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ACA &Ryan White

Ideas forImplementingHealth CareReform

The Basics on the Affordable Care Act

Updated August 28, 2013

http://targethiv.org/aca

Overview

Ryan White & ACA

Health Benefits and Access to

Providers

Changes in Medicaid and Medicare

Changes in Medicaid Eligibility

Tax Credits and Cost Sharing

Subsidies

Accessing Health Insurance:

Marketplaces

Changes in Care Systems

Changes in Financing

The first step for anyone seeking to

engage in ACA implementation is

to become informed. Multiple

activities are under way and many

resources are available to guide

states, agencies, and consumers.

The starting point for everything

about ACA isHealthCare.gov(sign

up for updates). A number of

nongovernmental websites (listed

on the Key Websites page) also

explain ACA and present various

implementation resources.

ACA is complex, so getting up to

speed on everything is quite a

challenge. Thus, decide what is

most relevant and focus on those

key areas. For example, you might

be most interested in learning

what benefits will be provided in

health insurance plans.

Alternatively, you may want tolearn about new eligibility

screening processes. Regardless

of the topic, be aware that

information contained here and

on the referenced websites can

provide you with the basic facts

and portals for digging deeper

into the intricate details, such as

federal implementation rules.

Overview

ACA is changing the nature of

health insurance and health care

delivery. Many changes are taking

place at the federal and state level,

although state changes are

variable as some jurisdictions

have moved more rapidly to

implement reforms.

In 2013, much attention is

directed to changes in the health

insurance Marketplace, which willopen for enrollment on October 1,

2013, and start offering coverage

on January 1, 2014. Every state

will have a Marketplace wherein

eligible individuals and small

businesses can shop for and

purchase private health insurance

plans, or enroll in Medicaid and

CHIP if they are eligible. Almost

everyone will be required to have

health insurance or pay a penalty if

they do not. This is called

theindividual mandate(see the

final rule on shared responsibilityand exemptionsand theIRSs

Affordable Care Act Tax

Provisions). Subsidies and tax

credits will be available to help

lower income individuals afford

health insurance (see below).

Health care delivery reforms have

been in progress since passage of

ACA in 2010 and will continue for

decades to come.

Here are key examples on health

insurance market reforms,

including provisions of particular

importance to people living with

HIV/AIDS.

Insurers can no longer denycoverage based on preexisting

conditions.

Higher premiums cannot becharged based on preexistingconditions.

http://healthcare.gov/http://healthcare.gov/http://healthcare.gov/https://signup.healthcare.gov/https://signup.healthcare.gov/https://signup.healthcare.gov/https://signup.healthcare.gov/http://healthreform.kff.org/the-basics/Requirement-to-buy-coverage-flowchart.aspxhttp://healthreform.kff.org/the-basics/Requirement-to-buy-coverage-flowchart.aspxhttp://healthreform.kff.org/the-basics/Requirement-to-buy-coverage-flowchart.aspxhttp://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-Sheets/2013-Fact-Sheets-Items/2013-06-26.html?DLPage=1&DLSort=0&DLSortDir=descendinghttp://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-Sheets/2013-Fact-Sheets-Items/2013-06-26.html?DLPage=1&DLSort=0&DLSortDir=descendinghttp://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-Sheets/2013-Fact-Sheets-Items/2013-06-26.html?DLPage=1&DLSort=0&DLSortDir=descendinghttp://www.irs.gov/uac/Affordable-Care-Act-Tax-Provisions-Homehttp://www.irs.gov/uac/Affordable-Care-Act-Tax-Provisions-Homehttp://www.irs.gov/uac/Affordable-Care-Act-Tax-Provisions-Homehttp://www.irs.gov/uac/Affordable-Care-Act-Tax-Provisions-Homehttp://www.irs.gov/uac/Affordable-Care-Act-Tax-Provisions-Homehttp://www.irs.gov/uac/Affordable-Care-Act-Tax-Provisions-Homehttp://www.irs.gov/uac/Affordable-Care-Act-Tax-Provisions-Homehttp://www.irs.gov/uac/Affordable-Care-Act-Tax-Provisions-Homehttp://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-Sheets/2013-Fact-Sheets-Items/2013-06-26.html?DLPage=1&DLSort=0&DLSortDir=descendinghttp://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-Sheets/2013-Fact-Sheets-Items/2013-06-26.html?DLPage=1&DLSort=0&DLSortDir=descendinghttp://healthreform.kff.org/the-basics/Requirement-to-buy-coverage-flowchart.aspxhttps://signup.healthcare.gov/https://signup.healthcare.gov/http://healthcare.gov/

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Insurers must cover "EssentialHealth Benefits" (EHBs,

described below).

Lifetime dollar limits oncoverage have ended.

Annual limits on EHBs will bephased out in 2014.

Insurers cannot droppolicyholders from coverage

simply because they become

sick or made a mistake on their

application.

Certain preventive healthservices are covered at no

charge.

Premium variations based onage (age rating) are limited to

3:1.

Payments from AIDS DrugAssistance Programs (ADAPs)

are considered true out-of-

pocket expenses under

Medicare Part D.

In addition, as discussed below,

ACA expands Medicaid eligibility(at state option) to all adults with

incomes up to 138% of the federal

poverty level.

On the health care delivery front,

changes include new ways to fund

and deliver care (eg, moving away

from the fee-for-service

mechanism traditionally found in

the U.S. health care system).

The above ACA reforms support

the goals of the National HIV/AIDS

Strategy to reduce new HIV

infections, increase access to

care/improve outcomes, reduce

disparities, and improve

coordination of the nation's

response to the U.S. HIV

epidemic. Ryan White agencies

and consumers can support ACA

and National Strategy

implementation by learning about

ACA, getting involved in

implementation activities, working

to further improve HIV/AIDS

services.

Learn more:

For a broad overview of ACA,see HealthCare.Gov'sHow the

Health Care Law Benefits

You,thePatient's Bill of

Rights,andHow the Affordable

Care Act Helps People Living

with HIV/AIDS: 2011 and

Beyond.

Learn the terminology: see theHealthCare.govGlossaryor theHIVMAKey Termslist.

Sign up for HealthCare.govemail updates.

Watch theHealth Reform HitsMain Street videofrom the

Kaiser Family

Foundation. Watch this video:

Training: Understanding the

Health Insurance Marketplace.

Use this Kaiser FamilyFoundationtoolto see how

ACA is projected to expand

coverage, by zip code.

Use the Commonwealth Fund'sHealth Reform Provisions Tool

to find information about

specific ACA provisions on

coverage, revenue, and

system/delivery reform.

See HRSA/HABsKeyProvisions of the Affordable

Care Act for the Ryan White

Program.

Ryan White and ACA

ACA has many implications for

Ryan White programs. An

increasing number of clients will

transition to public and private

health insurance. Service delivery

systems are undergoing many

changes to improve outcomes and

cut costs. HRSA's HIV/AIDS Bureau

has preparedRyan White & theAffordable Care Act: What You

Need to Know,highlighting ACA

issues with particular relevance to

Ryan White grantees and people

living with HIV/AIDS.

Health Benefits and Access to

Providers

HHS has issued ACA regulations

defining the benefits that must be

covered in most health insuranceplans. TheseEssential Health

Benefits(EHBs) comprise a core

set of services that must be

provided under Medicaid and

under health insurance plans that

are approved for offering

(Qualified Health Plans [QHPs]) in

the individual and small-group

markets both inside and outside

Marketplaces. QHPs must be equal

in scope to a typical employer

health plan, which each state hasdefined in its"benchmark" EHB

(ie, a plan currently being offered

in that state). Certification of QHPs

is by the state (if the state is

operating its own Marketplace -

see thischart of state QHP

certification standardsby State

Reforum) or by CMS (in states

participating in the federally

facilitated or partnership

Marketplace model).

Plans also must be at 1 of 4

actuarial value (AV) levels. These

levels are defined as the

percentage of health care costs

that a plan will cover. For example,

a plan with an AV of 80% would

pay 80% of costs for covered

benefits and the beneficiary would

be responsible for 20% of the

costs.

http://www.healthcare.gov/law/resources/benefits.htmlhttp://www.healthcare.gov/law/resources/benefits.htmlhttp://www.healthcare.gov/law/resources/benefits.htmlhttp://www.healthcare.gov/law/resources/benefits.htmlhttp://www.healthcare.gov/law/resources/benefits.htmlhttp://www.healthcare.gov/law/features/rights/bill-of-rights/http://www.healthcare.gov/law/features/rights/bill-of-rights/http://www.healthcare.gov/law/features/rights/bill-of-rights/http://www.healthcare.gov/law/features/rights/bill-of-rights/http://www.healthcare.gov/news/factsheets/2011/11/hiv-aids11092011a.htmlhttp://www.healthcare.gov/news/factsheets/2011/11/hiv-aids11092011a.htmlhttp://www.healthcare.gov/news/factsheets/2011/11/hiv-aids11092011a.htmlhttp://www.healthcare.gov/news/factsheets/2011/11/hiv-aids11092011a.htmlhttp://www.healthcare.gov/news/factsheets/2011/11/hiv-aids11092011a.htmlhttp://www.healthcare.gov/news/factsheets/2011/11/hiv-aids11092011a.htmlhttp://www.healthcare.gov/glossary/a/http://www.healthcare.gov/glossary/a/http://www.healthcare.gov/glossary/a/http://www.hivma.org/uploadedFiles/HIVMA/Policy_and_Advocacy/Policy_Priorities/Healthcare_Reform_Implementation/Resources/Key_Terms_Fact_Sheet_final.pdf#search=%22Preparing%20for%20the%20Affordable%20Care%20Act%E2%80%99s%20Health%20Care%20Coverage%22http://www.hivma.org/uploadedFiles/HIVMA/Policy_and_Advocacy/Policy_Priorities/Healthcare_Reform_Implementation/Resources/Key_Terms_Fact_Sheet_final.pdf#search=%22Preparing%20for%20the%20Affordable%20Care%20Act%E2%80%99s%20Health%20Care%20Coverage%22http://www.hivma.org/uploadedFiles/HIVMA/Policy_and_Advocacy/Policy_Priorities/Healthcare_Reform_Implementation/Resources/Key_Terms_Fact_Sheet_final.pdf#search=%22Preparing%20for%20the%20Affordable%20Care%20Act%E2%80%99s%20Health%20Care%20Coverage%22https://signup.healthcare.gov/https://signup.healthcare.gov/http://healthreform.kff.org/the-animation.aspx?source=QLhttp://healthreform.kff.org/the-animation.aspx?source=QLhttp://healthreform.kff.org/the-animation.aspx?source=QLhttp://healthreform.kff.org/the-animation.aspx?source=QLhttp://www.youtube.com/watch?v=zsqu_Ce8qec&feature=youtu.behttp://www.youtube.com/watch?v=zsqu_Ce8qec&feature=youtu.behttp://www.youtube.com/watch?v=zsqu_Ce8qec&feature=youtu.behttp://healthreform.kff.org/en/coverage-expansion-map.aspxhttp://healthreform.kff.org/en/coverage-expansion-map.aspxhttp://healthreform.kff.org/en/coverage-expansion-map.aspxhttp://www.commonwealthfund.org/Health-Reform/Health-Reform-Resource.aspxhttp://www.commonwealthfund.org/Health-Reform/Health-Reform-Resource.aspxhttp://hab.hrsa.gov/affordablecareact/keyprovisions.pdfhttp://hab.hrsa.gov/affordablecareact/keyprovisions.pdfhttp://hab.hrsa.gov/affordablecareact/keyprovisions.pdfhttp://hab.hrsa.gov/affordablecareact/keyprovisions.pdfhttp://hab.hrsa.gov/affordablecareact/keyprovisions.pdfhttp://hab.hrsa.gov/affordablecareact/keyprovisions.pdfhttp://hab.hrsa.gov/affordablecareact/index.htmlhttp://hab.hrsa.gov/affordablecareact/index.htmlhttp://hab.hrsa.gov/affordablecareact/index.htmlhttp://hab.hrsa.gov/affordablecareact/index.htmlhttp://hab.hrsa.gov/affordablecareact/index.htmlhttp://cciio.cms.gov/resources/factsheets/ehb-2-20-2013.htmlhttp://cciio.cms.gov/resources/factsheets/ehb-2-20-2013.htmlhttp://cciio.cms.gov/resources/factsheets/ehb-2-20-2013.htmlhttp://cciio.cms.gov/resources/factsheets/ehb-2-20-2013.htmlhttp://cciio.cms.gov/resources/data/ehb.htmlhttp://cciio.cms.gov/resources/data/ehb.htmlhttp://cciio.cms.gov/resources/data/ehb.htmlhttp://www.statereforum.org/state-QHP-certificationhttp://www.statereforum.org/state-QHP-certificationhttp://www.statereforum.org/state-QHP-certificationhttp://www.statereforum.org/state-QHP-certificationhttp://www.statereforum.org/state-QHP-certificationhttp://www.statereforum.org/state-QHP-certificationhttp://cciio.cms.gov/resources/data/ehb.htmlhttp://cciio.cms.gov/resources/factsheets/ehb-2-20-2013.htmlhttp://cciio.cms.gov/resources/factsheets/ehb-2-20-2013.htmlhttp://hab.hrsa.gov/affordablecareact/index.htmlhttp://hab.hrsa.gov/affordablecareact/index.htmlhttp://hab.hrsa.gov/affordablecareact/index.htmlhttp://hab.hrsa.gov/affordablecareact/keyprovisions.pdfhttp://hab.hrsa.gov/affordablecareact/keyprovisions.pdfhttp://hab.hrsa.gov/affordablecareact/keyprovisions.pdfhttp://hab.hrsa.gov/affordablecareact/keyprovisions.pdfhttp://www.commonwealthfund.org/Health-Reform/Health-Reform-Resource.aspxhttp://healthreform.kff.org/en/coverage-expansion-map.aspxhttp://www.youtube.com/watch?v=zsqu_Ce8qec&feature=youtu.behttp://www.youtube.com/watch?v=zsqu_Ce8qec&feature=youtu.behttp://healthreform.kff.org/the-animation.aspx?source=QLhttp://healthreform.kff.org/the-animation.aspx?source=QLhttps://signup.healthcare.gov/http://www.hivma.org/uploadedFiles/HIVMA/Policy_and_Advocacy/Policy_Priorities/Healthcare_Reform_Implementation/Resources/Key_Terms_Fact_Sheet_final.pdf#search=%22Preparing%20for%20the%20Affordable%20Care%20Act%E2%80%99s%20Health%20Care%20Coverage%22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In order to maximize access to

coverage for low-income

individuals, ACA requires plans to

contract with some, but not all,

Essential Community Providers

(ECPs)--providers that serve

predominately low-incomemedically underserved

individuals. ACA provides

examples of ECPs (eg, entities

defined in Section 340B(a)(4) of

the Public Health Services [PHS]

Act). Plans also are required to cap

the maximum out-of-pocket costs

for enrollees.

SeeHealthCare.govandState

Reforumfor more, including

insights on how state Marketplacesare further defining, refining, and

implementing these ACA

requirements. See the HHSfinal

ruleon EHBs, AV, and

accreditation. See the HHS

QHP resourcesfor states and

prospective QHP issuers in

preparing and submitting a QHP

application for the Marketplace.

Changes in Medicaid and

Medicare

A significant proporation of people

living with HIV/AIDS are covered

by Medicaid, Medicare, or both

(dually eligible). ACA changes are

underway in each of these areas.

Medicaid. The most well-known Medicaid change is the

state option to expand

eligibility (see below). ACA is

also changing Medicareeligibility and enrollment

processes (eg, streamlined

applications through

Marketplaces; verification of

eligibility primarily via

electronic means; new and

varied income eligibility

procedures, depending on

one's eligibility category).

Other changes include benefits

(eg, alternative benefit plans

for states that expand eligibilty

for the adult population with

incomes less than 138% of the

federal poverty level),

enhanced reimbursement for

providers, and financing of ITsystems updates. Finally, new

approaches to delivery of care

under Medicaid are being

explored (eg, Medicaid Health

Homes). Keep abreast of the

technical aspects of Medicaid

and ACA on the

HHS/CMSMedicaid and

ACAwebpages and

Kaiser'sMedicaid and

CHIPpages. SeeState Network

for technical information fromstates on their Medicaid

reforms, like thisStates'

Medicaid Checklist for 2014

and accompanyingresource

list.

Medicare.Medicare Part Dchangesinclude, for example,

the eventual phase out (by

2020) of the "donut hole"and

(effective 2011) lower cost

brand name drugs forindividuals in the "donut hole."

For Ryan White, a key change,

also implemented in 2011,

allowsADAP expenditures to

count as True Out of Pocket

(TrOOP) costs.This means that

ADAP expenditures for a Ryan

White client count as incurred

out-of-pocket expenses,

allowing the person to move

more rapidly through the

"donut hole" cost phase andinto the next Medicare Part D

phase--catastrophic coverage--

where Medicare Part D drugs

are available at nominal cost.

Learn more aboutMedicare

and ACA.

Medicaid-Medicare. ACAchanges for the dually eligible

include enhancedcoordination

of Medicaid and Medicare.

Changes in Medicaid Eligibility

States have the option of deciding

whether to expand Medicaid

eligibility to cover all individuals

earning up to 138% of the federal

poverty level.

In states that expand Medicaideligibility, low-income

individuals at or below 138%

(including persons living with

HIV/AIDS) will no longer have

to become disabled in order to

be Medicaid eligible.

In states that do not expandMedicaid eligibility, existing

state Medicaid eligibility rules

will continue to apply.

See this Kaiser chart on thestatus

of Medicaid expansion and current

eligibility levels in the states.See

Medicaid.Govfor information on

your state's Medicaid program. See

this HIVMAfact sheet overview of

new coverage options(Medicaid

expansion, Marketplaces, keyresources).

Ryan White programs must

conduct eligibility determinations

and recertifications, in accordance

with the Ryan White payer of last

resort provision.

See theHRSA policy guidanceson Ryan White and Medicaid,

which direct Ryan White

grantees to vigorously pursueMedicaid enrollment and

billing for Ryan White clients.

Relatedly, see HRSA policyguidances oneligibility

determinations and

recertifications.

See how Ryan Whiteservicecategories can be used to

http://www.healthcare.gov/news/factsheets/2012/11/ehb11202012a.htmlhttp://www.healthcare.gov/news/factsheets/2012/11/ehb11202012a.htmlhttp://www.healthcare.gov/news/factsheets/2012/11/ehb11202012a.htmlhttp://www.statereforum.org/analyses/state-progress-on-essential-health-benefitshttp://www.statereforum.org/analyses/state-progress-on-essential-health-benefitshttp://www.statereforum.org/analyses/state-progress-on-essential-health-benefitshttp://www.statereforum.org/analyses/state-progress-on-essential-health-benefitshttp://cciio.cms.gov/resources/factsheets/ehb-2-20-2013.htmlhttp://cciio.cms.gov/resources/factsheets/ehb-2-20-2013.htmlhttp://cciio.cms.gov/resources/factsheets/ehb-2-20-2013.htmlhttp://cciio.cms.gov/resources/factsheets/ehb-2-20-2013.htmlhttp://cciio.cms.gov/programs/exchanges/qhp.htmlhttp://cciio.cms.gov/programs/exchanges/qhp.htmlhttp://www.medicaid.gov/AffordableCareAct/Affordable-Care-Act.htmlhttp://www.medicaid.gov/AffordableCareAct/Affordable-Care-Act.htmlhttp://www.medicaid.gov/AffordableCareAct/Affordable-Care-Act.htmlhttp://www.medicaid.gov/AffordableCareAct/Affordable-Care-Act.htmlhttp://healthreform.kff.org/tags/medicaid-and-chip.aspx?source=QLhttp://healthreform.kff.org/tags/medicaid-and-chip.aspx?source=QLhttp://healthreform.kff.org/tags/medicaid-and-chip.aspx?source=QLhttp://healthreform.kff.org/tags/medicaid-and-chip.aspx?source=QLhttp://www.statenetwork.org/http://www.statenetwork.org/http://www.statenetwork.org/http://www.statenetwork.org/wp-content/uploads/2013/04/State-Network-NASHP-States-ACA-Medicaid-Checklist-for-2014.pdfhttp://www.statenetwork.org/wp-content/uploads/2013/04/State-Network-NASHP-States-ACA-Medicaid-Checklist-for-2014.pdfhttp://www.statenetwork.org/wp-content/uploads/2013/04/State-Network-NASHP-States-ACA-Medicaid-Checklist-for-2014.pdfhttp://www.statenetwork.org/wp-content/uploads/2013/04/State-Network-NASHP-States-ACA-Medicaid-Checklist-for-2014.pdfhttp://www.statenetwork.org/wp-content/uploads/2013/04/State-Network-NASHP-States-Medicaid-ACA-Checklist-Resource-List.pdfhttp://www.statenetwork.org/wp-content/uploads/2013/04/State-Network-NASHP-States-Medicaid-ACA-Checklist-Resource-List.pdfhttp://www.statenetwork.org/wp-content/uploads/2013/04/State-Network-NASHP-States-Medicaid-ACA-Checklist-Resource-List.pdfhttp://www.statenetwork.org/wp-content/uploads/2013/04/State-Network-NASHP-States-Medicaid-ACA-Checklist-Resource-List.pdfhttp://www.healthcare.gov/news/reports/affordablecareact.htmlhttp://www.healthcare.gov/news/reports/affordablecareact.htmlhttp://www.healthcare.gov/news/reports/affordablecareact.htmlhttp://www.healthcare.gov/news/reports/affordablecareact.htmlhttp://www.healthcare.gov/glossary/d/donuthole.htmlhttp://www.healthcare.gov/glossary/d/donuthole.htmlhttp://www.healthcare.gov/glossary/d/donuthole.htmlhttp://hab.hrsa.gov/manageyourgrant/pinspals/adaptroopltr1011.pdfhttp://hab.hrsa.gov/manageyourgrant/pinspals/adaptroopltr1011.pdfhttp://hab.hrsa.gov/manageyourgrant/pinspals/adaptroopltr1011.pdfhttp://hab.hrsa.gov/manageyourgrant/pinspals/adaptroopltr1011.pdfhttp://hab.hrsa.gov/manageyourgrant/pinspals/adaptroopltr1011.pdfhttp://www.medicare.gov/about-us/affordable-care-act/affordable-care-act.htmlhttp://www.medicare.gov/about-us/affordable-care-act/affordable-care-act.htmlhttp://www.medicare.gov/about-us/affordable-care-act/affordable-care-act.htmlhttp://www.medicare.gov/about-us/affordable-care-act/affordable-care-act.htmlhttp://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/index.htmlhttp://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/index.htmlhttp://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/index.htmlhttp://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/index.htmlhttp://www.statehealthfacts.org/comparereport.jsp?rep=158&cat=4http://www.statehealthfacts.org/comparereport.jsp?rep=158&cat=4http://www.statehealthfacts.org/comparereport.jsp?rep=158&cat=4http://www.statehealthfacts.org/comparereport.jsp?rep=158&cat=4http://www.statehealthfacts.org/comparereport.jsp?rep=158&cat=4http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-State/By-State.htmlhttp://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-State/By-State.htmlhttp://www.hivma.org/uploadedFiles/HIVMA/Policy_and_Advocacy/Policy_Priorities/Healthcare_Reform_Implementation/Resources/HCR_Coverage_Options.pdfhttp://www.hivma.org/uploadedFiles/HIVMA/Policy_and_Advocacy/Policy_Priorities/Healthcare_Reform_Implementation/Resources/HCR_Coverage_Options.pdfhttp://www.hivma.org/uploadedFiles/HIVMA/Policy_and_Advocacy/Policy_Priorities/Healthcare_Reform_Implementation/Resources/HCR_Coverage_Options.pdfhttp://www.hivma.org/uploadedFiles/HIVMA/Policy_and_Advocacy/Policy_Priorities/Healthcare_Reform_Implementation/Resources/HCR_Coverage_Options.pdfhttp://hab.hrsa.gov/affordablecareact/index.htmlhttp://hab.hrsa.gov/affordablecareact/index.htmlhttp://hab.hrsa.gov/affordablecareact/index.htmlhttp://hab.hrsa.gov/affordablecareact/index.htmlhttp://hab.hrsa.gov/affordablecareact/index.htmlhttp://hab.hrsa.gov/affordablecareact/index.htmlhttp://hab.hrsa.gov/affordablecareact/index.htmlhttp://hab.hrsa.gov/affordablecareact/index.htmlhttp://hab.hrsa.gov/affordablecareact/outreachenrollment.htmlhttp://hab.hrsa.gov/affordablecareact/outreachenrollment.htmlhttp://hab.hrsa.gov/affordablecareact/outreachenrollment.htmlhttp://hab.hrsa.gov/affordablecareact/outreachenrollment.htmlhttp://hab.hrsa.gov/affordablecareact/outreachenrollment.htmlhttp://hab.hrsa.gov/affordablecareact/index.htmlhttp://hab.hrsa.gov/affordablecareact/index.htmlhttp://hab.hrsa.gov/affordablecareact/index.htmlhttp://hab.hrsa.gov/affordablecareact/index.htmlhttp://www.hivma.org/uploadedFiles/HIVMA/Policy_and_Advocacy/Policy_Priorities/Healthcare_Reform_Implementation/Resources/HCR_Coverage_Options.pdfhttp://www.hivma.org/uploadedFiles/HIVMA/Policy_and_Advocacy/Policy_Priorities/Healthcare_Reform_Implementation/Resources/HCR_Coverage_Options.pdfhttp://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-State/By-State.htmlhttp://www.statehealthfacts.org/comparereport.jsp?rep=158&cat=4http://www.statehealthfacts.org/comparereport.jsp?rep=158&cat=4http://www.statehealthfacts.org/comparereport.jsp?rep=158&cat=4http://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/index.htmlhttp://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/index.htmlhttp://www.medicare.gov/about-us/affordable-care-act/affordable-care-act.htmlhttp://www.medicare.gov/about-us/affordable-care-act/affordable-care-act.htmlhttp://hab.hrsa.gov/manageyourgrant/pinspals/adaptroopltr1011.pdfhttp://hab.hrsa.gov/manageyourgrant/pinspals/adaptroopltr1011.pdfhttp://hab.hrsa.gov/manageyourgrant/pinspals/adaptroopltr1011.pdfhttp://www.healthcare.gov/glossary/d/donuthole.htmlhttp://www.healthcare.gov/news/reports/affordablecareact.htmlhttp://www.healthcare.gov/news/reports/affordablecareact.htmlhttp://www.statenetwork.org/wp-content/uploads/2013/04/State-Network-NASHP-States-Medicaid-ACA-Checklist-Resource-List.pdfhttp://www.statenetwork.org/wp-content/uploads/2013/04/State-Network-NASHP-States-Medicaid-ACA-Checklist-Resource-List.pdfhttp://www.statenetwork.org/wp-content/uploads/2013/04/State-Network-NASHP-States-ACA-Medicaid-Checklist-for-2014.pdfhttp://www.statenetwork.org/wp-content/uploads/2013/04/State-Network-NASHP-States-ACA-Medicaid-Checklist-for-2014.pdfhttp://www.statenetwork.org/http://healthreform.kff.org/tags/medicaid-and-chip.aspx?source=QLhttp://healthreform.kff.org/tags/medicaid-and-chip.aspx?source=QLhttp://www.medicaid.gov/AffordableCareAct/Affordable-Care-Act.htmlhttp://www.medicaid.gov/AffordableCareAct/Affordable-Care-Act.htmlhttp://cciio.cms.gov/programs/exchanges/qhp.htmlhttp://cciio.cms.gov/resources/factsheets/ehb-2-20-2013.htmlhttp://cciio.cms.gov/resources/factsheets/ehb-2-20-2013.htmlhttp://www.statereforum.org/analyses/state-progress-on-essential-health-benefitshttp://www.statereforum.org/analyses/state-progress-on-essential-health-benefitshttp://www.healthcare.gov/news/factsheets/2012/11/ehb11202012a.html

8/13/2019 ACA RW LrngModule Learn About Reform

4/5

4

Learn About Reform

support outreach, benefits

counseling and enrollment

activities.

Tax Credits & Cost Sharing

Subsidies

Federal tax credits and cost-

sharing subsidies are intended to

make health insurance affordable

to lower income individuals and

families. Tax credits/subsidies,

which are available to individuals

who purchase insurance on the

Marketplace:

Will be available to individualswho have incomes between

100% and 400% of the federal

poverty level who are

purchasing coverage on the

Marketplace. (More

specifically, premium tax

credits are available for

eligible individuals with

household incomes between

100-400% of the federal

poverty level, while cost-

sharing assistance is available

for eligible individuals

between 100-250% of thefederal poverty level. Tax

credits and subsidies are

calculated in relation to silver

level policies.)

Will be available to individualswhose employer-provided

coverage is not affordable

(defined as costing more than

9.5% of income) or does not

have an Actuarial Value (AV) of

at least 60%.

Will not be available topersons who are eligible for

public insurance programs

(Medicaid, Medicare, CHIP,

TriCare).Federal tax credits

and cost-sharing subsidies are

intended to make health

insurance affordable to lower

income individuals and

families. Tax credits/subsidies:

Learn more:

Read HRSA HIV/AIDS Bureaupolicy guidanceson premium

and cost sharing assistance forMedicaid and private health

insurance.

See theIRSs Affordable CareAct Tax Provisions.

For an explanation of taxcredits and subsidies, see

thisKaiser Family Foundation

Summary sheetand this

HealthCare.Gov page on tax

credits.Kaiser's onlinesubsidy

calculatorcan be used toestimate premium assistance

an individual would get when

buying insurance in the

Marketplace.

ThisNASTAD issuebriefexplains how tax

credits/subsidies might work,

with specifics around ADAPs.

See what low-cost andfree taxpreparation servicesareavailable for clients.

Seehow the individual mandate

works in relation to income and

affordability.

Accessing Health Insurance:

Marketplaces

Marketplaces are where

individuals and small businesses

will shop for health insurance

coverage from private insurers and

from public insurers such as

Medicaid. Here are some specifics:

Each state has the option ofdeciding whether to operate its

own state Marketplace, to

partner with the federal

government, or default to a

federally facilitated

Marketplace.

People looking for insurancecan shop from a menu of QHPs.

These QHPs must provide

EHBs and meet other

requirements, such asincluding ECPs in their

network of service agencies.

ECPs include many types of

safety-net providers, such as

those agencies defined in

Section 340B(a)(4)of the PHS

Act and section

1927(c)(1)(D)(i)(IV) of the

Social Security Act (safety-net

providers that the Secretary of

HHS determines would benefit

from nominal drug pricingunder Medicaid). (SeeHHS

information on ECPs.) Other

requirements pertain to

network adequacy, marketing,

quality reporting and

improvement, and

accreditation. Because states

regulate health insurance,

QHPs also must comply with

state licensure requirements.

State Marketplaces may

stipulate additionalrequirements for QHPs.

Marketplaces will present a"no wrong door" approach by

offering one-stop,

comprehensive screening to

determine eligibility for

various public and private

health insurance

programs. Marketplaces will

help individuals make plan

decisions via website portals,call centers, andenrollment

assisters(personnel/agencies

that provide education and

assistance with enrolling in a

plan). HRSA's HIV/AIDS

Bureau has issuedguidanceon

how Ryan White service

http://hab.hrsa.gov/affordablecareact/index.htmlhttp://hab.hrsa.gov/affordablecareact/index.htmlhttp://www.irs.gov/uac/Affordable-Care-Act-Tax-Provisions-Homehttp://www.irs.gov/uac/Affordable-Care-Act-Tax-Provisions-Homehttp://www.irs.gov/uac/Affordable-Care-Act-Tax-Provisions-Homehttp://www.irs.gov/uac/Affordable-Care-Act-Tax-Provisions-Homehttp://www.kff.org/healthreform/upload/7962-02.pdfhttp://www.kff.org/healthreform/upload/7962-02.pdfhttp://www.kff.org/healthreform/upload/7962-02.pdfhttp://www.kff.org/healthreform/upload/7962-02.pdfhttp://www.healthcare.gov/marketplace/costs/tax-credits/http://www.healthcare.gov/marketplace/costs/tax-credits/http://www.healthcare.gov/marketplace/costs/tax-credits/http://kff.org/interactive/subsidy-calculator/http://kff.org/interactive/subsidy-calculator/http://kff.org/interactive/subsidy-calculator/http://kff.org/interactive/subsidy-calculator/http://www.nastad.org/docs/HCA-Affordability-Brief-FINAL-February-2013.pdfhttp://www.nastad.org/docs/HCA-Affordability-Brief-FINAL-February-2013.pdfhttp://www.nastad.org/docs/HCA-Affordability-Brief-FINAL-February-2013.pdfhttp://www.nastad.org/docs/HCA-Affordability-Brief-FINAL-February-2013.pdfhttp://www.irs.gov/Individuals/Free-Tax-Return-Preparation-for-You-by-Volunteershttp://www.irs.gov/Individuals/Free-Tax-Return-Preparation-for-You-by-Volunteershttp://www.irs.gov/Individuals/Free-Tax-Return-Preparation-for-You-by-Volunteershttp://www.irs.gov/Individuals/Free-Tax-Return-Preparation-for-You-by-Volunteershttp://healthreform.kff.org/the-basics/Requirement-to-buy-coverage-flowchart.aspxhttp://healthreform.kff.org/the-basics/Requirement-to-buy-coverage-flowchart.aspxhttp://healthreform.kff.org/the-basics/Requirement-to-buy-coverage-flowchart.aspxhttp://healthreform.kff.org/the-basics/Requirement-to-buy-coverage-flowchart.aspxhttp://healthreform.kff.org/the-basics/Requirement-to-buy-coverage-flowchart.aspxhttp://www.hrsa.gov/opa/http://www.hrsa.gov/opa/http://cciio.cms.gov/programs/exchanges/qhp.htmlhttp://cciio.cms.gov/programs/exchanges/qhp.htmlhttp://cciio.cms.gov/programs/exchanges/qhp.htmlhttp://cciio.cms.gov/programs/exchanges/qhp.htmlhttps://careacttarget.org/library/affordable-care-act-ryan-white-educate-and-assist-your-clients#engagehttps://careacttarget.org/library/affordable-care-act-ryan-white-educate-and-assist-your-clients#engagehttps://careacttarget.org/library/affordable-care-act-ryan-white-educate-and-assist-your-clients#engagehttps://careacttarget.org/library/affordable-care-act-ryan-white-educate-and-assist-your-clients#engagehttp://hab.hrsa.gov/affordablecareact/outreachenrollment.htmlhttp://hab.hrsa.gov/affordablecareact/outreachenrollment.htmlhttp://hab.hrsa.gov/affordablecareact/outreachenrollment.htmlhttp://hab.hrsa.gov/affordablecareact/outreachenrollment.htmlhttps://careacttarget.org/library/affordable-care-act-ryan-white-educate-and-assist-your-clients#engagehttps://careacttarget.org/library/affordable-care-act-ryan-white-educate-and-assist-your-clients#engagehttp://cciio.cms.gov/programs/exchanges/qhp.htmlhttp://cciio.cms.gov/programs/exchanges/qhp.htmlhttp://www.hrsa.gov/opa/http://healthreform.kff.org/the-basics/Requirement-to-buy-coverage-flowchart.aspxhttp://healthreform.kff.org/the-basics/Requirement-to-buy-coverage-flowchart.aspxhttp://healthreform.kff.org/the-basics/Requirement-to-buy-coverage-flowchart.aspxhttp://www.irs.gov/Individuals/Free-Tax-Return-Preparation-for-You-by-Volunteershttp://www.irs.gov/Individuals/Free-Tax-Return-Preparation-for-You-by-Volunteershttp://www.nastad.org/docs/HCA-Affordability-Brief-FINAL-February-2013.pdfhttp://www.nastad.org/docs/HCA-Affordability-Brief-FINAL-February-2013.pdfhttp://kff.org/interactive/subsidy-calculator/http://kff.org/interactive/subsidy-calculator/http://www.healthcare.gov/marketplace/costs/tax-credits/http://www.healthcare.gov/marketplace/costs/tax-credits/http://www.kff.org/healthreform/upload/7962-02.pdfhttp://www.kff.org/healthreform/upload/7962-02.pdfhttp://www.irs.gov/uac/Affordable-Care-Act-Tax-Provisions-Homehttp://www.irs.gov/uac/Affordable-Care-Act-Tax-Provisions-Homehttp://hab.hrsa.gov/affordablecareact/index.html

8/13/2019 ACA RW LrngModule Learn About Reform

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Learn About Reform

categories can be used to

support Marketplace outreach,

benefits counseling, and

enrollment activities for Ryan

White clients who are enrolling

in private health insurance

plans or Medicaid.

Marketplaces will be beginenrolling consumers October 1,

2013, and must be fully

operational on January 1,

2014.

Learn more about Marketplaces

fromHealthCare.gov.Watch the

What Is the Health Insurance

Marketplace video.See thelist of

state Marketplaces and statepartnership Marketplaces(with

declaration letters, approvals, and

links to state websites). See what

states are doing atState Reforum.

See this HIVMAfact sheet

overview of new coverage options

(Medicaid expansion,

Marketplaces, key resources).

Changes in Care Systems

Reforms are under way to improve

the health care infrastructure and

develop new care delivery

approaches that can improve

quality and lower costs.

New funding has gone towardexpansion of theHealth

Centersprogram, administered

by HRSA's Bureau of Primary

Health Care.

Prevention enhancementsinclude, for example,little tono cost sharing for various

preventive services.Also, new

prevention initiatives have

been funded under the

Prevention and Public Health

Fund.

Regarding IT, under the Office

of the National Coordinator for

Health Information

Technology (HealthIT),

significant resources have also

gone into enhancing health

information technology

systems to enable providers tomanage care and share data

through Electronic Health

Records. Those efforts are

continuing underACA

implementationactivities to

enhance monitoring of care

quality, service use, and costs;

sharing of information among

providers and payers; and

interfacing Marketplace

eligibility and enrollment

systems.

Payment and care deliveryinnovations (e.g., managed

care, primary care medical

homes, accountable care

organizations, bundled

payments, global payments)

are largely happening through

CMS'sCenter for Medicare and

Medicaid Innovation

(CMMI). Key areas for Ryan

White agencies includesecuring status as aPrimary

Care Medical Homeand

delivering services under the

care/financing model of the

HRSA Health Center

program(as an FQHC or FQHC

Look Alike). Under Medicaid,

most states deliver care to

eligible individuals through

Medicaid managed care. ACA

allows states the option to

createHealth Homestoprovide coordinated care for

persons with chronic

conditions at enhanced

reimbursement rates.

There is increased attention toprogram integrity (i.e., fraud

and abuse).

Payments to disproportionateshare hospitals (which serve a

significantly disproportionate

number of

underserved/uninsured

patients) are being reduced,

starting in 2014, as morepeople are expected to gain

insurance coverage.

Learn more:

Use this map-based site to see

what's happening around the

country withmedical homes and

patient-centered medical care.

Changes in FinancingUnder ACA, Marketplaces will offerindividuals a number of coverage

options through Medicaid (in

states that expand eligibility) and

private health insurance plans. As a

result, an increasing proportion of

HIV/AIDS care will be covered by

these payers. In order to be well

positioned to continue serving

their clients--who will be making

choices from among these options-

-Ryan White agencies need to

enhance theirthird-party billing

systemsand establish new

relationships with multiple

provider networks and health

insurance plans.

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