Affordable Care Act and Ryan White Program

The effects on insurance coverage for people living with HIV in the Philadelphia EMA

Medicaid Eligibility 133% FPL

Insurance Market

Reforms & Individual Mandate

Premium Subsidies 133% -

400% FPL

Employer Sponsored Insurance

Universal Coverage

Summary of Patient Protection and Affordable Care Act Most individuals will be required to have health

insurance starting in 2014

Employers will be required to pay penalties for employees who receive tax credits for health insurance

Individuals who do not have access to employer-offered insurance will be able to purchase insurance through state exchanges Premium and cost-saving credits/subsidies will be

available for some people

Summary of Patient Protection and Affordable Care Act All (non-grandfathered) plans will be:

required to provide a minimum benefits package

prevented from denying coverage for any reasons

prevented from charging higher premiums based on health status and gender

prevented from imposing annual or lifetime spending caps

Required to include prevention services with no cost-sharing

Individual Mandate U.S. citizens and legal residents required to have health

coverage

Those without coverage pay tax penalty of $695/person, up to $2085 a year

Those exempt from mandate: Demonstrated financial hardship Religious objections Undocumented immigrants Incarcerated individuals Those for whom the lowest cost plan option exceeds 8% of the

individual’s income Those who do not file federal income tax returns

America Health Benefit Exchanges Access to exchanges limited to US citizens and legal immigrants

Exchange plans will be required to offer a minimum benefits package at four different levels

Platinum – covers 90% of benefits cost Gold – covers 80% of benefits costs

Silver – covers 70% of the benefits costs Bronze – covers 60% of the benefits costs

Catastrophic – Available to those under 30 years old and to those who are exempt from

the mandate. Provides catastrophic coverage only with the coverage level set at the

HSA current level laws except for prevention benefits and coverage for 3 primary care visits would be exempt from deductible.

Only available on individual market.

Essential Health Benefits Plans on Exchanges and newly eligible Medicaid must include

these services:

Ambulatory patient services Emergency services Hospitalization 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, and Pediatric services, including oral and vision care

Essential Health Benefits States will have the flexibility to select a benchmark plan

that reflects the scope of services offered by a “typical employer plan

If states choose not to select a benchmark, HHS intends to propose that the default benchmark will be the small group plan with the largest enrollment in the state. 

Plans could modify coverage within a benefit category so long as they do not reduce the value of coverage.

States will choose one of the following benchmark health insurance plans: One of the three largest small group plans in the state by enrollment; One of the three largest state employee health plans by enrollment;  One of the three largest federal employee health plan options by

enrollment; The largest HMO plan offered in the state’s commercial market by

enrollment.  

Cost-sharing SubsidiesIn order to help individuals and families purchase plan

on the exchanges:

Cost-sharing subsidies will also be available for those with incomes between 100%-250% FPL to limit out-of-pocket spending

Premium subsidies will be provided to families with incomes of up to 400% FPL ($29,327 to $88,200 for family of four) Subsidies on a sliding scale Subsidies will limit the cost of premiums to between 2%

and 9.5% of income

Premiums as Share of Income Household Income as a

Percent of FPLPremium Range as a Percent

of IncomeUp to 133% 2%133 - 150% 3-4%150 – 200% 4 – 6.3%200 – 250% 6.3 – 8.05%250 – 300% 8.05 – 9.5%300 – 400% 9.5%

Premium tax credits are advanceable – recipients immediately receive the credit (directly to insurer)

Recipients will have to reconcile the tax credit received with actual income and repay any excess credit

Cost-sharing Subsidies Reduced cost-sharing for people up to 250% of

FPL

Subsidies increase actuarial value of coverage Actuarial value is the average percentage of anticipated

costs that an insurer will pay towards care for people insured in a given plan

In other words, it is the percent of costs paid for by the insurer, the individual is responsible for the remaining percent

Household Income as Percent of FPL

Actuarial Value of Coverage

100 – 150% 94%150 – 200% 87%200 – 250% 73%250 – 400% 70%

Employer-Offered Health Plans Employers with more than 50 employees who

do not offer coverage and have at least one full-time employee receiving a premium subsidy will be fined $2000 per full-time employee

Employees who are offered coverage by employer are not eligible for premium tax credits unless the premium exceeds 9.5% of income

Expanded Medicaid Eligibility Many low income individuals will be covered

under Medicaid All adults with income at or below 133% FPL

will be eligible for Medicaid regardless of health/disability 133% FPL = $14,404 for individual and $29,327 for

family of 4 in 2009

For most Medicaid enrollees, income will be based on modified adjusted gross income without an assets test or resource test.

Newly-eligibles may have different package of services based on essential services under exchanges

ACA Medicaid Changes

Minimum Floor for Coverage 133% FPLAdditional Federal Financing for Newly

Eligible CoverageLong Term Care/ Coordination for DualsSupport for Health Care System

Private Health Insurance Health premiums will be allowed to vary based on age (by a 3

to 1 ratio), geographic location, tobacco use and the number of family members

No lifetime/annual limits on coverage

Increases in premiums will be subject to review by the state

No cost sharing for preventative services

Existing plans will be allowed to remain the same except: Required to extend coverage to dependents up to age 26 Prohibited from rescissions of coverage Eliminate waiting periods for coverage to over 90 days

Premium and Cost Sharing Limits for Individuals up to 400% FPL (non- Employer Coverage)

Income % FPL Coverage Premiums and Cost Sharing

< 138% Medicaid •No Premiums

•Cost sharing limited to nominal amounts for most services

139 – 250% Exchange •Sliding scale tax credits limit premium costs to 3-8.05%

•Sliding scale cost-sharing credits

251 – 400% Exchange •Sliding scale tax credits limit premium costs to 8.05 – 9.5%

•No cost-sharing credits

Exhibit 15. Distribution of Uninsured Nonelderly Individuals in 2010, by Income Level and Provisions of the Affordable Care Act

Note: FPL refers to federal poverty level.Source: Analysis of the March 2011 Current Population Survey by N. Tilipman and B. Sampat of Columbia University for The Commonwealth Fund.

Medicaid<133% FPL21.3 million

43%

133%–249% FPL11.7 million

24%

250%–399% FPL 6.3 million

13%

>400% FPL5 million

10%

49.1 million uninsured individuals, ages 0–64

Subsidized private coverage with

consumer protections

Nonsubsidized private coverage with consumer protections or parents’

policiesUndocumented

4.9 million10%

Exhibit 18. Source of Insurance Coverage Pre-Reform and Under the Affordable Care Act, 2020

Notes: Employees whose employers provide coverage through the exchange are shown as covered by their employers. ESI refers to employer-sponsored insurance. “Other” includes Medicare.Source: Testimony Statement of Douglas W. Elmendorf, Director, before the Subcommittee on Health Committee on Energy and Commerce U.S. House of Representatives, CBO’s Analysis of the Major Health Care Legislation Enacted in March 2010, March 30, 2011, http://www.cbo.gov/ftpdocs/121xx/doc12119/03-30-HealthCareLegislation.pdf .

Among 284 million people under age 65

Under Prior Law

163M (57%)ESI

36M (13%)Medicaid

56M (20%)Uninsured

15M (5%)Other

14M (5%)Nongroup

162M (57%)ESI

52M (18%)Medicaid

24M (8%)Exchanges

(Private Plans)

15M (5%)Other

8M (3%)Nongroup

23M (8%)Uninsured

Affordable Care Act

523 6901,450

2,315

3,279

4,5003,977 3,810

3,0502,185

1,221

$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

138% FPL 150% FPL 200% FPL 250% FPL 300% FPL 500% FPL

Required premium payment by policy holderPremium tax credit

Exhibit 17. Annual Premium and Tax Credits for a Single AdultUnder the Affordable Care Act, 2014

Full premium =

$4,500

* For a single adult, age 40, in a medium-cost area in 2014. Premium estimates are based on an actuarial value of 0.70. Actuarial value is the average percent of medical costs covered by a health plan. FPL refers to federal poverty level.Source: Premium estimates are from Kaiser Family Foundation Health Reform Subsidy Calculator, http://healthreform.kff.org/Subsidycalculator.aspx.

Contribution capped at 3.3% of income

Contribution capped at 4.0% of income

Contribution capped at 6.3% of income

Contribution capped at 8.05% of income

Contribution capped at 9.5% of income

Annual premium amount paid by policy holder and premium tax credit*

$15,877 $17,258 $23,011 $28,763 $34,516 $57,527

Four levels of cost-sharing: 1st tier (Bronze) actuarial value: 60% 2nd tier (Silver) actuarial value: 70% 3rd tier (Gold) actuarial value: 80%

4th tier (Platinum) actuarial value: 90%

Exhibit 14. Premium Tax Credits and Cost-Sharing ProtectionsUnder the Affordable Care Act

Federal poverty level Income Premium contribution

as a share of incomeOut-of-pocket

limitsActuarial value:

Silver plan

<133% S: <$14,484F: <$29,726 2% (or Medicaid)

S: $1,983F: $3,967

94%

133%–149% S: $16,335F: $33,525 3.0%–4.0% 94%

150%–199% S: $21,780F: $44,700 4.0%–6.3% 87%

200%–249% S: $27,225F: $55,875 6.3%–8.05%

S: $2,975F: $5,950

73%

250%–299% S: $32,670F: $67,050 8.05%–9.5% 70%

300%–399% S: $43,560F: $89,400 9.5% S: $3,967

F: $7,933 70%

>400% S: >$43,560F: >$89,400 — S: $5,950

F: $11,900 —

Notes: In the income and out-of-pocket limits columns, S refers to single and F refers to family. Actuarial values are the average percent of medical costs covered by a health plan. Premium and cost-sharing credits are for silver plan.Source: Federal poverty levels are for 2011; Commonwealth Fund Health Reform Resource Center: What’s in the Affordable Care Act? http://www.commonwealthfund.org/Health-Reform/Health-Reform-Resource.aspx.

Catastrophic policy with essential benefits package available to young adults and

people who cannot find plan with premium <=8% of income

Exhibit 2. Premium Tax Credit Amount for a Family of Four

Note: FPL refers to Federal Poverty Level. Source: Federal Register, Vol. 76, No. 159, Aug. 17, 2011, pp. 50931–50949, Commonwealth Fund analysis.

Annual family income: $30,000

Annual family income: $50,000

Annual family income: $50,000

older parents

Income as a percentage of FPL 133% 224% 224%

Expected family contributionAs a percent of income:Dollar amount:

3.0%$900

7.1%$3,570

7.1%$3,570

Premium for benchmark plan $9,000 $9,000 $14,000

Premium tax credit $8,100($9,000 – $900)

$5,430($9,000 – $3,570)

$10,430($14,000 – $3,570)

Premium for plan family chooses $9,000 $9,000 $14,000

Actual family contribution $900 $3,570 $3,570

No Wrong Door Individuals should be screened for eligibility for Medicaid,

Medicare, Exchange, subsidies, etc. at any point of enrollment

One form/method of enrollment for Exchanges, Medicaid, etc. will be developed by HHS Secretary

Application form will be available for submission by web, fax, mail, telephone or in-person

States will rely on trusted third party sources for data matches, if accurate, no additional documentation can be required from individual

Easy to understand and navigate websites/information

Total Population Insurance Type for NJ, PA and US, 2009

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

49.0

5.0

16.012.0

1.0

17.0

55.0

5.0

14.0 15.0

0.0

11.0

59.0

3.0

10.0 12.0

0.0

15.0

USPANJ

EMA General Population Income

0.00%10.00%20.00%30.00%40.00%50.00%60.00%70.00%80.00%90.00%

100.00%

27.02%42.71%

32.00%42.33%

30.47%27.42%40.41%

28.09%

65.06%

41.88%38.52%

Total Population under 150% FPL Total Population between 150% and 300% FPLTotal Population Below 300% FPL

RW Clients Income Level, 2009

9595;

78%

1548;

13%

675; 6%

437; 4%

<100% FPL100-199%200-299%>300%

78% of RW Clients earn less than $10,890/year

RW Client Insurance Status By Type, 2009

Private17%

Medicare13%

Med-icaid51%

Other Public1% None

17%

Unknown1% Many uninsured

will be eligible for Medicaid and sub-

sidies.

NO CHANGE in

COVERAGE for about

64% of RW Clients

Office of HIV Planning Coverage Estimates

NOW 2014 estimates

Medicaid 51% >78%Private insurance

17% 12%

Uninsured 17% 4-7%Medicare 13% 13%

• Estimate for Private Insurance and Uninsured are probably too large, because they are based on General Population estimates.

• 78% Medicaid coverage is based on eligibility by income (133% FPL) alone.

Resources HIV Health Reform

http://www.hivhealthreform.org/ Kaiser Family Foundation Health Reform

Gateway: http://www.healthreform.kff.org/

Commonwealth Fund http://

www.commonwealthfund.org/Health-Reform.aspx