Affordable Care Act (ACA) Health Insurance Exchanges and Medicaid Expansion

Transcription

1 Affordable Care Act (ACA) Health Insurance Exchanges and Medicaid Expansion

2 Table of Contents Expanded Coverage... 2 Health Insurance Exchanges... 3 Medicaid Expansion... 8 Novartis Pharmaceuticals Corporation is committed to providing patients and customers with information about the Affordable Care Act. To learn more, visit Other ACA Reforms in Effect Healthcare Reform Glossary More Information... 21

3 Expanded Coverage What Are Health Insurance Exchanges? Health Insurance Exchanges are virtual one-stop marketplaces that allow certain individuals, families, and small businesses to compare and enroll in health insurance plans.* Exchanges provide a side-by-side comparison of plans available for eligible... The Affordable Care Act (ACA) was passed and signed into law in March 2010, and healthcare reform has been moving forward since then. Several key components of the ACA went into effect in 2014, with the 2 largest changes being the Health Insurance Exchanges and Medicaid Expansion. Individuals and Families Small Businesses *The Exchanges primarily serve individuals and families buying insurance on their own and small businesses with 50 or fewer full-time equivalent employees. Beginning in 2016, in all states, employers with up to 100 employees will be able to buy insurance through the Exchanges, and, in 2017, states will be able to open their Exchanges to employers with more than 100 employees. Individuals who have coverage from their employer generally do not buy insurance through the Exchanges. 2 3

4 Health Insurance Exchanges Exchanges offer a choice of plans that meet benefit and cost standards, including private insurance plans and health programs such as the Children s Health Insurance Program (CHIP). Providing Individuals With a Choice of Insurance Plans Exchanges can help people find a plan with a set of essential health benefits. Assistance with premiums and cost-sharing is available for many individuals and families. Private Insurance Plans Multi-State Plans Nonprofit Plans CHIP Essential Health Benefits Help Paying for Coverage 10 health categories must be covered by Exchange plans: For people who purchase insurance through Exchanges: 1 State-Based Exchange: States create and operate their own Exchange. The federal government will provide some basic services. States have 3 options Federally Facilitated Exchange: The US Department of Health & Human Services (HHS) operates the Exchange. States may perform some Exchange-management functions. Federal-State Partnership Exchange: States partner with the federal government to run their Exchange. States operate plan-management and/or consumer assistance. Ambulatory patient services Emergency services Hospitalization Maternity and newborn care Mental health and substance use disorder services, including behavioral health treatment Prescription drugs Rehabilitative/habilitative services and devices Laboratory services Preventive/wellness services and chronic disease management Pediatric services, including oral and vision care Those between 100%-400% of the federal poverty level (FPL) are eligible for subsidies Up to 400% of FPL: premium assistance subsidies Tax credit that reduces premium for individuals on a sliding scale based on income Up to 250% of FPL: cost-sharing assistance subsidies Lower caps on out-of-pocket spending based on individual or family income (if enrolling in a certain level plan) For people who don t purchase insurance through Exchanges: Those between 0%-138% of FPL are covered by expanded Medicaid in some states 4 5

5 The Individual Mandate Under the ACA, individuals are required to be enrolled in a health insurance plan that meets basic minimum standards.* This is known as the individual mandate. Individuals who do not have coverage in 2015 may be required to pay a penalty. In 2015, the penalty will be the higher of: 2% of household income over the tax filing threshold The maximum penalty under this method is the national average premium for a bronze plan. Every year, the penalty will increase. For 2016, the penalty will be the higher of 2.5% of the household income or $695 per person. *Some individuals are exempt from this requirement, including those incarcerated, members of Indian tribes, those not lawfully present in the United States, and those meeting certain income requirements. All Plans Offer Drug Coverage as an Essential Health Benefit Plans must include the greater of: The number of drugs in every United States Pharmacopeia (USP) category and class covered by the benchmark plan. Including brands and generics. 6 $325 per person ($ per child under 18) The maximum penalty per family under this method is $975. One drug in every USP category and class. Exchanges: A Closer Look Every state has its own Exchange, whether it is run by the state, federal government, or a partnership between the two The Exchanges primarily serve individuals and families buying insurance on their own and small businesses with 50 or fewer full-time equivalent employees. Beginning in 2016, in all states, employers with up to 100 employees will be able to buy insurance through the Exchanges, and, in 2017, states will be able to open their Exchanges to employers with more than 100 employees. Individuals who have coverage from their employer generally do not buy insurance through the Exchanges The individual mandate the requirement that individuals obtain health insurance or pay a financial penalty went into effect January 1, Some individuals are exempt from this requirement, including those incarcerated, members of Indian tribes, those not lawfully present in the United States, and those meeting certain income requirements The employer mandate the requirement that businesses with 50 or more full-time equivalent employees provide employees with adequate health insurance or pay a fee was originally scheduled to take effect in 2014 but has been delayed Plans purchased through the Exchanges must offer certain minimum essential health benefits. Coverage levels of those benefits are determined using a state benchmark plan. Exchange plans are classified as bronze, silver, gold, or platinum, depending upon the amount of cost-sharing for essential health benefits. A catastrophic plan option is available for certain individuals Individuals and families with lower incomes are eligible for premium assistance through tax credits that can be applied toward purchasing any level of plan and may be eligible for cost-sharing subsidies if enrolling in a silver level plan 7

6 Medicaid Expansion The problem before the ACA Before the ACA was passed, Medicaid had very low income eligibility levels for parents, and states were not required to cover adults without dependent children. To be eligible for Medicaid coverage, a person had to satisfy 2 tests based on: Income Eligibility Inconsistency Prior to the passage of the ACA, the rules for income eligibility for Medicaid were different from state to state. For instance, in January 2013, the income eligibility for working parents ranged from 16% of FPL to 215% of FPL, depending on the state. Eligibility at or below 50% of FPL between 50% and 100% of FPL at or above 100% of FPL Number of states Income eligibility for Medicaid is primarily based on the FPL, which was $23,550 for a family of 4 in 2013, except in Alaska and Hawaii, which have slightly higher FPL guidelines. Income Category Categorically Inconsistent Prior to the passage of the ACA, members of the following categories were possibly eligible for Medicaid depending on the state and their income level: Coverage and eligibility were not consistent state to state Children Pregnant women Parents Disabled/ blind persons Elderly 8 9

7 Whom Does the ACA Benefit? The ACA intended Medicaid coverage to be provided for all individuals with income up to 138% of FPL, regardless of family status or category in all 50 states and the District of Columbia.* However, each state can choose whether or not to expand its program, and there is no deadline for states to make a decision. As of September 2014, more than half of the states had decided to expand Medicaid. Income Requirements Individuals who have incomes at or below 138% of FPL are eligible. $35,000 Income levels for Medicaid eligibility in states choosing expansion (2014) $32,913 Before ACA After ACA in states expanding Medicaid $25,000 $15,000 $16,105 Low-income adults without children or dependents Qualified for Medicaid in less than 10 states regardless of their income Covered $5000 Low-income parents Not qualified for Medicaid in more than 30 states even if their children qualify Covered Individual Family of 4 The numbers in this chart are based on 138% of the 2014 FPL for the 48 contiguous states and the District of Columbia. There are slightly higher FPL thresholds for Alaska and Hawaii. The FPL guidelines are updated each year. The ACA attempts to create consistency *The law specifies 133% of FPL but disregards 5% of income, effectively expanding Medicaid to 138% of FPL. Category Requirements Individuals who meet the income requirement and are less than 65 years of age are eligible

8 Medicaid Implementation For most states expanding Medicaid, the federal government will pay 100% of the cost of covering the newly eligible population through 2016, and beginning in 2017, the federal match rate will decline gradually, reaching 90% in 2020 and remaining at that level. For states choosing to expand Medicaid eligibility to the full 138% of FPL, the federal government will cover the cost of new enrollees % of cost covered 90% of cost covered Medicaid Expansion and the ACA: A Closer Look Prior to the passage of the ACA, eligibility rules for Medicaid were inconsistent among states. The ACA aimed to ensure consistency of eligibility by requiring all states to expand Medicaid In 2012, the US Supreme Court ruled in National Federation of Independent Business v. Sebelius that expansion of Medicaid is optional for the states Medicaid has been expanded to cover people with incomes up to 138% of FPL in many states For most states expanding Medicaid, the federal government will pay 100% of the cost of covering the newly eligible population through 2016, and beginning in 2017, the federal match rate will decline gradually, reaching 90% in 2020 and remaining at that level Some states are exploring different methods of expanding their Medicaid eligibility Other Options for Medicaid Expansion States have the option of finding other ways to expand their Medicaid coverage rather than standard enrollment. For example, some states have turned to alternative approaches, such as purchasing insurance for those newly eligible for Medicaid through Exchange plans

9 Other ACA Reforms in Effect This chart covers additional reforms from the ACA that are also in effect. Reform Description Reform Description Adult Dependent Private insurers are required to offer dependent coverage on a Accountable Care The Centers for Medicare & Medicaid Services (CMS) has Coverage to Age 26 parent s policy until age 26. Organizations (ACOs) developed models for ACOs in Medicare. ACOs are medical groups Children s Pre-Existing Insurers cannot alter or deny coverage for children under 19 that offer coordinated care and health management services. Conditions Coverage because of pre-existing conditions. Flexible Spending Annual contributions to FSAs for medical expenses are now Elimination of Lifetime Lifetime limits on most benefits are prohibited in any health Account (FSA) Limits limited to $2500. Coverage Limits plan or insurance policy. Patient-Centered PCORI is tasked with reviewing relative health outcomes and Minimum Medical Loss Ratio Health plans are required to spend a minimum percentage of premium revenue on medical care and quality improvement rather than administrative costs and profits. Outcomes Research Institute (PCORI) comparative effectiveness of medical treatments. The results of PCORI determinations cannot be used as the sole factor in making reimbursement decisions in federal health programs. Rate Increase Review Insurers proposing a rate increase over 10% are required to provide detailed information to the states in which they operate and/or HHS. Sunshine Act Manufacturers must report certain payments or transfers of value provided to physicians, teaching hospitals, and non-teaching hospital entities conducting research. Closing the Previously, Medicare Part D beneficiaries could face a gap Medicare Part D ( doughnut hole ) in drug coverage between a maximum Doughnut Hole benefits limit and eligibility for catastrophic coverage. Beneficiaries had to pay 100% of medication costs during this gap, which is being closed over several years. The costs of closing the doughnut hole are shared by pharmaceutical rebates and government subsidies to health plans

10 Healthcare Reform Glossary Accountable Care Organization (ACO) Groups of doctors, hospitals, and other healthcare providers that come together voluntarily to provide coordinated, highquality care to the Medicare patients they serve. The organization s payment is tied to achieving healthcare quality goals and outcomes that result in cost savings. Affordable Care Act (ACA) The comprehensive healthcare reform law enacted in March The law was enacted in 2 parts: the Patient Protection and Affordable Care Act was signed into law on March 23, 2010, and was amended by the Healthcare and Education Reconciliation Act on March 30, The name Affordable Care Act is used to refer to the final, amended version of the law. Children s Health Insurance Program (CHIP) Insurance program jointly funded by state and federal government that provides health insurance to low-income children and, in some states, pregnant women in families that earn too much income to qualify for Medicaid but cannot afford to purchase private health insurance coverage. Dependent Coverage Insurance coverage for family members of the policyholder, such as spouses, children, or partners. Doughnut Hole, Medicare Prescription Drug Most plans with Medicare prescription drug coverage (Part D) have a coverage gap referred to as a doughnut hole. This means that after a certain amount of money for covered drugs has been spent, individuals are required to pay all out-of-pocket costs for their prescriptions until they reach a yearly limit. Once the yearly limit has been spent, the coverage gap ends and drug plans help pay for covered drugs again. Since 2011, beneficiaries have received a 50% discount from the pharmaceutical industry on drugs purchased in the doughnut hole. Exchange (Marketplace) A transparent and competitive insurance marketplace where individuals and small businesses can buy qualified health benefit plans. Exchanges offer a choice of health plans that meet certain benefits and cost standards. Individuals, families, and small businesses are eligible to purchase health insurance through Exchanges. People with lower income levels may also be eligible for a tax credit to help purchase insurance through an Exchange. Federal Poverty Level (FPL) A measure of income level issued annually by the Department of Health and Human Services. Federal poverty levels are used to determine eligibility for certain programs and benefits. Flexible Spending Account (FSA) An account set up through an employer to pay for a patient s out-of-pocket medical expenses with tax-free dollars. These expenses include insurance co-payments and deductibles, and qualified prescription drugs, insulin, and medical devices. An individual decides how much of their pre-tax wages are taken out of each paycheck and put into an FSA. The amount that can be put into an FSA each year is limited to $2500. There is no carry-over of FSA funds from year to year. (Note: FSAs are sometimes called Flexible Spending Arrangements.) 16 17

11 Health Status Refers to medical conditions (both physical and mental health), claims experience, receipt of healthcare, medical history, genetic information, evidence of insurability, and disability. Individual Mandate Under the ACA, as of 2014 individuals are required to be enrolled in a health insurance plan that meets basic minimum standards. If individuals choose not to participate in a health plan, they may be required to pay a penalty. There are some exceptions to the mandate, including income restrictions and religious beliefs. Individuals can also apply to waive the penalty if not automatically exempted. Lifetime Limit A cap on the total lifetime benefits an individual may get from an insurance company. An insurance company may impose a total lifetime dollar limit on benefits (like a $1 million lifetime cap) or limits on specific benefits (like a $200,000 lifetime cap on organ transplants, or one gastric bypass per lifetime) or a combination of the 2. After a lifetime limit is reached, the insurance plan will no longer pay for covered services affected by the limit. Medicaid A state-administered health insurance program for low-income individuals, families and children, pregnant women, the elderly, people with disabilities, and, in some states, other adults. The federal government provides a portion of the funding for Medicaid and sets guidelines for the program. States also have choices about how they design their programs, so Medicaid varies state by state and may have different names in different states. Medicare A federal health insurance program for people who are 65 years or older and certain younger people with disabilities. Medicare also covers people with end-stage renal disease (permanent kidney failure, requiring dialysis or a transplant, sometimes called ESRD). Medicare Part D A voluntary program that helps pay for prescription drugs for people with Medicare who join a plan that includes Medicare prescription drug coverage. There are 2 ways to get Medicare prescription drug coverage: through a Medicare Prescription Drug Plan or a Medicare Advantage Plan that includes drug coverage. These plans are offered by insurance companies and other private companies approved by Medicare. Out-of-Pocket Limit The maximum amount an individual will have to pay for covered services in a year. Generally, this includes the deductible, co-insurance, and co-payments. The definition may vary from plan to plan. For example, in some plans the out-of-pocket limit does not include cost-sharing for all services, such as prescription drugs. Plans may have different out-of-pocket limits for different services. In Medicaid and CHIP, the limit includes premiums. Out-of-Pocket Costs These expenses for medical care are not reimbursed by insurance. Out-of-pocket costs include deductibles, co-insurance, and co-payments for covered services, plus all costs for services that are not covered. Plan Year A 12-month period of benefits coverage under a group health plan. This 12-month period may not be the same as the calendar year. To find out when a plan year begins, check out all relevant plan documents or contact a benefits provider. (Note: for individual health insurance policies, this 12-month period is called a policy year )

12 Pre-Existing Condition A condition, disability, or illness (either physical or mental) that an individual has prior to enrolling in a health plan. Genetic information without a diagnosis of a disease or a condition cannot be treated as a pre-existing condition. This term is defined under state law and varies significantly by state. More Information Premium The amount that must be paid for a health insurance plan. Premiums are usually paid monthly, quarterly, or yearly. Preventive Services Routine healthcare that includes screenings, check-ups, and patient counseling to prevent illnesses, disease, or other health problems. Primary Care A range of health services that cover prevention, wellness, and treatment for common illnesses. Primary care providers include doctors, nurses, nurse practitioners, and physician assistants. Primary care providers often maintain long-term relationships with their patients and advise and treat them on a range of health-related issues. They may also coordinate care with specialists. United States Pharmacopeia (USP) The USP is a set of standards for the identity, strength, quality, and purity of medicines, food ingredients, and dietary supplements manufactured, distributed, and consumed worldwide. The USP includes a national lexicon of drug names and formulas in the United States, specifying category and class for all approved drug products. Patient Assistance NOW General information healthreform.kff.org Medicaid information Medicare information State Exchange information kff.org/health-reform/state-indicator/state-health-insurance-marketplace-types/#map Tax information The websites listed on this page (other than the website for Patient Assistance NOW) are maintained by third parties over whom Novartis Pharmaceuticals Corporation has no control. As such, Novartis Pharmaceuticals Corporation makes no representation as to the accuracy or any other aspect of the information contained on these websites

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