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ACP has developed an Affordable Care Act (ACA) Outreach and Enrollment campaign that will provide members with information on the law's key coverage provisions and where patients can go for help. Posters, contact information and other materials are also available to promote health coverage to your patients.
The U.S. Department of Health and Human Services www.healthcare.gov website serves as the access point to federally-run marketplaces and also provides links to resources on state-operated marketplaces. (The ACA left it up to the states to decide if they wanted to operate their own marketplace, partner with the federal government to operate it, or let the federal government operate it for them).
Marketplace.cms.gov offers posters, fact sheets, and videos on health reform.
Unfortunately, President Trump and his allies in Congress oppose the ACA and support its repeal. ACP has strongly opposed efforts to repeal the ACA because the replacement proposals would, among other things, result in millions of people losing health insurance and undermine our nation’s efforts to achieve universal coverage (More on ACP’s advocacy efforts can be found here. The Trump Administration has also taken action to undermine the law. In January 2017, President Trump signed an executive order directing the Internal Revenue Service to cease enforcing the individual mandate, which penalizes certain people who do not have minimum creditable coverage. If the mandate is not enforced, fewer healthy people will purchase health insurance and premiums will increase to account for the higher-risk, sicker pool of enrollees. Additionally, the Administration has not committed to funding cost-sharing reductions (CSR) for 2018 and beyond. Without a guarantee that the CSR payments will be continued, many insurers have no choice but to leave the exchanges or to raise premiums by 20 percent or more to make up the shortfall. Finally, funding for outreach, marketplace promotion, and enrollment assistance activities has been slashed for the 2018 plan year. This is concerning because many consumers are unaware of the availability of financial assistance that can lower the cost of their insurance. More intensive outreach and enrollment efforts are especially vital as the open enrollment period for plan year 2018 has been shortened. In 2017, marketplace enrollment declined after HHS prematurely ended its open enrollment publicity and outreach campaign.
ACP believes that the Administration should work with Congress to take immediate action to stabilize the nongroup insurance market by committing to funding the cost-sharing reduction payments through 2018 and beyond, enforcing the individual mandate, providing funding and attention to outreach and marketing efforts, encouraging states to initiate state market stabilization efforts, and working with state governors to attract insurers.
Millions of uninsured people have gained coverage since passage of the ACA. According to the 2016 U.S. Census the uninsured rate is at the lowest point ever recorded. A 2017 study by Urban Institute analysts found that the uninsurance rate for nonelderly adults dropped by nearly 41% since the end of 2013. Although most enrollees are satisfied with their plan’s monthly premium, a growing number are less satisfied with their plan’s deductible.
That being said, the fifth year of open enrollment poses substantial challenges and an effective enrollment campaign is needed more than ever. The U.S. Department of Health and Human Services (HHS) has drastically reduced funding for outreach and education efforts to promote enrollment, which is especially important because the remaining uninsured may be harder to reach. Further, the open enrollment period for most states has been shortened to 45 days—November 1 to December 15, 2017—giving people less time to shop and enroll in the coverage that is right for them. The Trump Administration and Congress have also not committed to making long-term cost-sharing reduction payments to marketplace-based health insurers, causing instability in the market and fewer health insurance choices.
In 2016, HHS estimated that over 10 million people were eligible but not enrolled in a marketplace-based plan. The population that remains uninsured may be less able to afford coverage or may not know of the availability of subsidies. The uninsured are particularly concerned about the affordability of insurance. Nearly 80% have less than $1,000 in savings and half have less than $100, potentially undermining their ability to afford cost sharing requirements. A substantial portion of the uninsured marketplace-eligible group would qualify for cost-sharing assistance and premium tax credits to reduce the cost of coverage. The uninsured also have substantial unmet care needs and are less likely to receive preventive care than those with employer-sponsored insurance. However, many do not know of the availability of low-cost or free care from marketplace plans or Medicaid. Given this lack of awareness, it is important that physicians and their staff educate themselves about the health insurance options that may be available to their patients and be prepared to direct patients to their local health insurance Navigator or other assistance organization. ACP has developed state-specific patient resources that provide contact information for community-based enrollment assistance.
It is also important for current enrollees to re-enroll in marketplace coverage. Many may benefit from shopping around for better care since new plans from new carriers are available in many states and may be a better fit for patients.
Small businesses, defined as being up to 50 full-time equivalent (FTE) employees, can shop for and purchase health insurance for their employees through their state's SHOP marketplace. Similar to the individual marketplace, the SHOP will enable employers to make apples to apples comparisons of qualified health plans and pick one that meets their needs and budget. Businesses with up to 25 FTEs and an average annual employee wage of less than $52,000 are eligible for a sliding scale tax credit to purchase health insurance for their employees. The qualifying small business must also pay at least 50% of full-time employees' premium costs. Beginning in 2014, the amount of the credit is a maximum of 50% of the for-profit employer's health insurance contribution, and 35% for tax-exempt entities.
How do qualifying small business owners, e.g., physicians who qualify, claim the tax credit?
The definition of "business owner" includes a shareholder owning more than 2 percent of an "S" corporation, a sole proprietor, a partner in a partnership, an owner of more than 5 percent of other businesses, or a family member or dependent of such an individual. Additionally, an owner would not count as an employee when calculating the number of full-time employees. So, if a physician is also the owner of their practice, their salary would not be counted when determining if their firm qualifies for the small business tax credit. The salary of a physician employed by a practice would be considered if they do not meet the above criteria (partner in a partnership, sole proprietor, etc.). Employers (other than tax-exempt employers) with no taxable income for the year cannot use the credit for that year since it is applied to the employer's income tax liability. However, the IRS notes that an unused health insurance credit is considered a general business credit and can be applied to be carried back one year (excepting 2010 credits) and carried forward up to 20 years. It is unclear if physicians who claim business income as personal income for tax purposes will be eligible for the credit. Physicians are encouraged to consult their financial advisor to determine if their practice is eligible for the small business tax credit.
Employers can visit healthcare.gov for more information on how to enroll.
Employer contributions towards employees' individual market health insurance premiums
Some small employers have considered dropping their group health insurance and providing their employees a stipend or reimbursement to help them purchase individual market insurance. The ACA does not bar employers from providing such financial assistance, but it may be taxed. The federal government has clarified that funds provided through a tax-advantaged Health Reimbursement Arrangement or Premium Reimbursement Account cannot be used to help employees buy individual market health insurance through or outside of the marketplace. Such plans can be used to complement group health insurance coverage that adheres to the ACA's prohibition on annual dollar limits for essential health benefits and the preventive services coverage requirement. Small physician practices may find that providing their employees with funding to buy individual market insurance is a viable option, but a few points should be considered:
More information on this issue can be found here, and here.
For more information on health insurance options for small businesses, consult this guide from Small Business Majority.
Evidence shows that the ACA is improving self-reported coverage, access to primary care, medications, affordability and health. New insurance regulations cap cost-sharing and mandate minimum benefits for most health plans. Premium tax credits and cost-sharing assistance are available to make insurance more affordable. Shopping for and enrolling in health insurance is eventually less complicated and enrollment and post-enrollment assistance is available from Navigators, in-person assisters, and telephone hotlines.
The rising cost sharing burden has been increasing for the past decade, well before enactment of the ACA. Facing pressure from rising health insurance premium costs, employers have shifted a larger portion of the insurance cost burden to their employees, mostly in the form of deductibles. In 2005, the average annual deductible for single coverage was $584 for all plans; in 2016 it was $1,478. Many marketplace-based plans also have substantial cost sharing with 84% of all adults enrolled in a plan with a deductible. Despite this, a majority say they are confident they could afford needed care, although this number is lower among enrollees with self-reported fair or poor health or with at least one chronic condition.
Physicians should be aware that cost sharing assistance is available for silver plan-enrolled individuals with incomes up to 250% of the federal poverty level. This subsidy enhances the plan's generosity, reducing co-payments, deductibles and other cost sharing. Unfortunately, many enrollees are not aware of the availability of financial assistance or how to choose a plan with affordable cost sharing. Many of the newly insured may not understand health coverage concepts like deductibles and coinsurance, leading to cost-sharing collection problems. Many may be unaware of what health services and items are covered by their insurance or that certain preventive services are free. They may be confused about provider network policies and surprised when confronted with unexpected changes for receiving out-of-network care. For some enrollees, cost sharing - particularly deductibles - could create affordability problems.
Physicians can educate themselves about the law's coverage provisions and direct patients to Navigators and other consumer assistance resources. The Local Help search tool is a directory of trained community Navigators and assisters who can provide impartial information to patients about finding the right coverage.
There are resources that you can provide to your patients to educate them about how insurance works. The Center for Health Guidance has compiled a Consumer Guide with resources for patients to help explain how the law affects them.
CMS has developed From Coverage to Care series, resources to help patients learn about their insurance and how to use it wisely. The series can be accessed here.
Only if the service occurs in the first month that the enrollee enters the 3-month grace period before coverage is terminated. During months two and three of the grace period, insurers may pend claims for services provided during that period; if the patient's coverage is terminated, the insurer is not obligated to pay claims for services provided during the final 2 months of the grace period. The federal regulations state that insurers are required to notify providers that the patient has entered the grace period and that claims may go unpaid for services provided during final 60 days.
This is a potential problem, especially because it's unclear how quickly insurers will alert physicians about the grace period. To prevent any unpaid claims, staff should verify each patient's health coverage status to ensure they are in good standing. ACP is working to change this policy. On February 11, 2014, the College sent the following recommendations to Health and Human Services Secretary Kathleen Sebelius regarding the grace period:
ACP recommends that QHPs [qualified health plans] be required to adopt standards enabling physicians to access real-time patient enrollment verification, patient cost-sharing responsibility, and claims processing information. QHPs should be required to provide real-time notification when a patient enters the 90-day grace period. Notification should provide information on which month of the grace period the enrollee is in. Failure to notify a physician of grace period entry should initiate a binding eligibility determination upon the insurer, requiring the QHP to pay claims during the grace period.
CMS should track QHP adherence to grace period notification standards and consider such criteria during the initial certification and recertification process.
Opponents of the law claim that it will create "premium rate shock" in the market, where premiums will be much higher than they are in the existing market. Preliminary data show that many consumers will see modest premium increases for plan year 2018 silver-level plans, but there will be variation throughout the country: in Wilmington, the average benchmark silver plan premium for a 40-year-old non-smoker will increase by 49% while in Providence premiums will drop by 5%. Eighty-four percent of marketplace plan enrollees receive tax credits that will insulate them from dramatic premium changes; however, higher income individuals who are not eligible for premium assistance may pay premiums that are higher than employer-sponsored plans. Premiums may be particularly high in 2018 due to near-term market uncertainty caused in part by the Trump Administration’s decision to not enforce the individual mandate; lack of committed to long-term funding of cost-sharing reduction payments; and funding cuts for open enrollment period outreach, education, and promotion activities. Consumers are encouraged to shop around to see if another marketplace-based plan meets their affordability, provider network, and benefit needs.
In some cases and for some people, though, premiums may be higher than what they were paying in the individual insurance market prior to the ACA. However, the ACA's insurance regulations were created to help ensure that all people - not just the healthy - are able to access comprehensive insurance. As of 2014, all plans are required to offer minimum benefits, are prohibited from denying coverage based on pre-existing conditions, and are prevented from applying exceedingly high cost-sharing requirements.
Before the ACA, the market varied widely depending on state regulations. A few states required insurers to sell plans to all applicants, even those with serious health problems, leading to very high premium costs. Premiums under the ACA will likely be lower as more healthy people enter the market. Prior to health care reform, states had limited constraints on cost-sharing, benefits and other plan characteristics (in 2013 one individual market plan in Vermont had a deductible of $100,000), and allowed premiums to vary based on health status. The ACA however, bars medical underwriting based on health status, although plans can vary premiums based on some factors like age and tobacco use. Premiums for young people may rise, while premiums for older/sicker people may be lower. Economist Uwe Reinhardt says, "Less frequently noted in commentaries about the law - certainly among its critics - is that the law is likely to bring what I call 'premium joy' to individuals and families with health problems. Many such people simply could not afford the high, medically underwritten premiums they were quoted in the traditional nongroup market. This joy will be shared by high-risk applicants who were refused coverage by the insurer, along with people now in high-risk pools."
So, new plan premiums may appear to be higher in some states, but again, the new plans being offered are incomparable to pre-2014 products because they are more comprehensive and must be offered to all applicants.
Kaiser Family Foundation subsidy calculator.
Before the Affordable Care Act, individuals who needed to purchase insurance on their own were often denied coverage because of their age, or because they had a pre-existing condition. If they were able to buy insurance, it was often expensive and provided bare-bones coverage. The ACA sought to stabilize the volatile individual insurance market by mandating coverage of essential benefits, limiting some cost-sharing and requiring insurers to cover all applicants, regardless of health status. However, plans that existed before March 23, 2010 - the day the ACA was signed into law - could be "grandfathered" and be exempt from the new regulations.
Following passage of the ACA, regulatory language placed limits on how much an insurer could change a grandfathered plan and still be exempt from the ACA's market regulations. For instance, if a plan eliminated all or most benefits to diagnose or treat a particular condition, it would lose its grandfather status and would be required to meet the ACA's insurance requirements starting in 2014. Insurance plan contracts are written on a 12-month basis and insurers often change plan terms from year to year, altering the benefits covered and the amount of cost-sharing required of enrollees. Therefore, some people may have found their coverage was terminated because their plan's contract had expired or their plan had changed so it no longer met the definition of "grandfathered" and had to be written to meet the insurance regulations established in the ACA. It is estimated that the "cancellations" for non-grandfathered plans applied to fewer than 5% of the population, and the vast majority of them are eligible for tax credits (premium subsidies) to help them afford coverage.
As with the issue of rate shock, those who had individual insurance coverage that did not meet the ACA's requirements relating to 10 categories of minimum essential benefits, limits on out-of-pocket costs, guaranteed renewability, and prohibitions on excluding or charging more to people with pre-existing conditions and are now required to purchase comprehensive Marketplace-based qualified health plan coverage may end up paying higher premiums. In many cases, they will be getting better benefits and most importantly, can be assured that they will no longer be denied coverage because they have a pre-existing condition. Further, many will be eligible for premium tax credits that can only be used to purchase Marketplace-based health coverage. For more information on this issue, see this article from the Center for Health Insurance Reforms.
On November 14, 2013, President Obama announced that if permitted by State authorities, health insurance issuers may extend for an additional year individual and small group health coverage plans that were active on October 1, 2013 but subject to termination or cancellation because the plans would not meet the ACA's insurance reforms. This transitional policy was extended in 2016 to allow enrollees to remain in the plans until December 31, 2017. The policy applies to both individual and small group plans. If participating, health insurers must provide a written notice to enrollees who had or would have had their plans terminated. The letter must explain that the enrollee's existing plan is subject to renewal for at least another plan year, is not subject to the ACA's insurance market protections, the enrollee's right to shop for and enroll in qualified health plans through their state's marketplace, how to access the health insurance marketplace, and other information. The policy may not be implemented in all states, however, since some prohibit "early renewals" of insurance plans.
It should be noted that individual health insurance can be purchased outside of the marketplace but premium tax credits and cost sharing assistance is only available for qualified health plans purchased in through the health insurance marketplace.
The ACA requires that health plans make a provider directory available to provide information on which providers are in the plan's network. As recommended by ACP, the federally-facilitated marketplace requires health insurers to provide a link to their online provider directory. Plan shoppers can use a provider search tool to search for insurance based on whether their preferred provider is in the plan's network. Some state-based health insurance exchanges also offer a provider search tool.
ACP is pleased that the federal government has enhanced its requirements on provider directories for plans offered in federally-operated marketplaces. Insurers are now obligated to update their online provider directories at least monthly and provide more information to plan shoppers. Until this issue is fully addressed, patients can contact the health plan directly or their physician's office staff to see if their preferred physician or hospital is listed as a participating provider and considered in-network before signing up for a plan.
Some physicians have reported that they have been included in the networks of marketplace-based insurance plans without their knowledge or consent. A survey of New York doctors found that 40% were not aware that they were participating in an insurer's marketplace-based plan network. In some cases, this may be due to the inclusion of an all-products clause in the contract between the physician and health insurer. All-products clauses require that a physician accept all plans offered by the health insurer. For instance, a Blue Cross Blue Shield (BCBS) contract may include language that requires contracted physicians to serve all patients covered in all of the plans it offers, including marketplace-based BCBS products. Such clauses existed before the Affordable Care Act, and some states have laws prohibiting or limiting their use. Some insurance plans have not yet finalized their provider networks, making it difficult for patients to shop for and choose the insurance that meets their benefit needs and provider preferences. Physicians find it difficult to advise their patients on whether they're included in a plan's network. Physicians are encouraged to scrutinize insurer contracts for all-product clause language and consider their practice's capacity and existing patient panel prior to entering any new agreement with the insurer. Further, practices should be proactive and verify with insurers whether or not they are included in their marketplace-based insurance networks. If a plan's network has not yet been finalized and is not subject to an all-products clause, the practice can then make the decision whether it wants to participate in the plan's network or opt out.
ACP believes better access to information is crucial, especially as patients transfer between plans and/or health insurance programs and experience changes in advance premium tax credit and cost-sharing assistance eligibility. Marketplace-based health plans should facilitate physicians' verification of enrollment and health plan information through an online portal and must inform physicians that they are included in-network. This will ensure that clinicians can maintain patient panels that will guarantee access for existing patients and help clinicians accurately determine whether they can absorb additional patients covered by marketplace-based plans. With this in mind, the College has recommended that health insurers and federal and state marketplaces require QHPs to establish "health care provider hotlines" to connect physicians, hospitals and other providers to QHP representatives to answer questions, verify patient enrollment, and obtain other information.
Some insurers are forming limited networks of providers in an effort to curb costs. The ACA and state network rules are in place to ensure that plan networks are adequate to meet patient need. Federal regulations mandate that a plan's network be sufficient in number and types of providers to assure that services are accessible without unreasonable delay. States may have their own network adequacy requirements that compliment federal rules. Further, marketplace-based plans must ensure that "essential community providers" that serve predominately low-income, medically-underserved individuals are available in their network.
Despite these safeguards, narrow networks persist.
ACP remains concerned that narrow networks may prevent affordable access to high quality, local providers. Patients with limited health insurance literacy may not understand the implications of choosing a narrow network plan, including having to pay elevated cost sharing for seeking an out of network preferred physician. To function correctly and mitigate the potential for surprise charges and frustration, health plans need to improve network transparency and regulators need to provide ongoing scrutiny of provider networks to ensure they are adequate. To address the narrow network issue, ACP has made the following recommendations to federal and state regulators:
Prescription drug coverage is considered an essential health benefit that all qualified health plans offered through the marketplace are required to cover. However, there can be variation among plans as to which drugs are covered and which ones are not; a drug covered in one plan may not be covered in another. Qualified health plans are required to cover at least the greater of one drug in every U.S. Pharmacopeia category and class or the same number of drugs in each category and class as the state's essential health benefit benchmark plan. State benchmark plans can be found here. Health plans must also have procedures in place to ensure that enrollees have access to clinically appropriate drugs prescribed by a provider but not included in the health plan's drug formulary. It is best for the patient to review the prescription coverage offered by a plan in consultation with their doctor prior to purchasing the plan to ensure it covers their medications. If the patient is still unsure if their specific medications are covered, they should contact the plan directly to inquire about coverage.
ACP has asked health plans and federal and state regulators to provide increased oversight of formularies to ensure they are not unduly restrictive. Regulators should closely monitor formularies and other benefit design features to ensure that coverage does not exclude vulnerable patients. The prescription drug exception process should be strengthened so that patients can receive necessary services. The College has recommended that health plans with restrictive formularies should allow patients to have access to prescription drugs in dispute during the entire exception review process, with expedited internal appeals for urgent care situations, and if an exception is granted, plans should continue to provide coverage.
No. Physicians are not obligated to contract with commercial plans or public programs like Medicaid and Medicare. However, health plans offered through the marketplaces are required to meet "network adequacy standards" to ensure that there are a sufficient number of physicians and other clinicians available for their plan enrollees. In addition, the ACA includes a number of programs to increase the supply of primary care physicians including funding a near-tripling of the number of physicians who have received scholarships or loan forgiveness under the National Health Services Corps; increased funding for Community Health Centers; redistribution of unused residency positions to primary care residencies; and funding for innovative primary care delivery models including Patient-Centered Medical Homes. Team-based care arrangements-where physicians, advanced practice nurses, physician assistants, and health professionals work together to ensure that patients have access to the care they need-can also help meet the growing demand for primary care. Additional reforms will be needed, though, to alleviate shortages in primary care and other specialties.
Evidence shows that employer-sponsored insurance offer, take-up, and overall coverage rates remain stable. The vast majority of people will continue to receive their coverage from their employer and for the most part will remain unaffected by the law (except for some benefits, such as caps on out-of-pocket spending). Beginning in 2016, large employers (over 50 full-time equivalent employees) are required to provide comprehensive insurance to their employees or pay a fine. Generally, a large employer that does not offer employee health insurance will have to pay $2,000 for each employee who receives a premium tax credit to buy marketplace-based coverage Firms that do offer coverage but have at least one full-time employee receiving premium tax credits to purchase Marketplace-based insurance will be required to pay the lesser of $3,000 for each credit-receiving employee or $2,000 for each full-time employee. Small employers (under 50 full-time equivalent employees) are not subject to fines for not supplying coverage to their employees.
Yes! ACP has compiled extensive resources that you use to help your patients. In addition, brochures explaining the marketplaces and other key parts of the law are available from www.healthcare.gov. See all of the resources for you and your patients that are available through ACP.
Implementation of a law that aims to expand coverage to tens of millions of Americans and to provide better health insurance for everyone else, by its nature, is enormously complicated, and it is likely that there will be considerable public confusion and, as we saw in the first year of implementation, technical difficulties in the early stages of getting millions of persons signed up for coverage. It is not unusual for implementation of major coverage expansions to be chaotic in their initial months. When the Medicare Part D drug coverage benefits initially went into effect in 2006, many seniors were confused about the array of plans being offered to them and how to sign up. Over time, though, the confusion and initial implementation issues dissipated as seniors gained more familiarity with the benefits and as Medicare improved the program's administration. Now, Medicare Part D is enormously popular with seniors and signing up for benefits, for the most part, is going smoothly. The same is likely to be true of the ACA's programs.
In the days following the 2013 launch of healthcare.gov, many consumers were unable to shop for and enroll in coverage. Others reported communication glitches between the information systems needed to verify eligibility for coverage and subsidies. After 2 open enrollment periods, the healthcare.gov website is much more functional and reports of problems have decreased. In the 2017 plan year, the website will introduce new shopping tools to help consumers find plans that reflect their level of health care usage, a simplified re-enrollment process, a provider director and formulary search tool, and more resources designed to educate shoppers about health insurance and how to use it.
The healthcare.gov website is not the only way to apply for coverage. There are still four ways that consumers can sign up for health insurance:
Visit this page for more details on how to apply.
You must make your own decision on how you will respond to questions from patients about the new law. ACP, for its part, supports the ACA's programs to expand coverage to tens of millions of persons and provide better health insurance to everyone else. We urge all of our members to be helpful to your patients when they come to you with questions about the marketplaces, subsidies, and other benefits created by the ACA. Members who disagree with the ACA have every right to engage in the political and election processes to seek changes, but we hope that when it comes to one of your patients coming to you to seek help in understanding how they might get coverage from the marketplaces or Medicaid, you will use the practical resources available from ACP and others to make it as easy for them as possible.