The Affordable Care Act: A Policy and Implementation Update 5/27/2014

The Affordable Care Act and Breast
Health Coverage
Sara Eskrich, Project
Assistant – Health
Policy, UW Population
Health Institute
The Affordable Care Act: A Policy
and Implementation Update
Breast Cancer Conference for
Community Health Workers
May 30, 2014
Where do Wisconsin Women
Get Health Insurance?
What is the ACA?
• Stands for “Affordable Care Act” -- otherwise
known as the health care law or “Obamacare”
• Health insurance reform
• Became law on March 23, 2010
• Different parts affect different groups of
people, two main stages
– Stage 1 focuses on patient protections (now)
– Stage 2 focuses on expanding coverage (2014)
Women 19-64, 2010-11 US Census Bureau
Decline in Employer-sponsored Insurance
(CPS data for non-elderly population: 2000 to 2011)
Uninsured Non-Elderly Wisconsinites
518,246 uninsured, or 10.8% of Wisconsinites
Finances of ACA
• Builds on existing private insurance system
and seeks to outlaw abuses, fill gaps
• Aims to rein in health care costs; reduces
deficit by over $100 billion by 2020; by $1.3
trillion by 2030 (according to Congressional
Budget Office).
• Congressional Budget Office is the nonpartisan “scorekeeper” on budget issues for
Preexisting Conditions
in Wisconsin
• Nearly 1 million in Wisconsin under age 65
have a preexisting condition that would
deny coverage to them if they bought
insurance on their own
• An additional 1.5 million non-elderly
Wisconsinites have preexisting conditions
that would cause them to be denied
coverage or charged excessive rates.
Stage 1
• Outlaws insurance denials based on
preexisting conditions for kids (applies to
adults in 2014)
• Added $5B to state “preexisting pools” to
allow more participants and reduce
premiums until 2014 when it will be
illegal to discriminate against adults with
preexisting conditions.
Stage 1
• Allows young adults to stay on parents’
policies until they are 26
• Eliminates lifetime limits
• Phases out annual limits (gone in 2014)
• Can’t drop coverage after a person gets
sick or for an honest mistake on your
insurance application
Source: U.S. Department of Health & Human Services, January 2011
Stage 1
Stage 1
• Insurance must spend at least 80% of your
premiums on medical care
• Double digit premium increases must be
publicly reviewed, are subject to approval
• Small business tax credits: Up to 35% back
if providing employees health insurance
($40 billion in credits by 2019)
Additions to Medicare:
• Preventive services such as checkups and
screenings with no Part B co-pay or
• 50% discount on brand-name drugs when
you hit the “donut hole” coverage gap.
• Solvency of Medicare extended through
efficiencies, fighting waste, prevention,
ending subsidies to insurance companies
Stage 1
• Many preventive care services must now
also be offered by private insurance
without co-pay or deductible.
• Over 1.1 million Wisconsinites already
• Includes things such as:
– Mammograms, blood pressure screenings,
many cancer screenings, immunizations, diet
& losing weight, quitting smoking, etc.
– Full list at
Why Prevention?
• Chronic diseases are responsible for 7 in
10 American deaths and account for 75%
of U.S. health spending.
• BUT chronic diseases are often
• Often because of cost, Americans use
preventive services at about half the
recommended rate.
Source: U.S. Department of Health and Human Services.
Women’s Preventive Services
As of August 1st 2012, all new insurance plans and those
renewing without “grandfathered” status, are required to
provide (with no cost-sharing*) the following services:
•the full range of FDA-approved contraception methods and contraceptive
•well-woman visits
•screening for gestational diabetes
•human papillomavirus (HPV) DNA testing for women > 30 years
•sexually-transmitted infection counseling
•human immunodeficiency virus (HIV) screening and counseling;
•breastfeeding support, supplies, and counseling
•domestic violence screening and counseling
Nearly one million women in WI are expected to benefit.
*No copayments, deductibles or co-insurance.
Breast Cancer Screening and the ACA
• The ACA mandates coverage of mammography for
breast cancer screenings: USPSTF recommendation of
every 1-2 years for women 40+.
• Wisconsin law mandated 2 exams for 45-49 and one
per year for 50+.
• As part of the ACA, Medicare covers the full cost of one
mammogram per year for women 40+.
• Counseling and testing for BRCA 1 and BRCA 2 genes
for women who have a family history of breast and
ovarian cancer.
• Breast Cancer Chemoprevention counseling for women
at higher risk.
1-866-PILL-4-US or [email protected]
Stage 2
The bulk of the health care law
went into effect on January 1, 2014
to help expand coverage
Stage 2
Individual mandate in concert with:
• Preexisting condition exclusions outlawed for
everyone, no discriminatory practices, like
gender rating
• Expansion of Medicaid (BadgerCare)
• Creation of competitive health marketplace
• Addition of individual tax credits to help
middle class pay for insurance in exchange
• Increase small business tax credit to up to
The Individual Mandate
Individual Mandate Exemptions
Some individuals may be exempt including:
Most individuals will be required to have insurance or
pay a tax penalty/fee
• 2014: $95 per adult or 1% of income
• 2016: $695 per adult or 2.5% of income
• Penalty also referred to as the “Shared Responsibility
• Individuals may be uninsured for a period of up to three
months before penalty would apply
Religious conscience;
Membership in a health care sharing ministry;
Member of an Indian tribe;
Taxable income below the threshold to pay taxes ($9,750
for individual in 2013 tax year)
• Hardship (based on personal circumstance or a lack of
affordable coverage); and
• Ineligible for Medicaid based on a state’s decision not to
expand (In WI, incomes between $11,490-15,282 for
ACA and Employer Coverage
• Employees with coverage through their job:
o Most will experience no changes unless
the employer decides to make changes
ACA and Employer Coverage
• Employees without coverage through their job:
o If you work for a large employer (over 100
employees), they must offer insurance beginning in
January 2015 or pay a fine (Applies to employers
with 50-99 employees in 2016)
o If you work for a small employer (less than 50
employees) the employer is not required to offer
insurance, but can choose to through the SHOP
BadgerCare+ Groups, 2014
BadgerCare+ and ACA
• Under the ACA, states were to expand their
Medicaid programs, the Supreme Court
effectively made that a state option
• Wisconsin’s administration decided to modify
BadgerCare+ eligibility guidelines: expanding
coverage for some and eliminating coverage
for others
Premiums Start at 200%
Premiums Start at 200%
No Premiums
No Premiums
• Changes are pending federal CMS approval
Updated October 11, 2013
Premiums Start at 200%
Premiums Start at 200%
No Premiums
No Premiums
The Marketplace/Exchange
Who can Buy in the Marketplace?
People can access coverage in the Marketplace, if:
• Are currently uninsured
• Are not incarcerated
• Do not have access to affordable insurance through their
• Have affordable employer-sponsored coverage, but would
like to explore their options (Note: not eligible for tax credits)
Updated October 10, 2013
Insurance Plans in the Marketplace
• Insurance plans available through the Marketplace
must be qualified and cover 10 essential health
• Plans are categorized as Platinum, Gold, Silver, or
Pay monthly premium
for coverage
Essential Health Benefits
Minimum benefits for non-group and small group plans in and out
of exchanges (also some Medicaid and BHP)
10 Categories in the ACA:
Ambulatory patient services
Emergency services
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
Pediatric Services, including oral and vision care
States decide benchmark plan, largest small group plan is default,
UnitedHealthcare Choice Plus – will be default in 2014 and 2015
2016 presents an opportunity to reassess approach
Bronze – 60%, Silver – 70%, Gold – 80%, and
Platinum – 90%, catastrophic (high deductible plan)
All plans cover preventive services without out-ofpocket costs
• People can choose which plan works for them
based on value, cost, and a standard
summary of benefits and coverage
WI Insurers in the Marketplace
Available plans vary by County
Common Ground Healthcare Cooperative
Compcare Health Services Insurance Corporation
Dean Health Plan, Inc.
Group Health Cooperative of South Central Wisconsin
Gundersen Health Plan, Inc.
Health Tradition Health Plan
Medica Health Plans of Wisconsin
MercyCare HMO, Inc.
Molina Healthcare of Wisconsin, Inc.
Physicians Plus Insurance Corporation
Security Health Plan of Wisconsin, Inc.
Unity Health Plans Insurance Corp.
Arise (WPS Health Plan, Inc.)
– Important to be part of that conversation.
What is the cost of coverage?
• Cost is influenced by:
tobacco use
geographic location
• Costs will vary based on the plan and tier of coverage chosen
• The most an individual will pay is between 2-9.5% of their
• Go to the Kaiser Family Foundation Premium calculator for a
cost estimate:
Is there financial assistance available?
• Congressional Budget Office estimates that 7/8 will qualify for
a subsidy (discount)
• Subsidies are available for those between 100-400% FPL
$11,490-$45,960 for an individual
$23,550-$94,200 for a family of four
• Cost-sharing assistance is available for individuals with income
between 100-250% FPL (must purchase silver level plan!)
$28,725 for an individual
$58,875 for a family of four
• Maximum out-of-pocket limit in 2014 of $6,350 for an
individual and $12,700 for a family (applies to all
insurance plans)
Updated October 11, 2013
Amount of financial assistance
• Assessment of eligibility for and amount of premium tax
credit is made through the Marketplace
• Amount of subsidy = cost of second lowest cost silver plan
in the individual’s geographic area – amount the individual
is expected to pay (sliding scale of 2%-9.5% of family
• Full amount of tax credit can be used to purchase any plan
sold on the Marketplace
• So, if you buy a bronze level plan, the PTC will cover more
of the premium, if you buy a platinum level plan, the PTC
will cover less of the premium cost
Updated October 11, 2013
Receiving financial assistance
Cost-Sharing Reductions
• Cost-sharing reductions are automatically included for
individuals with income between 100-250% FPL who are
receiving premium tax credits and purchase a silver level plan
• When shopping for coverage, eligible individuals will see
the cost-sharing reductions reflected in prices
• Their purchased plan will have a lower deductible, out-ofpocket maximum, or copayments
Eligibility for financial assistance
• Must not have access to “minimum essential coverage”:
• Medicare
• Medicaid
• An offer of Employer-Sponsored Coverage that is
“adequate” and “affordable”
• What does “adequate and affordable” ESI mean?
• Adequate – minimum value of at least 60%
• Affordable – employee-only coverage costs less than 9.5%
of household income
• Ex) employee + dependent coverage offered and costs
less than 9.5% of household income – employee and
kids are not eligible for PTCs, however spouse
is eligible for PTCs
Updated October 11, 2013
Receiving financial assistance
• Premium tax credits are refundable, so individuals with little
or no income can still benefit (like the EITC)
• However, must file taxes in year PTC are received
• Premium tax credits can be paid “in advance,” directly to the
insurance company
• Advanced Premium Tax Credits allow individuals to only
pay their portion of the premium to the insurer
• Don’t have to take PTCs in advance, or take full amount
• APTCs are subject to reconciliation upon tax filing
• Reporting changes in income throughout the year
is critical
Updated October 11, 2013
Enrollment Periods
• October 1, 2013- March 31, 2014 (April 15): Open
Enrollment: Individuals can sign up for health insurance
plans on the Marketplace
• Special Enrollment Periods: qualifying life events such as
losing other insurance coverage, moving out of a plans
service area or gaining new dependents may qualify
someone for a special enrollment period
• Unlike PTCs, cost-sharing reductions are not administered like
a tax credit, and do not need to be reconciled at tax time,
however, income changes should be reported to recalculate
the PTC and cost-sharing reductions throughout
the year
Updated October 11, 2013
Updated October 11, 2013
Enrollment Assistance
Four Key Messages to Reach Most Uninsured
• In person:
Navigators and Certified Application Counselor organizations
Agents and brokers
Inventory available -
• By phone:
All insurance plans will have
to cover doctor visits,
hospitalizations, maternity
care, emergency room care,
and prescriptions.
You might be able to get
financial help to pay for a
health insurance plan.
If you have a pre-existing
condition, insurance plans
cannot deny you coverage.
All insurance plans will have
to show the costs and what is
covered in simple language
with no fine print.
One of these =
top message
for 89% of
through a national call center 1-800-318-2596,
Call 211 for local supports
• Online:
chat with a Marketplace representative when filling out an
application at
Updated October 11, 2013
Source: Enroll America, November 2012
Wisconsin Marketplace Enrollment, by Plans Selected,
2014 Open Enrollment: October 1, 2013 – April 19, 2014
Update: Wisconsin
Marketplace and
BadgerCare+ Enrollment
HHS Enrollment Report, May 2014,
Wisconsin BadgerCare+ Enrollment Changes for Adults,
Implemented April 1, 2014
Wisconsin Marketplace Enrollment, by Plans Selected,
October 1, 2013 – April 19, 2014
April 1, 2014 BadgerCare+ Changes
• Total enrollment in
BadgerCare+ grew by
about 34,000 in April, after
significant declines in the
previous year.
• Awaiting more data on
transitioning adults to
Marketplace coverage.
HHS Enrollment Report, May 2014,
Newly Eligible Childless Adults
Removed Adults from BC+
Training, fact sheets, blog, Wisconsin-specific resources, list serve
February 13, 2014
Local resources and training information, assistance request
Webcast, PowerPoint training, FAQs and information on Regional
Enrollment Networks
Updated October 10, 2013
Updated October 10, 2013
Spread the Word About Health
Care Reform!
» Tell someone you know about what women and our
families are getting from the ACA.
» Advocate on the state budget! Tell legislators to
cover more people for less money.
» Host an educational session in your neighborhood, your
church or community center.
» Share your story! Have you already benefited from
health care reform? Visit to
tell us how!
For more information visit or subscribe to our
health reform blog at
Sara Eskrich
MPH Candidate, UW School of Medicine and Public Health
Project Assistant, UW Population Health Institute,
Covering Kids & Families
[email protected]
Wisconsin Women: Get Covered!
WCCF: Frequently Asked Questions
Kaiser Family Foundation