begins•DHS begins phone calls

November 18•DHS will begin to send official notifications of BC coverage ending

December 15•Last day to apply and pay premium for coverage beginning on 1/14

January 1•Marketplace coverage may begin•BC changes begin•Individual mandate takes effect

March 31•Open enrollment ends

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Health Insurance in Wisconsin in 2014

TRICAREMilitary

TRICAREMilitary

VASome Veterans

VASome Veterans

MedicareSeniors and

SSDI

MedicareSeniors and

SSDI






Insured Products

HMOsPPOsFFSEtc.

Insured Products

HMOsPPOsFFSEtc.

ProvidersDoctors


ClinicsRx Drugs

Etc.

ProvidersDoctors


ClinicsRx Drugs

Etc.

InsuredInsured

Government Coverage

Government Coverage

Private Coverage

Private Coverage

Self-Insured

Employer

Self-Insured

Employer


SHOPMarketplace






ACA Changes

Status Quo System

UninsuredUninsured

Exempt

Exempt

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Health Insurance Options in Wisconsin Beginning January 1, 2014

% of FPL

0% 100% 133% 200% 300% 400%250%150%

FFM-facilitated QHP for legal aliens, no subsidy

QHP Actuarial Value with Cost-Sharing Subsidies

94% 87% 73%

FF-SHOP-Facilitated Small Employer-Sponsored Insurance with Tax Credits for the Business

Percent of Income Paid Towards Premium

2% 9.5%3% 4% 6.3% 8.1%

Individual FFM-Facilitated QHP

Small Employer-Sponsored Insurance in the Private Insurance Market with No Tax Credits

BadgerCare Plus for 18-64

Large Employer-Sponsored Insurance in the Private Insurance Market or Self-Insured with No Tax Credits

Medicare for 65+ and SSDI Recipients

TRICARE for some active members of the military and their dependents

VA for some veterans and their dependents

BadgerCare Plus for Children (After Spend Down)(With a Premium)

BadgerCare Plus for Pregnant Women (After Spend Down)

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Please feel free to contact us:

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

Thank you!

mailto:[email protected]

Statewide Outreach and Enrollment Efforts

Updates from the Wisconsin Primary Health Care

Association

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

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

Certified Application Counselors and Navigators– Funding– Training & Certification (State and Federal)– Outreach – Additional Standards– Conflict of Interest

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Mobilizers!

Overview



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.

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Overview



Four Key Messages to Reach Most Uninsured

One of these = top message

for 89% of population

Source: Enroll America

#1 Message

HEALTHCARE.GOV

Overview



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Timeline

September•REN Kick-Offs•DHS Sends BC letters•E4Health Website live

October•Open Enrollment Begins•DHS phone calls begin

November•11/18: DHS systems updated •DHS official notifications of coverage ending

December•12/15: Last day to apply and pay premium for coverage beginning on 1/4

January•Marketplace coverage begins•BC changes take effect•Individual mandate takes effect

March•3/31: Open enrollment ends

Overview



• 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

Tools and Resources

http://www.dhs.wisconsin.gov/health-care/

http://www.e4healthwi.org/

http://www.marketplace.cms.gov/

• 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

In-Person Assistance

Questions/Follow-Up

Lisa [email protected]

608-277-7477

mailto:[email protected]

1 the affordable care act the impact of the affordable care act on prevention in wisconsin october...

Documents

statewide outreach

enrollment assistance

sharekey datescoming

enrollment effortsupdates

key messages

partner organization

dollar coverage

interested organization