BY THE NUMBERS: Uninsured in Wisconsin. Outline. THE AFFORDABLE CARE ACT: What Child Care Providers Should Know. What is the ACA?

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1 Outline What is the Affordable Care Act (ACA)? THE AFFORDABLE CARE ACT: What Child Care Providers Should Know Emma Hynes, MPH MPA Health Policy Analyst January 13th, 2014 Why Should Child Care Providers Care? Who else might benefit from new insurance options? ACA Stage 1: What s already happened? ACA Stage 2 (+ State Changes): What s coming? Health Insurance Marketplace/Exchange BadgerCare Plus Changes Pulling it all together What is the ACA? Stands for Affordable Care Act AKA Obamacare Health insurance reform Became law: 3/23/2010 Different parts affect different groups of people & there are two main stages Stage 1 focuses on patient protections (ALREADY in effect) Stage 2 focuses on expanding coverage (enrollment starts October 1st, coverage begins Jan for some, April for others) Should Child Care Providers Care? Role as informers and mobilizers for children and families Children who have health insurance generally have better health throughout their childhood and into their teens. They are less likely to get sick and more likely to: Get the treatment they need when they are sick or injured; Receive needed shots that prevent disease; Get treatment for recurring illnesses such as ear infections and asthma; and Get preventative care, like immunizations and comprehensive screenings, to keep them well. Important to maintain health in order to care for children Role-modeling for children and families Risk reduction One Child Care Provider s Experience I believe the ACA will extend my life. My best health care insurance option used to be: Pay almost $500 a month. But I couldn't see a doctor using the health care plan until I came up with the $2000 deductible. I couldn't come up with a $2000 deductible because I used my money to pay for the health care plan. I was betting I might need catastrophic health care someday more than I needed to see a doctor when I was sick. Thanks to the ACA, I now have a health care plan for less than $300. Not only do I get to see a doctor for free, I also see a chiropractor for free for my back pain. Prescriptions are only $10 and I get reductions on my health club membership fees and the CSA organic veggies I buy from local farmers. The ACA isn't just extending my life, it has made it much more humane. I will be getting medical help when I need it and encouragement, through financial support, to take care of myself by eating local organic food and working out at the pool. All of this truly does bring a greater sense of joy to my life. I am so grateful. BY THE NUMBERS: Uninsured in Wisconsin - Oma Vic McMurray, Child Care Provider & Small Business Owner in Madison, WI for 36 years 1

2 2013 Federal Poverty Level () Uninsured Kids & Adults in WI Group Size 100% 138% 200% 250% 300% 400% One $11,490 $15,856 $22,980 $34,470 $34,470 $45,960 Two $15,510 $21,404 $31,020 $38,775 $46,530 $62,040 Three $19,530 $26,951 $39,060 $48,825 $58,590 $78, ,500 uninsured non-elderly adults (19-64) About 125,000 of these are under 100% and therefore eligible for BadgerCare (pending citizenship). The other 266,500 are between 100% and 400% of, so are potentially eligible for subsidized coverage in the Marketplace (assuming no access to affordable employer coverage). Four $23,550 $32,499 $47,100 $58,875 $70,650 $94,200 Five $27,570 $38,047 $55,140 $68,925 $82,710 $110,280 55,000 uninsured kids only 3,400 are above the BadgerCare income limit (300% ). Uninsured & Employed in WI Both Rural & Urban Uninsured OVER 500,000 WISCONSINITES ARE UNINSURED But..they re working.. Others who might seek coverage in the Exchange People looking for better or more affordable insurance About 25,000 people losing coverage in the state highrisk plan (called HIRSP) Roughly 77,000 parents and childless adults between 100% and 200% of who are losing their BadgerCare coverage 3,500 kids in BadgerCare who are losing their coverage when the state eliminates the option for families to buy unsubsidized coverage for kids over 300% of. Insurance Lingo Premium: The amount of money you pay each month for your insurance. In general, a higher premiums means less expensive out-of-pocket costs. Deductible: The amount of money you pay for eligible medical expenses in a calendar year. After deductible is met, you may pay nothing or you share the remaining costs with your company up to out-of-pocket maximum. (Tip: check in-network vs out-of-network) Co-pay: A flat dollar amount you pay for a covered service like a doctor's visit. It usually ranges between $10 and $80. (Tip: check in-network vs out-of-network) Co-insurance: Coinsurance is a form of cost sharing between you and your insurance company. The cost sharing ranges from 80/20 to 50/50. For example, if your coinsurance is 80/20, that means that your insurer covers 80% of annual medical expenses and you pay the remaining 20%. The cost sharing stops when medical expenses reach your out-of-pocket maximum. 2

3 Insurance Lingo Cost-sharing: The arrangement that defines how you and an insurer pay for insured services or items. Coinsurance, copayment and deductibles are all forms of cost sharing. Premiums, payments for uncovered health care supplies or services or fees paid to out-of-network providers are not shared costs. Out-of-Pocket Costs: These costs aren t covered by your health plan. Deductibles, co-insurance, and copayments are the primary examples. There is an Out-Of-Pocket Maximum to limit the amount of these costs (which may or may not include the deductible depending on how your insurer defines it). Lingo: Sample Scenario How do co-pays, deductibles, and co-insurance relate? Let s say you have a health insurance policy that has a $50 co-pay, a $500 deductible, and an 80% coinsurance. If you have outpatient surgery that costs $5,000, here s what you will pay: $50 co-pay $500 deductible $890 co-insurance (20% of the remaining $4550 after co-pay and deductible since your health insurance company only pays 80% of expenses up to $10,000). ACA STAGE 1 : What Already Happened? ALREADY IN EFFECT Outlaws insurance denials based on preexisting conditions for KIDS There 309,519 children in Wisconsin with pre-existing conditions Young adults can stay on parents policies until they are 26 Eliminates lifetime limits Phases out annual limits Can t drop coverage after a person gets sick or for an honest mistake on your insurance application ALREADY IN EFFECT cont Insurance must spend at least 80% of your premiums on medical care (First rebate checks were due last August) Double digit premium increases must be publicly reviewed & are subject to approval Small business tax credits to subsidize coverage ALREADY IN EFFECT cont Many preventive care services must now also be offered by private insurance without co-pay or deductible. Includes things such as: Mammograms, blood pressure screenings, many cancer screenings, immunizations, diet & losing weight, quitting smoking, etc. Full list at Over 1.1 million Wisconsinites already benefiting! 3

4 ALREADY IN EFFECT cont NO major Medicare changes, just enhancements: Preventive services such as checkups & screenings with no Part B co-pay or deductible. 50% discount on brand-name drugs when you hit the donut hole coverage gap. Solvency of Medicare extended through efficiencies, fighting waste, prevention, ending subsidies to insurance companies. Note: Medicare Advantage Enrollment Up 10% from 2012 ACA STAGE 2 : Beginning NOW (Individual Mandate & Marketplace) Key parts of the health care law went into effect on January 1, 2014 to help expand coverage STARTS JAN 1 st, 2014 Individual mandate BEGINS in 2014: This penalty will be assessed retrospectively when an individual files taxes for the year (3 month gap allowed) 2014 Greater of $95 per adult, or 1% of taxable income Greater of $325 per adult, or 2% of taxable income Greater of $695 per adult, or 2.5% of taxable income. Post 2016 Penalty increases annually based on a cost of-living adjustment. Exemptions: No Filing Requirement because income is too low, Short coverage gap, unaffordable coverage options (more than 8% income), No MA expansion in your state, religious conscience, health care sharing ministry, Indian tribes, hardship, incarceration, not lawfully present STARTS JAN 1 st, 2014 cont Individual mandate BEGINS in 2014 along with: Preexisting condition exclusions outlawed for everyone, no discriminatory practices, like gender rating. Only AGE, LOCATION & SMOKING status can affect rate Expansion of Medicaid (BadgerCare). In WI, this expansion is only for childless adults up to 100% Creation of competitive health insurance marketplace (exchange). Individual tax credits to help middle class pay for insurance in exchange. Cost-Sharing assistance to help lower-income individuals/families on exchange pay for their healthcare. STARTS JAN 1 st, 2014 cont Essential Health Benefits (EHB) Minimum benefits for Medicaid, non-group and small group plans in and out of exchanges 10 Categories in the ACA: i. Ambulatory patient services ii. Emergency services iii. Hospitalization iv. Maternity and newborn care v. Mental health and substance use disorder services, including behavioral health treatment vi. Prescription drugs vii. Rehabilitative and habilitative services and devices viii. Laboratory services ix. Preventive and wellness services and chronic disease management x. Pediatric Services, including oral and vision care Wisconsin s default plan in 2014 & 2015 is: United Healthcare Choice Plus EHB does NOT apply to large group employer plans President Obama says insurers can continue to offer existing noncompliant plans to existing customers in 2014 STARTS JAN 1 st, 2014 cont Creation of a Marketplace: One for Individuals & one for small businesses (SHOP) Achieves efficiencies by pooling into larger groups Financial Assistance available for most Apples to apples comparison, chose private insurance based on price, quality, coverage (4 precious metal tiers). Members of Congress will be required to purchase their health coverage through the Exchange. 4

5 PLAN TIERS IN MARKETPLACE Plan Tiers: Plan Level Actuarial Value Platinum 90% Gold 80% Silver 70% Bronze 60% Meaning the plan is: Expected to cover 90% of Expected to cover 80% of Expected to cover 70% of Expected to cover 60% of *People under 30 and some people with limited incomes may buy what is called a "catastrophic" health plan. It protects you from very high medical costs. 2 TYPES OF FINANCIAL ASSISTANCE IN MARKETPLACE TYPE #1: Premium Tax Credit (subsidy) Must be used within the Marketplace Must be ineligible for government-sponsored coverage or affordable employer-sponsored insurance. Reduces monthly premium amount for low to middle income folks Available for incomes between 100% - 400% of 2 ways to receive this credit (or combination of the two): 1) Monthly amount mailed to your insurance provider to reduce your monthly premium payment 2) Receive a tax credit for full amount when you file your taxes at the end of the year. How do they define affordable employer-sponsored insurance? The premium for an employee-only plan must cost less than 9.5% of the family s income. 2 TYPES OF FINANCIAL ASSISTANCE IN MARKETPLACE TYPE #2: Cost-Sharing Assistance Must be used within the Marketplace Must be ineligible for government-sponsored coverage or affordable employer-sponsored insurance. Helps with out-of-pocket expenses like co-pays, co-insurance, deductibles Available for incomes between 100% - 250% of Must be on a SILVER plan to get this assistance Example of Premium Subsidy Premium Subsidy calculator: healthreform.kff.org/subsidycalculator.aspx Calculator estimates that a 40 year old with family of four, making $60,000 would: Have a premium of $12,130 for the year With a tax credit of $7,193 Leaving the family with $4,937 to pay ($411/month) Maximum Out-Of-Pocket (for all plans unless you get cost-sharing assistance) $6,350 for individual $12,700 for families BadgerCare Coverage: NOW BadgerCare Changes. State-Based Decisions (218,000) (15,989) Source: Community Advocates Public Policy Institute 5

6 BadgerCare Coverage: FUTURE PULLING IT ALL TOGETHER THESE CHANGES DELAYED UNTIL APRIL 1!!! Source: Community Advocates Public Policy Institute Future of Insurance in WI (*For those without Employer Sponsored Insurance option) Pregnant Women Children Parents & Caretakers 0-100% BadgerCare No premium Childless Adults % Marketplace BadgerCare No premium % BadgerCare with tax credit & cost-sharing subsidy BadgerCare (up to 250% ) No premium With premium % FLP Marketplace with tax credit % Marketplace with tax credit (up to 400% ) 400% + Marketplace with no tax credit 15 or older Family Planning Only Services (FPOS) Basically No Changes (some small tweaks that should make more people eligible) Elderly or Disabled NO CHANGES October (Oct 1) Open Enrollment Began Dates to Know January (Jan 1) Marketplace coverage began (Jan 17) BadgerCare Tax Filer Information Amendment Forms Due February (Feb 3) Childless adults can start applying for coverage through ACCESS.wi.gov o Though their coverage won t begin until April 1 st March (March 15) Last day to apply on Marketplace for coverage to begin April 1 st o Important for parents/caretakers losing BadgerCare coverage (March 31) Open enrollment for the Marketplace ends April (April 1) New BadgerCare Income limits (100% for all adults) take effect What do we do next? 1. KEEP CALM. 2. Go to Healthcare.gov to see your options If childless adult below 100%, apply starting Feb 1 st! 3. Tell your friends, family & clients Tell them what?? No Wrong Door starting Feb 1 st Federal: When in doubt, go to and refer to healthcare.gov Federal call line: State: Access.wi.gov Definitely use ACCESS after Feb 1 st, if you re SURE to be under 100% Can contact your local Income Maintenance agency dhs.wisconsin.gov/forwardhealth/imagency/index.htm Foodshare, FPOS (family planning), childcare, etc. 6

7 Four Key Messages to Reach Most Uninsured New categories of Enrollment Support created by ACA All insurance plans will have to cover doctor visits, hospitalizations, maternity care, emergency room care, and prescriptions. If you have a pre-existing condition, insurance plans cannot deny you coverage. One of these = top message for 89% of population You might be able to get financial help to pay for a health insurance plan. All insurance plans will have to show the costs and what is covered in simple language with no fine print. Certified Application Counselors Many available at libraries, job centers, free clinics, hospitals, enrollment events, schools, etc. Both appointment and walk-in available. Navigators Federal grant Source: Enroll America, November 2012 In-Person Assistance GO TO for Wisconsinbased resources, to request a training and to see a Wisconsin enrollment directory Localhealth.healthcare.gov Direct enrollment assistance: Community Health Centers, Libraries, Job Centers, & other locations also offering assistance Emma Hynes, Health Policy Analyst Wisconsin Council on Children and Families ehynes@wccf.org Wiskids.blogger.com Questions/Follow-up x313 7