The effects on insurance coverage for people living with HIV/AIDS in the Philadelphia EMA (including Philadelphia, Montgomery, Delaware, Chester, and Bucks Counties in PA and Salem, Gloucester, Camden, and Burlington Counties in NJ)

1. Affordable Care Act and
Ryan White Program
The effects on insurance coverage for people living with HIV in
the Philadelphia EMA

2. Universal Coverage
Medicaid
Eligibility
133% FPL
Premium
Subsidies
133% -
400% FPL
Insurance
Market Employer
Reforms & Sponsored
Individual Insurance
Mandate

3. Summary of Patient Protection and
Affordable Care Act
 Most individuals will be required to have health
insurance starting in 2014
 Employers will be required to pay penalties for
employees who receive tax credits for health
insurance
 Individuals who do not have access to employer-
offered insurance will be able to purchase insurance
through state exchanges
 Premium and cost-saving credits/subsidies will be
available for some people

4. Summary of Patient Protection and
Affordable Care Act
 All (non-grandfathered) plans will be:
 required to provide a minimum benefits package
 prevented from denying coverage for any reasons
 prevented from charging higher premiums based on
health status and gender
 prevented from imposing annual or lifetime spending
caps
 Required to include prevention services with no cost-
sharing

5. Individual Mandate
 U.S. citizens and legal residents required to have health
coverage
 Those without coverage pay tax penalty of $695/person,
up to $2085 a year
 Those exempt from mandate:
 Demonstrated financial hardship
 Religious objections
 Undocumented immigrants
 Incarcerated individuals
 Those for whom the lowest cost plan option exceeds 8% of the
individual’s income
 Those who do not file federal income tax returns

6. America Health Benefit Exchanges
 Access to exchanges limited to US citizens and legal immigrants
 Exchange plans will be required to offer a minimum benefits package
at four different levels
 Platinum – covers 90% of benefits cost
 Gold – covers 80% of benefits costs
 Silver – covers 70% of the benefits costs
 Bronze – covers 60% of the benefits costs
 Catastrophic –
 Available to those under 30 years old and to those who are exempt from
the mandate.
 Provides catastrophic coverage only with the coverage level set at the
HSA current level laws except for prevention benefits and coverage for 3
primary care visits would be exempt from deductible.
 Only available on individual market.

7. Essential Health Benefits
 Plans on Exchanges and newly eligible Medicaid must include these
services:
 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 and wellness services and chronic disease
management, and
 Pediatric services, including oral and vision care

8. Essential Health Benefits
 States will have the flexibility to select a benchmark plan that reflects
the scope of services offered by a “typical employer plan
 If states choose not to select a benchmark, HHS intends to propose
that the default benchmark will be the small group plan with the
largest enrollment in the state.
 Plans could modify coverage within a benefit category so long as
they do not reduce the value of coverage.
 States will choose one of the following benchmark health insurance
plans:
 One of the three largest small group plans in the state by enrollment;
 One of the three largest state employee health plans by enrollment;
 One of the three largest federal employee health plan options by enrollment;
 The largest HMO plan offered in the state’s commercial market by enrollment.

9. Cost-sharing Subsidies
In order to help individuals and families purchase plan on
the exchanges:
 Cost-sharing subsidies will also be available for those
with incomes between 100%-250% FPL to limit out-of-
pocket spending
 Premium subsidies will be provided to families with
incomes of up to 400% FPL ($29,327 to $88,200 for
family of four)
 Subsidies on a sliding scale
 Subsidies will limit the cost of premiums to between 2% and
9.5% of income

10. Premiums as Share of Income
Household Income as a Percent of Premium Range as a Percent of
FPL Income
Up to 133% 2%
133 - 150% 3-4%
150 – 200% 4 – 6.3%
200 – 250% 6.3 – 8.05%
250 – 300% 8.05 – 9.5%
300 – 400% 9.5%
Premium tax credits are advanceable – recipients immediately
receive the credit (directly to insurer)
Recipients will have to reconcile the tax credit received with actual
income and repay any excess credit

11. Cost-sharing Subsidies
 Reduced cost-sharing for people up to 250% of FPL
 Subsidies increase actuarial value of coverage
 Actuarial value is the average percentage of anticipated costs that
an insurer will pay towards care for people insured in a given plan
 In other words, it is the percent of costs paid for by the insurer, the
individual is responsible for the remaining percent
Household Income as Actuarial Value of
Percent of FPL Coverage
100 – 150% 94%
150 – 200% 87%
200 – 250% 73%
250 – 400% 70%

12. Employer-Offered Health Plans
 Employers with more than 50 employees who do not
offer coverage and have at least one full-time
employee receiving a premium subsidy will be fined
$2000 per full-time employee
 Employees who are offered coverage by employer
are not eligible for premium tax credits unless the
premium exceeds 9.5% of income

13. Expanded Medicaid Eligibility
 Many low income individuals will be covered under
Medicaid
 All adults with income at or below 133% FPL will be
eligible for Medicaid regardless of health/disability
 133% FPL = $14,404 for individual and $29,327 for family
of 4 in 2009
 For most Medicaid enrollees, income will be based
on modified adjusted gross income without an assets
test or resource test.
 Newly-eligibles may have different package of
services based on essential services under
exchanges

14. ACA Medicaid Changes
Minimum
Support for Floor for
Health Coverage
Care 133% FPL
System
Additional
Long Term
Federal
Care/
Financing for
Coordination for
Newly Eligible
Duals
Coverage

15. Private Health Insurance
 Health premiums will be allowed to vary based on age (by a 3
to 1 ratio), geographic location, tobacco use and the number
of family members
 No lifetime/annual limits on coverage
 Increases in premiums will be subject to review by the state
 No cost sharing for preventative services
 Existing plans will be allowed to remain the same except:
 Required to extend coverage to dependents up to age 26
 Prohibited from rescissions of coverage
 Eliminate waiting periods for coverage to over 90 days

16. Premium and Cost Sharing Limits for Individuals up
to 400% FPL (non- Employer Coverage)
Income % FPL Coverage Premiums and Cost
Sharing
< 138% Medicaid •No Premiums
•Cost sharing limited to
nominal amounts for
most services
139 – 250% Exchange •Sliding scale tax credits
limit premium costs to 3-
8.05%
•Sliding scale cost-
sharing credits
251 – 400% Exchange •Sliding scale tax credits
limit premium costs to
8.05 – 9.5%
•No cost-sharing credits

17. Exhibit 15. Distribution of Uninsured Nonelderly Individuals in 2010,
by Income Level and Provisions of the Affordable Care Act
133%–249% FPL Subsidized private
11.7 million coverage with
Medicaid 24% consumer
<133% FPL protections
21.3 million
250%–399% FPL
43%
6.3 million
13%
>400% FPL
5 million Nonsubsidized private
10% coverage with consumer
Undocumented protections or parents’
4.9 million policies
10%
49.1 million uninsured individuals, ages 0–64
Note: FPL refers to federal poverty level.
Source: Analysis of the March 2011 Current Population Survey by N. Tilipman and B. Sampat
of Columbia University for The Commonwealth Fund.

18. Exhibit 18. Source of Insurance Coverage Pre-Reform
and Under the Affordable Care Act, 2020
23M (8%)
24M (8%) Uninsured
Exchanges
(Private Plans)
56M (20%)
15M (5%)
Uninsured
Other
15M (5%)
Other
163M (57%) 8M (3%) 162M (57%)
ESI Nongroup ESI
14M (5%)
Nongroup 52M (18%)
36M (13%) Medicaid
Medicaid
Under Prior Law Affordable Care Act
Among 284 million people under age 65
Notes: Employees whose employers provide coverage through the exchange are shown as covered by their employers.
ESI refers to employer-sponsored insurance. “Other” includes Medicare.
Source: Testimony Statement of Douglas W. Elmendorf, Director, before the Subcommittee on Health Committee on
Energy and Commerce U.S. House of Representatives, CBO’s Analysis of the Major Health Care Legislation Enacted
in March 2010, March 30, 2011, http://www.cbo.gov/ftpdocs/121xx/doc12119/03-30-HealthCareLegislation.pdf.

19. Exhibit 17. Annual Premium and Tax Credits for a Single Adult
Under the Affordable Care Act, 2014
Annual premium amount paid by policy holder and premium tax credit*
$6,000
Premium tax credit
Full
Required premium payment by policy holder premium =
$5,000 $4,500
$4,000 1,221 Contribution
capped at
2,185 9.5% of
$3,000 income
3,050 Contribution
3,810 capped at
3,977 8.05% of
Contribution income 4,500
$2,000
capped at
6.3% of 3,279
Contribution income
Contribution 2,315
$1,000 capped at
capped at
4.0% of 1,450
3.3% of
income
523 income 690
$0
138% FPL 150% FPL 200% FPL 250% FPL 300% FPL 500% FPL
$15,877 $17,258 $23,011 $28,763 $34,516 $57,527
* For a single adult, age 40, in a medium-cost area in 2014. Premium estimates are based on an actuarial value of 0.70.
Actuarial value is the average percent of medical costs covered by a health plan. FPL refers to federal poverty level.
Source: Premium estimates are from Kaiser Family Foundation Health Reform Subsidy Calculator,
http://healthreform.kff.org/Subsidycalculator.aspx.

20. Exhibit 14. Premium Tax Credits and Cost-Sharing Protections
Under the Affordable Care Act
Federal Premium contribution Out-of-pocket Actuarial value:
Income
poverty level as a share of income limits Silver plan
S: <$14,484
<133% 2% (or Medicaid) 94%
F: <$29,726
S: $16,335 S: $1,983
133%–149% 3.0%–4.0% 94%
F: $33,525 F: $3,967
S: $21,780
150%–199% 4.0%–6.3% 87%
F: $44,700
S: $27,225
200%–249% 6.3%–8.05% 73%
F: $55,875 S: $2,975
S: $32,670 F: $5,950
250%–299% 8.05%–9.5% 70%
F: $67,050
S: $43,560 S: $3,967
300%–399% 9.5% 70%
F: $89,400 F: $7,933
S: >$43,560 S: $5,950
>400% — —
F: >$89,400 F: $11,900
Four levels of cost-sharing: 1st tier (Bronze) actuarial value: 60% Catastrophic policy with essential benefits
2nd tier (Silver) actuarial value: 70% package available to young adults and
3rd tier (Gold) actuarial value: 80% people who cannot find plan with premium
4th tier (Platinum) actuarial value: 90% <=8% of income
Notes: In the income and out-of-pocket limits columns, S refers to single and F refers to family. Actuarial values are
the average percent of medical costs covered by a health plan. Premium and cost-sharing credits are for silver plan.
Source: Federal poverty levels are for 2011; Commonwealth Fund Health Reform Resource Center: What’s in the
Affordable Care Act? http://www.commonwealthfund.org/Health-Reform/Health-Reform-Resource.aspx.

21. Exhibit 2. Premium Tax Credit Amount for a Family of Four
Annual family
Annual family Annual family
income: $50,000
income: $30,000 income: $50,000
older parents
Income as a percentage of FPL 133% 224% 224%
Expected family contribution
As a percent of income: 3.0% 7.1% 7.1%
Dollar amount: $900 $3,570 $3,570
Premium for benchmark plan $9,000 $9,000 $14,000
$8,100 $5,430 $10,430
Premium tax credit
($9,000 – $900) ($9,000 – $3,570) ($14,000 – $3,570)
Premium for plan family
$9,000 $9,000 $14,000
chooses
Actual family contribution $900 $3,570 $3,570
Note: FPL refers to Federal Poverty Level.
Source: Federal Register, Vol. 76, No. 159, Aug. 17, 2011, pp. 50931–50949, Commonwealth Fund analysis.

22. No Wrong Door
 Individuals should be screened for eligibility for Medicaid,
Medicare, Exchange, subsidies, etc. at any point of enrollment
 One form/method of enrollment for Exchanges, Medicaid, etc.
will be developed by HHS Secretary
 Application form will be available for submission by web, fax,
mail, telephone or in-person
 States will rely on trusted third party sources for data matches,
if accurate, no additional documentation can be required from
individual
 Easy to understand and navigate websites/information

23. Total Population Insurance Type for
NJ, PA and US, 2009
70.0
59.0
60.0
55.0
49.0
50.0
40.0
US
30.0
PA
20.0
NJ
16.0 17.0
14.0 15.0 15.0
12.0 12.0 11.0
10.0
10.0
5.0 5.0
3.0
1.0 0.0 0.0
0.0
Employment Based Nongroup Other
Individual/ Medicaid Medicare Other Public Uninsured

24. EMA General Population Income
100.00%
90.00%
80.00%
70.00% 65.06%
60.00%
50.00% 42.71% 42.33% 40.41% 38.52% 41.88%
40.00% 27.02% 32.00% 30.47%27.42% 28.09%
30.00%
20.00%
10.00%
0.00%
Total Population under 150% FPL
Total Population between 150% and 300% FPL
Total Population Below 300% FPL

25. RW Clients Income Level, 2009
437, 4%
675, 5% 78% of
RW Clients
earn less than
$10,890/year
1548, 13%
<100% FPL
100-199%
200-299%
9595, 78% >300%

26. RW Client Insurance Status By
Type, 2009
Unknown
1% Many uninsured
will be eligible
None Private for Medicaid and
subsidies.
Other Public 17% 17%
1%
Medicare
13%
NO CHANGE
Medicaid in
51% COVERAGE
for about 64%
of RW Clients

27. Office of HIV Planning Coverage Estimates
NOW 2014 estimates
Medicaid 51% >78%
Private 17% 12%
insurance
Uninsured 17% 4-7%
Medicare 13% 13%
• Estimate for Private Insurance and Uninsured are probably too
large, because they are based on General Population estimates.
• 78% Medicaid coverage is based on eligibility by income (133%
FPL) alone.

28. Resources
 HIV Health Reform
 http://www.hivhealthreform.org/
 Kaiser Family Foundation Health Reform Gateway:
 http://www.healthreform.kff.org/
 Commonwealth Fund
 http://www.commonwealthfund.org/Health-Reform.aspx