Prepared by the
American Association of Colleges of Nursing
Updated November 2015
Why is it Important for Nurses to
Understand the New Law?
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Nursing expertise is critical to health systems reform.
As the Institute of Medicine’s (IOM) Future of Nursing: Leading Change,
Advancing Health report states:
 Nurses should be full partners with other healthcare professionals in
redesigning health care in the United States.
○ Recommendation 7: Prepare and enable nurses to lead change to
advance health. Nurses, nursing education programs, and nursing
associations should prepare the nursing workforce to assume leadership
positions across all levels, while public, private, and governmental
health care decision makers should ensure that leadership positions are
available to and filled by nurses. (IOM, Future of Nursing, Leading
Change, Advancing Health: Report Recommendations, National
Academies of Science, Washington, DC, p. 5).
The Patient Protection and Affordable Care Act or ACA [Public Law 111148] is, in many ways, the redesign of healthcare in America and it is the
law.
What Does This Mean for Nurses?
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Through the ACA, more Americans will be able to obtain
health insurance. As the number of insured individuals
increases, the demand for care providers will also grow.
Under the ACA, there were a number of key areas that
impacted nursing education and practices. These key
areas can be found here:
http://www.aacn.nche.edu/government-affairs/HCRreview.pdf
American Association of Colleges of Nursing (2010). Patient Protection and Affordable
Care Act Nursing Education and Practice Provisions. Retrieved from:
http://www.aacn.nche.edu/government-affairs/HCRreview.pdf
What is the Health Insurance
Marketplace?
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The Health Insurance Marketplace was created through
the Patient Protection and Affordable Care Act or ACA
[Public Law 111-148] specifically in relation to Subtitle
D—Available Coverage Choices for All Americans.
The core components of the ACA are the Individual
Mandate and the State Exchanges.
 Individual Mandate requires most individuals to
obtain health insurance or pay a penalty in the form
of a tax. In order to incentivize health insurance
acquisition, the ACA provides cost assistance
subsidies to individuals who qualify.
 State Exchanges allow for each state to decide if
they will create their own exchange, partner with
the federal government, or have a federallyfacilitated exchange for individuals to gain
coverage.
Kaiser Family Foundation (2014). State Decisions For Creating Health Insurance Marketplaces, 2014
Retrieved from http://kff.org/health-reform/state-indicator/health-insurance-exchanges/
Understanding the Individual
Mandate
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The individual mandate requires that everyone have health
insurance coverage or else they will pay a tax penalty.
Roughly 3 to 6 million individuals had to pay a tax penalty for not
enrolling in health insurance in 2014.
In 2016, the penalty will be the greater of
 $695 for each adult and $347.40 for each child, up to $2,085
per family, or
 2.5% of family income that is above the federal tax return filing
threshold for your filing status
 The penalty amount is capped at the cost of the national
average for a bronze level health plan available through the
Marketplace in 2016.
HealthCare.gov (2015). The fee you pay if you don’t have health coverage. Retrieved from
https://www.healthcare.gov/fees-exemptions/fee-for-not-being-covered/
CNN.com (2015) Millions to own Obamacare tax penalty. Retrieved from
http://money.cnn.com/2015/01/28/news/economy/obamacare-tax-penalty/
Understanding Cost Assistance Subsidies
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There are three types of cost assistance subsidies
 Premium tax credits which lower your premiums
 Cost sharing reduction subsidies for lower out of pocket costs
 Medicaid/Children’s Health Insurance Program (CHIP)
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As of 2015:
 The average monthly premium for an individual after the
advanced premium tax credit was applied was $105
 More than 8 in 10 individuals with a Marketplace plan qualified
for an advanced premium tax credit
Health and Human Services (2015). Health Insurance Marketplace 2015: Average
premiums after advance premium tax credits through January 30 in 37 States using
the healthcare.gov platform. Retrieved from
http://aspe.hhs.gov/health/reports/2015/MarketPlaceEnrollment/APTC/ib_APTC.pdf
Understanding the State Exchanges
There are four categories of state Marketplaces/Exchanges.
 Types of State Exchanges
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 State-based Marketplace
○ States are responsible for performing all Marketplace functions.
Consumers in these states apply for and enroll in coverage through
Marketplace websites established and maintained by states.
 Federally-supported State-based Marketplace
○ States are responsible for performing all Marketplace functions,
except that they will rely on the Federally-Facilitated Marketplace IT
platform. Consumers in these states apply for and enroll in coverage
through healthcare.gov.
 State-Partnership Marketplace
○ States may administer in-person consumer assistance functions and
HHS will perform the remaining Marketplace functions. Consumers
apply for and enroll in coverage through healthcare.gov.
 Federally-Facilitated Marketplace
○ HHS performs all marketplace functions. Consumers apply for and
enroll in coverage through healthcare.gov.
Kaiser Family Foundation (2015). State Health Insurance Marketplace Types, 2015
Retrieved from http://kff.org/health-reform/state-indicator/state-health-insurance-marketplacetypes/#note-3
State Structure for Health Insurance Marketplace/Exchanges
State breakdown of Health Insurance Marketplace, 2016
Kaiser Family Foundation (2015). State Health Insurance Marketplace Types, 2016
Retrieved from http://kff.org/health-reform/state-indicator/state-health-insurancemarketplace-types/#map
Learn About the State Marketplace Plans
There are five categories of plans that
individuals can access through the Marketplace.
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Bronze
 Your health plan pays 60% on average and
you pay about 40%.
Sliver
 Your health plan pays 70% on average. You
pay about 30%.
Gold
 Your health plan pays about 80% on
average. You pay about 20%.
Platinum
 Your Health plan pays about 90% on
average. You pay about 10%.
Catastrophic
 This plan pays less than 60% of the total
average cost of care. They’re only available
to people under 30 or have a hardship
exemption.
Healthcare.gov (2015). Marketplace Insurance Categories.
Retrieved from https://www.healthcare.gov/choose-a-plan/plans-categories/
Understanding the Medicaid Expansion
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Marketplace cost subsidies only cover individuals and families that earn
incomes between 100-400% of the federal poverty line (FPL). As of April
2015, the median Medicaid eligibility limit for states was 44% of the FPL.
This leaves individuals who earn between 45-99% of FPL unable to take
advantage of cost subsidies and ineligible for Medicaid
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The Medicaid “Coverage Gap” is a term used to describe the gap
between state Medicaid eligibility and Marketplace subsidy eligibility in
state’s that don’t expand
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To alleviate the Coverage Gap, the ACA provides states with additional
funding to expand their Medicaid program to cover adults under 65 with
income up to 133% of the federal poverty level
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The Medicaid expansion was intended to be national, however, in June
2012 the Supreme Court made it optional for states
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Currently, 19 states are not moving forward with Medicaid expansion
HealthCare.gov (2015). Medicaid expansions & what it means for you. Retrieved
from https://www.healthcare.gov/medicaid-chip/medicaid-expansion-and-you/
Kaiser Family Foundation (2015). The coverage gap: Uninsured poor adults in states that do not
expand Medicaid- An update.
Retrieved from http://kff.org/health-reform/slide/current-status-of-the-medicaid-expansion-decision/
Current Status of State Medicaid Expansion
Decisions
VT
WA
MT**
ND
NH*
MN
OR
NV
WI*
SD
ID
WY
CO
CA
AZ
NM
PA*
IL
KS
OK
MO
OH
IN*
WV
KY
AR*
AL
VA
MA
CT RI
NJ
DE
MD
DC
NC
TN
MS
TX
NY
MI*
IA*
NE
UT
ME
SC
GA
LA
AK
FL
HI
Adopted (31 States including DC)
Adoption Under Discussion (1 State)
Not Adopting At This Time (19 States)
Kaiser Family Foundation (2015). Current Status of State Medicaid Expansion Decisions.
Retrieved from http://kff.org/health-reform/slide/current-status-of-the-medicaid-expansion-decision/
Please note that many of these activities require access to the Health Insurance Marketplace to complete and are therefore best for after
Open Enrollment begins.
Discussion Groups: Answering Patient
Questions
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Each group will investigate one of the following
scenarios and report back to the class what they
would tell their patient.
 My daughter just turned 27, and no longer
can stay on my insurance. She lives in Ohio
and does not have a job yet. She is really
healthy, does she have to have insurance?
 I am a small business owner with 55
employees. Do I have to provide them with
health insurance?
 My husband currently has insurance that
covers our family, but it is not great. Can I
get a new plan?
 I have a pre-existing condition. What are my
options for coverage if I live in New Mexico?
Creating Your Own Resource:
Considering Healthcare Literacy
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Create a one-pager for the clinical population
you are currently working with (i.e. children,
families, adults).
 What information about the Marketplace is
pertinent to this population?
 What will they need to enroll?
 How would you guide them?
○ Consider such things as the
patient’s/family’s resources, educational
level.
Then create a distribution plan.
 How would you distribute this information to
your patient population? (i.e. text messages,
office visits)
 What resources would be needed?
State Exchange Discussion
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There are four categories of state Marketplaces/Exchanges.
Breakup into four groups and investigate:
 What does it mean for a state to have this type of
exchange?
 How many states have this type of exchange?
 Select a state that has this type of exchange and review
what it is offering.
Provide a summary to the class.
Types of State Exchanges
 State-Run Exchange
 State/Federal Partnership
 State Running Small Business Exchange, Federally
Facilitated Marketplace
 Federally Facilitated Marketplace
Discussion Groups: Learn About the
Plans
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There are five categories of plans that individuals can access through the
Marketplace. Breakup into five groups and investigate what types of services your
patient would receive. Provide a summary to the class.
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Bronze
Sliver
Gold
Platinum
Catastrophic
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