whats next in health care reform: training for trainers

What’s Next in Health Care Reform: Training for Trainers.

Goals: 1) To provide an overview of the new law. 2) To prepare you to talk about the new law. 3) To introduce you to state and federal

implementation of the new law.

What it is not: 1) A PhD Program in Health Policy.2) How the law will affect your Aunt Edna.

4) A Health Care Town Hall Forum,

circa August of 2009.

3) Scripture via Powerpoint.

Agenda: 1) Introduction and Overview (10 min)2) Law Overview (40 min)3) Presentation Practice (20 min)4) Presentation Practice Debrief (15 min)5) Q&A on Law (20 min) 6) Next Steps (10 min)7) Evaluation (5 min)

Law Overview: 1) What Happened and Why?

2) What Does The New Law Do?

3) What Does the New Law Mean for You and

Your Fellow Minnesotans?4) What’s Next?

In March 2010, President Obama signed the “Patient Protection and Affordable Care Act” (PPACA) into law.What it is… What it is

NOT…Insurance Industry Reform

“Single-Payer”

Medicaid Expansion “Socialized Medicine”

Medicare Improvements

“Medicare for All”

Delivery System Reform

“Death Panels”

New Requirements to Have Insurance

Tea Act of 1773, The October Revolution, Natl Socialism

Govt Help to Buy Insurance

The Apocalypse

What Happened…?

This slide developed from Health Care for All New York’s Health Reform: What is itand What Does it Mean for New York?

…and Why?

-Today, only 4 cents of every health care dollar is spent on prevention.

-Since 2000, premiums have more than doubled while wages have

virtually stood still.-Since 1987, the cost of the average family health insurance policy has

risen from 7% of median family income to 17%.-At least 46 million Americans were uninsured ‐ more than 85% of

whom are in working families.-Since the recession began, an estimated 4 million additional Americans

have lost their health insurance – and were losing coverage at an

average of 10,680 workers each day.-In 2009, 53% of Americans say their household cut back on

health care due to cost concerns.

-In 2007, 60% of U.S. bankruptcies were due to medical costs.

1) Expands Health Insurance Coverage

What Does the New Law Do?

2) Regulates the Health Insurance Industry 3) Makes Health Insurance More Affordable 4) Reforms the Health Care Delivery System 5) Includes Measures to Increase

Prevention and Decrease Inequality

Increases Bargaining Power with Insurers

What Does the New Law Do? Expanding Health Insurance

Coverage

Individual Market: Ex. Individual Consumers who purchase for themselves.Small Group Market: Ex. Small businesses, non-profits, local government, etc.

Large Group Market: Ex. Large Corporations, State Government Pools, etc.

Self-Insured: Ex. Organizations that pool resources to pay own claims.

How people are insured: pre-reform.


Coverage

How people are insured: post-reform.


Coverage

Expanding Public Coverage


Coverage

MedicaidMedicaid will be expanded to all individuals under age 65 with incomes up to 133% of the federal poverty level ($14,404 for an individual and $29,327 for a family of four in 2009) based on modified adjusted gross income.

Children’s Health Insurance ProgramEligibility for Medicaid and the Children’s Health Insurance Program (CHIP) for children is extended at their current eligibility levels until 2019.

Individual Mandate


CoverageAll individuals will be required to have health insurance, with some exceptions, beginning in 2014. Those who do not have coverage will be required to pay a yearly financial penalty of the greater of $695 per person (up to a maximum of $2,085 per family), or 2.5% of household income, which will be phased-in from 2014-2016. Exceptions will be given for…

…those for whom the lowest cost health plan exceeds 8% of income

…religious objections

…people who have been uninsured for less than three months

…American Indians

…financial hardship

…individuals with income below the tax filing threshold ($9,350 for an individual and $18,700 for a married couple in 2009).

Employer Penalty


CoverageThere is no employer mandate but employers with 50 or more employees will be assessed a fee of $2,000 per full-time employee (in excess of 30 employees) if they do not offer coverage and if they have at least one employee who receives a premium credit through an Exchange.

Auto Enrollment: Large employers that offer coverage will be required to automatically enroll employees into the employer’s lowest cost premium plan if the employee does not sign up for employer coverage or does not opt out of coverage.

Free Choice Voucher: Employers that offer coverage will be required to provide a voucher to employees with incomes below 400% of the poverty level if their share of the premium cost is between 8-9.8% of income to enable them to enroll in a plan in an Exchange. Employers that offer a free choice voucher will not be subject to penalty.

Regulates the Health Insurance Industry


Getting Insurance -Guaranteed Issue-Pre-Existing Conditions-Limiting Waiting Periods-Dependent Coverage-Lifetime & Annual Limits-Prohibiting Rescission

Benefits Package-Comprehensive Benefits-Standard Benefit Categories

Price-Premium Rating-Rate Review-Medical Loss Ratios



Sec. 2702. Guaranteed availability of coverage. Each health insurance issuer must accept every employer and individual in the State that applies for coverage, permitting annual and special open enrollment periods for those with qualifying lifetime events.

Sec. 2703. Guaranteed renewability of coverage. Requires guaranteed renewability of coverage regardless of health status, utilization of health services or any other related factor.






Sec. 2704. Prohibition of preexisting condition exclusions or other discrimination based on health status. No group health plan or insurer offering group or individual coverage may impose any pre-existing condition exclusion or discriminate against those who have been sick in the past.

Sec. 2705. Prohibiting discrimination against individual participants and beneficiaries based on health status. No group health plan or insurer offering group or individual coverage may set eligibility rules based on health status, medical condition, claims experience, receipt of health care, medical history, genetic information, evidence of insurability – including acts of domestic violence or disability.






Sec. 2708. Prohibition on excessive waiting periods. Prohibits any waiting periods for group coverage that exceeds 90 days.






Sec. 2714. Extension of dependent coverage. Requires all plans offering dependent coverage to allow unmarried individuals until age 26 to remain on their parents’ health insurance.






Sec. 2711. No lifetime or annual limits. As amended by Section 10101, prohibits plans from establishing lifetime limits, and annual limits beginning in 2014, on the dollar value of benefits. Prior to 2014, plans may only establish restricted annual limits as defined by the Secretary of Health and Human Services (HHS), ensuring access to needed services with minimal impact on premiums.






Sec. 2712. Prohibition on rescissions. Prohibits all plans from rescinding coverage except in instances of fraud or misrepresentation.






Sec. 2707. Comprehensive health insurance coverage. Requires health insurance issuers in the small group and individual markets to include coverage which incorporates defined essential benefits, provides a specified actuarial value, and requires all health plans to comply with limitations on allowable cost-sharing.

Sec. 2713. Coverage of preventive health services. Requires all plans to cover preventive services and immunizations recommended by the U.S. Preventive Services Task Force and the CDC, certain child preventive services recommended by the Health Resources and Services Administration (HRSA), and women’s preventive care and screening recommended by HRSA, without any cost-sharing.






Getting Insurance -Guaranteed Issue-Pre-Existing Conditions-Limit Waiting Periods-Dependent Coverage-Lifetime Limits-Prohibits Rescission

PricePremium RatingLimit Deductibles Rate ReviewMedical Loss Ratios


Sec. 1302. Essential health benefits requirements. Defines an essential health benefits package as one that covers essential health benefits, limits cost-sharing, and has a specified actuarial value (pays for a specified percentage of costs), as follows:

1. For the individual and small group markets, requires the Secretary to define essential health benefits, which must be equal in scope to the benefits of a typical employer plan.

2. For all plans in all markets, prohibits out-of-pocket limits that are greater than the limits for Health Savings Accounts. For the small group market, prohibits deductibles that are greater than $2,000 for individuals and $4,000 for families. Indexes the limits and deductible amounts by the percentage increase in average per capita premiums.

3. For the individual and small group markets, requires one of the following levels of coverage, under which the plan pays for the specified percentage of costs: Bronze: 60 percent Silver: 70 percent Gold: 80 percent Platinum: 90 percent



Sec. 2701. Fair health insurance premiums. Establishes that premiums in the individual and small group markets may vary only by family structure, geography, the actuarial value of the benefit, age (limited to a ratio of 3 to 1), and tobacco use (limited to a ratio of 1.5 to 1). Section 10103 clarifies that this provision applies to insured plans in the large group market, not self-insured plans.






Sec. 1003. Ensuring that consumers get value for their dollars. For plan years beginning in 2010, the Secretary and States will establish a process for the annual review of increases in premiums for health insurance coverage. Requires States to make recommendations to their Exchanges about whether health insurance issuers should be excluded from participation in the Exchanges based on unjustified premium increases. Provides $250 million in funding to States from 2010 until 2014 to assist States in reviewing and, if appropriate under State law, approving premium increases for health insurance coverage and in providing information and recommendations to the Secretary.









Sec. 2718. Bringing down the cost of health care coverage. As amended by Section 10101, requires plans offering coverage in the group and individual markets (including grandfathered plans but excluding self-insured plans) to report to the Secretary the amount of premium revenues spent on clinical services, activities to improve quality, and all other non-claims costs as defined by the National Association of Insurance Commissioners and certified by the Secretary of HHS. Beginning in 2011, large group plans that spend less than 85 percent of premium revenue and small group and individual market plans that spend less than 80 percent of premium revenue on clinical services and quality must provide a rebate to enrollees. In addition, each hospital operating within the United States shall publish a list of standard charges for items and services provided by the hospital.



Creating a Health Insurance ExchangeThe law creates state-based

American Health Benefit Exchanges and Small Business

Health Options Program (SHOP) Exchanges, administered by a

governmental agency or non-profit organization, through which

individuals and small businesses with up to 100 employees can purchase qualified coverage.

What is a Health Insurance Exchange?

Are there Non-Profit Options?

How Can People Use the Exchange?

Who Can and Can’t Use the Exchange?

What benefits will be offered?



Creating a Health Insurance ExchangeIndividuals who are not

incarcerated, are lawfully residing in a State, and who do

not have access to affordable employer coverage are qualified to enroll in qualified health plans through that State’s Exchange.








Creating a Health Insurance ExchangeThe law requires Exchanges to

certify qualified health plans, operate a toll-free hotline and

Internet website, rate qualified health plans, present plan

options in a standard format, inform individuals of eligibility for Medicaid and CHIP, provide an

electronic calculator to calculate plan costs, and grant

certifications of exemption from the individual responsibility

requirement.








Creating a Health Insurance ExchangeYes, the law requires the Office of

Personnel Management to contract with insurers to offer at least two

multi-state plans in each Exchange. At least one plan

must be offered by a nonprofit entity. The law also creates the Consumer

Operated and Oriented Plan (CO-OP) program to foster the

creation of non-profit, member-run health insurance companies in all

50 states and District of Columbia to offer qualified health plans.








Creating a Health Insurance ExchangeThe law requires the DHHSSecretary to

define essential health benefits, which must include at least the following general

services: ambulatory patient services, emergency services, hospitalization,

maternity and newborn care, mental health benefits and substance use disorder services, 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.

.








Creating a Health Insurance ExchangeWhat is a Health Insurance Exchange?





The scope of these benefits must be equal to the scope of benefits provided under a typical employer plan,. The four levels of coverage, which vary depending on how

much the insurer pays, include:

• Bronze: equivalent to 60% of the full actuarial value of plan benefits

• Silver: equivalent to 70% of full value

• Gold: equivalent to 80% full value

• Platinum: equivalent to 90% of full value

Makes Health Insurance More Affordable


Before

No Federal Caps on Out-of-Pocket Costs for non-HSA plans

AfterIncome as a percent

of the Federal Poverty Level

Annual salary (for a

family of three)

Annual Out-of-Pocket Cap for Those Who

Qualify for

Subsidies

150% $27,465 $3,867

200% $36,620 $3,867

300% $54,930 $5,800

400% $73,240 $7,733

Caps on Out of Pocket Costs



Eligibility

Subsidies for Low Income

Premium Credits

Cost Sharing Subsidies

-The availability of premium credits and cost-sharing subsidies through the Exchanges is limited to U.S. citizens and legal immigrants who meet income limits.

-Employees who are offered coverage by an employer are not eligible for premium credits unless the employer plan does not have an actuarial value of at least 60% or if the employee share of the premium exceeds 9.5% of income.

-Legal immigrants who are barred from enrolling in Medicaid during their first five years in the U.S. will be eligible for premium credits.



Eligibility


Premium Credits


The law provides refundable and advanceable premium credits to eligible individuals and families with incomes between 133-400% FPL to purchase insurance through the Exchanges. The premiumcontributions are limited to the following percentages of income for specified income levels:

Up to 133% FPL: 2% of income133-150% FPL: 3 – 4% of income150-200% FPL: 4 – 6.3% of income200-250% FPL: 6.3 – 8.05% of income250-300% FPL: 8.05 – 9.5% of income300-400% FPL: 9.5% of income



What is Actuarial Value? Subsidies for Low Income

Plan Premium Benefits Cost-sharing

1) Total Tonsils Plan $4/Month Tonsillectomies only 100% on Tonsillectomies

2) Every Inch Plan $50/Month All Doctor Visits 98% You / 2% Insurance

3) Worse Plan $200/Month Limited Doctor Visits $2500 Deductible $35 Co-Pays 80% You / 20% Insurance on Everything

4) Better Plan $300/Month All Doctor Visits $500 Deductible $5 Co-Pays 80% / 20% Some Electives 100% on Everything Else



What is Actuarial Value? Subsidies for Low Income

A measure of the average value of benefits in a health insurance plan.

It is calculated as the percentage of benefit costs a health insurance plan expects to pay for a standard population, using standard assumptions and taking into account cost-sharing provisions.

Placing an average value on health plan benefits allows different health plans to be compared.



Eligibility


Premium Credits


The law provides cost-sharing subsidies to eligible individuals and families. The cost-sharing credits reduce the cost-sharing amounts and annual cost-sharing limits and have the effect of increasing the actuarial value of the basic benefit plan to the following percentages of the full value of the plan for the specified income level:

100-150% FPL: 94%150-200% FPL: 87%200-250% FPL: 73%250-400% FPL: 70%



Medicaid ExpansionSec. 2001. Medicaid coverage for the lowest income populations. Eligibility. Creates a new State option to provide Medicaid coverage through a State plan amendment beginning on April 1, 2010, as amended by Section 10201. Eligible individuals include: all non-elderly, non-pregnant individuals who are not entitled to Medicare (e.g., childless adults and certain parents). Creates a new mandatory Medicaid eligibility category for all such “newly-eligible” individuals with income at or below 133 percent of the Federal Poverty Level (FPL) beginning January 1, 2014.



Medicaid Expansion

To finance the coverage for the newly eligible, states will receive: 100% federal funding for 2014 through 2016, 95% federal financing in 2017 94% federal financing in 2018 93% federal financing in 201990% federal financing for 2020 and years after.

Medicaid is usually paid 50% by the federal government and 50% by the state government.

Medicaid payments to primary care doctors for primary care services will be increased to 100% of Medicare payment rates in 2013 and 2014 with 100% federal financing.

Reforms the Health Care Delivery System


“Turn to page 621 of the Senate version, the section entitled “Transforming the Health Care Delivery System,” and start reading. Does the bill end medicine’s destructive piecemeal payment system? Does it replace paying for quantity with paying for quality? Does it institute nationwide structural changes that curb costs and raise quality? It does not. Instead, what it offers is . . . pilot programs.”

-Dr. Atul Gawande

“Getting our medical communities, town by town, to improve care and control costs isn’t a task that we’ve asked government to take on before.

But we have no choice. At this point, we can’t afford any illusions: the system won’t fix itself, and there’s no piece

of legislation that will have all the answers, either. The task will require dedicated and talented people in government agencies and in communities who recognize that the country’s future depends their sidestepping the ideological battles, encouraging local change, and following the results. But if we’re willing to accept an arduous, messy, and continuous process we can come to grips with a

problem even of this immensity.”

- Dr. Atul Guwande



Sec. 1254. Study of large group market.Sec. 1416. Study of geographic variation in application of FPL.Sec. 1562. GAO study regarding the rate of denial of coverage and enrollment by health insurance issuers and group health plans.Sec. 2403. Money Follows the Person Rebalancing Demonstration.Sec. 2704. Demonstration project to evaluate integrated care around a hospitalization.Sec. 2705. Medicaid global payment system demonstration project.Sec. 2705. Prohibiting discrimination against individual participants and beneficiaries based on health status.Sec. 2706. Pediatric Accountable Care Organization demonstration project.Sec. 2707. Medicaid emergency psychiatric demonstration project.Sec. 3023. National pilot program on payment bundling.Sec. 3024. Independence at home demonstration program.Sec. 3113. Treatment of certain complex diagnostic laboratory tests. Sec. 3123. Extension of the Rural Community Hospital Demonstration Program.Sec. 3126. Improvements to the demonstration project on community health integration models in certain rural counties.Sec. 3127. MedPAC study on adequacy of Medicare payments for health care providers serving in rural areas.Sec. 3138. Treatment of certain cancer hospitals.Sec. 3140. Medicare hospice concurrent care demonstration program.Sec. 3142. HHS study on urban Medicare-dependent hospitals.Sec. 3208. Making senior housing facility demonstration permanent.Sec. 3313. Office of the Inspector General studies and reports.Sec. 3504. Design and implementation of regionalized systems for emergency care. Sec. 3508. Demonstration program to integrate quality improvement and patient safety training into clinical education of health professionals.Sec. 3510. Patient navigator program.



Examples of Demonstrations, Pilots, and Studies

Sec. 3512. GAO study and report on causes of action.Sec. 4102. Oral healthcare prevention activities.Sec. 4202. Healthy aging, living well; evaluation of community-based prevention and wellness programs for Medicare beneficiaries.Sec. 4204. Immunizations.Sec. 4206. Demonstration project concerning individualized wellness plan.Sec. 4306. Funding for childhood obesity demonstration project.Sec. 5304. Alternative dental health care provider demonstration project.Sec. 5317. Demonstration grants for family nurse practitioner training programs.Sec. 5507. Demonstration project to address health professions workforce needs; extension of family-to-family health information centers.Sec. 5509. Graduate nurse education demonstration program.Sec. 6112. National independent monitor demonstration project.Sec. 6114. National demonstration projects on culture change and use of information technology in nursing homes.Sec. 6107. GAO study and report on Five-Star Quality Rating System.Sec. 7103. GAO study to make recommendations on improving the 340B program.Sec. 9011. Study and report of effect on veterans health care.Sec. 10336. GAO study and report on Medicare beneficiary access to high- quality dialysis services.Sec. 10326. Pilot testing pay-for-performance programs for certain Medicare providers.Sec. 10504. Demonstration project to provide access to affordable care.Sec. 10607. State demonstration programs to evaluate alternatives to current medical tort litigation.

Rural Community Hospital

Oral healthcare

tort litigation

Medicare

family nurse practitioner training



Sec. 3011. National strategy. Requires the Secretary to establish and update annually a national strategy to improve the delivery of health care services, patient health outcomes, and population health.

Sec. 3015. Data Collection; Public Reporting. Requires the Secretary to collect and aggregate consistent data on quality and resource use measures from information systems used to support health care delivery to implement the public reporting of performance information.

Sec. 6301. Patient-Centered Outcomes Research. Establishes a private, nonprofit entity (the Patient-Centered Outcomes Research Institute) governed by a public-private sector board appointed by the Comptroller General to identify priorities for and provide for the conduct of comparative outcomes research.

Includes Measures to Increase Prevention and Decrease

Inequity


Measures to Decrease Racial Health Disparities

1) Workforce Development

2) Data Collection and Reporting

3) Community Health Center Funding

4) Indian Health Care Improvement

5) Quality Improvements

6) Community Health Needs Assessment

Workforce RecruitmentSection 5401 Centers of ExcellenceSection 5402 Health Professions Training for Diversity Section 5404 Workforce Diversity Grants Section 5606 State Grants to Health Care Providers Who Provide Services to a High Percentage of Medically Underserved Population or Other Special Population Section 10501 Rural Physician Training GrantsSection 5403 Interdisciplinary, community-based linkages


Inequity


1) Workforce DevelopmentWorkforce Development & TrainingSection 5102 State Healthcare Workforce Development Grants Section 5301 Primary Care Training and Enhancement Section 5303 Training in General, Pediatric, and Public Health Dentistry Section 5307 Cultural Competency, Prevention, and Public Health and Individuals with Disability Training Section 5313 Grants to Promote the Community Health Workforce Section 5507 Demonstration Projects to Address Health Professions Workforce Needs Section 5405 Primary Care Extension Program

Loan RepaymentsSection 5203 Healthcare Workforce Loan Repayment Programs Section 5207 Funding for National Health Services Corps


Inequity


2) Data Collection and ReportingSection 6301 Patient-Centered Outcomes Research Institute Section 4302 Understanding Health Disparities: Data Collection and Analysis

3) Community Health Center FundingSection 2303 Community Health Centers.

4) Indian Health Care Improvement ActSection 10221 Indian Healthcare Improvement

5) Quality ImprovementsSection 1311 Rewarding Quality Through Market Based Incentives Section 3501 Quality Improvement Technical Assistance and Implementation Section 2951Maternal, Infant and Early Childhood Home Visiting Programs Section 3502 Establishing Community Health Teams to Support the Patient-Centered Medical Home Section 1331 To provide for transparency in coverage.

6) Community Health Needs AssessmentSection 4959 Additional Requirements for Non-Profit Tax-Exempt Hospitals


Inequity


Sec. 4001. National Prevention, Health Promotion and Public Health Council. Creates an interagency council dedicated to promoting healthy policies at the Federal level. The Council shall consist of representatives of Federal agencies that interact with Federal health and safety policy, including the departments of HHS, Agriculture, Education, Labor, Transportation, and others.

Sec. 4002. Prevention and Public Health Fund. Establishes a Prevention and Public Health Investment Fund. This will involve a dedicated, stable funding stream for prevention, wellness and public health activities authorized by the Public Health Service Act.

Sec. 4004. Education and outreach campaign regarding preventive benefits. Directs the Secretary to convene a national public/private partnership for the purposes of conducting a national prevention and health promotion outreach and education campaign.

Increasing Access to Clinical Preventive Services Sec. 4101. School-based health centers. Sec. 4102. Oral healthcare prevention activities. Sec. 4103. Medicare coverage of annual wellness visit providing

a personalized prevention plan. Sec. 4104. Removal of barriers to preventive services in Medicare. Sec. 4105. Evidence-based coverage of preventive services in

Medicare. Sec. 4106. Improving access to preventive services for eligible

adults in Medicaid. Sec. 4107. Coverage of comprehensive tobacco cessation services for pregnant women in Medicaid. Sec. 4108. Incentives for prevention of chronic diseases in Medicaid.


Inequity


Increasing Prevention

Creating Healthier Communities Sec. 4201. Community transformation grants. Sec. 4202. Healthy aging, living well; evaluation of community- based prevention and wellness programs for Medicare beneficiaries. Sec. 4203. Removing barriers and improving access to wellness for individuals with disabilities. Sec. 4204. Immunizations. Sec. 4205. Nutrition labeling of standard menu items at chain restaurants. Sec. 4206. Demonstration project concerning individualized wellness plan. Sec. 4207. Reasonable break time for nursing mothers.


Inequity



Support for Prevention and Public Health Innovation Sec. 4301. Research on optimizing the delivery of public health

services. Sec. 4302. Understanding health disparities; data collection and

analysis. Sec. 4303. CDC and employer-based wellness programs. Sec. 4304. Epidemiology-Laboratory Capacity Grants. Sec. 4305. Advancing research and treatment for pain care management. Sec. 4306. Funding for childhood obesity demonstration project.


Inequity



What Does the New Law Mean for You and Your Fellow Minnesotans?

What is your current health care situation?

Are you insured through work?

Through Medicare? Medicaid?

Are you uninsured?


2010No canceling policies when you get sick or setting lifetime limits.

Children up to age 26 can stay on your plan.

Insurance companies will have to cover children with pre-existing conditions.

No lifetime limits on coverage.

New plans must provide free preventative services & allow you to appeal denials of coverage.

2010No canceling policies when you get sick or setting lifetime limits.

Children up to age 26 can stay on your plan.

Insurance companies will have to cover children with pre-existing conditions.

No lifetime limits on coverage.

New plans must provide free preventative services & allow you to appeal denials of coverage.

2011 – 2013Insurance companies required to spend 80-85% of premium dollars on medical services or else provide rebates to their policyholders.

States can require insurance companies to submit justification for premium increases.

2011 – 2013Insurance companies required to spend 80-85% of premium dollars on medical services or else provide rebates to their policyholders.

States can require insurance companies to submit justification for premium increases.

2014Insurers will have to cover adults with pre-existing conditions.

No annual limits on coverage.

Qualified individuals can begin buying subsidized coverage in the Exchange.

Begin employer requirement and standards.

2014Insurers will have to cover adults with pre-existing conditions.

No annual limits on coverage.

Qualified individuals can begin buying subsidized coverage in the Exchange.

Begin employer requirement and standards.

2018Insurers will have to pay a 40% excise tax on high cost insurance plans. The tax is on the cost of coverage in excess of $27,500 (family coverage) and $10,200 (individual coverage).

2018Insurers will have to pay a 40% excise tax on high cost insurance plans. The tax is on the cost of coverage in excess of $27,500 (family coverage) and $10,200 (individual coverage).

If you are insured through an employer

This slide developed from PICO National Network’s Bringing Health Reform Home


2010Seniors on traditional Medicare will have no losses in coverage and will add important benefits.

Seniors that reach the “donut hole” will receive a $250 rebate for prescription drugs.

2010Seniors on traditional Medicare will have no losses in coverage and will add important benefits.

Seniors that reach the “donut hole” will receive a $250 rebate for prescription drugs.

2011Seniors in the “donut hole” will receive a 50% discount on brand name drugs. The “donut hole” will be closed slowly through 2020.

Annual checkups and most preventative care and screenings are at no cost.

2011Seniors in the “donut hole” will receive a 50% discount on brand name drugs. The “donut hole” will be closed slowly through 2020.

Annual checkups and most preventative care and screenings are at no cost.

2020The donut hole will fully close.

2020The donut hole will fully close.

2013Government begins to cut subsidies to Medicare Advantage, which costs the government more than traditional Medicare. Seniors on these plans may face reduced benefits or higher costs. Seniors have the option of transitioning to traditional Medicare during the first 45 days of the year.

2013Government begins to cut subsidies to Medicare Advantage, which costs the government more than traditional Medicare. Seniors on these plans may face reduced benefits or higher costs. Seniors have the option of transitioning to traditional Medicare during the first 45 days of the year.

If you are insured through Medicare



2010Temporary high-risk pool for people with pre-existing conditions uninsured for at least 6 months

For early retirees, age 55-64, a temporary re-insurance program is created until the Exchange is running.

A large expansion in funds to Community Health Centers. This is expected to double the number of patients that clinics serve. This will help millions of undocumented immigrants.

If you are under age 26, you can join your parent’s plan.

2010Temporary high-risk pool for people with pre-existing conditions uninsured for at least 6 months

For early retirees, age 55-64, a temporary re-insurance program is created until the Exchange is running.

A large expansion in funds to Community Health Centers. This is expected to double the number of patients that clinics serve. This will help millions of undocumented immigrants.

If you are under age 26, you can join your parent’s plan.

2014Individuals and families will be able to purchase health insurance in state-based Exchanges. Those earning up to 400% FPL ($88,200 for a family of 4) will have access to subsidies on a sliding scale.

Cap on out-of-pocket costs of $5,950 for individuals and $11,900 for families, with lower caps for lower-income families.Individuals and families under 133% FPL will be eligible for Medicaid.

Most Americans will be required to buy health insurance or pay a penalty. Undocumented immigrants will not be able to purchase insurance in the Exchange.

Those who are exempt, or under 30, can buy a catastrophic policy (must also allow for 3 primary care visits a year).

Members of Congress will get their health insurance through the Exchange.

2014Individuals and families will be able to purchase health insurance in state-based Exchanges. Those earning up to 400% FPL ($88,200 for a family of 4) will have access to subsidies on a sliding scale.

Cap on out-of-pocket costs of $5,950 for individuals and $11,900 for families, with lower caps for lower-income families.Individuals and families under 133% FPL will be eligible for Medicaid.

Most Americans will be required to buy health insurance or pay a penalty. Undocumented immigrants will not be able to purchase insurance in the Exchange.

Those who are exempt, or under 30, can buy a catastrophic policy (must also allow for 3 primary care visits a year).

Members of Congress will get their health insurance through the Exchange.

If you are uninsured



2010All children currently receiving Medicaid and CHIP can continue to receive coverage. States cannot cut children from Medicaid or CHIP until 2019, at which point some children may transition into the Exchange.

All adults under 133% of the Federal Poverty Level can continue to receive coverage. States cannot cut adults that make under 133% FPL from Medicaid.

Many preventive services will be offered without cost.

2010All children currently receiving Medicaid and CHIP can continue to receive coverage. States cannot cut children from Medicaid or CHIP until 2019, at which point some children may transition into the Exchange.

All adults under 133% of the Federal Poverty Level can continue to receive coverage. States cannot cut adults that make under 133% FPL from Medicaid.

Many preventive services will be offered without cost.

2014Medicaid’s physician reimbursement levels for specific primary care services will be increased, leading more doctors to accept Medicaid.

Anyone with an income below 133% FPL, about $29,327 in 2009 for a family of four, will be eligible for Medicaid.

When the Exchange is operating, states can decide to keep adults on Medicaid that are over 133% FPL or transition them into the Exchange.

2014Medicaid’s physician reimbursement levels for specific primary care services will be increased, leading more doctors to accept Medicaid.

Anyone with an income below 133% FPL, about $29,327 in 2009 for a family of four, will be eligible for Medicaid.

When the Exchange is operating, states can decide to keep adults on Medicaid that are over 133% FPL or transition them into the Exchange.

If you are insured by Medicaid



Starting 2010: Cost saving changes in MedicareGreater oversight and enforcement to reduce fraud, waste and abuse; greater efficiency and collaboration among doctors and reduced over-payments to the Medicare Advantage companies.

Starting 2010: Cost saving changes in MedicareGreater oversight and enforcement to reduce fraud, waste and abuse; greater efficiency and collaboration among doctors and reduced over-payments to the Medicare Advantage companies.

Starting in 2011-2013: Increasing penalties on contribution loopholes in Health Saving AccountsIncreased penalties on nonqualified distributions from Health Saving Accounts, a lower cap on Flexible Spending Accounts contributions, and a standardization of the definition of qualified medical expenses.

Starting in 2011-2013: Increasing penalties on contribution loopholes in Health Saving AccountsIncreased penalties on nonqualified distributions from Health Saving Accounts, a lower cap on Flexible Spending Accounts contributions, and a standardization of the definition of qualified medical expenses.

Starting in 2018: insurers will have to pay a 40% excise tax on high cost group plansThe tax is on the cost of coverage in excess of $27,500 (family coverage) and $10,200 (individual coverage). There are higher thresholds for retirees and employees in high risk professions.

Starting in 2018: insurers will have to pay a 40% excise tax on high cost group plansThe tax is on the cost of coverage in excess of $27,500 (family coverage) and $10,200 (individual coverage). There are higher thresholds for retirees and employees in high risk professions.

Starting in 2013: High-income earners will contribute more to the Medicare fundIndividuals earning over $200,000 and families earning over $250,000 will contribute 2.35% for income above the threshold instead of the current 1.45%. They will also pay a 3.8% tax on net investment income (excluding retirement plans).

Starting in 2013: High-income earners will contribute more to the Medicare fundIndividuals earning over $200,000 and families earning over $250,000 will contribute 2.35% for income above the threshold instead of the current 1.45%. They will also pay a 3.8% tax on net investment income (excluding retirement plans).

How is it paid for?


1) Building Public Support and Implementing Early Reforms

What’s Next?

2) Defending Existing Programs and Current Levels of Coverage3) Developing Policy and Regulations at the National and State

Levels 4) Enrolling People in New Programs and Monitoring Impact of

Reform 5) Ensuring the Sustainability of Reform through Health Care

Delivery System Reforms

1) Early Expansion of Medicaid

What’s Next?

2) Preparing our Health Insurance Exchange 3) Insurance Regulation

4) Appropriations for Health Equity Provisions 5) The 2011 Legislative Session

Signable by Governor till January 15, 2011

Health Care Access Commission vs. Governor’s, Benefit Set

Natl Assoc of Insurance Commissioners, Early Adoption of Insurance Regulations

Indian Health Services, Community Transformation Grants

$5.8 Billion Dollar Deficit

What’s Next?

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Thanks and ResourcesCommunity Catalyst: www.communitycatalyst.orgHealth Care for America Now!: www.healthcareforamericanow.orgHealth Rights Organizing Project: www.healthrightsproject.orgPICO National Network: www.piconetwork.orgKaiser Family Foundation: www.kff.orgFamilies USA: www.familiesusa.orgRobert Wood Johnson Foundation: www.rwjf.orgUrban Institute: www.urban.orgHealth Reform GPS: www.healthreformgps.org

United States Government: www.healthcare.govDemocratic Policy Committee: www.dpc.senate.govNational Association of Insurance Commissioners: www.naic.org

National Academy for State Health Policy: www.nashp.orgGeorgetown Center for Children and Families: www.ccf.georgetown.edu

whats next in health care reform: training for trainers

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