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Affordable Care Act and Ryan White Program
The effects on insurance coverage for people living with HIV in the Philadelphia EMA
Medicaid Eligibility 133% FPL
Insurance Market
Reforms & Individual Mandate
Premium Subsidies 133% -
400% FPL
Employer Sponsored Insurance
Universal Coverage
Summary of Patient Protection and Affordable Care Act Most individuals will be required to have health
insurance starting in 2014
Employers will be required to pay penalties for employees who receive tax credits for health insurance
Individuals who do not have access to employer-offered insurance will be able to purchase insurance through state exchanges Premium and cost-saving credits/subsidies will be
available for some people
Summary of Patient Protection and Affordable Care Act All (non-grandfathered) plans will be:
required to provide a minimum benefits package
prevented from denying coverage for any reasons
prevented from charging higher premiums based on health status and gender
prevented from imposing annual or lifetime spending caps
Required to include prevention services with no cost-sharing
Individual Mandate U.S. citizens and legal residents required to have health
coverage
Those without coverage pay tax penalty of $695/person, up to $2085 a year
Those exempt from mandate: Demonstrated financial hardship Religious objections Undocumented immigrants Incarcerated individuals Those for whom the lowest cost plan option exceeds 8% of the
individual’s income Those who do not file federal income tax returns
America Health Benefit Exchanges Access to exchanges limited to US citizens and legal immigrants
Exchange plans will be required to offer a minimum benefits package at four different levels
Platinum – covers 90% of benefits cost Gold – covers 80% of benefits costs
Silver – covers 70% of the benefits costs Bronze – covers 60% of the benefits costs
Catastrophic – Available to those under 30 years old and to those who are exempt from
the mandate. Provides catastrophic coverage only with the coverage level set at the
HSA current level laws except for prevention benefits and coverage for 3 primary care visits would be exempt from deductible.
Only available on individual market.
Essential Health Benefits Plans on Exchanges and newly eligible Medicaid must include
these services:
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, and Pediatric services, including oral and vision care
Essential Health Benefits States will have the flexibility to select a benchmark plan
that reflects the scope of services offered by a “typical employer plan
If states choose not to select a benchmark, HHS intends to propose that the default benchmark will be the small group plan with the largest enrollment in the state.
Plans could modify coverage within a benefit category so long as they do not reduce the value of coverage.
States will choose one of the following benchmark health insurance plans: One of the three largest small group plans in the state by enrollment; One of the three largest state employee health plans by enrollment; One of the three largest federal employee health plan options by
enrollment; The largest HMO plan offered in the state’s commercial market by
enrollment.
Cost-sharing SubsidiesIn order to help individuals and families purchase plan
on the exchanges:
Cost-sharing subsidies will also be available for those with incomes between 100%-250% FPL to limit out-of-pocket spending
Premium subsidies will be provided to families with incomes of up to 400% FPL ($29,327 to $88,200 for family of four) Subsidies on a sliding scale Subsidies will limit the cost of premiums to between 2%
and 9.5% of income
Premiums as Share of Income Household Income as a
Percent of FPLPremium Range as a Percent
of IncomeUp to 133% 2%133 - 150% 3-4%150 – 200% 4 – 6.3%200 – 250% 6.3 – 8.05%250 – 300% 8.05 – 9.5%300 – 400% 9.5%
Premium tax credits are advanceable – recipients immediately receive the credit (directly to insurer)
Recipients will have to reconcile the tax credit received with actual income and repay any excess credit
Cost-sharing Subsidies Reduced cost-sharing for people up to 250% of
FPL
Subsidies increase actuarial value of coverage Actuarial value is the average percentage of anticipated
costs that an insurer will pay towards care for people insured in a given plan
In other words, it is the percent of costs paid for by the insurer, the individual is responsible for the remaining percent
Household Income as Percent of FPL
Actuarial Value of Coverage
100 – 150% 94%150 – 200% 87%200 – 250% 73%250 – 400% 70%
Employer-Offered Health Plans Employers with more than 50 employees who
do not offer coverage and have at least one full-time employee receiving a premium subsidy will be fined $2000 per full-time employee
Employees who are offered coverage by employer are not eligible for premium tax credits unless the premium exceeds 9.5% of income
Expanded Medicaid Eligibility Many low income individuals will be covered
under Medicaid All adults with income at or below 133% FPL
will be eligible for Medicaid regardless of health/disability 133% FPL = $14,404 for individual and $29,327 for
family of 4 in 2009
For most Medicaid enrollees, income will be based on modified adjusted gross income without an assets test or resource test.
Newly-eligibles may have different package of services based on essential services under exchanges
ACA Medicaid Changes
Minimum Floor for Coverage 133% FPLAdditional Federal Financing for Newly
Eligible CoverageLong Term Care/ Coordination for DualsSupport for Health Care System
Private Health Insurance Health premiums will be allowed to vary based on age (by a 3
to 1 ratio), geographic location, tobacco use and the number of family members
No lifetime/annual limits on coverage
Increases in premiums will be subject to review by the state
No cost sharing for preventative services
Existing plans will be allowed to remain the same except: Required to extend coverage to dependents up to age 26 Prohibited from rescissions of coverage Eliminate waiting periods for coverage to over 90 days
Premium and Cost Sharing Limits for Individuals up to 400% FPL (non- Employer Coverage)
Income % FPL Coverage Premiums and Cost Sharing
< 138% Medicaid •No Premiums
•Cost sharing limited to nominal amounts for most services
139 – 250% Exchange •Sliding scale tax credits limit premium costs to 3-8.05%
•Sliding scale cost-sharing credits
251 – 400% Exchange •Sliding scale tax credits limit premium costs to 8.05 – 9.5%
•No cost-sharing credits
Exhibit 15. Distribution of Uninsured Nonelderly Individuals in 2010, by Income Level and Provisions of the Affordable Care Act
Note: FPL refers to federal poverty level.Source: Analysis of the March 2011 Current Population Survey by N. Tilipman and B. Sampat of Columbia University for The Commonwealth Fund.
Medicaid<133% FPL21.3 million
43%
133%–249% FPL11.7 million
24%
250%–399% FPL 6.3 million
13%
>400% FPL5 million
10%
49.1 million uninsured individuals, ages 0–64
Subsidized private coverage with
consumer protections
Nonsubsidized private coverage with consumer protections or parents’
policiesUndocumented
4.9 million10%
Exhibit 18. Source of Insurance Coverage Pre-Reform and Under the Affordable Care Act, 2020
Notes: Employees whose employers provide coverage through the exchange are shown as covered by their employers. ESI refers to employer-sponsored insurance. “Other” includes Medicare.Source: Testimony Statement of Douglas W. Elmendorf, Director, before the Subcommittee on Health Committee on Energy and Commerce U.S. House of Representatives, CBO’s Analysis of the Major Health Care Legislation Enacted in March 2010, March 30, 2011, http://www.cbo.gov/ftpdocs/121xx/doc12119/03-30-HealthCareLegislation.pdf .
Among 284 million people under age 65
Under Prior Law
163M (57%)ESI
36M (13%)Medicaid
56M (20%)Uninsured
15M (5%)Other
14M (5%)Nongroup
162M (57%)ESI
52M (18%)Medicaid
24M (8%)Exchanges
(Private Plans)
15M (5%)Other
8M (3%)Nongroup
23M (8%)Uninsured
Affordable Care Act
523 6901,450
2,315
3,279
4,5003,977 3,810
3,0502,185
1,221
$0
$1,000
$2,000
$3,000
$4,000
$5,000
$6,000
138% FPL 150% FPL 200% FPL 250% FPL 300% FPL 500% FPL
Required premium payment by policy holderPremium tax credit
Exhibit 17. Annual Premium and Tax Credits for a Single AdultUnder the Affordable Care Act, 2014
Full premium =
$4,500
* For a single adult, age 40, in a medium-cost area in 2014. Premium estimates are based on an actuarial value of 0.70. Actuarial value is the average percent of medical costs covered by a health plan. FPL refers to federal poverty level.Source: Premium estimates are from Kaiser Family Foundation Health Reform Subsidy Calculator, http://healthreform.kff.org/Subsidycalculator.aspx.
Contribution capped at 3.3% of income
Contribution capped at 4.0% of income
Contribution capped at 6.3% of income
Contribution capped at 8.05% of income
Contribution capped at 9.5% of income
Annual premium amount paid by policy holder and premium tax credit*
$15,877 $17,258 $23,011 $28,763 $34,516 $57,527
Four levels of cost-sharing: 1st tier (Bronze) actuarial value: 60% 2nd tier (Silver) actuarial value: 70% 3rd tier (Gold) actuarial value: 80%
4th tier (Platinum) actuarial value: 90%
Exhibit 14. Premium Tax Credits and Cost-Sharing ProtectionsUnder the Affordable Care Act
Federal poverty level Income Premium contribution
as a share of incomeOut-of-pocket
limitsActuarial value:
Silver plan
<133% S: <$14,484F: <$29,726 2% (or Medicaid)
S: $1,983F: $3,967
94%
133%–149% S: $16,335F: $33,525 3.0%–4.0% 94%
150%–199% S: $21,780F: $44,700 4.0%–6.3% 87%
200%–249% S: $27,225F: $55,875 6.3%–8.05%
S: $2,975F: $5,950
73%
250%–299% S: $32,670F: $67,050 8.05%–9.5% 70%
300%–399% S: $43,560F: $89,400 9.5% S: $3,967
F: $7,933 70%
>400% S: >$43,560F: >$89,400 — S: $5,950
F: $11,900 —
Notes: In the income and out-of-pocket limits columns, S refers to single and F refers to family. Actuarial values are the average percent of medical costs covered by a health plan. Premium and cost-sharing credits are for silver plan.Source: Federal poverty levels are for 2011; Commonwealth Fund Health Reform Resource Center: What’s in the Affordable Care Act? http://www.commonwealthfund.org/Health-Reform/Health-Reform-Resource.aspx.
Catastrophic policy with essential benefits package available to young adults and
people who cannot find plan with premium <=8% of income
Exhibit 2. Premium Tax Credit Amount for a Family of Four
Note: FPL refers to Federal Poverty Level. Source: Federal Register, Vol. 76, No. 159, Aug. 17, 2011, pp. 50931–50949, Commonwealth Fund analysis.
Annual family income: $30,000
Annual family income: $50,000
Annual family income: $50,000
older parents
Income as a percentage of FPL 133% 224% 224%
Expected family contributionAs a percent of income:Dollar amount:
3.0%$900
7.1%$3,570
7.1%$3,570
Premium for benchmark plan $9,000 $9,000 $14,000
Premium tax credit $8,100($9,000 – $900)
$5,430($9,000 – $3,570)
$10,430($14,000 – $3,570)
Premium for plan family chooses $9,000 $9,000 $14,000
Actual family contribution $900 $3,570 $3,570
No Wrong Door Individuals should be screened for eligibility for Medicaid,
Medicare, Exchange, subsidies, etc. at any point of enrollment
One form/method of enrollment for Exchanges, Medicaid, etc. will be developed by HHS Secretary
Application form will be available for submission by web, fax, mail, telephone or in-person
States will rely on trusted third party sources for data matches, if accurate, no additional documentation can be required from individual
Easy to understand and navigate websites/information
Total Population Insurance Type for NJ, PA and US, 2009
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
49.0
5.0
16.012.0
1.0
17.0
55.0
5.0
14.0 15.0
0.0
11.0
59.0
3.0
10.0 12.0
0.0
15.0
USPANJ
EMA General Population Income
0.00%10.00%20.00%30.00%40.00%50.00%60.00%70.00%80.00%90.00%
100.00%
27.02%42.71%
32.00%42.33%
30.47%27.42%40.41%
28.09%
65.06%
41.88%38.52%
Total Population under 150% FPL Total Population between 150% and 300% FPLTotal Population Below 300% FPL
RW Clients Income Level, 2009
9595;
78%
1548;
13%
675; 6%
437; 4%
<100% FPL100-199%200-299%>300%
78% of RW Clients earn less than $10,890/year
RW Client Insurance Status By Type, 2009
Private17%
Medicare13%
Med-icaid51%
Other Public1% None
17%
Unknown1% Many uninsured
will be eligible for Medicaid and sub-
sidies.
NO CHANGE in
COVERAGE for about
64% of RW Clients
Office of HIV Planning Coverage Estimates
NOW 2014 estimates
Medicaid 51% >78%Private insurance
17% 12%
Uninsured 17% 4-7%Medicare 13% 13%
• Estimate for Private Insurance and Uninsured are probably too large, because they are based on General Population estimates.
• 78% Medicaid coverage is based on eligibility by income (133% FPL) alone.
Resources HIV Health Reform
http://www.hivhealthreform.org/ Kaiser Family Foundation Health Reform
Gateway: http://www.healthreform.kff.org/
Commonwealth Fund http://
www.commonwealthfund.org/Health-Reform.aspx