The Affordable Care Act

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What is the Affordable Care Act (ACA)?

a law consisting of two pieces of legislation that are collectively referred to as "Healthcare Reform" or "Obamacare"

What are the individual laws that make up the ACA?

1. The Patient Protection and Affordable Care Act (PPACA), enacted on March 23, 2010 2. The Health Care and Education Reconciliation Act (HCERA), enacted on March 30, 2010

What is the main objective of the ACA?

to expand health insurance coverage to an estimated 32 million uninsured Americans and strengthen existing coverage

What does the ACA do?

– increase benefits and lower costs for consumers – provide new funding for public health and prevention – bolster health care and public health workforce and infrastructure – foster innovation and quality in our system

What points encompass the Patient’s Bill of Rights?

– Coverage – Costs – Care

What are the main ideals of Coverage?

– ends preexisting condition exclusions for children – keeps young adults covered – ends arbitrary withdrawals of insurance coverage – guarantees the patient’s right to appeal

What are the main ideals of Costs?

– ends lifetime limits on Coverage – reviews premium increases – helps patients get the most from their premium dollars

What are the main ideals of Care?

– covers preventive care at no cost to patients – protects the patient’s choice of doctors – removes insurance company barriers to emergency services

What are the 10 essential health benefits?

1. Ambulatory Patient Services 2. Emergency Services 3. Hospitalization 4. Maternity and Newborn Care 5. Mental Health and Substance Use Disorder Services 6. Prescription Drugs 7. Rehabilitative and Habilitative Services 8. Laboratory Services 9. Preventive and Wellness Services and Chronic Disease Management 10. Pediatric Services

As of April, 2014, how many individuals were eligible to enroll in a Marketplace Plan in the U.S.? Florida?

U.S. = 13,547,592 Florida = 1,603,575

As of April, 2014, how many individuals had selected a Marketplace Plan in the U.S.? Florida?

U.S. = 8,019,763 Florida = 983,775

As of April, 2014, how many individuals could potentially enroll in Marketplace Coverage in the U.S.? Florida?

U.S. = 28,605,000 Florida = 2,545,000

As of April, 2014, how many uninsured individuals were eligible for Medicaid under the ACA in the U.S.? Florida?

U.S. = 8,748,000 adults & 5,220,000 children Florida = 94,000 adults & 362,000 children

As of April, 2014, how many adults were in a Coverage Gap in the U.S.? Florida?

U.S. = 4,831,580 Florida = 763,890

According to the ACA in 2010, insurance companies will no longer be able to do what?

– deny coverage to children with pre-existing illnesses – rescind coverage due to an error on a customer’s application – impose lifetime dollar limits on essential benefits – impose annual dollar limits on insurance coverage

What benefits were allowed to consumers by the ACA in 2010?

– consumers had the right to appeal insurance company decisions – uninsured Americans with preexisting conditions could access insurance coverage – the establishment of consumer assistance programs

In 2010, what was provided to seniors in the Medicare prescription drug "Donut Hole"?

a $250 rebate check

In 2010, what were tax credits provided to?

small business health insurance

In 2010, what were new plans required to cover?

free preventive care

In 2010, the ACA also began focusing efforts on what?

cracking down on healthcare fraud

In 2010, what were the main guarantees of the ACA?

– extending coverage for young adults until age 26 – expanding coverage for early retirees – rebuilding of the primary care workforce – insurance companies are held accountable for rate hikers – Medicaid expansion for states – increased payments for rural healthcare providers – strengthening of community health centers

What benefits were guaranteed for senior citizens by the ACA in 2011?

– 50% off for Medicare Part D brand name drugs – free preventive care – community care transitions program for high Medicare beneficiaries

What was established by the ACA in 2011?

the Center for Medicare & Medicaid Innovation and the Community First Choice Option

What does the Community First Choice Option allow?

states to offer home and community-based services to disabled individuals

In 2011, in what ways were prices reduced for consumers?

– health care premiums were reduced – overpayments to big insurance companies were stopped

Health Care Premiums were reduced in 2011, but in what way?

at least 85% of all premium dollars collected by insurance companies for large employer plans are spent on healthcare quality improvement

How was Medicare Advantage strengthened in 2011?

enrollees were able to receive all guaranteed Medicare benefits while also having bonus payments for high quality care provided for

In what way were payments linked to quality outcomes by the ACA in 2012?

financial incentives were provided to hospitals to improve the quality of care provided to Medicaid patients

How were care organizations for physicians made accountable in 2012?

– they were able to better coordinate and improve patient care and quality – help prevent disease and illness – reduce unnecessary hospital admissions

In 2012, how did the ACA improve the understanding of health disparities?

by collecting and reporting racial, ethnic, and language data

What new ACA policies came into effect in January of 2013?

– new funding to state Medicaid programs covering preventive services – establishment of a national pilot program to improve coordination and quality of patient care (runs on a flat fee) – increased Medicaid payments for primary care doctors

When did open enrollment in the health insurance marketplace begin?

October 1, 2013

What ACA policies were changed in January of 2014?

– discrimination due to preexisting conditions or gender were prohibited – annual limits on insurance coverage were eliminated – individuals participating in clinical trials are ensured – healthcare was made more affordable for middle class

How was healthcare made more affordable for those in the middle class?

tax credits became available for people with an income between 100% and 400% of the poverty line who were not eligible for other afforable coverage

What was established in 2014?

the Health Insurance Marketplace

What option did a patient have if their employer did not offer them with insurance?

they could buy it directly from the Health Insurance Marketplace

What was increased in 2014?

– the small business tax credit – access to Medicaid

How was access to Medicaid increased?

people earning less than 133% of the poverty level (about $14,000 for an individual and $29,000 for a family) were eligible to enroll in Medicaid

What was the goal of the ACA in 2014?

to promote individual responsibility

What will become effective in January of 2015?

physicians will be paid based on value rather than volume based on a new provision

How will the new provision for physician payment work?

physicians who provide higher quality care will receive higher payments than those who provide lower quality care

When did the ACA require most individuals to have health insurance or health coverage by?

January 1, 2014

How can health insurance by obtained?

Through an employer or individual health plan

How can health coverage be obtained?

Through programs such as: – Medicare, Medicaid, Florida Healthy Kids – Tri-Care, federal employee health benefit plans – Veteran’s Health Care, Indian Health Services (IHS)

What were some exceptions to the ACA’s healthcare reform deadline?

– individuals at or below 100% of the federal property level and eligible for Medicaid Expansion – individuals for whom coverage would be unaffordable – under a hardship which prevents the consumer from obtaining health coverage – undocumented immigrants – individuals that are members of the healthcare sharing ministries as well as the Amish, Mennonite, and Indian tribe communities

What was the consequence for people who did not meet the health coverage deadline and were not exempt from the federal requirement?

they were subject to a Shared Responsibility Payment collected by the Internal Revenue Service (IRS)

When would individuals who did not meet the deadline NOT have to make a payment?

– when the coverage was unaffordable for them – when they spent less than three consecutive months without coverage – when they qualified for an exemption

What was the total annual tax penalty for the eligible who did not meet the deadline?

the greater amount of either a flat dollar amount or a percentage of taxable income – $95 per person or 1% taxable income for 2014 – $326 per person or 2% taxable income for 2015 – $695 per person or 2.5% taxable income for 2016

What happens to the tax penalty after 2016?

it will increase annually based on a cost of living adjustment

How does the ACA affect women and families?

by protecting them from the worst insurance company abuses, making healthcare more affordable, and giving people better access to care (through preventive benefits and coverage for preexisting conditions)

How does the ACA affect young adults?

by expanding affordable options for health insurance and giving hardworking families security (through coverage) and important new benefits (through preventive services)

How does the ACA affect seniors?

will help save them money ensure that people with Medicare can see a doctor that they know and trust

What will the ACA do for seniors?

– provide cheaper prescription drugs – end limits on care – provide free preventive services – better coordinate care – fight fraud – protect medicate benefits

How does the ACA affect employers?

makes it easier for businesses to find better coverage options while also building on the employer-based insurance market that is already in place, giving the consumer and business owner more control while making healthcare coverage more afforable

How does the ACA affect healthcare providers?

by holding health insurance companies accountable, protecting providers and patients, while also guaranteeing choice and control (through the provision of opportunities and incentives to coordinate care and by strengthening the workforce)

How does the ACA hold health insurance companies accountable?

by reducing the burden of uncompensated care on physicians and hospitals by making access to care easier and more affordable

How does the ACA affect people with disabilities?

by ending insurance company abuses and discrimination against preexisting conditions, expanding affordable coverage, and through the creation of new long-term and community-based care options

Why do we need the Affordable Care Act?

to help minimize the high uninsured rate, unsustainable spending, poor health outcomes, lack of preventative emphasis, and health disparities

According to the Congressional Budget Office, how many Americans were uninsured in 2012?

about 55 million under the age of 65 (1 in 5 people)

Why do the uninsured usually face higher treatment costs?

they are less likely to receive preventive care and less likely to seek care when they are sick or injured, resulting in higher overall costs

In 2012, how much of the U.S. gross domestic product (GDP) was represented by healthcare?


How much is the GDP expected to reach by 2020?


What was life expectancy in the U.S. in 2011?

78.7 years

Where does the U.S. rank among Organization for Economic Cooperation and Development (OECD) countries?


What is the OECD average life expectancy?

80.2 years

How many U.S. deaths are related to preventable diseases (ie. obesity, diabetes, high blood pressure, heart disease, cancer)?

7 in 10

How much of the national healthcare funds are spent towards treating preventable diseases?


How much of the national healthcare funds are spent towards prevention of preventable diseases?

$0.03 of every $1.00

African-American women have the highest death rates from which conditions?

heart disease, breast cancer, lung cancer, stroke, and pregnancy

Which five areas of the Affordable Care Act focus on pharmacy involvement?

1. Delivery Systems Reform 2. Payment Reform and Quality 3. Comparative Effectiveness Research 4. Workforce Issues 5. 340B Drug Pricing Program

Why was the Marketplace established?

to provide an easier means of shopping and purchasing individual and small group health coverage

How will Florida residents and employers participate in the marketplace?

through a Federally Facilitated Marketplace (FFM)

Why do Floridians have to participate in this slightly altered version of the marketplace?

because Florida did not create a state-based exchange

What are the two types of federal exchanges?

1. Individual Marketplace 2. Small Business Health Options Program (SHOP)

Why is the Individual Marketplace available?

so that individuals can purchase qualified coverage

Why is the Small Business Health Options Program (SHOP) available?

so that small businesses of 2 to 50 employees can purchase a Qualified Health Plan (QHP)

Will there be any changes to the QHP?

Yes, in 2016 the number of employees required for eligibility will increase to up to 100 employees

How do self-employed individuals participate in the Marketplace?

through the Individual Marketplace

What requirements must be met for health plans to be offered on the Marketplace?

– must receive certification by the HHS – muse meet certain minimum standards

What are the four coverage tiers?

1. Platinum Plans (90% coverage) 2. Gold Plans (80% coverage) 3. Silver Plans (70% coverage) 4. Bronze Plans (60% coverage)

What are the coverage tiers based on?

the percentage of the total allowed cost of benefit paid by a health plan on average

When is the next enrollment period for 2015 coverage?

from November 15, 2014 through February 15, 2015

When is the enrollment period for 2016 coverage?

October 15, 2015 through December 7, 2015

What is the goal of Medicaid Expansion?

to extend Medicaid coverage to most low-income people

Who did the ACA expanding Medicaid eligibility to in 2014?

138% of the federal poverty line (FPL) for citizens and qualified immigrants

Who is funding the Medicaid Expansion?

– funded 100% by the federal government for the first 3 years (2014 – 2016) – funded at least 90% by the federal government afterwards

How much Medicaid was provided for individuals in 2014? For a family of 3?

– $15,415 for individuals – $26,344 for a family of 3 (citizens and qualified immigrants)

How does a coverage gap occur?

as a result of states deciding not to expand Medicaid

How many will fall into the coverage gap?

almost 5 million uninsured adults

What percentage of individuals who fall into the coverage gap live in Florida?


Which states are not expanding Medicaid?

Pennsylvania (6% coverage gap) North Carolina (7% coverage gap) Georgia (9% coverage gap) Florida (16% coverage gap) Texas (22% coverage gap)

How many Floridians selected a marketplace plan?

983,775 individuals

Of the Floridians who selected a plan, how many are: female and male?

55% and 45%, respectively

Of the Floridians who selected a plan, how many are: under 35?


Of the Floridians who selected a plan, how many are: between the ages of 18 and 34?


Of the Floridians who selected a plan, how many have: selected a Silver Plan?


Of the Floridians who selected a plan, how many have: selected a Bronze Plan?


Of the Floridians who selected a plan, how many have: selected a plan with financial assistance?


In 2014, what were insurance companies no longer allowed to do under Healthcare Reform?

– deny adults coverage – charge adults with higher premiums due to preexisting conditions

How many children in Florida who were diagnosed with conditions that resulted in denials in coverage are now protected?


Which aspects of insurance company abuses will also be changed with healthcare reformed?

– insurers will no longer be able to charge higher premiums based on gender or health status – insurers will be required to spend at least a set share of premium dollars on actual medical care

How will the competitive marketplace help uninsured consumers?

by driving down costs, guaranteeing choice, and putting consumers in control through the forced competition between insurance companies

How will people with moderate incomes be able to get health insurance?

through tax credits provided through these new exchanges

How many people were eligible for these new tax credits in 2014?

nearly 2.0 million people

What are the requirements for small businesses to also qualify for tax credits?

– have less than 25 employees – average wages less that $50,000

How many Florida businesses qualified for a tax credit in 2011?


What percentage of the cost of coverage is currently covered by the tax credits for small businesses?

up to 35% previously with an increase to 50% in 2014

How many seniors and people with disabilities who are on Medicare now have access to free preventive services in Florida?

3.4 million

How many Floridians received a rebate check for their prescription drugs in 2010?


By 2019, how much will each Florida household save on healthcare costs on average?


What will happen to the ACA each year?

a new aspect will be implemented

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