Affordable Care Act

Presented by:

Doyle Forrestal, Regional Outreach SpecialistU.S. Department of Health & Human Services Region VIII

August 2011

What is the Affordable Care Act?

Affordable Care Act: The comprehensive health

care reform law enacted in March 2010.

• The law was enacted in two parts: The Patient Protection

and Affordable Care Act was signed into law on March 23,

2010 and was amended by the Health Care and Education

Reconciliation Act on March 30, 2010.

• The name ―Affordable Care Act‖ is used to refer to the final,

amended version of the law.

Major Provisions

1) Coverage Expansions Medicaid Expansions

Medicare Enhancements

2) Private Insurance Reforms

3) State-Based Health Insurance Exchanges

4) Prevention and Wellness

5) Health Care System Redesign and Payment Reform Accountable Care Organizations

Medical Homes

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Medicaid Expansions

• Expands the Medicaid Program: Expands the Medicaid program to more Americans. States have the option to expand their programs now, and the program will be expanded nationwide in 2014.

• By 2014: Medicaid will be available to all individuals under age 65 with incomes up to 133% of the Federal Poverty Level (FPL) ▫ This is approximately $14,404 for an individual in 2009

• Expansion creates a uniform minimum eligibility threshold--allows for childless adults to qualify

• Federal Government will provide states funding for newly eligible:▫ 100% from 2014-2016▫ 95% for 2017▫ 94% for 2018▫ 93% for 2019▫ 90% for 2020 and beyond.

Medicare Enhancements• $250 rebate for donut hole (2010)

▫ In Colorado, 42,351 Medicare beneficiaries received a one-time, tax free $250 rebate to help pay for prescriptions in the ‗donut hole‖ coverage gap.

• 50% discount on brand name prescriptions (2011)▫ Starting January 1, 2011—Seniors who fall into the Medicare prescription drug coverage gap

known as the ―donut hole‖ will receive a 50% discount on covered brand name prescription drugs and lower co-pays for generic drugs.

• Free preventive services and free annual wellness exam (2011)▫ Starting Jan. 2011—Medicare recipients will receive an annual ―wellness exam‖ and are now

eligible to obtain certain preventive services with no out-of-pocket-costs:

Mammograms, Colonoscopies

Cholesterol and diabetes screening

Prostate cancer screening

Annual flu shot

• Medicare donut hole eliminated by 2020

• Medicare trust fund extended by 12 years▫ More tools to crack down on waste, fraud and abuse and to recover wrongful payments▫ This will help extend the life of the Medicare Trust fund to at least 2029, a 12 year

extension

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Eliminates Insurance Company Discrimination

• As of September 23, 2010:

▫ health plans cannot limit or deny benefits or deny coverage outright for a child younger than age 19 simply because the child has a ―pre-existing condition.‖

▫ health plans that cover children must make coverage available to children up to age 26.

▫ prohibits health plans from putting a lifetime dollar limit on most benefits

▫ requires health plans to cover many preventive services without charging a copayment, coinsurance, or deductible.

• In 2014, the Act will prohibit insurance companies from denying coverage or charging more to any person based on their medical history.

• The Act also restricts and phases out the annual dollar limits a health plan can place on most of your benefits—and does away with these limits entirely in 2014.

Pre-Existing Condition Insurance Program

• On July 1,2010 Secretary Sebelius announced the establishment of the Pre-Existing Condition Insurance Program (PCIP) to provide coverage for eligible Americans who have been uninsured for six months because of a pre-existing condition.

• This program helps build a bridge to 2014, when Americans will have access to quality, affordable care in health insurance Exchanges.

• The PCIP, which is administered by GettingUsCovered in Colorado, provides a health coverage option if:▫ you have been uninsured for at least six months, ▫ you have a pre-existing condition or have been denied health coverage because of

your health condition, ▫ and are a U.S. citizen or are residing here legally.

• Covers a broad range of health benefits, including primary and specialty care, hospital care, and prescription drugs. All covered benefits are available to you, even to treat a pre-existing condition.

• To learn more about Colorado‘s Pre-Existing Condition Insurance Plan, called GettingUSCovered, please call 1-877-779-0387 or visit www.gettinguscovered.org

Health Exchanges

• One-Stop Shopping and Accessibility: The new Exchanges will

supply easy to understand, standard, accessible information on

available health insurance plans, so people can compare and easily

identify the quality, affordable option that is right for them.

• Provides credits & subsidies to purchase insurance: The new

Exchanges will provide credits and subsides up to 400% of the

federal poverty level to help individuals and families purchase

insurance.

• Out of pocket limits: Going forward, plans in the health insurance

Exchanges, and all new plans, will have a cap on what insurance

companies can require beneficiaries to pay in out-of-pocket

expenses, such as co-pays and deductibles.

Health ExchangesState-based health insurance Exchanges will be established to

provide families with the same private insurance choices that the President and Members of Congress will have, to foster competition and increase consumer choice.

State-based health insurance exchanges▫ state-based, competitive marketplaces where individuals and

small businesses can purchase qualified private coverage

▫ Must be operational by Jan. 1, 2014

▫ Coordination between Exchange, Medicaid and CHIP coverage

▫ Grants for Navigators: entities that have relations with consumers and can provide information and facilitate enrollment

▫ Four benefits categories, bronze, silver, gold, platinum

Small Business Statistics

On average, a small business spends 18% more for the same health insurance policy purchased by a large business.

Nationally, health insurance premiums for family coverage at a small business increased by 123 percent between 1999 and 2009.

U.S. businesses spend nearly three times as much per worker per hour for health benefits, making it difficult to compete in a global economy.*

*Source: New America Foundation and University of Denver’s Center for Colorado’s Economic Future. “The future of Colorado Health Care: A preview to the forthcoming report on an economic analysis of health care . . .” www.coloradohealth.org/studies.aspx

Benefits for Small Businesses

and Non-Profits

• No small business mandate to provide insurance

• Tax credit for small businesses that insure their employees

• Reduced cost for purchasing health insurance through the Exchange

Individual and Employer Responsibility

• Starting in 2014, individuals will be required to have health insurance

• Businesses with fewer than 50 full-time employees are exempt from any requirement to contribute toward employee health coverage

• Large employers are required to pay a shared responsibility fee only if they do not offer coverage and have one or more full-time employees that receives coverage through an exchange

More than 96 percent of employers with 50 or more employees already offer their employees health insurance coverage

National Prevention, Health Promotion, and

Public Health Council

The National Prevention Strategy: America’s Plan for Better Health and Wellness▫ On June 16, 2011 the National Prevention, Health Promotion, and

Public Health Council, announced the release of the National Prevention Strategy ,a comprehensive plan that will help increase the number of Americans who are healthy at every stage of life.

▫ The National Prevention Strategy focus on the importance of: access to quality medical care clean air and water safe outdoor spaces for physical activity safe worksites healthy foods violence-free environments healthy homes

▫ Everyone—businesses, educators, health care institutions, government, communities and every single American—has a role in creating a healthier nation.

Prevention and Public Health Investment Fund

• The Affordable Care Act invests in prevention through the Creation of the

Prevention and Public Health Investment Fund (the ―Fund‖).

• This new initiative has new resources – $15 billion over ten years in mandatory

spending – to expand and sustain the necessary infrastructure to prevent disease,

detect it early, and manage conditions before they become severe.

• The Fund reinforces a renewed focus on prevention and public health to improve

well-being and improve quality of care.

• For FY2010, $500 million is dedicated to improving community and clinical

prevention efforts, strengthening public health infrastructure, improving research

and data collection and bolstering the training of public health and primary care

professionals.

Additional Resources

The Affordable Care Act created a new consumer

friendly website to find information about

health reform.

www.healthcare.gov

www.cuidadodesalud.gov

Contact Information

Doyle Forrestal

Regional Outreach Specialist, Region VIII

U.S. Department of Health & Human Services

Doyle.Forrestal@hhs.gov

303-844-7335