January 2014
CO Coalition for Elder Rights & Abuse Prevention
Presentation Outline
• Overview of the Affordable Care Act
• The Marketplace/Connect for Health Colorado
• Medicare and the ACA
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What is the Affordable Care Act (ACA)
• Refers to the federal laws and regulations contained in
the Patient Protection and Affordable Care Act and the
subsequent Health Care and Education Reconciliation
Act have come to be called the Affordable Care Act
(ACA).
• The main goal of the ACA is to provide insurance
coverage, both public and private, to reduce the
number of Americans who are uninsured.
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Key Features of the ACA
• New Consumer Rights Insurance Marketplace
and Protections
• Strengthening
• Individual
Medicare
Mandate/Shared
• Medicaid Expansion
Responsibility
• Affordable Health
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New Consumer Rights and Protections
• Stops insurance companies from dropping
coverage
• Adds more preventive care
• Extends coverage for young adults
• Stops insurance companies from denying
coverage because of pre-existing conditions
• Bans lifetime limits
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Shared Responsibility/The Individual Mandate
Important Points:
• Starting in 2014, individuals must either have health
care coverage, an exemption from coverage, or pay a
penalty on their tax return for not having insurance.
• Only health plans with minimum essential coverage
will fulfill the mandate.
• Some populations are exempt from the mandate.
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Penalties for Not Having Health Coverage
The penalty in 2014 is calculated one of two ways. You’ll pay
whichever of these amounts is higher. The fee increases every
year.
• 2014: 1% of your yearly household income or $95 per
person for the year ($47.50 per child under 18).
• 2015: 2% of income or $325 per person.
• 2016 and later: 2.5% of income or $695 per person.
• After: Adjusted for inflation.
• If you’re uninsured for just part of the year, 1/12 of the
yearly penalty applies to each month you’re uninsured.
• If you’re uninsured for less than 3 months, you don’t have a
make a payment.
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Minimum Essential Coverage
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Ambulatory patient services
Emergency Services
Hospitalization
Maternity/newborn care
Mental health/substance abuse
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Minimum Essential Coverage, cont.
• Prescription drugs
• Rehab/habilitative services and devices
• Laboratory services
• Preventive and wellness care/chronic disease
management
• Pediatric services, including oral and vision care
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Plans that Meet the Individual Mandate
• Any Connect for Health Colorado Marketplace plan, or any
individual insurance plan that you may already have
• Any employer plan (including COBRA) with or without
"grandfathered" status, including retiree plans
• Medicare
• Medicaid
• Child Health Plan Plus (CHP+)
• TRICARE (for veterans and veteran families)
• Veterans health care programs
• Peace Corps volunteer plans
• Other plans may qualify: ask your health coverage provider
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Exceptions to the Individual Mandate
• Uninsured for less than 3 months of the year
• The lowest-priced coverage available to you would cost
more than 8% of your household income
• You don’t have to file a tax return because your income
is too low (Learn about the filing limit.)
• You’re a member of a federally recognized tribe or
eligible for services through an Indian Health Services
provider
• You’re a member of a recognized health care sharing
ministry
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Exceptions, cont.
• You’re a member of a recognized religious sect with
religious objections to insurance, including Social
Security and Medicare
• You’re incarcerated, and not awaiting the disposition of
charges against you
• You’re not lawfully present in the U.S.
• Hardship Exemptions. (Examples include: Homeless,
eviction, death in immediate family, bankruptcy filing
and others)
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Hardship Exemptions
• If you have any of the circumstances below that
affect your ability to purchase health insurance
coverage, you may qualify for a “hardship”
exemption:
• You were homeless.
• You were evicted in the past 6 months or were
facing eviction or foreclosure.
• You received a shut-off notice from a utility
company.
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• You recently experienced domestic violence.
• You recently experienced the death of a close family
member.
• You experienced a fire, flood, or other natural or
human-caused disaster that caused substantial damage
to your property.
• You filed for bankruptcy in the last 6 months.
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• You had medical expenses you couldn’t pay in the last
24 months.
• You experienced unexpected increases in necessary
expenses due to caring for an ill, disabled, or aging
family member.
• You expect to claim a child as a tax dependent who’s
been denied coverage in Medicaid and CHIP, and
another person is required by court order to give
medical support to the child. In this case, you do not
have to pay the penalty for the child.
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• As a result of an eligibility appeals decision, you’re
eligible for enrollment in a qualified health plan (QHP)
through the Marketplace, lower costs on your monthly
premiums, or cost-sharing reductions for a time period
when you weren’t enrolled in a QHP through the
Marketplace.
• You were determined ineligible for Medicaid because
your state didn’t expand eligibility for Medicaid under
the Affordable Care Act.
• Your individual insurance plan was cancelled and you
believe other Marketplace plans are unaffordable.
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ACA Key Takeaways
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New consumer rights and protections
Shared Responsibility/Individual Mandate
New Health Insurance Marketplace
Medicare Improvements
Medicaid Expansion
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The Marketplace/Connect for Health Colorado
What is Connect for Health Colorado?
• Colorado’s state health insurance marketplace
• Browse, compare, and purchase plans online
• Only way to access the federally subsidized discounts.
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Key Features of Connect for Health Colorado
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Apply online, on paper, in-person or on the phone
Determine Medicaid Eligibility
Apply for financial assistance
Shop and Compare Health Plans
Purchase and Manage Your Plan Online
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Application Process
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Paper
Phone
Online
In-Person
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Medicaid Determination
• In order to be eligible to purchase a plan the
Marketplace, customers must first be determined
ineligible for Medicaid. Currently, the Medicaid
determination must be completed on PEAK.
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Application Flow Chart
Connect
for Health
Colorado
PEAK
Apply for
Financial
Assistance
Medicaid
Application
Shop for
Health
Plan
Ineligible
Purchase
Plan
Manage Coverage
on Connect for
Health Colorado
Manage Coverage
on PEAK
Eligible
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Shop and Compare Plans
• Comparison Shopping
• Metal Tiers
• Carriers
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Comparison Shopping
• All plans offer minimal benefits
• Beyond minimal coverage, benefits may differ from
plan to plan.
• Health Plans are also divided in four categories or
“metal tiers”, based on actuarial value.
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Actuarial Value
• Actuarial value= the average percentage of the health
care expenses the carrier expects to pay. A health
plan’s members pay the remaining expenses in the
form of cost sharing like deductibles, copays, and
coinsurance.
*The percentage does not reflect non-covered expenses.
*Premiums are not calculated into actuarial value.
*Higher premiums tend to accompany higher actuarial
values.
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Metal Tiers
• Bronze-tier health plans have a value of 60 percent
• Silver-tier health plans have a value of 70 percent
• Gold-tier health plans have a value of 80 percent
• Platinum-tier health plans have a value of 90 percent
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Medical Plans
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Access Health Colorado
Anthem Blue Cross and Blue Shield / HMO Colorado
Cigna
Colorado Choice Health Plans
Colorado HealthOP
Denver Health Medical Plan
Humana
Kaiser Permanente
Rocky Mountain Health Plans
UnitedHealthcare
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Dental Plans
• Anthem Blue Cross and Blue Shield / HMO
Colorado
• BEST Life and Health Insurance Company
• Cigna
• Delta Dental of Colorado
• Dentegra Insurance Company
• Premier Access Dental and Vision
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Apply for Financial Assistance
Two types of financial assistance available to offset costs
of plans purchased on the Marketplace:
• Advance Premium Tax Credits (APTC)
• Cost-sharing Reductions (CSR)
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Advance Premium Tax Credit (APTC)
• Tax credit available to lower the cost of health
insurance premiums.
• Available to individuals and families with incomes
between 100% and 400% of the federal poverty line.
• Available only for plans purchased on the Marketplace.
• Available to citizens and lawfully present residents.
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APTC, cont.
• Two choices for how to receive the APTC:
o Applied directly to your premium cost through the carrier.
o Received as a tax rebate at the end of the year.
• Discrepancies in your APTC due to differences between
predicted (as reported on the financial application) and
actual income will be reconciled by the IRS at the end
of the year.
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Cost Sharing Reductions (CSR)
• A federal benefit that reduces the out-of-pocket
charges for health plan (co-pays, deductibles, and coinsurance).
• Three levels of cost-sharing reductions based on
income.
• Available to individuals with income up to 250% of the
federal poverty line.
• Available to citizens and lawfully present residents.
• Must purchase a Silver-tier plan to receive the benefit.
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How the CSR is Provided
• Federal government pays the health insurer upfront.
• Enrollee cost sharing charges are automatically
reduced when an eligible person or family enrolls in a
silver plan .
• People do not have to keep track of their spending or
get reimbursed.
• Not provided as a tax credit.
• Not “reconciled” at the end of the year.
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Marketplace: Key Takeaways
• Connect for Health Colorado is the State of Colorado’s
new Health Insurance Marketplace
• You can browse, compare, and purchase a plan
online.
• You can also apply on paper, over the phone, or in
person.
• Purchasing on the Marketplace is the only way to
access federally subsides discounts on health
coverage.
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Medicare and the ACA: Important Changes
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Closes the “Doughnut Hole”
Improves Access to Primary Care
Changes to Medicare Advantage Plan
Changes to Premiums based on Income
Crackdowns on Fraud
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Closes the “Doughnut Hole”
The “doughnut hole” is a gap in coverage in Medicare Part D Drug costs.
Here’s how it works:
• You pay out-of-pocket for monthly Part D premiums all year.
• You pay 100% of your drug costs until you reach the $310 deductible
amount.
• After reaching the deductible, you pay 25% of the cost of your drugs,
while the Part D plan pays the rest, until the total you and your plan
spend on your drugs reaches $2,800.
• Once you reach this limit, you have hit the coverage gap referred to as
the “donut hole,” and you are now responsible for the full cost of your
drugs until the total you have spent for your drugs reaches the yearly
out-of-pocket spending limit of $4,550.
• After this yearly spending limit, you are only responsible for a small
amount of the cost, usually 5% of the cost of your drugs.
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“Doughnut Hole,” cont.
Under the ACA, if you reach the Medicare Part D coverage gap, you can get discounts on
your prescription drugs. The discounts will gradually increase until the coverage gap
disappears in 2020.
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2014: 52.5% discount on brand-name; 28% discount on generic drugs.
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2015: 55% discount on brand-name; 35% discount on generic drugs.
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2016: 55% discount on brand-name; 42% discount on generic drugs.
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2017: 60% discount on brand-name; 49% discount on generic drugs.
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2018: 65% discount on brand-name; 56% discount on generic drugs.
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2019: 70% discount on brand-name; 63% discount on generic drugs.
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2020: The Medicare Part D coverage gap is completely closed.
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Improves Access to Primary Care
• Gives incentives to physicians and nurses who provide
primary care in areas with doctor shortages.
• Gives primary care providers who treat people with
Medicare bonus payments for providing quality care.
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Changes to Medicare Advantage Plan
• New rating system. Plans that rate at least four out of
five stars will receive bonus payments for providing
better quality care. You can review your plan’s rating on
Medicare’s website www.medicare.gov/find-a-plan.
• Plans must use some of the bonus payments they
receive for extra benefits and rebates to people
participating in Medicare Advantage plans.
• Plans must now limit how much they spend each year
on administrative costs. For each dollar received in
premiums, Medicare Advantage plans must spend at
least 85 cents on care.
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Changes to Premiums based on Income
• In 2010, beneficiaries filing singly became subject to
increased premiums if their MAGI is over $85,000; married
beneficiaries filing joint returns are subject to increased
premiums if their MAGI is over $170,000. In 2010, about 5
percent of Medicare beneficiaries pay the higher incomerelated premium.
• Since 2011, income-related premiums now also apply to
those who have Part D prescription drug coverage. The
income levels are the same as for Part B.
• These income levels will stay the same until 2020, not
increasing for inflation, which means that more individuals
will be subject to the premium increase at a faster rate until
that time.
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Crackdowns on Medicare Fraud
Medicare fraud results in higher health care costs for everyone.
Eliminating fraud cuts costs for families, businesses, and the federal
government. It also increases the quality of services for those who
need care. Examples of Medicare Fraud include:
• A healthcare provider bills Medicare for services you never
received.
• A supplier bills Medicare for equipment you never got.
• Someone uses your Medicare card to get medical care, supplies,
or equipment.
• A company offers a Medicare drug plan that has not been
approved by Medicare.
• A company uses false information to mislead you into joining a
Medicare plan.
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ACA Fraud-Reduction Provisions
• Tough new rules and sentences for criminals: The law
increases federal sentencing guidelines for health care
fraud by 20-50% for crimes with over $1 million in losses.
• Enhanced screening: Providers and suppliers who may pose
a higher risk of fraud or abuse are now required to undergo
more scrutiny, including license checks and site visits.
• State-of-the-art technology: To target resources to highly
suspect behaviors, the Center for Medicare & Medicaid
Services now uses advanced predictive modeling
technology.
• New resources: The law provides an additional $350 million
over 10 years to boost anti-fraud efforts.
• These provisions have recovered over $10.7 billion since
2010.
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Medicare: Key Takeaways
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Closes the “Doughnut Hole”
Increases access to Primary Care
Changes to Medicare Advantage
Changes to premiums based on income
Crackdowns on Fraud
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On to Medicaid and Peak…
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