ACA QUESTIONS AND ANSWERS 2023

ACA QUESTIONS AND ANSWERS 2023 What is it actually called and when was it passed? • Patient Protection and Affordable Care Act, signed March 23, 2010 What is the main government website about the ACA and HC? What were some of the factors that lead to its passage and what threatened its passage? The large amount of uninsured, the rising cost of HC Threatened by political opposition, stigma of socialized healthcare What main problem was it trying to solve? • Uninsurance - how to get access to affordable insurance for the uninsured Which of uninsured did it target? • The sick, low-wage/under-employed/part-time workers, small business owners and employees, self-employed, young adults, retirees 65 What is the individual mandate and how do you get exempt? • US citizens and legal aliens required to have insurance • Exemptions: financial hardship, religious, those for whom the lowest cost option exceeds 8% of an individual's income, undocumented How is the mandate enforced and what is the penalty for not having insurance? • Those without coverage pay tax penalty of $695-$2,085 up to 2.5% of taxable income How does the ACA expand access to insurance for the uninsured? • People can be entitled to insurance subsidies - can be eligible for Medicaid, can get premium tax credits to shop with, and some people get cost sharing subsidies • Limits out-of-pocket costs for everyone up to 400% of FPL to $5,950 How does the Medicaid expansion work? Who qualifies? • Individuals up to 133% of FPL (only if state accepts expansion) What's an Exchange? How do they work? • An exchange is a health insurance marketplace set up to facilitate the purchase of health insurance • The insurance companies that are allowed to participate are predetermined and regulated - promotes transparency and accountability, facilitates enrollment and delivery of subsidies What are the two mechanisms the ACA supports to help people afford insurance purchased through the Exchanges? How do people qualify for these? • People between 144% and 400% of FPL get premium tax credits to shop with • Individuals up to 250% of FPL get cost-sharing subsidies • Qualified through income eligibility Roughly what is the limit on out of pocket costs for those qualifying for premiums in the exchange? • $5,950 for everyone up to 400% of FPL What is King v. Burwell about? What impact will the ruling have? • King v. Burwell challenges the subsidies in the federal exchange since the language of the ACA only spoke to premium subsidies in state exchanges • Could also undermine insurance mandates in federal-exchange states • 13.4 million people could lose subsidies and by a product, insurance How does the ACA encourage employers to offer affordable insurance to their employees? • Employers have to pay a penalty if they don't offer it or it is not affordable What is the obligation of employers with fewer than 50 employees to provide insurance (and for those with 100 or more this year, 50 or more next year)? • 50 employees: no mandate • +50 employees: offer coverage to 70% (95% in 2016) of full-time employees and dependent children • for 50+, need to provide affordable insurance or pay penalty How does the ACA help small employers? • Employers with 25 or fewer employees get up to 35% subsidies if they pay 50% of total premium What are the employer rules around part-time or seasonal employees and insurance? • No obligation to provide insurance How does the employer mandate work? Enforcement? Penalties? What triggers a penalty? • Penalties are triggered if they have at least one full-time employee using premium tax credits to buy insurance through an exchange What is a grandfathered plan? • Employer and individual plans in existence at time of ACA What's the ACA's rule on young people? • Can stay on parents' insurance plan until age 26 How does the ACA restrict how insurance companies choose who they cover? • Ban on denying insurance to children with pre-existing conditions • Ban on rescission and lifetime caps How does the ACA restrict what insurance companies cover? • Must cover 10 essential benefits • Provide minimum actuarial value and maximum out-of-pocket costs What information about insurance applicants can insurance companies use in setting premium prices? • Geography, family size, age, tobacco use • CANNOT set prices based on gender or health status How does the ACA restrict how much insurance companies take for profit and administration? • Set MLR at 80/20, meaning that 80% must be used for insurance, 20% can be used elsewhere What is "rescission" and what does the ACA say about it? • Rescission is kicking people off/dropping the sick from an insurance plan. The ACA bans it. What's the medical loss ratio rules? • Amount of money spent on clinical services and quality improvement - pay it or rebate it, meaning that they reimburse the customer if they fail How does the ACA support access to primary care other than through insurance access? • Loans given to primary care, pediatrics, and nursing students • Funding to community health centers and NHS for clinicians for the underserved • Medicare increases primary care payments What are some ways that the ACA tries to provide healthcare consumers with more information with which to make decisions? • Summary of benefits and coverage • Hospital Compare (2012) • Physician Compare (2010) What is the Summary of Benefits and Coverage and what is included? • Clear standardized information that includes your costs for common medical services, services not included in your coverage, coverage examples, standard definitions for insurance and medical terms, your right (to continue coverage, how to complain), contact information for company or plan What are Essential Benefits? • Ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services, including behavioral health treatment, prescription drugs, rehabilitative and habilitative services and devices, laboratory services, preventive wellness services and chronic disease management, and pediatric services, including oral and vision care How does the ACA help women with regard to reproductive health care? • Can't discriminate on basis of gender • New plans must cover and eliminate cost-sharing for recommended preventive services and screenings • Medicaid expanding means more women have access to family planning • Some states have plans that include abortion coverage How is abortion coverage by insurance handled in the exchanges? • No federal funds for abortions, but it is determined by the state. Some have coverage through the marketplace, while other have no plan offering coverage What is an example of how the ACA tries to improve healthcare outcomes and quality? • Medicare launches "Accountable Care Organization" incentives • Providers form HMO-style groups that aim to improve quality while lowering costs through coordination What's an example of how the ACA limits cost-sharing (through rules rather than subsidies)? • People who receive cost-sharing subsidies have to be enrolled in the silver-tier plan, and going by the % of FPL, it limits how much consumers have to pay out of pocket per year What were the big provisions of the ACA that started in 2014? • Essential Benefits standardized and required for individual and small group plans sold through exchanges (shopping in the Health Insurance Marketplace), insurers pay fees based on market share, insurers can't restrict coverage or base premiums on health status or gender, premium subsidies for middle-income exchange plan purchasers, individual and employer mandates (delayed), insurance exchanges, Medicaid expansion What's an example of a delay in the ACA requirements? • Individual and employer mandates What does Actuarial Value refer to? What are the metal levels? • Actuarial value: a measure of the percentage of expected health care costs a health plan will cover based on their standard population • Metal levels: Bronze-60%, Silver-70%, Gold-80%, Platinum-90% Why did the ACA support the development of insurance co-ops? • Non-profit organizations get low interest loans to start new insurance plans owned by members on a cooperative business model • Supported because it is hard to get into the insurance market in the first place, and they wanted to support start-ups