Affordable Care Act: Key Provisions for People with MS

Transcription

1 Affordable Care Act: Key Provisions for People with MS October 2013

2 Why reform healthcare? By 2008, 15% of the U.S. population, or approximately 47 million Americans, lacked health insurance Documented link between lack of insurance and bankruptcy, death, barrier to global economy, perception the system was unfair The United States is spending more per capita than other nations, yet health status is significantly worse Healthcare costs double every 10 years; amounts to 17% of GDP Significant evidence that much of healthcare is ineffective, wasteful, or even harmful The Dartmouth Atlas Project shows wide, inexplicable variations in cost of the same services across the U.S. Growing consensus among public, employers, and the medical community that the current system is unsustainable

3 Quick Facts Historically, many people with MS faced challenges in finding and keeping adequate, affordable health coverage. Coverage (Iezonni, 2007) Cost (Minden, 2006, 2008) People with MS are more likely to be unemployed. 30% of those with MS put off seeking health care because of costs. 20% of people living with MS could not fill prescriptions or skipped doses because did not have access. The average annual cost of living with MS is approximately $70,000. The average lifetime cost of living with MS is approximately $2 million. Out-of-pocket costs for health care among people with MS (deductibles, copay, co-insurance) os almost twice as much as the general population.

4 Primary Source of Coverage for People with MS Before the Affordable Care Act Insurance for People with MS 4% 5% 4% 20% 9% 56% Private Insurance Medicare Medicaid Medicare & Medicaid Uninsured Other Source: Iezzoni & Ngo. Health, disability and life insurance experiences of working-age persons with multiple sclerosis. Multiple Sclerosis 2007; 13:

5 National MS Society takes a principled position Principles for Health Care Reform Accessible health care coverage Affordable health care services and coverage Standards of coverage for specific treatments Elimination of disparities in care Comprehensive, quality health care for all Increased value of health coverage Access to high-quality, long-term supports and services

6 Key Provisions Will Improve Lives of Those Living with MS Provisions ACCESS for those with pre-existing conditions AFFORDABLE coverage and care ADEQUACY of Benefits Description Phase-in of prohibition on coverage denials based on pre-existing conditions began with special high-risk pool until 2014, AND prohibition on denials for children (up to age 19) with pre-existing condition. In 2014, prohibits discriminating for pre-existing conditions. Ban on rescissions took effect immediately (2010). Lifetime caps on benefits prohibited, annual caps limited. Premium credits up to 400% of the Federal Poverty Level (FPL). Out-of-pocket costs limited. Medicaid expansion to 133% FPL. (22 states so far) All qualified health plans must cover essential health benefits -- at least. Preventive health benefits covered with no deductibles or co-pays in public and private health coverage. Coverage of costs for care in clinical trials.

7 ACA Improves Private Health Insurance Private Insurance Provision Effective date Prohibits discrimination based on pre-existing conditions in all plans Children: 2012 Adults: 2014 Guaranteed renewal of insurance policies Effective 2014 Prohibits use of rescissions except for fraud or non-payment Effective 2010 Premiums subsidized through tax credits for all at/below 400% Federal Poverty Level (FPL) Limits out-of-pocket costs for all plans sold in the exchange (approx. $6250 for individuals and $12,500 for families in 2014) Effective 2014 Effective 2014 Bans lifetime benefit caps; restricts annual benefit caps Effective 2011

8 ACA and Medicare: reducing costs, expanding benefits, rewarding quality Medicare Provision No cost-sharing for evidence-based preventive services, annual wellness visit and personalized prevention plan New demonstration programs to help ID best ways to reward the quality of care rather than the quantity of care Effective date Effective 2011 Phased in from 2012 Medicare Rx coverage gap phases out by 2020 In 2010, $250 rebate Starting 2011, brand name drugs cost 50% less during coverage gap Gap gets smaller until 2020 then beneficiaries pay 25% of drug costs all year Phased in from 2010

9 ACA Expands, Improves Medicaid Medicaid Provision Income eligibility becomes standardized (133% FPL) in states that choose to expand Medicaid Money Follows the Person Demonstration grants extended making it easier for some to move back into their communities New Federal Coordinated Health Care Office to improve care coordination for people in both Medicare and Medicaid Effective date Effective 2014 Effective Formally established by CMS Dec. 30, 2010

10 What Is Not Changing? 1. Employers and individual policyholders can keep same plans 2. Individuals can still get COBRA benefits 3. HIPAA/Medical Privacy 4. Family Medical Leave Act (FMLA)

11 Other Notable Changes in the ACA Other Important Provisions Provision FDA is authorized to approve biosimilar versions of biologic drugs New standards for accessibility for medical diagnostic equipment including exam tables, chairs, scales, X-ray and other imaging technology Health insurers must use standardized information and terminology in all documents to make coverage easier to understand and use. Effective date Effective upon enactment Effective March 2012 Effective September 2012

12 Health Insurance Exchanges: A New Way to Shop for Coverage States choices for establishing new online marketplaces: Create their own Exchange (16 and District of Columbia) Use the federal Marketplace (34) Purpose of Exchange/Marketplace To compare / purchase private health insurance Qualified Health Plans (QHPs) Premium Tax Credits only available with FFM plans Also available to small employers Fewer than 50 full time equivalent employees Small Business Health Options Program SHOP

13 Open Enrollment October 1,2013 March 31,2014 Coverage can begin January 1, 2014 IF ENROLLED BY Special Enrollment after March to enroll in or change QHPs (45 CFR ). For example: Loss of other coverage (except for non-payment, rescission) Birth, adoption, marriage Change in immigration status Error by FFM Other exceptional circumstances Note: Medicaid applications accepted & processed all year

14 Basic Eligibility for Marketplace Insurance with Premium Tax Credits Income between 100%-400% federal poverty line Family Size 100% FPL 400% FPL 1 $11,490 $45,960 2 $15,510 $62,040 3 $19,530 $78,120 4 $23,550 $94,200 No affordable job-based coverage Not affordable if employee-only plan: costs 9.5% family income; or covers 60% costs

15 Insurance Marketplace How to Apply Multiple doors for applications Online Phone Local Departments of Social Services By mail: Federal Paper Application - Other-Resources/Downloads/marketplace-app-standard.pdf

16 Information Needed to Apply Availability of Employer-based Coverage Identity of applicants Name and contact info Social Security Number Immigration Status Household Size Using tax code principles & expected HH in 2014 Countable Income Using tax code principles & expected income in 2014 Data bases will verify a lot of information Paper documents last resort

17 Standardized coverage = 10 essential health benefits (EHB) All qualified health plans must cover: 1.Ambulatory patient services 2.Emergency services 3.Hospitalization 4.Maternity & newborn care 5.Mental health & substance use disorder services, including behavioral health treatment 6.Prescription drugs 7.Rehabilitative & habilitative services & devices 8.Laboratory services 9.Preventive & wellness services & chronic disease management, & 10.Pediatric services, including oral & vision care

18 Help for People with High Medical Costs Annual maximum out-of-pocket costs for all In-Network, Essential Health Benefits More cost-sharing help for low income households: SILVER PLAN ONLY If under 200% of Federal Poverty Level, max out-of-pocket $2250 Individual/$4500 Family If % of Federal Poverty Level, $5200 Individual or $10,400 Family Expanded appeal rights including external review Lifetime caps abolished, annual caps limited

19 Conclusion Overall, many structural changes in health care system Some changes were immediate, others on schedule to 2020 The National MS Society will continue to analyze how new provisions will impact people and families living with MS Look for notifications on our webpage,, on , and through our periodicals like Momentum. For general questions about health care reform: The official site of the federal government, provides comprehensive information about the new law, with details on health insurance options for individuals in every state. (In English and Spanish) If you have specific questions about how ACA will impact your MS treatment, contact the National MS Society Call us! Online: