1. SYNCing Chronic Disease
Advocacy with State Health Care
Reform Implementation
Marc Boutin
Executive Vice President & COO
National Health Council
© National Health Council

2. The mission of the National Health Council is
to provide a united voice for people with
chronic diseases and disabilities.

3. Timeline for Implementation
© National Health Council

4. Federal Activities
Final Deadline for Approval
Exchange or Conditional Exchanges
Proposed
Affordable Care Rule Approval of State Begin
Exchange Rule
Act Passed Expected Exchange Plan 2014
Released
March 23, 2010 Late 2011 January 1, 2013
July 2011
2010 2011 2012 2013 2014
Pursue Legislation or Executive Order File Exchange
to Implement an Exchange Plan
Establish Governing Boards
Operational Planning & Implementation
State Activities
Plan Bids Open
Submitted Enrollment

5. ACA: Minimum Essential Benefits
 The ACA creates 10 categories of essential benefits
that plans must cover beginning in 2014:
 Ambulatory patient services  Prescription drugs
 Emergency services  Laboratory services
 Hospitalization  Preventive and wellness
 Mental health and services and chronic disease
substance abuse services management
 Rehabilitative and  Maternity and newborn care
habilitative services and  Pediatric services
devices
© National Health Council

6. ACA: Minimum Essential Benefits
 The essential benefits requirements also place
limits on patient costs
» Limits out-of-pocket costs to $5,950 for
individuals
» Limits deductibles for small group plans to
$2,000 for individuals and $4,000 for families
 Premium based on actuarial value of cost of
benefit
© National Health Council

7. ACA: Minimum Essential Benefits
 Platinum 90%
 Gold 80%
 Silver 70%
 Bronze 60%
© National Health Council

8. © National Health Council

9. At 250% FPL: Family of Four,
One Person with Kidney Disease
Annual Income (Gross) $55,875
Subtract the cost of taxes, child
Median Necessities* care, food, housing, transportation,
(at 71%) – $39,671
and miscellaneous expenses of 10%
$16,204 Subtract ACA-defined maximum
premium for family at 250% FPL
Maximum Premiums** – $4,500 (compared to ~$8,000 for a silver plan
with no subsidy)
$11,704 Subtract reduced out-of-pocket
maximum due to 250% FPL
OOP Maximum*** – $5,950 (compared to $11,900 with no subsidy)
$5,754 Divide by 12 for estimate of
Per Month remaining funds in monthly budget
÷ 12
~ $480
Actuarial analysis performed for NHC by
Actuarial Research Corporation and Avalere Health

10. Room in Household Budget for Health Care?
Necessities +
Reported Necessities +
Necessities + Premium + 90th
Income (% Necessities Premium + Median
Premium Percentile OOP
poverty level) OOP Cost
Cost
<Poverty 17.30% 17.30% 17.30% 17.30%
101–150 7.50% 8.40% 8.50% 10.80%
151–200 3.70% 7.60% 9.00% 17.50%
201–250 3.00% 5.70% 8.80% 26.20%
251–300 1.10% 5.30% 6.90% 24.20%
301–350 0.70% 4.20% 5.30% 17.50%
351–400 1.20% 3.50% 3.90% 12.50%
401–450 0.50% 2.70% 3.70% 15.30%
451–500 0.40% 3.60% 4.70% 12.00%
>500 0.20% 0.60% 0.60% 2.50%
(c) Jonathan Gruber and Ian Perry, The Commonwealth Fund

11. Regulatory Opportunities
Coverage/Cost
Protections/Patient Services
Oversight
© National Health Council

12. Essential Health Benefits: A Pathway Forward
Broad Definition
of Covered Services
―
Specific List of
Exclusions
© National Health Council

13. Essential Health Benefits: A Pathway Forward
Broad Definition of
Covered Services
+
Statutory
Requirements
―
Specific List of
Exclusions

14. Separate Rulemaking Will Address
Additional Topics
Detailed requirements on federal “fall-back exchange” in states that fail to
establish an exchange will likely be covered in subregulatory guidance

15. “Very few of the groups we spoke with took
the time to be as thoughtful about their
priorities, to understand both the scope
and limitations of the legislation, and to
research the implications of what they
were asking for. “
from U.S. Department of Health
and Human Services e-mail
© National Health Council

16. Marc Boutin
Executive Vice President & COO
National Health Council
mboutin@nhcouncil.org
© National Health Council