Navigating the Affordable Care Act

Kim L. Isaacs, MD, PhDUniversity of North Carolina at Chapel HillDecember 4, 2014

March 23, 2010•Patient Protection and Affordable Care Act becomes federal law.

•Initiated the most significant changes in health care in the United States in 50 years *Medicare established in 1965

Why do we need an intervention in US health care?

• Problems with cost of medical care in US▫2010 – $2.6 trillion in 2010

• Access▫> 50 million uninsured.

• Quality ▫US ranks last among 11 industrialized

countries in health system quality, efficiency, access, equity and healthy lives – Commonwealth Fund Report

ACA

Quality

Access Cost

Complicated piece of legislation that attempts to address these issues.

What is the affordable care act?

ACA: 10 titles that cover more than just insurance• Quality affordable health care for all Americans• Role of public programs• Improving quality and efficiency of health care• Prevention of chronic disease and improving public

health• Health Care workforce• Transparency and program integrity• Improving access to innovative medical programs• Community living assistance services and supports

act• Revenue provisions• Reauthorization of the Indian Health Care

Improvement Act

http://www.hhs.gov/healthcare/rights/law/index.html

How are patients insured?Based on March 2012 Census and 2013 Current population Survey (CPS)

47.7 million uninsured

How this plays out for our patients•If the patient is insured:

▫Children can remain on parent’s plan until age 26

▫Companies can not drop coverage if the patient becomes sick

▫There is not a lifetime limit on coverage▫Insurers are barred from using the patients

health history to set rates▫Certain preventive services have to be

covered.

How this plays out for our patients•If the patient is insured with Medicare

▫By 2020 the law closed the Part D “Donut Hole” which is a temporary limit on what the plan covers for prescription drugs

▫Certain preventative services are covered without patient cost sharing.

How this plays out for our patients•If the patient is uninsured and does not

meet exemption requirements ▫Patient may be covered by expansion in

states Medicaid program OR

▫They will need to purchase health insurance through the Health Insurance Market Place

If our patients are uninsured..

•Can purchase coverage through the health insurance market place

•Private insurers – offering multiple plans•Consumers can compare the plans and

see if they are eligible for subsidies to help cover costs.

•Different degrees of “cost-sharing” on available plans.

Some patients may be covered by expansion of Medicaid

Limited to certain low income populations

Extends to adults < 138% FPL

http://kff.org/health-reform/issue-brief/the-coverage-gap-uninsured-poor-adults-in-states-that-do-not-expand-medicaid/

Health Insurance Market Places•For those who need to buy their own

insurance•State by state – state run, federal

government facilitation, state-federal partnership

•Offer a range of plans – private insurers with different coverage options.▫Plans may have different network providers

Market places: states, federal, combination

https://news.leavitt.com/health-care-reform/marketplaces-exchanges-information-employers-individuals/#!prettyPhoto/0/

Who can use the health care market places?

www.healthcare.gov

ACA and 2 patients with IBDCS – Crohn’s since age 10 now 50 SB – UC since age 14 now 24

Unable to get affordable insurance due to pre-existing conditionHad to go part time due to health issues10 years no insurance

ACA was meant for someone like

me!

UC in prolonged remission.Quit job as a prison nurse due to stress of the jobGot ACA marketplace coverage and then had a UC flair

I thought the silver plan

would work but I can’t afford my

medicines..

The Plans: Level of Coverage

Silver GoldBronze Platinum

Lowest PremiumsHighest Out-of-Pocket Costs

Highest PremiumsLowest Out-of-Pocket Costs

60 % 70% 80% 90%

Covered Percent of Total Cost of Care

Benefit Bronze Silver Gold Platinum

Deductible $5000 Med/Rx $2000 Med $ 0 $0

Preventive $0 $0 $0 $0

Doctor Visit $65 for 1st 3 $45 $30 $20

Specialist $70 after d $65 $50 $40

Generic Rx $15 after d $15 $15 $5

Brand Rx $50 after d $50 after $250 d

$50 $15

Lab testing 30% after d $65 $30 $20

X ray 30% after d $45 $50 $40

Maternity 30% after d 20% after d $600 per day HMO***/20% PPO

$250 per day HMO***/10%

OP Surgery 30% after d 20% after d $600 HMO/20% PPO

$250 HMO/10% PPO

Hospital Stay

30% after d 20% after d $600 per day HMO***/20% PPO

$250 per day HMO***/10%

ER $300 after d $250 after d $250 $150

Urgent Care $120 after d $90 $60 $40

Out of Pocket Max

$6,350/$12,000 $6,350/$12,000 $6,350/$12,000 $4,000/$8,000http://www.medicoverage.com/health-insurance-blog/news/comparing-exchange-plans-bronze-silver-gold-platinum

Most consumers in the market place will be eligible for subsidies to help afford their care•http://www.kff.org/interactive/subsidy-calc

ulator/Example: Silver Plan for a 21 year old, non-smoker from North Carolina – No state expansion for Medicaid

% FPL % Income Salary Cost of Plan/yr

Tax Credit

Amount paid /yr

<133% 2% $ 15,167 $ 2,526 $2,222 $303

350% 9.5% $ 40,215 $2,526 $0 $2,526

Tax credits are only available to people between 100 – 400% of FPL

What are the questions that need to be asked by the patient

choosing a plan?•What are the drugs that are covered by

the plan.▫Drug formularies are available online on

the health care market place site• What is the plan network of doctors.

▫Not all doctors are covered by certain plans.

•Are there other financial resources available in my state?▫Patient advocacy groups, patient assistance

programs

Specialty Drug Coverage important for the patient with IBD

http://www.lls.org/#/diseaseinformation/getinformationsupport/aca/details/

ACA Essential Health Benefits

Ambulatory Patient Services Emergency Services

Hospitalization Maternity and Newborn Care

Mental Health and substance abuse services including counseling and psychotherapy

Prescription drugs

Rehabilitative and habilitative services and devices

Laboratory services

Preventive and wellness services and chronic disease management

Pediatric services

Preventive services covered by the ACA

AAA one time screening in male non-smokers

Depression screening for adults

Obesity screening and counseling for all adults

Alcohol misuse screening and counseling

Diabetes screening for adults with HBP

STD prevention counseling for adults at high risk

BP screening for all adults

Diet counseling for adults at higher risk for chronic disease

Aspirin use to prevent CV disease in men and women of certain ages

Cholesterol screening for adults of certain ages or high risk

HIV screening for all –15-65 and other ages at increased risk

Syphillis screening for all adults at higher risk

Colorectal cancer screening for adults over the age of 50

Immunizations based on age and risk factors

Tobacco use screening for all adults and cessation interventions

Are ambulances covered by insurance under the ACA?

YES if an EMERGENCY

• Emergency to the Hospital

• Between Hospitals or to a skilled nursing facility

NO if not an EMERGENCY

• To doctors office for a clinic visit

• To the morgue

Are dental services covered by the ACA?

Not for adults however some market place plans do include dental insurance for a fee.

Are ostomy supplies covered by the ACA?

Yes – as well as multiple other durable goods.

Resources

•www.healthcare.gov•Kaiser Family Foundation

▫http://kff.org/aca-consumer-resources/•http://minorityhealth.hhs.gov/NPA/Materi

als/AffordableCareActResourceKit.pdf•Leukemia and Lymphoma Society

▫http://www.lls.org/diseaseinformation/getinformationsupport/aca/