Expanded Health Insurance Coverage Options under the ACA

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1 Page 1 Expanded Health Insurance Coverage Options under the ACA by Shanna Hanson, FHFMA Summary One of our industry s reform knowledge leaders overviews ways health care coverage is being expanded under the ACA. These include Medicaid programs as well as Qualified Health Plans available through the Marketplaces (Exchanges). Advanced Premium Tax Credits (APTCs), cost sharing, immigrant coverage and the Small Business Health Options Program (SHOP) are also touched upon.

2 Page 2 Introduction The Affordable Care Act (ACA) was signed into law by President Obama in Several key aspects of the ACA impact eligibility and enrollment. It s important to understand a few foundational aspects of the law before you can understand the ACA expanded coverage options and how these will impact self pay patients, hospital staff and provider revenue. The Individual Mandate The ACA requires, through an Individual Mandate, all people to have health insurance coverage of some kind beginning in If an individual does not have health coverage, he or she must procure coverage to comply with the law. Individuals who do not obtain coverage by 2014 will incur a fine, although there are some exceptions. Medicaid Expansion Originally, the ACA called for all states to expand their Medicaid programs up to 133% of the Federal Poverty Level (FPL). Many states resisted, culminating in the Supreme Court of the United States ruling in June 2012 that Medicaid expansion is constitutional but Congress enforcement power to compel states to comply with the new expansion is limited. Medicaid participation by states was ruled voluntary. States that do not want to comply with the new expansion can be penalized only by forgoing new program dollars not by restricting all federal dollars for their entire Medicaid programs. As a result, some are choosing to expand Medicaid and some are not. Online Health Insurance Marketplaces Health Insurance Marketplaces (also called Exchanges) provide consumers a one stop shop to apply for and obtain health insurance coverage, whether through a government funded Insurance Affordability Program (IAP) or commercial health insurance plan. The ACA requires all states participate in the online Marketplaces, even if a state chooses not to expand Medicaid. Consumers using a Marketplace will: 1 Fill out an application. Learn if they potentially qualify for Medicaid or CHIP program coverage. Find out if they are eligible for lower monthly premiums or lower out of pocket costs. See all Qualified Health Plans (QHPs) available in their area. 1 What is the Insurance Marketplace? Healthcare.gov, accessible at https://www.healthcare.gov/what is the health insurance marketplace/

3 Page 3 There are three types of Marketplaces: Federally Facilitated Marketplaces run by the federal government. About 70% of states have chosen not to run their own Marketplace. Instead, these states will use the Marketplace that is established and run by the federal government. Federal/State Partnership Marketplaces a collaborative effort between the state and federal government. State based Marketplaces run by the state government. Regardless of the type of Marketplace utilized in each state, financial assistance to help buy insurance will be available in all states for consumers who earn up to 400% of the FPL. Qualified Health Plans Qualified Health Plans (QHPs) will be introduced October 1, 2013, when open enrollment through the Marketplaces begins, with QHP coverage effective January 1, A QHP is a commercial or private insurance product that is approved by and offered through the Marketplace for purchase by consumers. Plans, offerings and prices will vary from state to state but two items will not: Each plan will be required to offer a set of 10 essential health benefits. Each will offer four plan levels: bronze, silver, gold and platinum. The type of coverage (e.g., quality and amount of care) will not deviate between each of the four, but the out of pocket costs to consumers will. For example, a bronze plan will have an actuarial value of 60, calculated as the percentage of total average costs for covered benefits that a plan will cover. The consumer will be responsible for paying the other 40% cost of services. As a result of paying a higher percentage of the cost of services, the consumer will have a lower monthly premium payment. This initially may make the bronze plan more attractive to consumers. The platinum offering, on the other hand, will feature a 90/10 split, with the consumer responsible for paying 10% of the cost of services. As a result, the platinum plan will have the most expensive monthly premium payment of the plan offerings in the Marketplace. Alternatively, the silver plan will offer a 70/30 split and the gold plan an 80/20. Monthly premium payments for the silver and gold plans will stand somewhere between the bronze and platinum premium payments. Whatever option a consumer chooses, QHP coverage is not retroactive and will start the first of the following month if application is made between the first and the fifteenth or the first of the second month if application is made between the sixteenth and final day of the month. So for providers, it will be beneficial to ensure patients who are not eligible for Medicaid or CHIP are enrolled in coverage prior to obtaining services.

4 Page 4 Once a consumer chooses a health plan, he or she cannot change that plan until the next annual open enrollment period, so it is important he or she understand the long term financial commitment of each plan. Medicaid Expansion In states that expand Medicaid, individuals with incomes up to 133% of the FPL will be eligible for Medicaid as of January 1, You may hear this group of individuals referred to as the new adult group. These adults are not currently (prior to 2014) eligible for Medicaid for any of a number of reasons. In states that choose to expand their Medicaid programs, these individuals will have a new Medicaid eligibility option not previously available to them. In states that do not expand Medicaid, the income eligibility threshold will remain where it is today and vary by state. Non expansion states will continue to have a relatively high number of uninsured residents, but the number of uninsured in these states likely will decrease slightly because of the woodwork effect. The woodwork effect posits that individuals those who are currently eligible but not enrolled in fact will enroll because of heightened awareness due to all the publicity and the simplified application process. Insurance Affordability Programs beyond Medicaid Medicaid and the Children s Health Insurance Program (CHIP) are just two types of Insurance Affordability Program (IAP) for consumers seeking medical coverage and financial assistance to pay for it. Under the ACA, in all states, consumers earning up to 400% of the Federal Poverty Level will be eligible for assistance to offset their out of pocket costs to purchase insurance. There are two types of assistance: Advanced Premium Tax Credits (APTCs) and Cost Sharing Reduction. Eligibility for APTCs and Cost Sharing Reduction is determined based on household size and income as a percentage of the FPL. As with Medicaid and CHIP, once the individual s household size is determined, his/her income level is assessed. Noteworthy is that this calculation differs from the Medicaid/CHIP calculation in some ways. Additionally, the APTC and Cost Sharing income level calculation does not factor in the 5% disregard of income that the Medicaid/CHIP calculation does. Advanced Premium Tax Credits (APTCs) Consumers with income between 100% and 400% can use APTCs (advanced tax credit paid directly to the insurance company) to subsidize the premium cost of purchasing a QHP from the Marketplace. When applying through the Marketplace, eligible consumers will see adjusted monthly premium prices based on the amount of APTC for which they are eligible. The amount of APTC for which the consumer qualifies is based not only on income but also on the cost of the second lowest

5 Page 5 silver plan in his or her Marketplace; however, consumers may use APTCs toward the purchase of any of the four plan levels (although the subsidy remains the same regardless of plan selected). Individuals eligible for Medicaid are not eligible for APTCs. Exceptions could exist in the form of waivers, however, but would need to be approved by the Department of Health and Human Services. Cost Sharing Reduction Consumers eligible for APTCs with income between 100% and 250% of the FPL are also eligible for a second type of assistance under APTC regulations, called Cost Sharing Reduction or just Cost Sharing. Cost Sharing Reduction is a discount that lowers the amount one has to pay out ofpocket for deductibles, coinsurance, and copayments. A consumer can get this reduction if he/she gets health insurance through the Marketplace, his/her household income does not exceed 250% of the FPL for the benefit year for which coverage is requested, and he/she chooses a health plan from the silver plan category. If a member of a federally recognized tribe, the consumer may qualify for additional cost sharing benefits. Immigrant Coverage Lawfully residing immigrants currently are required to hold that status for five years before they are eligible for Medicaid. Some states (25 of them) waive the five year bar for children, and 20 states waive the bar for pregnant women under the Children s Health Insurance Program. Beginning in 2014, the ACA will increase coverage options for lawfully residing immigrants. Lawfully residing immigrants without access to employer based coverage, who are ineligible for Medicaid due to their immigration status, and who have income less than 100% of the FPL will have the opportunity to purchase coverage through the Marketplace and receive tax credits to subsidize the coverage. 2 Nothing in the Affordable Care Act changes the requirement that states provide emergency services to individuals not eligible for full Medicaid benefits due to their immigration status. Emergency Medicaid coverage will continue to be available for undocumented immigrants who will not be allowed to purchase coverage from the Marketplace. States will still need to determine eligibility for emergency services for such populations. Small Business Health Options Program (SHOP) SHOP is the Small Business Health Options Program for small businesses to access affordable health insurance for their employees. A small business is defined as having fewer than 100 employees, although states have the option to keep it under 50 employees until Some 2 Key Facts on Health Coverage for Low Income Immigrants Today and Under the Affordable Care Act, Jessica Stephens and Samantha Artiga, Kaiser Commission on Medicaid and the Uninsured, March 2013,

6 Page 6 states may merge their individual and SHOP Marketplaces into one, while others may set up their SHOP Marketplace in addition to their individual Marketplace. Employers have the advantage of contributing one payment to SHOP instead of payments to different plans, and they can choose their level of contribution. Administrative costs and risk are shared across employers in SHOP. Although initially targeted to begin January 1, 2014, SHOP has been delayed until Smallbusiness employees will still be able to get insurance, but the states have the option to limit that to one choice, rather than a variety of plans, for the first year. Impact to Providers In states that don t expand their Medicaid programs, hospitals will continue to serve a higher population of uninsured, forgoing reimbursement dollars to bad debt and charity care. Before the Supreme Court decision that made states participation in Medicaid expansion voluntary, hospitals agreed to accept a reduction in their Disproportionate Share Hospital (DSH) allocations. They did this with the understanding that Medicaid expansion in every state would result in a dramatic reduction in the number of uninsured patients in turn leading to reimbursement for services to these patients who would, without Medicaid expansion, otherwise not have coverage. Medicaid expansion was expected to create a cushion that would make up for reduced DSH payments. Now that many states are choosing not to expand, many hospitals are faced with incurring a double hit to their bottom line a reduction in their DSH dollars without an offsetting increase in their reimbursement. There is a concern that some hospitals may not be able to weather the storm and will be forced to close. Another consideration is seen in individuals enrolled in QHPs who fall behind on paying their monthly premiums. ACA regulations originally called for a 90 day grace period before an insurance company could drop consumers who fall behind on payments. After feedback from the insurance companies, these regulations were changed: during the first 30 days, burden of payment is on the insurance company. During the following 60 days, the burden of payment falls on the hospitals. 3 This adds an additional layer of complexity to an already highly complex situation. To ensure patients choose a plan that best suits their individual medical coverage and financial needs in the long run, it may prove beneficial to provide resources that can help guide them through applying for assistance, understanding the financial commitment of each plan, and enrolling in QHPs. 3 Hospitals May Absorb Burden of Insurers Debtor Patients, by Samuel Adams, Bloomberg.com, August 17, 2013, accessible at /hospitals may pay for insurers debtor patients under obamacare.html

7 Page 7 About the Author Shanna Hanson, FHFMA, is Manager of Business Knowledge for Human Arc (Cleveland, OH), an innovation leader in reimbursement and revenue enhancement services for hospitals and health plans nationwide. She has responsibility for research and reporting on all legislative and environmental changes and trends impacting the company s markets, services and product development initiatives. This includes strategic knowledge leadership for the company on national reform and the Affordable Care Act which she has researched for many years. Prior to her present role, Ms. Hanson served 14 years as Human Arc Midwest Operations Leader for its Medicaid eligibility enrollment services. She has been a driving force behind her region s Healthcare Financial Management Association for many years. Ms. Hanson has served as its President and earned the designation of Fellow of the Healthcare Financial Management Association (FHFMA). She holds the organization s Certificate of Advanced Technical Study in Mastering Patient Financial Services as well as the Founders Medal of Honor Award. She is a recognized industry writer and speaker on and related topics, conducts webinars on reform, and is a frequent reform blog contributor. Human Arc 1457 East 40 th Street, Cleveland, Ohio Fax by Human Arc EES0052A-0913

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