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.
Dec 25, 2015
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.
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
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)
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
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
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
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
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
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
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
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
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
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
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
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.
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
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
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)
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.
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
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
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
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
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
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
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
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
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
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.
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
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
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
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
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
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
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
ACA Information Resources
Marketplace 1-800-318-2596
www.healthcare.gov
www.azahcccs.gov
www.kff.org