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 Moon
LCDR Jacquelyne Ivery

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
AMSUS Presentation November 2013

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
Marketplace
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 the
FFMs

 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 services
2. Emergency services
3. Hospitalization
4. Maternity and newborn care
5. Mental health and
substance use disorder
services, including
behavioral health treatment
6. Prescription drugs
7. Rehabilitative and
habilitative services and
devices
8. Laboratory services
9. 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 240,000
Minnesota 423,000
Nevada 474,000
New York 1,915,000
New Mexico 360,000
Oregon 520,000
Rhode Island 101,000
Washington 835,000
Vermont 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)

Questions?
jennifer.moon@cms.hhs.gov
jacquelyne.ivery@cms.hhs.gov

 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

 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

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