Our Journey

Understanding the Affordable Care Act

June
Understanding ACA ACA Impact on Womens Contraceptives ACA Objection Handling

October
ACA Health Exchanges

Today

July

Chapter 1 Learning Objectives:

After completion of this e-learning module you should be able to:
1. Understand the legislation background and main objectives of the ACA
2. Understand the insurance reforms that became effective in 2010 3. Understand a a key reform related to womens preventive services 4. Become aware of several major reforms to go in effect in 2014 5. Identify the timing of the major health coverage elements over the next two years

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E-Learning Instructions
Please review each educational slide in its entirety before proceeding to the
next

You will be asked to complete several knowledge check questions

throughout the e-learning activity

At the completion of this e-learning activity, please proceed to the

assessment to complete the requirement for this training

For internal use only. Not to be forwarded or distributed to customers.

These materials are current as of Summer 2013 and are subject to change at any time.

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Chapter 1:

OVERVIEW OF THE AFFORDABLE CARE ACT (ACA)

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Table of Contents
Section 1: Legislative Background Section 2: Provisions Effective in 2010 Section 3: Understanding A Key Reform for Womens
Preventive Services

Section 4: Future Reforms in 2014

Timeline of Key Insurance Reforms

Summary

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Section 1: Legislative Background

What is the ACA?
Major Objectives of the Legislation Legal Challenges to ACA & States Decisions Impact of Grandfathered Health Plans

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What is the ACA?

In March 2010, Congress passed major health reform legislation, the Patient Protection and Affordable Care Act, also known as the Affordable Care Act or simply the ACA. It is also referred to as federal health reform.

Background

Phased Implementation
The 900+ page legislation is extensive and contains numerous provisions that have rolled out incrementally over the past 2 years.

Health Insurance Reform Provisions

As of 2013, a majority of the ACA provisions have been implemented. However, a number of health insurance reform provisions will take effect beginning January 1, 2014.

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Major Objectives of the ACA

Insurance Reforms & Increased Access to Coverage
Provisions around insurance mandates, market reforms, health insurance exchanges, Medicaid expansion, coverage for preventive care, and premium subsidies

Improvements in Quality & Efficiency of Care

Provisions related to incentive payments for better outcomes within Medicare & Medicaid, significant investments to improve quality and the delivery of care, and new care model

Cost Containment & Financing

Provisions for new taxes and fees to fund and to pay for additional coverage and reform provisions

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Legal Challenges to ACA & States Decisions

Constitutionality of the law
26 states filed lawsuits soon after the law was passed Primary legal challenge was around two major provisions of the ACA: the requirement for individuals to have health insurance known as the Individual Mandate and the Medicaid expansion

U.S. Supreme Court Decision

Individual mandate is constitutional

Requiring the states to expand Medicaid coverage is unconstitutional the decision to expand Medicaid is left up to each individual state
State governors are now left to make decisions regarding their states implementation of ACAs Medicaid expansion and insurance exchanges

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Impact of Grandfathered Health Plans

What is a Grandfathered Health Plan?

A group health plan or a plan in the individual health insurance market that existed on the date of ACAs enactment, March 23, 2010

What is the Impact?

Exempt from certain requirements of the ACA Most Americans are in grandfathered health plans Plans may lose grandfather status over time

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Knowledge Check
Section 1

1. The major objectives of the ACA are to (check all that apply):

A. B. C. D. E.

Curb the rising cost of medical malpractice insurance. Improve quality and efficiency of care

Increase access to health insurance coverage

Require all employers to provide coverage for their employees Require new taxes and fees to pay for additional coverage

Answers: B, C, E

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Section 2: Provisions Effective in 2010

Health Insurance Reforms
Increased access to coverage
More consumer protections

Free Coverage for Preventive Care

Adults Infants, children and adolescents Seniors (Medicare)

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Timeline of Key Insurance Reform Provisions

ACA Insurance Reforms: 2010
No Denials for Pre-existing Conditions

Free Preventive Care Jul

2010
May Jul
July

2012

2014

Sep

Extending Adult Dependent Coverage to Age 26

No Lifetime / Annual Limits

No Rescinding of Coverage

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Health Insurance Reforms

Reforms that increase access to coverage and provide more consumer protections 1. 2. Extends Coverage for Young Adults Access to Insurance for Uninsured Individuals with a Pre-Existing Condition

3. Eliminates Lifetime Limits 4. Regulates Use of Annual Limits

5. Prohibits Rescinding of Coverage

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Free Coverage for Preventive Care

Summary of Preventive Services for Adults and Children/Adolescents Services Specific for Women
Breast Cancer Screenings Cervical Cancer Screenings Osteoporosis

Screenings

Healthy Behaviors
Tobacco Cessation Interventions Alcohol Misuse Screening/ Counseling Aspirin Use in Adults Healthy Diet Counseling STI / HIV Screenings and Counseling Immunizations

Additional for Children and Adolescents

Developmental and Behavioral Assessments Alcohol and Drug Use Assessments Newborn Screenings Autism

Blood Pressure

Cholesterol

Colorectal Cancer

Pregnancy-Related Screenings Folic Acid Supplements for Pregnancy

Obesity Screening and Counseling Type 2 Diabetes

Iron Supplements Lead Screening Hearing Screening Vision and Oral Health Depression Screening for Adolescents
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Depression

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Additional Preventive Services for Seniors

services and screenings for adults, Medicare beneficiaries receive other age-appropriate preventive services and screenings without cost-sharing1:
Annual Wellness Visits. This is a comprehensive exam as well as education and counseling about preventive services and other care.

Seniors within Medicare. In addition to all covered preventive care

Bone mass measurement

Prostate cancer screening Glaucoma screening

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Knowledge Check
Section 2

2. A key reforms that increased access to coverage and provided more consumer protections was (select all that apply):

A. Extending coverage for young adults under age 26 B. Requiring young adults under age 26 to have insurance C. Prohibiting insurers from denying coverage based on pre-existing
conditions D. Allowing insurers to apply actuarial rules based on gender and health status E. Establishing lifetime limits on benefits

Answers: A, C

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Section 3: Understanding A Key Reform for Womens Preventive Services

HHS Guidelines for Womens Preventive Services
Additional services without cost-sharing

Religious Exemption Summary of Key Preventive Services Important for Women

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Timeline of Key Insurance Reform Provisions

ACA Insurance Reforms: 2010 - 2012
No Denials for Pre-existing Conditions Coverage Mandate of Womens Preventive Services Jul

Free Preventive Care

2010
May Jul
July

2012
Jan

2014

Sep

Extending Adult Dependent Coverage to Age 26

No Lifetime / Annual Limits

No Rescinding of Coverage

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Eight Additional Preventive Care Services for Women with No Cost-Sharing

HHS Guidelines require:

1. 2. 3. 4. 5. 6. 7. 8.

Annual well-woman visits Screening for gestational diabetes HPV DNA testing for women 30 years and older Sexually-transmitted infection counseling HIV screening and counseling Breastfeeding support, supplies and counseling Screening and counseling for interpersonal and domestic violence Contraception: All Food and Drug Administration (FDA)-approved contraception methods, sterilization procedures, patient education and counseling

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Religious Exemption for Contraception

Certain religious employers do not have to cover contraception services if they have religious objections to contraception.

What is the exemption?

How are religious employers defined?

Primarily churches, other houses of worship, and their affiliated organizations

What accommodations are made for non-profit religious organizations?

Women are provided separate individual health insurance policies, without cost sharing or additional premiums

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Summary of Preventive Services Important to Women

Womens Preventive Services Covered Without Cost Sharing, by Category Screenings
Well Woman-Visits Cervical Cancer

Reproductive Health
FDA Approved Contraception Methods Contraception Patient Education and Counseling HPV DNA Testing

Pregnancy Related
BRCA Counseling about Genetic Testing Bacteriuria Urinary Tract Screening Gestational Diabetes Screening Anemia Screening Rh Incompatibility Screening

Breast Cancer Screenings

Osteoporosis Screening

STIs/HIV Screening and Counseling Folic Acid Supplements Pre-Pregnancy

Domestic Violence Screening and Counseling

Expanded Counseling for Pregnant Tobacco Users Breastfeeding Supports

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Knowledge Check
Section 3

3. Under the HHS guidelines that took effect in 2012, womens preventive
services must now cover what additional services? (select all that apply)

A. Dermatology screenings B. Mammography C. Contraception D. Sexually transmitted infection counseling E. Contraception patient education and counseling

Answers: C, D, E

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Section 4: Future Reforms in 2014

I.
Essential Health Benefits

II. Insurance Exchanges

III. Medicaid Expansion IV. Individual Mandate V. Employer Requirements

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Timeline of Key Insurance Reform Provisions

ACA Insurance Reforms - 2010-2014
Pre-existing Condition Insurance Plan Coverage Mandate of Womens Preventive Services Jul Individual Mandate

Free Preventive Care

Employer Requirements

2010
May Jul
July

2012
Aug

2014
Jan

Sep

Extending Adult Dependent Coverage to Age 26

No Rescinding of Insurance No Lifetime / Annual Limits

Health Insurance Exchanges

Expanded Medicaid Coverage Essential Health Benefits

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4.1

I. Essential Health Benefits

A minimum package of items and services that health plans must offer

What are Essential Health Benefits? Essential health benefits must include items and services within at least
the following 10 categories:
Ambulatory patient services Emergency services Hospitalization Maternity and newborn care Mental health and substance use disorder services, including behavioral health treatment Prescription drugs Rehabilitative services and devices Laboratory services Preventive and wellness services and chronic disease management Pediatric services, including oral and vision care

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4.2

II. American Health Benefit Exchanges

What are Health Benefit Exchanges? A set of government-regulated and standardized health care plans,
administered at the state level, where individuals and small businesses will be able to shop for coverage

The Health Benefit Exchanges purpose is to attempt to provide:

A competitive market Common rules Information to help consumers
The ACA requires all exchanges to be ready to begin enrolling consumers by October 1, 2013 and be fully certified and operational by January 1, 2014.

If a state fails to set up an Exchange by January 1, 2014, HHS will set up and operate an Exchange in the state, either directly or through an agreement with a nonprofit entity.

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4.2

Access, Benefits and Premiums in the Exchanges

Access
Limited to U.S. citizens and legal immigrants. Small businesses with up to 100 employees

Benefits
Required to offer Essential Health Benefits

Four levels of benefits coverage based on premiums and out-of-pocket costs

Subsidies for Premiums

Subsidies or tax credits on a sliding scale Cost-sharing subsidies and caps on out-of-pocket costs

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4.3

III. Expansion of Medicaid

Who are under age 65 and not eligible for Medicare (children, pregnant women, parents, and adults without dependent children) with incomes up to 133% of Federal Poverty Level, beginning January 1, 2014

Medicaid may be expanded to individuals:

Approximately 19 million people maybe eligible to enroll

States have a choice Per the U.S. Supreme Court Ruling in 2012, states have a choice
whether to expand Medicaid coverage and still receive federal funding
States must make a decision on whether to expand current Medicaid coverage for low income individuals

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4.3

Potential Medicaid Expansion by State in 2014

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4.4

IV. Individual Mandate for Health Insurance

have qualifying health insurance coverage or pay a penalty (known as the individual mandate)

Beginning in 2014, the ACA requires U.S. citizens and legal residents to There are exceptions in the following cases:
You are part of a religion opposed to acceptance of benefits from a health insurance policy

You are an undocumented immigrant

You are incarcerated You are a member of an Indian tribe Your family income is below the threshold for filing a tax return ($10,000 for an individual, $20,000 for a family in 2013) You have to pay more than 8% of your income for health insurance, after taking into account any employer contributions or tax credits

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4.4

Qualifying Health Insurance Coverage

mandate requirement includes: Medicare

Types of qualifying health coverage that meet the individual

Medicaid / CHIP Tricare VA health benefits Individual health insurance (bronze level or higher) Employer coverage Grandfathered health plan

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4.5

V. Employer Requirements in 2014

Large Employers
Those with more than 50 employees must offer affordable health insurance coverage or pay a penalty.

The penalty can range between $2,000 to $3000 for each full-time
employee, excluding the first 30 employees

Small employers
Those with less than 50 employees are exempt from penalties

Employers with 25 or few employees

Do not have to offer coverage, but those that do offer coverage will receive tax credits to help offset the insurance costs

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Knowledge Check
Section 4

4. Which statements are true about the Health Benefit Exchanges? (select all that apply)

A. Employers with 200 employees can purchase insurance through the

B.
C. D. E.

Exchanges. All plans that participate in the Exchanges must offer Essential Health Benefits. If a state fails to set up an Exchange, then HHS will set up and operate one in that state. Only U.S. citizens are eligible to purchase insurance in the Exchanges. Low income families can receive subsidies for premiums.

Answers: B, C, E

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Timeline of Key Insurance Reform Provisions

ACA Insurance Reforms - 2010-2014
Pre-existing Condition Insurance Plan Coverage Mandate of Womens Preventive Services Jul Individual Mandate

Free Preventive Care

Employer Requirements

2010
May Jul
July

2012
Aug

2014
Jan

Sep

Extending Adult Dependent Coverage to Age 26

No Rescinding of Insurance No Lifetime / Annual Limits

Health Insurance Exchanges

Expanded Medicaid Coverage Essential Health Benefits

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Summary
The Patient Protection and Affordable Care Act, also known as ACA,
enacted in March 2010 is comprehensive and complex.

Key objectives of the ACA are to enact insurance reforms and provide
increased access to coverage, make improvements in quality & efficiency of care, and to address cost containment and financing.

There are number of health insurance reforms and provisions with various
effective dates through 2014.

A key reform that took place in 2012 was a coverage mandate for Womens
Preventive Services, including contraception, with no cost-sharing.

Some of the key reforms that will take place in 2014 include: Essential
Health Benefits, Health Exchanges, Individual Mandate, Employer Requirements, and Potential Expansion of Medicaid

The Department of Health and Human Services (HHS) is currently working

closely with states and health care stakeholders to implement new health coverage options effective January 1, 2014
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