1 December 16, 2014 Presented by Steve Clark & Scott Prior
2 Patient Protection and Affordable Care Act of 2010 Obamacare or ACA or PPACA or Health Care Reform (HCR) Signed in to law on March 23, 2010 The bill itself is over 2700 pages long So how many pages are in the Affordable Care Act? In the actual legislation itself, there are just over 2,400. But the legislation is incomplete without the accompanying regulations, most of which have yet to be published. In April 2011 the first set of HHS regulations released covered six pages of the actual legislation but resulted in 429 pages of clarifying regulations.
3 What exactly does the ACA include? Allows the FDA to approve more generic drugs. Increases rebates on drugs through Medicare. Gradually closes the Part D Medicare Coverage Gap or "Donut Hole". The PCORI, an independent non profit advisory board, studies different types of treatments in order to ensure quality affordable health care under ACA. Chain restaurants must now display calories on their menus. Health Insurance companies can't rescind coverage when you re sick.
4 What exactly does the ACA include? ** Individuals can't be denied coverage for preexisting conditions. ** Children under the age of 19 can't be declined acceptance due to a preexisting condition. Children under the age of 26 can stay on their parents insurance. Income exclusion for Indian Tribe health benefits that were provided after March 23rd, 2010 Medicare cuts to hospitals and other health care facilities. Comparative Effectiveness Research, or CER studies the effectiveness of drugs by comparing drug to drug and seeing which one works best.
5 What exactly does the ACA include? Establishes a Patient Centered Outcomes Research Institute (PCORI) a public private entity that oversees ACA's funding, goals, and outside partnerships. Creates a high risk pool for individuals with preexisting conditions. Insurance companies can no longer discriminate for disabilities or domestic abuse Imposes a 10% tax on tanning booths. Rate Hike Review is implemented. Insurers must justify to the government rate increases above 10%. Insurers must spend a minimum of 80% of their premiums on claims. If not the balance is rebated back to the insured s (80% or less Medical Loss Ratio).
6 What exactly does the ACA include? Mandates women s health coverage including no charge contraceptive coverage, Health Insurance companies can no longer turn down a claim without an appeal process. Anti fraud funding is increased and new ways to stop fraud are created. Increases rebates for brand name pharmaceuticals purchased through Medicaid. New Annual taxes on pharmaceutical companies Payment increases to physicians, mostly in rural areas. Created tax credits for some small employers.
7 What exactly does the ACA include? Improves treatment for patients with chronic illnesses. ** Prohibits non group plans from canceling coverage. ** Limits the ability to use HSA and FSA money to purchase over the counter prescriptions. Employers must list employee benefits on the employees W 2 tax form. Hospitals in "Frontier States" (ND, MT, WY, SD, UT ) receive higher Medicare Payments Hospitals in "low cost" areas receive higher Medicare payments for 2 years
8 What exactly does the ACA include? All new plans must provide preventative care free of charge. Removes or increases spending caps from insurance plans. Removes life time maximum limits from insurance plans. Establishes new tools to fight fraud. Cuts $716 Billion from Medicare and Medicare advantage. Reduces the FSA (Flexible Spending Accounts) amount allowed by employees to $2500.
9 What exactly does the ACA include? Establishes state consumer assistance programs to help consumers file complaints, appeals, enroll in health care and other consumer related assistance to better understand trouble spots that need oversight. Created a hospital "pay for quality" program. This is part of an overall effort to promote quality not quantity in the health care industry. Imposes a 3.8% tax increase on capital gains over, unearned income, interest, dividends, annuities, rent, royalties, and inactive businesses. Exemptions include income from tax exempt bonds, veterans benefits and qualified plan distributions such as those from an IRA or 401k. The 3.8% tax does not apply to selling your primary residence in most cases.
10 What exactly does the ACA include? Developing a 5 year plan that works to simplify administrative tasks associated with health insurance such as reducing paperwork. **Mandates a specific SBC (Summary of Benefits and Coverage) template that insurers must use to lay out plan information for insured s. New documents are 10 pages or more in length. Created a new tax on private health insurance plans in ACA Health Care Reform 2013 ** Creating Health Insurance Exchanges (now will be called Marketplace) for low to middle income Americans to make it easier for them to shop for health insurance. Those making over 400% of the poverty level can shop on the exchange but will not receive tax credits or discounts. The insurance purchased on the exchange doesn't go into effect until Jan 1st, Metal plans are established (Bronze, Silver, Gold, and Platinum).
11 What exactly does the ACA include? Tax credits, discounts on out of pocket costs, tax breaks and other subsides are available on the exchange. Created a.9% ACA Medicare tax on those making over $200k as an individual or $250k as a business or family. Created a 3.8% Medicare tax on unearned income over $200 for individuals and $250 for families and businesses. $500,000 deduction cap on income paid to insurance company workers Eliminates deduction for Part D retiree drug subsidies for employers Increases (7.5% to 10%) threshold at which medical expenses, as a % of income, can be deductible)
12 What exactly does the ACA include? ACA Health Care Reform 2014 Tax penalties ($2000 or $3000 fee) to employers above 50 full time (30 hrs or more per week) that do not offer health insurance or when their employees get subsidies on the exchange. (This was delayed until 2015) Created a penalty (tax) for people who do not get health insurance. There is a tax starting at 1% of your income or $95 and raising to 2.5% of your income or $685 by 2016 for individuals. For a family it's capped at $285 in 2014 and rises to $2,085 by 2016 It cannot exceed these amounts. Congress must shop on the exchange. Created a new tax for Pharmaceutical companies. Expanding Medicaid to 17 million low income individuals. Medicaid limit raised to 133% of Poverty level. Federal government covers 93% of the new eligible s from the expanded limit. (Supreme court ruled this is optional for states.)
13 What exactly does ACA include? A health insurance exchange is set up by states or the federal government if the state decides not to run their own exchange. Metal plans are established. Employers will be able to shop on the health insurance exchanges for employee insurance (Shop Exchange was delayed until 2015) Tax credits, tax breaks and help with up front costs are available to those struggling to pay for insurance. Created a new tax on medical devices. Created a market share tax on Insurance companies. ACA 2015 Doctors income is based on quality of care not quantity of care. This is a vast simplification of the actual documentation in the bill. It is a protection from the current fee for service payment model.
14 What exactly does the ACA include? ACA Health Care Reform 2017 States can implement their own plans which meet the standards of ACA such as single payer. (similar to ACA, but instead of buying private insurance everyone pays a tax and everyone has coverage) Provides states flexibility to allow businesses with more than 100 employees to purchase coverage in the SHOP Exchange No more preexisting conditions for anyone including high risk customers.
15 What exactly does it include? ACA Health Care Reform 2018 All healthcare plans including plans held since before plans had to offer preventive care must now offer preventive coverage. The "Cadillac" tax for higher quality coverage for individuals and employers purchasing insurance for employees is put in place. ACA Health Care Reform 2020 ACA fully eliminates the Medicare Part D Gap or Donut Hole drugs will be covered 75% for those on Medicare
16 The Ten Essential Health Benefits. 1.Outpatient care 2.Trips to the emergency room 3.Inpatient Care 4.Maternity Services 5.Mental health and substance use disorder services: This includes behavioral health treatment, counseling, and psychotherapy
17 The Ten Essential Health Benefits. 1.Prescription drugs 2.Habilitative and rehabilitative services and devices. 3.Lab tests 4.Preventive services including counseling, screenings, and vaccines to keep you healthy and care for managing a chronic disease. 5.Pediatric services: This includes dental care and vision care for kids
18 What does this mean for small business? (Businesses with less than 50 employees) There is still no requirement for small businesses to offer health insurance to employees. If small business does offer insurance participation rules and contribution rules still apply. (75% and 50%) No underwriting on small business! No need for medical forms. Street rates are readily available but in most cases higher! Rates are all age based. All plans follow the Metal Level definitions.
19 What does this mean for small business? (Businesses with less than 50 employees) No subsidies for employees that are offered affordable coverage. Employees not offered coverage can get subsidies. Employer cannot help pay for the subsidized insurance! Any financial assistance to employee must be in the form of compensation. Employee can do whatever they want and choose any plan or not. The employer is not involved. Some employees and their family members may be Medicaid eligible. See subsidy chart and rates.
20 What does the individual market look like for employees? On Exchange plans (subsidy eligible) Off Exchange plans (no subsidy) Medicaid No underwriting.
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