Aca marketplace presentation_amsus 102213

Implementation of the Affordable Care Act (ACA) and Health Insurance Marketplaces and Implications for Public Health and Federal

Collaboration

Presented by:CDR Jennifer MoonLCDR Jacquelyne Ivery

AMSUS Presentation November 2013

This continuing education activity is managed and accredited by Profession Education Services Group (PESG) in cooperation with AMSUS. Neither PESG, AMSUS or any accrediting organization support of endorse and product or service mentioned in this activity.PESG and AMSUS staff have no financial interest to disclose.Commercial support was not received for this activity.

Disclosures


CDR Jennifer Moon nor LCDR Jacquelyne Ivery have any financial interest to disclose.

Disclosures Cont.


At the conclusion of this activity, the participant will be able to: Describe the ACA federal and state

exchange/marketplace infrastructure Explain the public health implications for

underserved and vulnerable population Discuss current, future and potential federal

interagency collaboration

Objectives


• 3.1 million young adults have gained insurance through their parent’s plans

• 6.1 million people with Medicare through 2012 received $5.7 billion in prescription drug discounts

• 34 million people with Medicare received a free preventive service

• 71 million privately insured people gained improved coverage for preventive services

• 105 million Americans have had lifetime limits removed from their insurance

ACA Accomplishments


On October 1, 2013, the Health Insurance Marketplace (Affordable Insurance Exchange) opened in each state, providing a new, simplified way to compare individual market health insurance plans.

In 36 states the Department of Health and Human Services (HHS) will support or fully run the Health Insurance Marketplace

Individuals will have an average of 53 qualified health plan choices in states where HHS will fully or partially run the Marketplace

Premiums before tax credits will be more than 16 percent lower than projected

Marketplace Specific Accomplishments


Section 1311(b) (1) of the ACA and implementing regulations (45 CFR§ C.F.R §155.410(c) (i)) requires Marketplaces to offer coverage in every state starting on January 1, 2014.

Section 1321(c)(1) of the Affordable Care Act directs the Secretary of The Department of Health & Human Services (HHS) to establish and operate a Federally-Facilitated Marketplace (FFM) in any state that does not elect to operate a State Based Marketplace (SBM), or in one that will not have an operable Marketplace for the 2014 coverage year.

The Marketplace (or Exchange) - Place for individuals and small employers to directly compare private health insurance options known as Qualified Health Plans (QHPs)

Introduction to The Marketplace


Market Reforms


Each state had the option to choose between:• State Based Marketplace (SBM) – State creates and runs

its own Marketplace• State Partnership Marketplace (SPM) – State partners

with Federal government to run some Marketplace functions

• Federally Facilitated Marketplace (FFM) – State has a Marketplace established and operated by the Federal government

Marketplace Establishment


The FFM and SPM have two components: Individual Market – governs eligibility and enrollment

for consumers seeking coverage not connected to job-based coverage.

Small Business Health Options Program (SHOP) Market – governs eligibility and enrollment for employers seeking coverage for their employees.

Individual Market and SHOP


Implementation of the Marketplace


Helps enhance competition in the health insurance market Increases affordability through premium tax credits, cost

sharing reductions, or public insurance programs Ensures quality through QHPs that must meet basic

standards, including quality standards, consumer protections, and access to an adequate range of clinicians

Makes costs clear by providing information about prices and benefits in simple terms consumers can understand, so they don’t have to guess about costs

Advantages of the Marketplace


Marketplace initial open enrollment period began October 1, 2013 and ends March 31, 2014

Marketplace eligibility requires consumers to• Live in its service area, and• Be a U.S. citizen or national, or• Be a non-citizen who is lawfully present in the U.S. for the

entire period for which enrollment is sought• Not be incarcerated

Eligibility and Enrollment


Application and Eligibility

Submit single,

streamlined

application to the Marketpla

ce

Verify and

determine eligibility

• Online• Phone• Mail• In Person

Supported by Data Services Hub

Eligible for Marketplace or Medicaid/CHIP

Enroll(Marketplace)

Enroll(Medicaid/CHIP)


Health plans offered in the Exchanges/Marketplaces must be certified as Qualified Health Plans (QHP)

Through the QHP certification process, FFMs will check that health plans meet basic standards, as established in the Exchange final rule (45 CFR 156 Subpart C: QHP Minimum Certification Standards)

Issuers will need to ensure each QHP complies with the minimum certification standards on an ongoing basis

Examples of QHP Certification Requirements include:• Network Adequacy, Essential Community Providers, Service Area and

Benefit Design

Requirements for QHPs Offered in theFFMs


A Qualified Health Plan (QHP)• Is offered by an issuer that is licensed by the state and in

good standing• Covers Essential Health Benefits (EHBs)• Offers at least one plan at the “silver” level and one at the

“gold” level of cost sharing• Agrees to charge the same premium rate whether offered

directly through Marketplace or outside the Marketplace (except stand alone dental plans/SADPs)

Qualified Health Plan (QHP)


1. Ambulatory patient services2. Emergency services3. Hospitalization4. Maternity and newborn care5. Mental health and

substance use disorder services, including behavioral health treatment

6. Prescription drugs

7. Rehabilitative and habilitative services and devices

8. Laboratory services9. Preventive and wellness

services and chronic disease management

10. Pediatric services, including oral and vision care

All Qualified Health Plans Will Cover These Essential Health Benefits


Who is eligible?• Young adults under 30 years of age• Those who can not afford coverage and obtain a hardship

waiver from the Marketplace What is catastrophic coverage?

• Plans with high-deductibles and lower premiums• Includes coverage of 3 primary care visits and preventive

services with no out-of-pocket costs• Protects consumers from high out-of-pocket costs

Catastrophic Plans


Grant program sponsored by each Marketplace• Navigators will

Raise awareness about the Marketplace Provide unbiased information about enrollment Help consumers understand health plan differences

And help submit consumers’ selections to the Marketplace Provide culturally/linguistically appropriate information Give referrals May be an agent or a broker if standards are met

Can’t be paid by issuer for enrolling people in QHPs/non-QHPs Other assistance also may be available beyond Navigators

Navigator Program


SHOP is a Marketplace for small businesses and their employees (fewer than 100 employees)• States may limit participation to those with 50 or fewer

employees for the first 2 years• Employer will access the SHOP where its principle business

office is located• Employer must offer coverage to all full-time employees• Sole proprietors may buy through the Marketplace rather

than the SHOP

Small Business Health Options Program (SHOP)- Employees


The Marketplace is a new way to find and buy health insurance

Individuals and small businesses can shop for health insurance that fits their budget

States have flexibility to establish their own Marketplace There is financial help for working families and other

people with limited income There is assistance available to help consumers get the

best coverage for their needs

Marketplaces: Key Points to Remember

State # of Uninsured

California 5,560,000

Colorado 656,000

Connecticut 243,000

Washington, DC 42,000

Idaho 223,000

Hawaii 90,000

Kentucky 622,000

Maryland 481,000

Consumer Impact: Number of Uninsured (SBMs)

22

State # of Uninsured

Massachusetts 240,000Minnesota 423,000Nevada 474,000New York 1,915,000New Mexico 360,000Oregon 520,000Rhode Island 101,000Washington 835,000Vermont 44,000


Individuals and families with household incomes between 100 percent and 400 percent of the Federal Poverty Level (FPL) who are not eligible for certain other types of coverage may qualify for tax credits to make premiums more affordable

Tax credits will make premiums even more affordable for individuals and families

After taking tax credits into account, fifty-six percent of uninsured Americans (nearly 6 in 10) may qualify for health coverage in the Marketplace for less than $100 per person per month, including Medicaid and CHIP in states expanding Medicaid

Implications for Underserved and Vulnerable Populations


Underserved and vulnerable populations often have limited access to relevant health information

Vulnerable populations are subject to serious disparities in health care

Insurance alone does not constitute affordable, quality care, or improved long-term health and equity

Provider shortages, particularly relating to primary care, impact vulnerable populations

Public Health Challenges


ACA Provisions with Direct References to “Health Literacy” Sect 3501. Health Care Delivery System Research; Quality

Improvement Technical Assistance Sect 3506. Program to Facilitate Shared Decision-making Sect 3507. Presentation of Prescription Drug Benefit and

Risk Information Sect 5301. Training in Family Medicine, General Internal

Medicine, General Pediatrics, and Physician Assistantship

Health Literacy


HRSA• Essential Community Provider (ECP)• National Health Service Corps (NHSC)• Federally Qualified Health Centers (FQHC)

AHRQ • Funding is used to develop research, reports, practical

tools, and other resources to improve the quality, safety, effectiveness, and efficiency of health care.

CDC• HAI prevention

Examples of Interagency Collaboration


Tricare and most VA medical coverage meets the minimum essential coverage requirement

Tricare Young Adult (TYA) signed in 2011• your dependent must be under age 26, unmarried, and not

eligible for their own employer-sponsored health insurance plan

Separation from service (not retirement) is a special enrollment period

How does this impact you as an Uniformed Service Member?


1. The Marketplace is a new way to shop for health coverage. 2. Each state will have a Marketplace, run either by the state,

through a state-federal partnership, or by the federal government. 3. Open Enrollment begins on October 1, 2013, and ends on March

31, 2014. Coverage can begin as soon as January 1, 2014. 4. Health plans offered in a Marketplace will generally offer

comprehensive coverage, including a set of “essential health benefits”.

5. Individuals can buy insurance through a Marketplace if they live in the United States, are U.S. citizens or U.S. nationals (or are lawfully present), and aren’t currently incarcerated.

10 Things Providers Need to Know


6. Nobody can be turned away or charged more because of their gender or a pre-existing condition.

7. Depending on household income and family size, many individuals may qualify for tax credits to help lower their share of monthly premiums, or help that reduces deductible, copayment or other cost-sharing amounts.

8. Individuals will be able to choose a Marketplace plan by health plan category (bronze, silver, gold, or platinum).

9. Consumers can apply on the web, over the phone or with 1-on-1 assistance in person.

10 Things Providers Need to Know (continued)


10. Resources are available now.• Marketplace.cms.gov: Where organizations and individuals looking to

help can get the latest resources and learn more about the Marketplace

• HealthCare.gov: Where individuals can learn about the Marketplace and the upcoming benefits (including where they can find local assistance), or be connected to appropriate resources in states that are running their own Marketplace.

• Health Insurance Marketplace Call Center: If you have questions, call 1-800 318 2596. TTY users should call 1-855-889-4325‑ ‑ .

10 Things Providers Need to Know (continued)


[email protected]

[email protected]

mailto:[email protected]





Training Materials for Stakeholders• marketplace.cms.gov

Educational Materials for Consumers• healthcare.gov

CMS/CCIIO Resource website• http://www.cms.gov/cciio/index.html

The full text of the ACA is available at: • http://www.healthcare.gov/law/full/index.html

Resources

http://www.marketplace.cms.gov/

http://www.healthcare.gov/news/brochures/index.html

http://www.cms.gov/cciio/index.html

http://www.healthcare.gov/law/full/index.html




Congressional Refresher Briefing (May 16, 2013) ASPE Issue Brief (Sept 25, 2013) Health Literacy Implications of the ACA (IOM, Nov

2010) “Closing Racial And Ethnic Disparity Gaps:

Implications Of The Affordable Care Act”, www.forbes.com (5/28/13)

References


If you would like to receive continuing education credit for attending this activity, please visit:

http://amsus.cds.pesgce.com

Obtaining CME/CE Credit

http://amsus.cds.pesgce.com/

http://amsus.cds.pesgce.com/

Aca marketplace presentation_amsus 102213

Healthcare

Transcript of Aca marketplace presentation_amsus 102213