navigating the affordable care act kim l. isaacs, md, phd university of north carolina at chapel...
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Navigating the Affordable Care Act
Kim L. Isaacs, MD, PhDUniversity of North Carolina at Chapel HillDecember 4, 2014
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March 23, 2010•Patient Protection and Affordable Care Act becomes federal law.
•Initiated the most significant changes in health care in the United States in 50 years *Medicare established in 1965
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Why do we need an intervention in US health care?
• Problems with cost of medical care in US▫2010 – $2.6 trillion in 2010
• Access▫> 50 million uninsured.
• Quality ▫US ranks last among 11 industrialized
countries in health system quality, efficiency, access, equity and healthy lives – Commonwealth Fund Report
ACA
Quality
Access Cost
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Complicated piece of legislation that attempts to address these issues.
What is the affordable care act?
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ACA: 10 titles that cover more than just insurance• Quality affordable health care for all Americans• Role of public programs• Improving quality and efficiency of health care• Prevention of chronic disease and improving public
health• Health Care workforce• Transparency and program integrity• Improving access to innovative medical programs• Community living assistance services and supports
act• Revenue provisions• Reauthorization of the Indian Health Care
Improvement Act
http://www.hhs.gov/healthcare/rights/law/index.html
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How are patients insured?Based on March 2012 Census and 2013 Current population Survey (CPS)
47.7 million uninsured
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How this plays out for our patients•If the patient is insured:
▫Children can remain on parent’s plan until age 26
▫Companies can not drop coverage if the patient becomes sick
▫There is not a lifetime limit on coverage▫Insurers are barred from using the patients
health history to set rates▫Certain preventive services have to be
covered.
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How this plays out for our patients•If the patient is insured with Medicare
▫By 2020 the law closed the Part D “Donut Hole” which is a temporary limit on what the plan covers for prescription drugs
▫Certain preventative services are covered without patient cost sharing.
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How this plays out for our patients•If the patient is uninsured and does not
meet exemption requirements ▫Patient may be covered by expansion in
states Medicaid program OR
▫They will need to purchase health insurance through the Health Insurance Market Place
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If our patients are uninsured..
•Can purchase coverage through the health insurance market place
•Private insurers – offering multiple plans•Consumers can compare the plans and
see if they are eligible for subsidies to help cover costs.
•Different degrees of “cost-sharing” on available plans.
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Some patients may be covered by expansion of Medicaid
Limited to certain low income populations
Extends to adults < 138% FPL
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http://kff.org/health-reform/issue-brief/the-coverage-gap-uninsured-poor-adults-in-states-that-do-not-expand-medicaid/
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Health Insurance Market Places•For those who need to buy their own
insurance•State by state – state run, federal
government facilitation, state-federal partnership
•Offer a range of plans – private insurers with different coverage options.▫Plans may have different network providers
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Market places: states, federal, combination
https://news.leavitt.com/health-care-reform/marketplaces-exchanges-information-employers-individuals/#!prettyPhoto/0/
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Who can use the health care market places?
www.healthcare.gov
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ACA and 2 patients with IBDCS – Crohn’s since age 10 now 50 SB – UC since age 14 now 24
Unable to get affordable insurance due to pre-existing conditionHad to go part time due to health issues10 years no insurance
ACA was meant for someone like
me!
UC in prolonged remission.Quit job as a prison nurse due to stress of the jobGot ACA marketplace coverage and then had a UC flair
I thought the silver plan
would work but I can’t afford my
medicines..
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The Plans: Level of Coverage
Silver GoldBronze Platinum
Lowest PremiumsHighest Out-of-Pocket Costs
Highest PremiumsLowest Out-of-Pocket Costs
60 % 70% 80% 90%
Covered Percent of Total Cost of Care
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Benefit Bronze Silver Gold Platinum
Deductible $5000 Med/Rx $2000 Med $ 0 $0
Preventive $0 $0 $0 $0
Doctor Visit $65 for 1st 3 $45 $30 $20
Specialist $70 after d $65 $50 $40
Generic Rx $15 after d $15 $15 $5
Brand Rx $50 after d $50 after $250 d
$50 $15
Lab testing 30% after d $65 $30 $20
X ray 30% after d $45 $50 $40
Maternity 30% after d 20% after d $600 per day HMO***/20% PPO
$250 per day HMO***/10%
OP Surgery 30% after d 20% after d $600 HMO/20% PPO
$250 HMO/10% PPO
Hospital Stay
30% after d 20% after d $600 per day HMO***/20% PPO
$250 per day HMO***/10%
ER $300 after d $250 after d $250 $150
Urgent Care $120 after d $90 $60 $40
Out of Pocket Max
$6,350/$12,000 $6,350/$12,000 $6,350/$12,000 $4,000/$8,000http://www.medicoverage.com/health-insurance-blog/news/comparing-exchange-plans-bronze-silver-gold-platinum
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Most consumers in the market place will be eligible for subsidies to help afford their care•http://www.kff.org/interactive/subsidy-calc
ulator/Example: Silver Plan for a 21 year old, non-smoker from North Carolina – No state expansion for Medicaid
% FPL % Income Salary Cost of Plan/yr
Tax Credit
Amount paid /yr
<133% 2% $ 15,167 $ 2,526 $2,222 $303
350% 9.5% $ 40,215 $2,526 $0 $2,526
Tax credits are only available to people between 100 – 400% of FPL
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What are the questions that need to be asked by the patient
choosing a plan?•What are the drugs that are covered by
the plan.▫Drug formularies are available online on
the health care market place site• What is the plan network of doctors.
▫Not all doctors are covered by certain plans.
•Are there other financial resources available in my state?▫Patient advocacy groups, patient assistance
programs
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Specialty Drug Coverage important for the patient with IBD
http://www.lls.org/#/diseaseinformation/getinformationsupport/aca/details/
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ACA Essential Health Benefits
Ambulatory Patient Services Emergency Services
Hospitalization Maternity and Newborn Care
Mental Health and substance abuse services including counseling and psychotherapy
Prescription drugs
Rehabilitative and habilitative services and devices
Laboratory services
Preventive and wellness services and chronic disease management
Pediatric services
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Preventive services covered by the ACA
AAA one time screening in male non-smokers
Depression screening for adults
Obesity screening and counseling for all adults
Alcohol misuse screening and counseling
Diabetes screening for adults with HBP
STD prevention counseling for adults at high risk
BP screening for all adults
Diet counseling for adults at higher risk for chronic disease
Aspirin use to prevent CV disease in men and women of certain ages
Cholesterol screening for adults of certain ages or high risk
HIV screening for all –15-65 and other ages at increased risk
Syphillis screening for all adults at higher risk
Colorectal cancer screening for adults over the age of 50
Immunizations based on age and risk factors
Tobacco use screening for all adults and cessation interventions
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Are ambulances covered by insurance under the ACA?
YES if an EMERGENCY
• Emergency to the Hospital
• Between Hospitals or to a skilled nursing facility
NO if not an EMERGENCY
• To doctors office for a clinic visit
• To the morgue
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Are dental services covered by the ACA?
Not for adults however some market place plans do include dental insurance for a fee.
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Are ostomy supplies covered by the ACA?
Yes – as well as multiple other durable goods.
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Resources
•www.healthcare.gov•Kaiser Family Foundation
▫http://kff.org/aca-consumer-resources/•http://minorityhealth.hhs.gov/NPA/Materi
als/AffordableCareActResourceKit.pdf•Leukemia and Lymphoma Society
▫http://www.lls.org/diseaseinformation/getinformationsupport/aca/
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