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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
Small Groups1-50 FTEs
Large Groups50+ FTEs
Large Groups50+ FTEs
Insured Products
HMOsPPOsFFSEtc.
Insured Products
HMOsPPOsFFSEtc.
ProvidersDoctors
SpecialistsHospitals
ClinicsRx Drugs
Etc.
ProvidersDoctors
SpecialistsHospitals
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
Individuals and Self-EmployedIndividuals and Self-Employed
Small Groups1-50 FTEs
Small Groups1-50 FTEs
Large Groups50+ FTEs
Large Groups50+ FTEs
Insured Products
HMOsPPOsFFSEtc.
Insured Products
HMOsPPOsFFSEtc.
ProvidersDoctors
SpecialistsHospitals
ClinicsRx Drugs
Etc.
ProvidersDoctors
SpecialistsHospitals
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
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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
Small Groups1-50 FTEs
Large Groups50+ FTEs
Insured Products
HMOsPPOsFFSEtc.
ProvidersDoctors
SpecialistsHospitals
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
Individuals and Self-EmployedIndividuals and Self-Employed
Small Groups1-50 FTEs
Small Groups1-50 FTEs
Large Groups50+ FTEs
Large Groups50+ FTEs
Insured Products
HMOsPPOsFFSEtc.
Insured Products
HMOsPPOsFFSEtc.
ProvidersDoctors
SpecialistsHospitals
ClinicsRx Drugs
Etc.
ProvidersDoctors
SpecialistsHospitals
ClinicsRx Drugs
Etc.
InsuredInsured
Government Coverage
Government Coverage
Private Coverage
Private Coverage
Self-Insured
Employer
Self-Insured
Employer
IndividualMarketplace
SHOPMarketplace
Grand-Fathered Plans
Grand-Fathered Plans
Medicaid< 100% of FPL,
EBD, SSI, Pregnant Women & Children
UninsuredUninsured
Exempt
Exempt
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Marketplace Functions
IndividualMarketplace
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
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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
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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
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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
Individuals and Self-EmployedIndividuals and Self-Employed
Small Groups1-50 FTEs
Small Groups1-50 FTEs
Large Groups50+ FTEs
Large Groups50+ FTEs
Insured Products
HMOsPPOsFFSEtc.
Insured Products
HMOsPPOsFFSEtc.
ProvidersDoctors
SpecialistsHospitals
ClinicsRx Drugs
Etc.
ProvidersDoctors
SpecialistsHospitals
ClinicsRx Drugs
Etc.
InsuredInsured
Government Coverage
Government Coverage
Private Coverage
Private Coverage
Self-Insured
Employer
Self-Insured
Employer
IndividualMarketplace
SHOPMarketplace
Grand-Fathered Plans
Grand-Fathered Plans
Medicaid< 100% of FPL,
EBD, SSI, Pregnant Women & Children
Essential Health Benefits
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
IndividualMarketplace
SHOPMarketplace
Medicaid< 100% of FPL,
EBD, SSI, Pregnant Women & Children
Individuals and Self-EmployedIndividuals and Self-Employed
Small Groups1-50 FTEs
Small Groups1-50 FTEs
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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
Individuals and Self-EmployedIndividuals and Self-Employed
Small Groups1-50 FTEs
Small Groups1-50 FTEs
Large Groups50+ FTEs
Large Groups50+ FTEs
Insured Products
HMOsPPOsFFSEtc.
Insured Products
HMOsPPOsFFSEtc.
ProvidersDoctors
SpecialistsHospitals
ClinicsRx Drugs
Etc.
ProvidersDoctors
SpecialistsHospitals
ClinicsRx Drugs
Etc.
InsuredInsured
Government Coverage
Government Coverage
Private Coverage
Private Coverage
Self-Insured
Employer
Self-Insured
Employer
IndividualMarketplace
SHOPMarketplace
Grand-Fathered Plans
Grand-Fathered Plans
Medicaid< 100% of FPL,
EBD, SSI, Pregnant Women & Children
Essential Health Benefits
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!
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
• 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
• 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
• 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
One of these = top message
for 89% of population
Source: Enroll America
#1 Message
HEALTHCARE.GOV
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!
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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
• Enrollment Assistance today and in the future• Wisconsin’s coordinated approach to outreach
and enrollment• Key outreach messages to share• Key dates• Coming Soon!
• 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
• 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