Get Covered KentuckyThe Affordable Care Act:

What It Means for Kentuckians

Erin Hoben, Esq.

Outline

Part 1 – The Big Picture: Understanding the Affordable Care Act (A.C.A.)

Part 2 – Gaining Perspective: Kentucky and the A.C.A.

Part 3 – The Nuts and Bolts: Getting Covered with Kynect

Part 4 – Truths about the Affordable Care Act

Part I

Understanding the Affordable Care Act

1) On a scale of one to ten, how would you rate your overall level of comfort explaining the Affordable Care Act to others?

2) Approximately how many Kentuckians currently lack health insurance?

a) 310,000 b) 460,000 c) 550,000 d) 640,000

Supreme Court

The ACA was challenged in the Supreme Court in March 2012 and was upheld in June 2012

The Supreme Court upheld the ACA in its entirety, except for the provision requiring states to expand Medicaid or lose federal funding

States were then able to choose whether or not they would expand Medicaid for their residents

26 states have decided to expand

Affordable Care Act (ACA)Establishes a marketplace for individuals,

families and small businesses to purchase affordable and quality healthcare, called Exchanges

Kentucky is operating a state-based exchange, known as the Kentucky Health Benefit Exchange (KHBE)

Beginning in 2014, individuals and large employers will be required to purchase insurance or pay a penalty

ACA Timeline: Current ProvisionsProgress toward closing of the Medicare donut hole

Tax credits to small businesses with up to 25 employees

Pre-existing condition insurance plan

Assistance to employers providing coverage to retirees over age 55

Young adults can remain on parents insurance up to age 26

Covered preventive services on new health plans

Increase in payments to rural health providers

Funding for community health centers

Increase in payments to primary care providers (2013)

ACA Timeline: Current ProvisionsHealth insurers are prohibited from:

Denying coverage to children because of pre-existing conditions

Placing lifetime dollar limits on coverage Dropping people from health coverage

when they get sick

Health insurers must spend at least 80% of the premiums they collect on medical services or give customer rebates

Preventive Care

Private health plans are required to cover preventive services without any cost-sharing

By eliminating cost-sharing for preventive services, it reduces barriers to prevention for low-income communities

An estimated 975,000 Kentuckians with private health insurance have received preventive care without having to pay any out-of-pockets costs

New Coverage and Protections for Women and Children

New coverage options: Insurance companies will not be able to deny coverage to women for pre-existing conditions, like cancer or being pregnant

Choose your doctor: In the Exchange, you can choose from any primary care provider, OB-GYN, or pediatrician in your health plan's network without a referral

Women cannot be charged more for coverage than men

No-Cost Women's Preventive Services

Well-woman services

Screening for gestational diabetes

Human papillomavirus testing

Counseling for sexually transmitted infections

Counseling and screening for HIV

Contraceptive methods and counseling

Breastfeeding support, supplies and counseling

Screening and counseling for interpersonal and domestic violence

ACA Timeline: What's in store

Medicaid expansion (Oct. 2013)

Open enrollment in the Exchange (Oct. 2013-Mar. 2014)

Coverage for pre-existing conditions (Jan. 2014)

Savings on monthly premiums and out-of-pocket costs (Jan. 2014)

No more yearly limits on coverage (Jan. 2014)

Part 2

Kentucky and the Affordable Care Act

Current Health Outcomes in Kentucky

• 50th in smoking

• 40th in obesity

• 43rd in sedentary lifestyles

• 41st in diabetes

• 48th in poor mental health days

• 49th in poor physical health days

• 50th in cancer deaths

• 49th in cardiac heart disease

• 43rd in high cholesterol

• 48th in heart attacks

• 44th in annual dental visits

Small employers

Uninsured individuals & families

ScreeningThe Exchange will screen consumers for eligibility for public health insurance, including expanded Medicaid.

“kynectors” will help consumers find a health care plan that fits their needs. The KHBE will contract with groups to do this work.

The Exchange is a virtual marketplace where approved health insurance plans will be offered. A website and call center must be created.

All plans sold in the Exchange will:• Cover “Essential Health Benefits”• Have an easy-to-understand

summary of benefits & costs• Meet performance standards

Subsidies, in the form of federal tax credits, will be available to people with moderate incomes. These can be used to buy plans in the Exchange.

kynectors Private Health Care Plans

Adapted from a Center on Budget and Policy Priorities presentation

KY Health Benefit Exchange

Public Programs

No plan or insurer can discriminate based on race, sex, sexual orientation, gender identity, etc.

MedicaidKChip

Eligibility

All citizens of the United States are eligible to participate in the Exchange

Undocumented immigrants are not permitted to purchase plans on the Exchange

Lawful immigrants can purchase plans after five years

Small businesses may purchase plans on the Exchange

EnforcementIndividual mandate

– Affects any individual/family not covered by their employer, Medicare or another private or public insurance program

– Must become insured or pay a penalty in 2014

• $95 or 1% of income, whichever is greater

Employer mandate

– Affects businesses with more than 50 full-time employees

– Must provide health insurance or pay a penalty in 2015

• $2000 per uncovered employee

Medicaid Expansion

Medicaid ExpansionGovernor Beshear signed an executive order to

expand Medicaid on May 9, 2013

Sets a floor of 138% FPL for eligibility

Over 300,000 people in Kentucky will benefit from the expansion

Kentucky will benefit more than any other state, with 57% of its uninsured population becoming eligible under the expansion

Medicaid ExpansionThe federal government will pay an

enhanced federal funds participation (FFP) rate to states who expand Medicaid

Currently, the FFP rate in Kentucky is 70%, with Kentucky paying 30% of the costs

Under expansion, the FFP rate will be 100% and will phase out to 90% in 2020

This will enable Kentucky to provide coverage to both newly eligibles and those who enroll as a result of the “woodwork” effect

Current Medicaid EligibilityParents with dependent children are

eligible up to 33% FPL ($7606 for a family of four) if they are jobless, and up to 57% FPL ($13,138 for a family of four) if they are working

Adults without dependent children are not eligible

Medicaid is available for the aged, blind and disabled

Pregnant women are eligible up to 185% FPL

Medicaid ExpansionCreates a newly eligible population:

The Childless Adult

Currently, you must have children to be eligible for Medicaid

Under the expansion, this requirement disappears and income eligibility becomes the only factor

With Medicaid Expansion…

A family of three could make $26,915/yr and qualify for coverage, up from $11,132/yr.

A family of four could make $31,809/yr and qualify for coverage, up from $13,138/yr.

More working-age adults without children would receive health care coverage.

Under the ACA, nearly 95% of Kentucky’s non-elderly population could be covered with Medicaid or with health insurance subsidies or tax credits.

Essential Health Benefits

Ambulatory patient services

Emergency services & hospitalization

Maternity and newborn care

Mental health and substance use disorder services

Prescription drugs

Rehabilitative services and devices

Laboratory services

Preventive chronic disease management

Pediatric services, including oral and vision care

Part 3

How to get coverage in Kentucky

Dates to Remember

October 1, 2013: Open Enrollment BeginsJanuary 1, 2014: Coverage Begins

March 31, 2014: Open Enrollment Ends

*Medicaid and SHOP can purchase plans outside of open enrollment

*If you have a qualifying event, you may purchase outside of open enrollment

Kentucky Health Benefit Exchange:kynect

Marketplace where Kentuckians can purchase insurance

Travelocity for health insuranceAllows consumers to compare and choose

plansPromotes competitionAll insurance affordability programs will be

accessed using kynect

The “Exchange Population”This term has been used to describe

people who earn too much to qualify for Medicaid, but cannot afford to purchase private health insurance without government assistance

Subsidies are available to this group between 138% and 400% FPL

They will receive premium assistance in the form of tax credits

Who You Are What You May Receive Cost to You

18 or older making less than $15,857 (citizen or authorized immigrant for 5 years or more)

Medicaid coverage No cost

18 or older making $20,000 or more

Premium assistance to purchase plan through exchange

Estimated $67/month or $800/year (Silver plan)

18 or older making over $45,960 No assistance, but can purchase plan through exchange

Family of four making $48,000 Premium assistance to purchase plan through exchange

Estimated $252/month or $3,024 /year (Silver plan)

Family of four making $80,000 A tax credit to help pay insurance premium

$634/month or $7,600/year (Silver plan)

Family of four making $31,800 or less

Medicaid coverage No Cost

Family of four making over $94,200

No assistance, but can purchase plan through exchange

What plans are offered on the Exchange?

The Exchange will offer plans at four levels:

– Platinum

– Gold

– Silver

– Bronze

Platinum plans have lower premiums, but higher out-of-pocket costs

Bronze plans have higher premiums, but lower out-of-pockets costs

The Exchange will also offer catastrophic coverage to people under 30 with very low incomes

What if someone does not qualify for Medicaid or a tax subsidy?

91.25% of uninsured Kentuckians qualify for Medicaid or at least some tax credit

The other 56,000 must purchase health insurance, get it through their employer or face a penalty

They may do so using the Exchange

What if I have employer sponsored insurance?

You are already benefitting from ACA provisions such as no cost-sharing preventive services, elimination of lifetime limits, and starting in January, you will also have guaranteed issue

If your employer's insurance is not “affordable,” you could purchase a plan on kynect in the future

All plans must meet an affordability test – cannot exceed 9.5% of your income

Okay, let's get everyone enrolled!

Open enrollment begins October 1, 2013 and is available through March 31, 2014

Individuals can sign up: Online using kynect.ky.gov Over the phone by calling 1-855-4kynect By visiting a kynector By mailing in their application

kynectorsThe ACA includes a provision to allow for states

to implement an in-person assister (IPA) or navigator program

Kentucky has coined these assisters “kynectors”

Guidelines:

– Must provide public education about QHPs

– Must distribute fair and impartial information

– Will be able to facilitate enrollment

– Must refer Kentuckians to a consumer assistance program or ombudsmen to resolve grievances

– Must be culturally and linguistically competent

kynectorsThese will be existing community organizations

They are funded through the state and will receive training in August 2013

The program will be comprehensive, ensuring coverage in all eight Medicaid regions throughout the state

Small Business Health Options Program (SHOP)

Simplifies the process of buying health insurance for your small business

Open enrollment begins October 1, 2013

Insurance plans cannot turn you down based on the health status of your employees or their dependents, even if they have pre-existing conditions

Cannot charge you higher premiums for women, or increase your group's premium for employees with high medical costs

These protections do not apply to grandfathered plans

Small Business Health Options Program (SHOP)

There is a sliding scale tax credit of up to 35% of the employer's eligible premium expenses for tax years 2010-2013

Currently, employers with 10 or fewer FTEs, paying annual wages of $25,000 or less, qualify for the maximum credit if they offer coverage

In 2014, the maximum tax credit increases to 50% of premium expenses and coverage MUST be purchased on kynect

For tax-exempt employers, the same employee and wage requirements apply, but the maximum tax credit is 25% of eligible premium expenses for 2010-2013, to 35% in 2014

Impact on KentuckyMedicaid expansion is estimated to create

17,000 jobs annually

Estimated economic impact of $15.6 million through 2021 because of the federal government's assistance

Will reduce enrollment in SSDI and SSI and incentivize those individuals to stay in the workforce

Spillover effect of preventing absenteeism

Allows workers to be mobile

Stability and growth of small businesses

Part 4

ACA Truths

Truths about the ACAThe Bill has withstood its legal challenges and has not

been struck down, it is the law of the land.

The government is not going to make me drop/change my existing coverage.

Expanding Medicaid will benefit Kentucky's economy.

Privacy protections are in place to ensure that our information is kept secure.

kynect will offer robust and comprehensive health insurance options.

Premiums on kynect will be more affordable than private health insurance sold on the individual market today.

The ACA is puts consumer protections in place to benefit even those with employer-sponsored insurance.

Contact Information

@GetCoveredKY

Facebook.com/getcoveredky

www.getcovered-ky.org

kvhmedicaidexpansion@gmail.com

502.653.9059

Useful ResourcesOfficial website of the Federal gov.: www.healthcare.gov

Kaiser Family Foundation: http://kff.org/health-reform/

Small Business Majority: www.smallbusinessmajority.org

Families USA: www.familiesusa.org

Kentucky Voices for Health: www.kyvoicesforhealth.org

kynect: www.kynect.ky.gov

Governor's White Paper on Medicaid Expansion: http://governor.ky.gov/healthierky/Documents/MedicaidExpansionWhitePaper.pdf