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S The Affordable Care Act 2013 Update This publication has been created by the Area Agency on Aging, Region One with Financial assistance, in whole or in part, Through a grant from the Center for Medicare and Medicaid Services.
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The Affordable Care Act 2013 Update This publication has been created by the Area Agency on Aging, Region One with Financial assistance, in whole or.

Dec 25, 2015

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Page 1: The Affordable Care Act 2013 Update This publication has been created by the Area Agency on Aging, Region One with Financial assistance, in whole or.

S

The Affordable Care Act 2013 Update

This publication has been created by the Area Agency on Aging, Region One with Financial assistance, in whole or in part,

Through a grant from the Center forMedicare and Medicaid Services.

Page 2: The Affordable Care Act 2013 Update This publication has been created by the Area Agency on Aging, Region One with Financial assistance, in whole or.

The Affordable Care Act

The Patient & Protection Affordable Care Act (PPACA) passed in 2010 has provisions that take effect each year until 2020.

The PPACA affects Medicare, Medicaid, Private and Group Health Insurance, and mandates the availability of affordable health insurance to all Americans beginning in 2014

Page 3: The Affordable Care Act 2013 Update This publication has been created by the Area Agency on Aging, Region One with Financial assistance, in whole or.

Helpful Acronyms

ACA – Affordable Care Act (short for the PPACA)

CMS – Centers for Medicare and Medicaid Services

FPL – Federal Poverty Level (annual levels announced every February)

Page 4: The Affordable Care Act 2013 Update This publication has been created by the Area Agency on Aging, Region One with Financial assistance, in whole or.

The ACA and Medicare

In general, the ACA will restructure payments made by Medicare with a combination of reductions in some areas, increases in others, as well as a combination of financial incentives and penalties based quality performance

Page 5: The Affordable Care Act 2013 Update This publication has been created by the Area Agency on Aging, Region One with Financial assistance, in whole or.

The ACA and Medicare

the ACA will restructure payments made by Medicare to a “value-based” payment system measured by the health of patients versus a “volume-based” payment system measured by the number of services provided

Page 6: The Affordable Care Act 2013 Update This publication has been created by the Area Agency on Aging, Region One with Financial assistance, in whole or.

2013 Part D Drug Costs

In 2013 the cost of prescription drugs to Medicare beneficiaries in the donut hole will continue to reduce

In 2013 beneficiaries will pay 47.5% for brand-name drugs, and 79% for generic drugs in the donut hole

Page 7: The Affordable Care Act 2013 Update This publication has been created by the Area Agency on Aging, Region One with Financial assistance, in whole or.

The ACA & Part D Drug Costs

Part D drug co-insurance continues to gradually reduce for beneficiaries until 2020 when the donut hold goes away

In 2020 the donut hole coverage period will effectively become an extended initial coverage period where the costs of all drugs is 25% of the total drug cost

Page 8: The Affordable Care Act 2013 Update This publication has been created by the Area Agency on Aging, Region One with Financial assistance, in whole or.

Hospital Reimbursements

Reduces or eliminates payments to hospitals for preventable and excessive hospital re-admissions effective October, 2012

Reduces Medicare payments to certain hospitals for hospital-acquired conditions by 1% beginning in 2015

Page 9: The Affordable Care Act 2013 Update This publication has been created by the Area Agency on Aging, Region One with Financial assistance, in whole or.

Primary Care Physicians

Increases reimbursement rates to primary care physicians beginning in 2013

Provides for financial incentives to doctors for keeping patients healthy based on standardized criteria

Page 10: The Affordable Care Act 2013 Update This publication has been created by the Area Agency on Aging, Region One with Financial assistance, in whole or.

Medicare Accountable Care Organizations

The ACA has selected medical networks as designated Accountable Care Organizations (ACO’s)

The ACO’s provide coordinated care through a network of primary care and specialty providers

Page 11: The Affordable Care Act 2013 Update This publication has been created by the Area Agency on Aging, Region One with Financial assistance, in whole or.

Medicare Accountable Care Organizations

Accountable Care Organizations (ACO’s) are selectively available in some areas to Original Medicare beneficiaries

ACO’s are not HMO’s, and members have the same flexibility as all Original Medicare beneficiaries

Page 12: The Affordable Care Act 2013 Update This publication has been created by the Area Agency on Aging, Region One with Financial assistance, in whole or.

Medicare Electronic Health Records

The ACA imposes penalties on medical providers not showing “meaningful use” toward the implementation of electronic health records beginning in 2015

Electronic Health Records (EHR) are envisioned as key to coordinated care

Page 13: The Affordable Care Act 2013 Update This publication has been created by the Area Agency on Aging, Region One with Financial assistance, in whole or.

Medicare Demonstration Projects

Various demonstration projects (pilot projects) are being established to provide better care to beneficiaries and save costs

Care Transitions demonstration projects

DMEPOS Competitive Bidding in Maricopa and Pima Counties on 7-1-13

Page 14: The Affordable Care Act 2013 Update This publication has been created by the Area Agency on Aging, Region One with Financial assistance, in whole or.

Medicare Fraud & Abuse

The ACA’s ongoing effort to prevent Medicare fraud and abuse continues with enhanced fraud detection capabilities

Senior Medicare Patrol programs empower beneficiaries to be watchful for fraud and abuse

Page 15: The Affordable Care Act 2013 Update This publication has been created by the Area Agency on Aging, Region One with Financial assistance, in whole or.

ACA Fraud Schemes

Medicare beneficiaries should be wary of fraudulent schemes that seek to convince them that they need to enroll into Obamacare to prevent tax penalties.

Medicare beneficiaries do not need to enroll into new programs in 2013/2014.

Page 16: The Affordable Care Act 2013 Update This publication has been created by the Area Agency on Aging, Region One with Financial assistance, in whole or.

Medicare Advantage Plans

Payments to Medicare Advantage Plans are gradually reduced in 2012, 2014, and 2016 to be more in-line with average fee-for-service payments

80% of plan expenditures must go toward members care to avoid penalties

Page 17: The Affordable Care Act 2013 Update This publication has been created by the Area Agency on Aging, Region One with Financial assistance, in whole or.

Medigap Review Under the ACA

The ACA requires the NAIC to review Plans C and F for potential revision to include “nominal cost-sharing to encourage the use of appropriate physician services under (Medicare) Part B.” The new benefit standards are to be made available beginning January 2015

Page 18: The Affordable Care Act 2013 Update This publication has been created by the Area Agency on Aging, Region One with Financial assistance, in whole or.

Medicaid Expansion

States are permitted to opt into Medicaid expansion beginning in 2014

Medicaid will be available to all U.S. citizens and legal, permanent residents with income below 133% (138% in some cases) of the Federal Poverty Level

Expanded Medicaid will be available to all adults under the age of 65 (no impact on Medicare eligible adults)

Page 19: The Affordable Care Act 2013 Update This publication has been created by the Area Agency on Aging, Region One with Financial assistance, in whole or.

Arizona & Medicaid Expansion

Arizona has passed legislation to fully participate in Medicaid Expansion in 2014.

Enrollment into Arizona’s expanded Medicaid will be available beginning on October 1st at www.healthearizonaplus.org, at local DES offices, or through Certified Application Counselors.

Page 20: The Affordable Care Act 2013 Update This publication has been created by the Area Agency on Aging, Region One with Financial assistance, in whole or.

Health Insurance Marketplace

The ACA mandates that states either establish their own health insurance marketplace by October 1, 2013 or use the federal marketplace

The health insurance marketplace will offer citizens and legal residents affordable health care options regardless of pre-existing conditions

Page 21: The Affordable Care Act 2013 Update This publication has been created by the Area Agency on Aging, Region One with Financial assistance, in whole or.

Arizona’s Marketplace

Arizona has decided not to establish its own marketplace

Arizona’s exchange will be established and operated by the Federal Government

Administration by CMS, and will be available to consumers on 10/1/13

Page 22: The Affordable Care Act 2013 Update This publication has been created by the Area Agency on Aging, Region One with Financial assistance, in whole or.

Eligibility

Citizens and legal residents

Premium subsidies are available to individuals and families with income between 100% FPL and 400% FPL

Employees offered coverage by their employer are not eligible for premium credits

Page 23: The Affordable Care Act 2013 Update This publication has been created by the Area Agency on Aging, Region One with Financial assistance, in whole or.

Individual Premium Limits

Premium payment limits based on income 100-133% FPL: 2% of income 133-150% FPL: 3-4% of income 150-200% FPL: 4-6.3% of income 200-250% FPL: 6.3-8.05% of income 250-300% FPL: 8.05-9.5% of income 300-400% FPL: 9.5% of income

Page 24: The Affordable Care Act 2013 Update This publication has been created by the Area Agency on Aging, Region One with Financial assistance, in whole or.

Income Examples

For a single person (annual income 100% of FPL = $11,490; 400% of FPL =

$45,960

For a couple (annual income) 100% of FPL = $15,510; 400% of FPL =

$62,040

For a family of four (annual income) 100% of FPL = $23,550; 400% of FPL =

$94,200

Page 25: The Affordable Care Act 2013 Update This publication has been created by the Area Agency on Aging, Region One with Financial assistance, in whole or.

Essential Benefits Package

Creates an essential health benefits package that provides a comprehensive set of services

Coverage for at least 60% of health costs

Limits annual cost-sharing to the HSA limits ($5,950/individual and $11,900/family); lower limits for those with income less than 250% FPL

Page 26: The Affordable Care Act 2013 Update This publication has been created by the Area Agency on Aging, Region One with Financial assistance, in whole or.

Benefit Tiers

Bronze Plan pays 60% of costs

Silver Plan pays 70% of costs

Gold Plan pays 80% of costs

Platinum Plan pays 90% of costs

All Plans must provide essential benefits

Page 27: The Affordable Care Act 2013 Update This publication has been created by the Area Agency on Aging, Region One with Financial assistance, in whole or.

The Individual Mandate

Requires U.S. Citizens and Legal Residents to have qualifying health coverage beginning in 2014

Those without coverage face tax penalties beginning in 2014 if not covered

Page 28: The Affordable Care Act 2013 Update This publication has been created by the Area Agency on Aging, Region One with Financial assistance, in whole or.

The Individual Mandate

2014 penalty is $95 or 1% of taxable income, whichever is greater

2015 penalty is $325 or 2% of taxable income, whichever is greater

2016 penalty is $695 or 2.5% of taxable income, whichever is greater

Page 29: The Affordable Care Act 2013 Update This publication has been created by the Area Agency on Aging, Region One with Financial assistance, in whole or.

The Individual Mandate

Exemptions to the tax penalties are available for financial hardship, religious objections, American Indians, those without coverage for less than 3 months, undocumented immigrants, and incarcerated individuals.

People with income under the limit to require a tax filing will not be subject to penalties.

Page 30: The Affordable Care Act 2013 Update This publication has been created by the Area Agency on Aging, Region One with Financial assistance, in whole or.

Navigators and Certified Application Counselors

The ACA requires that Navigator programs be available in 2013 and 2014 to help people shopping for new health insurance

Many organizations will also be certified to provide application counseling to help with enrollments

Insurance brokers who are trained and certified can also help with enrollments

Page 31: The Affordable Care Act 2013 Update This publication has been created by the Area Agency on Aging, Region One with Financial assistance, in whole or.

Private & Group Health Insurance

The ACA bans annual or lifetime limits on the cost of care

The ACA mandates preventive health services without a co-pay

The ACA requires that 80% of insurance revenue be spent on healthcare, and that shortfalls be refunded to members

Page 32: The Affordable Care Act 2013 Update This publication has been created by the Area Agency on Aging, Region One with Financial assistance, in whole or.

Private & Group Health Insurance

Requires dependent coverage for children up to age 26

Prevents denials or increased premiums due to pre-existing conditions, and limits waiting periods to 90 days

Page 33: The Affordable Care Act 2013 Update This publication has been created by the Area Agency on Aging, Region One with Financial assistance, in whole or.

Employer Requirements

Assesses employers with 50 or more FT employees that do not offer group coverage, and have at least one FT employee who receives a premium tax credit, a fee of $2,000 per FT employee (excluding first 30 employees)

This provision has been delayed to 2015

Page 34: The Affordable Care Act 2013 Update This publication has been created by the Area Agency on Aging, Region One with Financial assistance, in whole or.

Employer Requirements

Employers with 50 or more FT employees that offer coverage, but have at least one FT employee receiving a premium tax credit, will pay the lesser of $3,000 for each employee receiving a premium tax credit or $2,000 for each FT employee (excluding first 30 employees)

This provision has been delayed to 2015

Page 35: The Affordable Care Act 2013 Update This publication has been created by the Area Agency on Aging, Region One with Financial assistance, in whole or.

Employer Requirements

Employers with more than 200 employees are required to automatically enroll employees into employer sponsored group health insurance coverage

Employees may opt out, but will not be eligible for premium tax credits

This provision has been delayed to 2015

Page 36: The Affordable Care Act 2013 Update This publication has been created by the Area Agency on Aging, Region One with Financial assistance, in whole or.

The SHOP Program

Employers with 50 or less employees and average annual wages of less than $50,000 that offer their employees group health coverage are eligible for business tax credits beginning in 2014

Page 37: The Affordable Care Act 2013 Update This publication has been created by the Area Agency on Aging, Region One with Financial assistance, in whole or.

ACA Information Resources

Marketplace 1-800-318-2596

www.healthcare.gov

www.azahcccs.gov

www.kff.org