1. Navigating the Affordable Care Act Kim L. Isaacs, MD, PhD University of North Carolina at Chapel Hill December 4, 2014

2. 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

3. 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 AccessCost

4. Complicated piece of legislation that attempts to address these issues. What is the affordable care act?

5. 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

6. How are patients insured? Based on March 2012 Census and 2013 Current population Survey (CPS) 47.7 million uninsured

7. 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.

8. 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.

9. 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

10. 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.

11. Some patients may be covered by expansion of Medicaid Limited to certain low income populations Extends to adults < 138% FPL

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

13. 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

14. Market places: states, federal, combination https://news.leavitt.com/health-care-reform/marketplaces-exchanges-information-employers-individuals/#!prettyPhoto/0/

15. Who can use the health care market places? www.healthcare.gov

16. ACA and 2 patients with IBD CS – Crohn’s since age 10 now 50SB – UC since age 14 now 24 Unable to get affordable insurance due to pre- existing condition Had to go part time due to health issues 10 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 job Got ACA marketplace coverage and then had a UC flair I thought the silver plan would work but I can’t afford my medicines..

17. The Plans: Level of Coverage SilverGoldBronzePlatinum Lowest Premiums Highest Out-of-Pocket Costs Highest Premiums Lowest Out-of-Pocket Costs 60 % 70% 80% 90% Covered Percent of Total Cost of Care

18. BenefitBronzeSilverGoldPlatinum Deductible $5000 Med/Rx$2000 Med$ 0 Preventive $0 Doctor Visit $65 for 1 st 3$45$30$20 Specialist $70 after d$65$50$40 Generic Rx $15 after d$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 d20% after d $600 per day HMO***/20% PPO $250 per day HMO***/10% OP Surgery 30% after d20% after d $600 HMO/20% PPO$250 HMO/10% PPO Hospital Stay 30% after d20% 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 $4,000/$8,000 http://www.medicoverage.com/health-insurance-blog/news/comparing-exchange-plans-bronze-silver-gold-platinum

19. Most consumers in the market place will be eligible for subsidies to help afford their care http://www.kff.org/interactive/subsidy- calculator/http://www.kff.org/interactive/subsidy- calculator/ Example: Silver Plan for a 21 year old, non-smoker from North Carolina – No state expansion for Medicaid % FPL% IncomeSalaryCost of Plan/yr Tax CreditAmount 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

20. 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

21. Specialty Drug Coverage  important for the patient with IBD http://www.lls.org/#/diseaseinformation/getinformationsupport/aca/details/

22. ACA Essential Health Benefits Ambulatory Patient ServicesEmergency Services HospitalizationMaternity 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

23. 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

24. 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

25. Are dental services covered by the ACA? Not for adults however some market place plans do include dental insurance for a fee.

26. Are ostomy supplies covered by the ACA? Yes – as well as multiple other durable goods.

27. Resources www.healthcare.gov Kaiser Family Foundation ▫http://kff.org/aca-consumer-resources/http://kff.org/aca-consumer-resources/ http://minorityhealth.hhs.gov/NPA/Materials/ AffordableCareActResourceKit.pdfhttp://minorityhealth.hhs.gov/NPA/Materials/ AffordableCareActResourceKit.pdf Leukemia and Lymphoma Society ▫http://www.lls.org/diseaseinformation/getinform ationsupport/aca/