Health Care Reform Overview of The Patient Protection and Affordable Care Act - PowerPoint PPT Presentation

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Health Care Reform Overview of The Patient Protection and Affordable Care Act

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Health Care Reform Overview of The Patient Protection and Affordable Care Act June 5, 2010 Chris Barley, Staff Attorney Ohio Poverty Law Center * What is a Health ... – PowerPoint PPT presentation

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Title: Health Care Reform Overview of The Patient Protection and Affordable Care Act


1
Health Care ReformOverview of The Patient
Protection and Affordable Care Act
  • June 5, 2010
  • Chris Barley, Staff Attorney
  • Ohio Poverty Law Center

2
Presentation Overview
  • Limited to major provisions
  • Details to be determined later
  • Effect of reform will be different across states
  • Many interpretations exist

3
Structure of Reform
3
4
Key Insurance Provisions
  • Health insurance market reforms
  • Ombudsman program
  • High risk pool
  • Reinsurance program
  • Health Insurance Exchange
  • Required Purchase of insurance
  • Subsidies

5
Pre-Reform BlueprintWhat It Looks Like NOW.
Chart prepared by PICO National Network,
Washington D.C. 2010
5
6
Post-Reform Blueprint2014
Chart prepared by PICO National Network,
Washington D.C. 2010
6
7
Early Insurance Market Reforms
  • No lifetime limits
  • Restrictions on allowable annual benefit limits
  • Coverage of dependents up to age 26
  • Pre-existing condition exclusions prohibited for
    children up to age 19
  • Appeals processes for enrollees
  • May not discriminate based on salary
  • Benefits for preventive services required
  • Coverage for emergency services at in-network
    level

8
Early Insurance Market Reforms
  • Review of Premium Rates
  • Federal HHS will develop a process for the annual
    review of premium rate increases
  • Federal HHS will distribute 250 million in
    grants over 5 years to cover state costs

9
Early Insurance Market Reforms
  • Health Plan Loss Ratio Requirements
  • Loss ratios reported to HHS
  • Report must breakdown on how premiums are spent
  • Reporting requirements to be developed by HHS
    NAIC
  • In January 2011, rebates provided when plans do
    not meet loss ratio targets.
  • Loss ratio expenses based on clinical services
    and activities that improve health care quality

10
Early Insurance Market Reforms
  • Health Plan Disclosure Requirements
  • Payment policies and practices
  • Financial disclosures
  • Enrollment and disenrollment data
  • Claims denial information
  • Data on rating practices
  • Information on cost-sharing and payments with
    respect to out-of-network coverage

11
Insurance Market Reforms
  • Must provide
  • uniform summary of benefits
  • explanation of coverage documents.
  • Must use standardized definitions
  • HHS to publish standards in 12 months

12
Insurance Market Reforms
  • Guaranteed issuance
  • Elimination of
  • Preexisting condition
  • Annual limits on coverage
  • Waiting periods
  • Limitation on deductibles
  • Rating restrictions for group and individual
    market
  • Small employer redefined (1-100 employees)

13
Consumer Ombudsman Program
  • Provides grants to create health ombudsman
    program
  • Serves as an advocate for consumers
  • Assists with insurance-related complaints and
    appeals
  • Assists consumers with enrollment
  • In 2014, Resolves problems with subsidies
  • Collects, tracks and quantifies consumer problems
    and insurance inquiries

14
Temporary High Risk Pool
  • For individuals with pre-existing conditions
  • For uninsured for 6 months or longer
  • May contract with states or non-profit entities
    to provide coverage

15
Temporary High Risk Pool (continued)
  • Federal funding of 5 billion allocated to fund
    eligible enrollees until 2014.
  • Federal HHS working with states to develop
    program guidelines

16
Temporary Reinsurance Program for Early Retirees
  • For employers providing insurance to retirees age
    55
  • Including state government programs like PERS,
    STRS
  • Program pays 80 of claims costs between 15,000
    and 90,000 annually
  • Payments under the program must be used to lower
    costs of the plan
  • Must submit application to HHS to participate
  • Funding of 5 billion

17
Electronic Health Care Transactions
  • Requires compliance with standard electronic
    health care transactions
  • Imposes new, earlier deadlines for federal HHS
    rules and implementation

18
Health Insurance Exchange
  • Directs states to establish American Health
    Benefit Exchanges
  • Small Business Health Options Program (SHOP).
  • Exchanges must be operational by January 2014
  • Must be administered by governmental agency or
    non-profit organization
  • HHS will establish exchanges in those States
    where they fail to create one.

19
What is a Health Care Exchange?
  • Virtual Marketplace
  • Run by the state or the federal government (at
    the states choice)
  • Insurance companies that want to sell insurance
    in the Exchange must sell plans that meet
    certain standards
  • The Exchange will allow consumers to comparison
    shop
  • The Exchange will also determine appropriate
    levels of subsidies for consumers to help them
    afford coverage, up to 400 FPL.

20
Health Insurance Exchange Program Features
  • One-stop insurance shopping
  • Provide a selection of Exchange qualified plans
  • Standardizes presentation of insurance options
    for plan comparability
  • Provides a rating system for plans
  • Redefines small businesses as 1-100 employees
  • Must contract with navigators
  • Four levels of plans
  • Catastrophic plans available to individuals under
    age 30
  • Insurers must offer children-only plans
  • Exchange must provide a seamless application
  • Federal funding implementation grants to states

21
Other Provisions
  • Co-Op program
  • Merging of individual and small group markets
  • Employer rewards
  • Health Care Choice Compacts
  • Nationwide plans

22
Individual Requirement to Purchase Insurance
  • Individuals required to obtain coverage
  • Can be an individual or group plan
  • Exemptions
  • religious objections,
  • financial hardship,
  • undocumented immigrants,
  • American Indians,
  • people earning under the tax filing threshold,
    and
  • short gaps in coverage.
  • Subsidies
  • up to 400 of federal poverty level

23
Individual Requirement to Purchase
Insurance(continued)
  • Penalties for non-compliance
  • 95 per person in 2014
  • 325 per person in 2015
  • 695 per person in 2016
  • Enforcement through IRS.

24
Small Employer Requirements and Tax Credits
  • Small employers exempt
  • Part - time workers
  • How are the counted?
  • Not required to offer coverage
  • Tax Credits for small employers
  • lt 25 employees
  • lt50,000 in average annual salary
  • 35 of premium, 50 in 2014
  • Credits phased out gradually

25
Large Employer Requirements to Purchase
Insurance
  • gt50 full time employees
  • Must offer insurance
  • If employees receive public subsidies employer
    pays 2,000 per year
  • Large employers whose employees who receive
    premium assistance pay the lesser of
  • 1) 3,000 per year
  • 2) 2000 per year
  • Penalties calculated monthly based on number of
    applicable employees
  • gt200 employees must automatically enroll new
    employees

26
Impact on Market and Consumers
  • Premium rates will change
  • Minimum loss ratio requirements may mitigate some
    increased premiums
  • Uninsured individuals with preexisting conditions
    to be able to obtain coverage through the
    temporary insurance risk pool
  • Rating requirements and guarantee issue will
    impact small and individual markets

27
Impact on Market and Consumerscontinued
  • All plans issued going forward must meet federal
    requirements
  • Employers with existing group plans can continue
    to enroll new employees
  • All private plans sold after March 23rd must
    comply with new benefit provisions

28
Additional Information
  • Ohio Consumers for Health Coverage
  • www.OhioConsumersForHealthCoverage.org
  • www.aarp.org
  • www.CommunityCatalyst.org
  • www.FamiliesUSA.org
  • www.HealthReformGPS.org tracking news and
    developments
  • www.HDAdvocates.org experts on people with
    disabilities
  • www.kff.org Kaiser Family Foundation
  • www.NationalPartnership.org working on
    delivery reforms

29
For More Information
  • Cathy Levine, Executive Director
  • UHCAN OHIO
  • OCHC, Co-Chair
  • (614) 456-0060 x 222
  • clevine_at_uhcanohio.org
  • Col Owens, Senior Attorney,
  • Legal Aid of Southwest Ohio
  • OCHC Co-Chair
  • 215 E. Ninth Street
  • Cincinnati, Ohio 45202
  • (513) 300-3042
  • cowens_at_lascinti.org
  • Kathleen Gmeiner, UHCAN Ohio
  • OCHC Project Director
  • (614) 456-0060 x 223
  • kgmeiner_at_uhcanohio.org
  • Gene King, Director
  • Ohio Poverty Law Center
  • 555 Buttles Ave.
  • Columbus, Ohio 43215
  • (614) 221-7201
  • gking_at_OhioPovertyLaw.org
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