The Affordable Care Act of 2010:
What is Happening Next
What You Need to Know
Training Sections
1. Recent History of Health Care Reform
2. Overview of Changes in Affordable Care Act (ACA)
3. Timeline of Major Changes
4. Resources
Training Section 1:
Recent History of Health Care Reform
Recent History
March 2010
U.S. Congress passed:
•
Patient Protection and Affordable Care Act
(HR 3590)
•
Health Care and Education Reconciliation Act of 2010
(HR 4872)
4
Recent History
March 2010
President Obama signed into law, creating:
• Patient Protection and Affordable Care Act
(Public Law 111-148)
•
Health Care and Education Reconciliation Act of 2010
(Public Law 111-152 )
•
Together, commonly known as
The Affordable Care Act (ACA) of 2010
5
Training Section 2:
Overview of Changes in
Affordable Care Act (ACA)
Overview
The Affordable Care Act (ACA) of 2010:
•
Impacts many areas of health care
•
Result of many compromises
•
Does not go into effect all at once
•
Relies heavily on state and local implementation
7
Overview
Affordable Care Act makes major changes in 4 basic areas:
1. Insurance company accountability
2. Lowering costs and improving quality
3. Increasing access and choice
4. Patient rights and consumer protections
8
Key Strategies in Reform Approach
Adapted from Gerben DeJong, PhD, National Rehabilitation Hospital
MedStar Health Research Institute
1. Leave “good enough” alone
–
No drastic changes
2. Share the Responsibility
–
Everybody in the pool
3. Market-Based Solutions
–
Shift to competition for price and quality
4. Contain Costs
–
Focusing on the populations that have the highest health care costs
5. Innovate and Test
–
Half of ACA text focuses on testing laboratories to avoid
implementation mistakes
9
Overview: HealthCare.Gov
Training Section 3:
Timeline of Major Changes
Explaining the Timeline
How Timeline Works:
• Changes take effect over many years, through 2020
• Timeline shows when major reforms go into effect
• Designed to give more detailed information about changes
coming soon, summarizes changes down the road
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Explaining Timeline: [Date]
[Type of Reform]
Who: Population reform impacts
Why: Need or problem reform is addressing
What: Specifics of what reform does
When: When reform goes into effect
How: Details of how reform will be implemented or accessed
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TIMELINE:
IN PROGRESS NOW
14
Timeline: In Progress Now
Pre-existing Condition Insurance Plans
Who:
• People who can’t get insurance because of pre-existing
medical conditions, including mental health conditions
Why:
• Before ACA, people with pre-existing conditions often
couldn’t get any insurance
15
Timeline: In Progress Now
Pre-existing Condition Insurance Plans
What:
• People who can’t get insurance because of pre-existing
medical conditions can apply for a Pre-Existing Condition
Insurance Plan (PCIP)
• Law limits premiums to “standard rates” - the average amount
private insurers in the state charge for premiums for similar
coverage
• Limits out-of-pocket expenses
– $5,950/year for individual (does not include premiums)
16
Timeline: In Progress Now
Pre-existing Condition Insurance Plans
What:
• States can run PCIPs, with federal funding, or use federal PCIP
– 29 states chose to run plans themselves
– 21 states chose to let the federal government run them
• PCIPs in each state operate under ACA standards
– But plans may vary from state to state
17
Timeline: In Progress Now
Pre-existing Condition Insurance Plans
What:
• For people who live in states where the PCIP is run by the
federal government, there are now three options for plans:
– Standard plan
– Extended plan
– Health savings account plan
– For more information about these plans, go to:
http://www.healthcare.gov/news/factsheets/new_plan_opt
ions_2011.html
• The federal PCIP will now offer a special child-only rate for
children under 18.
18
Timeline: In Progress Now
Pre-existing Condition Insurance Plans
When:
• States letting the federal government run their PCIP:
– Can apply online now and get coverage within a month
• States running their own PCIP:
– Different application and enrollment dates
19
Timeline: In Progress Now
Pre-existing Condition Insurance Plans
When:
• PCIPs are meant to be temporary:
– End on January 1, 2014, when insurance companies won’t
be allowed to deny people coverage because of preexisting conditions
– On January 1, 2014, the state-run health insurance
Exchanges will be operational.
20
Timeline: In Progress Now
Pre-existing Condition Insurance Plans
How:
• To apply for a PCIP you must:
– Be a U.S. citizen or lawfully present in the United States
– Have had no health coverage for the last 6 months
– Have a pre-existing condition, as defined by each PCIP
– You can apply no matter what your income is
• To find details for your state:
www.HealthCare.Gov/law/about/provisions/pcip/index.html
21
Timeline: In Progress Now
Money Follows the Person Grants
Who:
• People on Medicaid who need long-term care services
Why:
• In the past, Medicaid’s Money Follows the Person grants have
provided flexible funding that lets a person who needs longterm care services get services that are most appropriate to
what they need and want
• MFP funding gives flexibility to move from institutional to
community-based services and keep funding
22
Timeline: In Progress Now
Money Follows the Person Grants
What:
• ACA extends these grants and adds $2.25 billion in funding
• Broadens eligibility standards
• Helps states pay for the costs of moving someone from
institution to home
When:
• MFP grants have been extended until September 2016
How:
• The program is continuing to operate as before
23
Timeline: In Progress Now
Rescission Outlawed
Who:
• Anyone who has insurance and might get sick
Why:
• Before ACA, when someone with insurance got sick with an
expensive or chronic illness, insurance companies would often
go back and search their application for mistakes, looking for
reason to drop their coverage
• This is called rescission, and happened to thousands of
Americans each year
24
Timeline: In Progress Now
Rescission Outlawed
What:
• Under ACA, insurance companies aren’t allowed to drop
people’s coverage because they get sick
When:
• Rescission is now illegal
How:
• Department of Health and Human Services is responsible for
regulation and enforcement details
25
Timeline: In Progress Now
Ban on Discriminating Against Kids with PEC
Who:
• Children under 19 with pre-existing conditions
Why:
• Before ACA, insurance companies could legally deny insurance
to children because they had a pre-existing condition
What:
• Under ACA, it is illegal for insurance companies to deny or
restrict insurance to children because of pre-existing condition
26
Timeline: In Progress Now
Ban on Discriminating Against Kids with PEC
When:
• Applies to health plan years starting after September 23, 2010
How:
• As with any group plan, insurance companies may decide to
restrict enrollment to specific enrollment periods
• Department of Health and Human Services is responsible for
regulation and enforcement details
27
Timeline: In Progress Now
Expanded Coverage for Young Adults
Who:
• Adult children up to age 26
Why:
• Before ACA, children were often dropped from parents’
insurance plans when they turned 18 or finished college
• Many young people have difficulty finding jobs with employersponsored coverage and can’t afford to buy individual
coverage, so they often would go without insurance
28
Timeline: In Progress Now
Expanded Coverage for Young Adults
What:
• Children can stay on (or be added to) their parents’ insurance
until they turn 26
– Applies to plans that offer dependent coverage
When:
• Open enrollment for coverage started on September 23, 2010
and was required by law to continue for at least 30 days, with
annual open enrollment periods
• Finding Insurance Options
29
Timeline: In Progress Now
Ban on Lifetime Coverage Limits
Who:
• Anyone who has insurance or will ever use insurance
Why:
• In the past, insurance companies have used lifetime coverage
limits to limit amount of money they will pay out for a
customer’s health care needs
• If someone got sick and reached their lifetime coverage limit
during treatment, the insurance company could just stop
paying for treatment
30
Timeline: In Progress Now
Ban on Lifetime Coverage Limits
What:
• Insurance companies not allowed to put caps on amount they
will spend on lifetime coverage costs for essential benefits
• Essential benefits include things like hospital stays, doctor
visits, and prescription drugs
31
Timeline: In Progress Now
Ban on Lifetime Coverage Limits
When:
• Ban started September 23, 2010, for all new individual
insurance plans and all group plans
• Annual limits are restricted in all group plans and new
individual plans, until 2014, when banned completely
How:
• The law includes a detailed list of essential benefits that must
be covered without limit
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Timeline: In Progress Now
Free Preventive Services - Private Coverage
Who:
• Anyone who has private insurance
Why:
• Before ACA, many health plans charged for preventive
services, so people often chose to skip them
• Preventive services can help avoid many costly health
problems down the road
33
Timeline: In Progress Now
Free Preventive Services - Private Coverage
What:
• Private insurance plans have to cover certain recommended
preventive services, like cancer screenings
• Insurance companies are required to offer these services free
to patient - without deductible, coinsurance, or copayment
charges
• Law ensures many free preventive health services for
children, including many vaccines
34
Timeline: In Progress Now
Free Preventive Services - Private Coverage
When:
• All new individual and group plans after September 23, 2010
How:
• Coverage for these services is offered through existing private
insurance plans
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Timeline: In Progress Now
Improvements to Medicaid HCBS
Who:
• People who use Medicaid’s Home and Community-Based
Services (HCBS)
Why:
• In 2005, 1915(i) was added to Social Security Act
• Gave state Medicaid programs option to provide HCBS to
people with disabilities before they need institutional care
• Many states did not choose to provide these services
36
Timeline: In Progress Now
Improvements to Medicaid HCBS
What:
• ACA changes and adds to Section 1915(i)
– Removes many barriers to states to offering these services
– Allows states to amend their plans instead of having to
apply for waiver
– Improves quality of services and access to HCBS for people
with disabilities
• Expands services that state can offer as part of HCBS
• Allows states to extend full Medicaid benefits to people using
HCBS
37
Timeline: In Progress Now
Improvements to Medicaid HCBS
When:
• Changes went into effect on October 1, 2010
How:
• As long as people meet a state’s eligibility requirements, HCBS
have to be offered to every eligible person in the state
• States can now provide services to people with incomes up to
300% of the Supplemental Security Income (SSI) Federal
Benefit Rate ($2,022 per month in 2011)
38
Timeline: In Progress Now
Drug Discounts for People in Donut Hole
Who:
• People who fall in Medicare’s donut hole
39
Timeline: In Progress Now
Drug Discounts for People in Donut Hole
Why:
• Under Medicare Part D, when person’s prescription drug costs
reach a certain amount ($2,840 in 2011):
– Medicare stops paying for any prescription drug costs
– They have to pay for 100% of their drugs out-of-pocket, until
they reach the maximum out-of-pocket amount
– Once they reach this maximum ($4,550.00), they are
out of the donut hole - Catastrophic Coverage begins,
and Medicare starts to help cover the costs again
40
Timeline: In Progress Now
Drug Discounts for People in Donut Hole
What:
• People in donut hole get up to 50% discount on brand name
drugs, 7% discount on generics for 2011 and 14% for 2012
• People who qualify for Extra Help, and join a Medicare drug
plan, will have no coverage gap.
When:
• Discount started January 1, 2011
– Will grow until 2020, when donut hole is closed completely
How:
• Full cost of drugs (rather than discounted amount) still counts
towards person’s out-of-pocket maximum
41
Timeline: In Progress Now
More Preventive Services Under Medicare
Who:
• Anyone on Medicare
Why:
• Preventive services can help avoid many costly health
problems down the road
42
Timeline: In Progress Now
More Preventive Services Under Medicare
What:
• People on Medicare can get a free wellness visit and
personalized prevention plan each year
• Must have had Part B for longer than 12 months
• No copayment, deductible, or coinsurance charges for
recommended preventive services
43
Timeline: In Progress Now
More Preventive Services Under Medicare
When:
• Started January 1, 2011
How:
• Coverage for these services are offered through existing
Medicare plans
44
Timeline: In Progress Now
Medicaid Community First Choice Option
Who:
• People with disabilities who are on Medicaid with income less
than or equal to 150% of Federal Poverty Level, or if greater,
meet an institutional level of care
Why:
• People with disabilities have the right to choose to live in and
receive services in their homes and communities whenever
possible
45
Timeline: In Progress Now
Medicaid Community First Choice Option
What:
• Provides HCBS such as attendant services and supports to
increase a person’s ability to live in the community
• Allows Medicaid plans to choose HCBS as a rule, rather than
the exception
When:
• CFC Option will be effective October 1, 2011
46
Timeline: In Progress Now
Medicaid Community First Choice Option
How:
• ACA provides a 6 percentage point increase in federal
Medicaid match for states that choose the CFC Option
47
TIMELINE:
BY 2012
48
Timeline: By 2012
CLASS Act
Who:
• Everyone
Why:
• Paying for long-term care is expensive
– Many people can’t afford it and don’t budget for it
• People need options that give them more choice and flexibility
about long-term care
49
Timeline: By 2012
CLASS Act
What:
• The Community Living Assistance Services and Support Act
(CLASS Act) provides for voluntary, self-funded, long-term care
insurance through the workplace
• Insurance will help pay for long-term care costs for people
with disabilities and elderly people
• People will be able to use cash benefit to pay for their choice
of variety of long-term care services, including home health
care workers, assistive technology, adult day care,
transportation, or assisted living
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Timeline: By 2012
CLASS Act
When:
• Departments of Health and Human Services (HHS) will write
rules about how much premiums will cost and what disabilities
qualify for the insurance benefits
• Rules must be written by October 1, 2012
51
Timeline: By 2012
CLASS Act
How:
• Employers decide whether they want to participate
• If employer participates, people are auto-enrolled, can opt out
• Premiums taken through payroll deductions
– Employers can pay premiums, not required
• Will be way for self-employed and employees of companies
that don’t participate to choose to enroll
52
Timeline: By 2012
CLASS Act
How:
• People pay premiums for five years before they can collect
benefits, which will be a minimum average of $50 a day
– Amount of benefit depends on assessment of disability
– This benefit will not count as income when determining eligibility for benefit
programs like SSI, SSDI
• No income or asset limit
• There are eligibility criteria, but no screening for pre-existing
conditions
• No lifetime benefit limit
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TIMELINE:
BY 2014
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Timeline: January 1, 2014
Ban on PEC Discrimination
Who:
• Anyone with a pre-existing condition
Why:
• Before ACA, insurance companies could legally deny insurance
to people because they had a pre-existing condition
What:
• Under ACA, will be illegal for insurance companies to deny or
limit insurance to anyone because of a pre-existing condition
55
Timeline: January 1, 2014
Ban on PEC Discrimination
When:
• Starting on January 1, 2014
How:
• Department of Health and Human Services is responsible for
regulation and enforcement details
56
Timeline: January 1, 2014
Expansion of Medicaid Eligibility
Who:
• Low-income people who have previously made too much
money to qualify for Medicaid
• Low-income adults without children
• Low-income adults without a disability
Why:
• Many people who did not qualify for Medicaid did not have
access to affordable insurance through their job, and did not
make enough to be able to pay for private insurance
57
Timeline: January 1, 2014
Expansion of Medicaid Eligibility
What:
• Medicaid will expand to cover more low-income people
including adults without children, and adults without a
disability
• Anyone below a certain income level will be eligible
for Medicaid
– Unlike current eligibility that is based on a population or
category (such as having a disability)
• Will help people with disabilities who did not meet the
current Medicaid disability determination requirements
58
Timeline: January 1, 2014
Expansion of Medicaid Eligibility
When:
• Starting January 1, 2014
• States can choose to expand Medicaid eligibility before 2014
• As of March 2011, 2 states (CT, MN) and the District of
Columbia have expanded Medicaid eligibility
How:
• Expansion will include most people (age 19 and older)
with incomes up to 133% of Federal Poverty Level
(about $28,000 for family of 4)
59
Timeline: January 1, 2014
Expansion of Medicaid Eligibility
People eligible for this Medicaid category cannot be:
• Age 65 or older
• Pregnant
• Entitled to or enrolled in benefits under Medicare Part A
• Enrolled under Medicare Part B, or:
• Part of any of the other “mandatory” groups described in the
Medicaid law
– Such as certain parents, children, or
people who are eligible because they get Supplemental
Security Income (SSI) benefits
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Timeline: January 1, 2014
Expansion of Medicaid Eligibility
• Most people get benchmark (or benchmark-equivalent)
benefits
• All rules that apply under the Medicaid program in general
apply to this new eligibility group
– Including rules related to cost sharing, retroactive
coverage, and immigration status
• This expansion also gets rid of the asset test for:
– New eligibility group
– People eligible through Medicare or other programs
– People with disabilities
61
Timeline: January 1, 2014
State Health Insurance Exchanges
Who:
• Everyone in private insurance market
Why:
• In the past, it has been complicated for people to compare
private insurance plans
• People buying individual plans have not been able to negotiate
for better prices, the way people buying group coverage can
62
Timeline: January 1, 2014
State Health Insurance Exchanges
What:
• States will create exchanges, a marketplace where people can
comparison shop for standardized health packages
• Exchanges will provide way for individuals and small
businesses to buy more affordable coverage
• People will also be able to join together in groups to negotiate
more affordable group insurance
• Provides subsidies for low-income people on a sliding scale
63
Timeline: January 1, 2014
State Health Insurance Exchanges
What:
• The exchanges inspect policies to make sure they meet
standards
– Can ask companies to justify rate hikes
When:
• Starts January 1, 2014
64
Timeline: January 1, 2014
State Health Insurance Exchanges
How:
• Exchange packages will include essential health benefits:
• Outpatient care
• Emergency services
• Hospitalization
• Maternity and newborn care
• Mental health and substance use disorder services
• Prescription drugs
• Rehabilitative services and devices
• Laboratory services
• Preventive services and chronic disease management
• Pediatric services
65
Training Section 4:
Resources
HealthCare.Gov
• Finding Insurance Options
• Timeline
• Information for Specific Situations
• Comparing Quality of Facilities
• Information about Implementation
67
HealthCare.Gov
• The ACA includes many new regulations
• Each new regulation goes through a period known as NPRM:
Notice of Proposed RuleMaking
• During this period the public can comment, giving input and
expertise about the proposed regulation before the final
version of the regulation is written
• HealthCare.Gov has a section where you can find more
information on regulations, including those with “NPRM”
periods that are open for comment:
http://www.healthcare.gov/center/regulations/index.html
68