Prepared by the American Association of Colleges of

NursingUpdated November 2015

Teaching Nursing Students About the

Health Insurance Marketplace

Explaining the ACA’s

Importance to the

Profession

Why is it Important for Nurses to Understand the New Law?

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 111-148] is, in many ways, the redesign of healthcare in America and it is the law.

What Does This Mean for Nurses?

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

The Marketplace:

Individual Mandate and

State Exchanges

What is the Health Insurance Marketplace? 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 federally-facilitated exchange for individuals to gain coverage.

Kaiser Family Foundation (2014). State Decisions For Creating Health Insurance Marketplaces, 2014Retrieved from http://kff.org/health-reform/state-indicator/health-insurance-exchanges/

Understanding the Individual Mandate 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

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)

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 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, 2015Retrieved from http://kff.org/health-reform/state-indicator/state-health-insurance-marketplace-types/#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-insurance-marketplace-types/#map

Learn About the State Marketplace PlansThere are five categories of plans that individuals can access through the Marketplace. 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/

Medicaid Expansio

n

Understanding the Medicaid Expansion

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

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

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

The Medicaid expansion was intended to be national, however, in June 2012 the Supreme Court made it optional for states

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/

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/

Current Status of State Medicaid Expansion Decisions

WY

WI*

WV

WA

VA

VT

UT

TX

TN

SD

SC

RI PA*

OR

OK

OH

ND

NC

NY

NM

NJ

NH*

NV NE

MT**

MO

MS

MN

MI*

MA

MD

ME

LA

KY KS

IA*

IN* IL

ID

HI

GA

FL

DC

DE

CT

CO CA

AR*AZ

AK

AL

Adopted (31 States including DC)

Adoption Under Discussion (1 State)

Not Adopting At This Time (19 States)

Example Activities

and Assignments

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

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

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

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 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.

Bronze Sliver Gold Platinum Catastrophic