What you need to know

Exploring

The Affordable Care Act

Maternal Child Adolescent Health Advisory Board Meeting August 1, 2013

Vanessa Raditz, vraditz@berkeley.edu

Why do we need this training?

Many people are confused

April 2013 Kaiser Family Foundation poll: http://kff.org/health-reform/poll-finding/kaiser-health-tracking-poll-april-2013/

Why do we need this training?

Many people are confused

We need to focus on

Wellness not Sickness

The ACA can help us do this

Focus on prevention,

primary care, public health

Why do we need Health Reform?

The system is broken

and people are falling

through the cracks

The Affordable Care Act (ACA)

The Affordable Care Act (ACA) Expand Access

– Health Insurance Exchange

– Expanded Medicaid

Health Center Expansion

Workforce Expansion

Care Delivery Models

Prevention

Subsidized

Unsubsidized

Previously eligible

Newly eligible

Quality Improvements

Improve transparency and accountability & consumer protections

Improve access to medical technologies

Primary Care

Public Health

The Individual Mandate

A federal law requiring most citizens to be enrolled

in a health insurance plan or pay a penalty

Penalty:

2014- $95 per adult,

or 1% of family income

2015- $325 per adult,

or 2% of family income

2016- $695 per adult,

or 2.5% of family income

Mandate Exemptions

Undocumented immigrants

Legal immigrants in U.S. less than 5 years

Income below the threshold for filing a tax return

(In 2013: $10,000 for single, $20,000 for family)

If cheapest policy will still cost more than 8% of their

annual household income

Individuals part of a religion opposed to acceptance of

benefits for a health insurer

Incarcerated individuals

Members of a Native American Tribe

Medicaid Expansion

Currently eligible:

Children, Pregnant women, disabled, elderly, and

some parents of children that meet income guidelines

(Generally <100% FPL)

Newly eligible starting Jan 1st 2014:

Non-disabled, childless adults at or below 138% FPL

Must be US citizen or legal resident >5yrs!

Medicaid Expansion

Medicaid currently covers 1 in 5 Americans

After reform: will cover 1 in 4 Americans o Healthcare for the Homeless, Barbara DiPietro

Medicaid Expansion is a Women’s Health issue:

Women more likely to experience poverty & financial hardship

Women make up more than 2/3 of the Medicaid population

Medicaid finances nearly half of all births in the US

11% of children <100% FPL still uninsured

Medicaid Expansion by State Supreme Court ruled that the ACA is constitutional, but said that states could

choose whether or not they want to expand Medicaid. CA is first to expand!

In CA, we

call Medicaid

“MediCal”

The Exchange

An online marketplace where individuals and

small businesses can compare and enroll in health

insurance plans with support from state and fed. govt.

Plans are regulated:

Essential Health Benefits

Preventive Services

with no co-pay or

deductible

The Exchange

Essential Health Benefits

Previously, only 10% of plans purchased on the

private market covered Maternity & Newborn care.

Now Essential, along with:

Ambulatory patient services;

emergency services;

hospitalization;

maternity and newborn care;

mental health and substance use;

prescription drugs; rehabilitative

and habilitative services and

devices; laboratory services;

preventive and wellness services

and chronic disease management;

and pediatric services, including oral and vision care

The Exchange

Essential Health Benefits

Preventive Services with no co-pay

Yearly physical, well women checks,

routine prenatal care visits,

early detection screenings,

immunizations, breast-

feeding counseling and

support and supplies,

contraceptive methods,

screenings for

domestic violence,

Autism screenings…

…and so much more!

The Exchange

An online marketplace where individuals can

compare and enroll in health insurance plans

Plans are regulated

Essential Health Benefits

Preventive Services

with no co-pay

Cannot be denied for

pre-existing conditions

or charged more

Cannot be charged more

for being a woman!

Covered California

www.coveredca.com

You can go online right now to find out how

much insurance will cost for you and your family

Open Enrollment begins October 1st, 2013

Benefits begin January 1st, 2014

Try using

this calculator

on Covered

California’s

website!

Choosing your Plan

There are four different levels of coverage

They all have same Essential Health Benefits

Pay more monthly or more at time of service?

Choosing your Plan

http://coveredca.com/PDFs/English/CoveredCA-HealthPlanBenefitsComparisonChart.pdf

Tax Credits and Subsidies

http://coveredca.com/PDFs/English/CoveredCA_HealthPlanBenefitsSummary.pdf

Upcoming Challenges

Challenge 1: Education and Enrollment Certified Educators and Enrollers in the Community

Online

Challenge 2: What will happen to Safety Net Programs? What will happen to CMSP? How will people roll-over to expanded MediCal?

Healthy Families has rolled over to MediCal with some complications

Hospitals losing some funding to help pay for the ACA- what will happen?

FamPact, Every Women Counts, AIM, etc… what will happen in the long-term?

Challenge 3: The Remaining Uninsured Undocumented, those objecting for political reasons, and many others

Of the 60 million currently uninsured in the US,

30 million will still be uninsured by 2016

Remembering our Goals

Remembering our Goals

High quality, innovative medicine

Increasing access & affordability

Low-cost to insurers, providers, and patients

Keeping people healthy! Focus on Prevention

Long-term impacts on community wellness,

stronger local economies

Long-term decreases to medical costs

http://jama.jamanetwork.com/article.aspx?articleid=1487506

For Further Reading FAQ about the exchange:

CA: http://coveredca.com/frequently_asked_questions.html

News and Fact Sheets: Kaiser Family Foundation: http://kff.org/ Know your Care: http://www.knowyourcare.org/aca/ National Exchange Marketplace: http://www.enrollamerica.org/ National Association Of Community Health Centers: http://www.nachc.com/MedicaidExpansion.cfm

Preventive services: http://www.healthcare.gov/news/factsheets/2010/07/preventive-services-list.html

Preventive health for women: http://www.healthcare.gov/news/factsheets/2011/08/womensprevention08012011a.html

Quiz Go through these slides as a Powerpoint, and imagine that a

patient, a community member, or a friend is asking you this

question and try to think of what you would say to them.

Then click to check your answer!

You can also take this quick 10-question quiz online:

http://kff.org/quiz/health-reform-quiz/

Please email me: vanessar@phealthcenter.org if you have any

questions or want more information or resources

Please refer patients with more questions to Resource Clinic,

Wednesdays from 11am to 1pm.

Question 1

Q: What is the Individual Mandate?

A: A Federal Law requiring most citizens of the United States to

be enrolled in a health insurance plan, or pay a penalty.

Question 2

Q: Will I have to pay a penalty? (Give at least 3 examples of groups who are exempt)

A: Undocumented immigrants

Legal immigrants in U.S. less than 5 years

Income below the threshold for filing a tax return (In 2013: $10,000 for single, $20,000 for family)

If cheapest policy will still cost more than 8% of their annual household income

Individuals part of a religion opposed to acceptance of benefits for a health insurer

Incarcerated individuals

Members of a Native American Tribe

Question 3

Q: I heard that I will be penalized if I don’t get insurance. How bad is it going to be? (What are the tax penalties for being without insurance?)

A:

2014 - $95 per adult and $47.50 per child, up to $285 per family, or 1.0% of family income, whichever is greater

2015- $325 per adult and $162.50 per child, up to $975 per family, or 2.0% of family income, whichever is greater

2014 - $695 per adult and $347.50 per child, up to $2,085 per family, or 2.5% of family income, whichever is greater

Question 4

Q: What was the reason behind the Individual Mandate?

A:

Incentive for buy-in from healthy adults, spreads the risk between the

very healthy and the very sick, which makes the plan feasible for insurers

Without an individual mandate, health care economists project that premiums

would be affected by going up 2 to 40 percent.

Question 5

Q: A friend of mine received an $875 rebate check from his

insurer, what is a rebate check?

A: The health law says that most insurers must spend at least 80 percent

(85 percent for insurers covering large employers) of the premiums you pay

on medical care and quality improvements. If insurers spend too much on

overhead, such as salaries, bonuses, or administrative costs, as opposed to

health care, they must issue premium rebates to consumers each summer.

Question 6 Q: I heard that there are a bunch of free preventive

services now, what does this mean? A: Preventive services help prevent further complications, catch disease at an

earlier stage, or help keep people well.

Not Free – Covered by Insurance with no Share of Cost / Co-pay

Some examples (there are many more!) Blood Pressure screening for all adults

Colorectal Cancer screening for adults over 50

Depression screening for adults

Type 2 Diabetes screening for adults with high bp

Diet counseling for adults at higher risk

HIV screening for all adults at higher risk

Immunization vaccines for adults and children

Obesity screening and counseling for adults and children

Sexually Transmitted Infection (STI) testing and prevention counseling

Alcohol Misuse screening and counseling

Tobacco Use screening and counseling

Lead screening for children at risk of exposure

Well-woman visits to obtain recommended preventive services*

BRCA counseling about genetic testing for women at higher risk

Mammography screenings every 1 to 2 years for women over 40

Cervical Cancer screening for sexually active women

Breastfeeding comprehensive support and counseling from trained providers, as

well as access to breastfeeding supplies, for pregnant and nursing women*

Contraception: Food and Drug Administration-approved contraceptive methods,

sterilization procedures, and patient education and counseling, not including

abortifacient drugs*

Behavioral & Autism screening for children at 18 and 24 months

Oral Health risk assessment for young children

Fluoride Chemoprevention supplements for children

Vision screening for all children

Question 7

Q: I saw that I am still going to have a deductible and have a

bunch of co-pays on top of my premium with the plan I want

on the exchange, but I thought the point was to make sure I

don’t go broke. What’s keeping me from having tens of

thousands of dollars of debt if I get cancer? Or hit by a car?

A: There are “Maximum Out of Pocket” annual limits included in

each plan. This is supposed to keep costs within a reasonable

amount in the event of catastrophic injury or illness.

Question 8

Q: I just turned 27 and am now off my parents’ insurance. I

only make 15,000 dollars a year, which I know is slightly

higher than the Federal Poverty Limit (FPL). What health

insurance options do I have?

A: Medicaid now goes up to 138% for childless adults, if you live in a

state which expands Medicaid. You can also purchase insurance on the

exchange with a government subsidy, if you want.

Question 9

Q: I work with homeless patients who usually have a

really hard time with all the follow-up paperwork to get

MediCal, even though they were already eligible. How

does the ACA make it easier for people to access benefits

they already are entitled to?

A:

No longer have to prove residency/address/citizenship - gets directed straight

to homeland security; you can write in “no fixed address.”

Don’t have to prove income - gets directed straight to IRS

Single access point - can use exchange site to get MediCal

Funds in act for more outreach enrollment workers

Question 10

Q: My family came into the country as undocumented

immigrants, but I just got approved to start my path to

legal residency through the Dream Act. I have been in

the country way more than 5 years. Will I be able to buy

insurance on the exchange with my own money?

A:

No. But this may change depending on current immigration talks

Further reading:

Young Immigrants Shut Out of Health Reform

Lawfully Present Individuals – definition on coveredca

Question 11

Q: Where can I go to find out about the exchange

marketplace in California?

A: Covered California! www.coveredca.com

Question 12

Q: When is the open-enrollment period?

What does that mean?

A: Open enrollment begins October 2013, through March 2014. Future

enrollment will be open only from October through December.

After open enrollment, you are locked into your plan for the coming year,

but you can change during the next open enrollment.

You must purchase health insurance during the open enrollment period in

order to obtain coverage. If you do not enroll during this period, you will

not be assured a health plan will cover you – either through Covered

California or in the private market.

Question 13

Q: Will I be covered once I’ve registered on Covered

California’s exchange during open enrollment?

A: No, benefits will not start until January 1st, 2014

Question 14

Q: How do I choose what plan is best for me?

A: You can compare plans on coveredca.com

Individuals enrolled in a level with higher monthly premiums, will pay less

when coverage is needed. Individuals enrolled in a level with lower monthly

premiums, will pay more when coverage is needed.

All plans are eligible for federal subsidy, but even if a subsidy-eligible

person chooses a Bronze, Gold, or Platinum plan, his or her subsidy amount

is calculated based on the benchmark Silver Plan.

Question 15 Q: The reason that I don’t have health insurance is not that I don’t

want it, it’s just that it’s been too expensive for me. How is shopping online on this exchange thing supposed to make health insurance more affordable for me?

A: You can compare plans more easily instead of having to apply to each company

separately and then comparing prices for different levels of benefits Tax credits: Tax credits are available to lower the cost of health coverage for

individuals and families who meet certain income requirements and do not have health insurance from an employer or a government program. When you enroll in a health plan through Covered California, tax credits can be immediately applied to the insurance premium, which reduces the amount you pay each month.

Cost-sharing subsidies: Cost-sharing subsidies reduce the amount of out-of-pocket health care expenses an individual or family has to pay. These expenses might include the copayments for health care services or other costs.

Expanded MediCal! You may now be covered for free public insurance.