The Patient Protection and Affordable Care Act

1. The Patient Protection andAffordable Care Act What Does It Do, To Whom, When and How?

2. History (in the making…) • The Patient Protection and Affordable Care Act (ACA) - March 23, 2010 • The Health Care and Education Reconciliation Act - March 30, 2010 • Key Implementation Dates: • Immediately upon passage • September 23, 2010 (6 month mark) • January 1, 2011 and annually thereafter • Other dates as designated in regulations

3. Key Provisions • Grandfathered Plans • Which plans? • For how long? • What does it mean? • Pre-Existing Conditions • Under 19 • Everyone • Rescission of Coverage

4. Key Provisions • Lifetime/Annual Limits • Dependents • Minimum Loss Ratios • Simple Cafeteria Plans • Retiree Reinsurance

5. Key Provisions • Nondiscrimination Rules • “Highly Compensated Employees” • Two part test: • Eligibility • Benefits • Effective Date delayed • Preventive Services Requirement • Form W-2 Reporting

6. Bigger Pieces: The Individual Mandate • What is it? • What is its impact? • What if you don’t comply? • What exemptions exist?

7. Bigger Pieces: The Medicaid Expansion • Who is eligible? • Who will pay? • States would be required to participate or lose ALL Medicaid funding.

8. Bigger Pieces: Health Insurance Exchanges • What is a Health Insurance Exchange? • State Based Exchanges • Federally Facilitated Exchanges • Who May Purchase from Exchange? • Individuals • Small Businesses • ACA – 1-100 • States – 1-50 (if desired until 1/1/16) • Larger Businesses (2017) • Benefit tiers

9. Health Insurance ExchangesPart II • Qualified Health Plans • Essential Health Benefits • Rating Variation: • Benefit coverage • Age (3 to 1) • Tobacco use (1.5 to 1) • Family composition

10. Health Insurance ExchangesPart III • Navigators • Financial Sustainability • January 1, 2015 • Participation by States Nationally • http://www.healthcare.gov/news/factsheets/2011/05/exchanges05232011a.html

11. Premium Assistance Who is eligible? How is it paid? How much is available? Starting when?

12. Example – Premium Assistance • Family of 4 at 200% of FPL • $48,677 • Cannot pay more than 6.3% for health insurance. • $3,067 • Cost of 2d lowest silver plan is $14,100 • CREDIT = difference - $11,033

13. The Employer Mandate

14. The Employer Mandate • Provide Affordable Coverage that provides at least Minimum Value, or else (sort of). • “Affordable Coverage” defined. • “Minimum Value” defined. • Size matters! • What are the recognized categories? • How do we count employees? • Employers’ four basic options: • Stay “small” and do what you want • Provide no coverage • Provide affordable coverage • Provide unaffordable coverage

15. Stay Small: Tax Credit (2010-13) Small Business Tax Credit 25 or fewer full-time employees [defined]; and average annual wages of less than $50,000 10 or fewer full time employees [defined]; and average annual wages of less than $25,000 Employers must pay for at least 50% of the employee's premium.

16. Stay Small Tax Credit (2014) Under same parameters: 25 or fewer employees Tax credit goes to maximum of 50%. 10 or fewer full time employees and average annual wages of less than $25,000 GET FULL 50% CREDIT. Only in effect for two years beginning in 2014 Only if employees are in the Exchange.

18. Tax Credit Scenario 1

19. Tax Credit Scenario 2

20. Tax Credit Scenario 3

21. “Large Employer” – Providing No Coverage • If Employer employs at least 50; AND • Provides no health ins. coverage; AND • At least one full-time employee goes to Exchange and receives a subsidy; THEN • Penalty of $2000 per employee per year • Calculated on monthly basis • First 30 employees exempt from calculation.

22. “Large Employer” – “Unaffordable” Coverage IF 50 or more FTEs; AND Do not offer “affordable coverage”; AND At least one employee goes to Exchange and receives a subsidy; THEN $3000 per employee who enrolls through the Exchange Capped at amount of penalty that would have applied for no coverage.

23. Taxes, Fees, Fines and Penalties

24. Individual Taxes: High Incomes Medicare payroll tax increase by .9% Additional Medicare tax 3.8% on unearned income “High income” defined $200,000 single; $250,000 joint Effective Tax Year 2013

25. Fees on Plans For each fiscal year 2013-2019 there is a fee on employer-sponsored plans to fund Comparative Clinical Effectiveness Research. $1 for policy year ending 2013 $2 times average # of lives covered under the policy 2014-2019 Insured and Self Insured.

26. Tax Deductions Medical expense deduction raised from 7.5% to 10% If taxpayor or spouse is 65+ then stays at 7.5% for tax years 2013-2016 Effective Tax Year 2013 Floor on deductible medical expenses is raised to 10% AGI for all taxpayers, including 65 and over in 2017

27. Cafeteria Plans Small Employers [100 or less] can create Simple Cafeteria Plans. Must meet certain employee eligibility and minimum contribution requirements in order to have safe harbor from non-discrimination requirements relating to highly compensated employees. Effective Year 2011.

28. FSA Limits Lower contribution limits on Health Flexible Spending Arrangements (FSAs) take effect for purposes of being a "qualified benefit" (employee contribution limited to $2,500 per year ). Includes grandfathered plans. Effective Year 2013.

29. HSAs, FSAs, Archer MSAs What are HSAs, FSAs and Archer MSAs? These vehicles no longer approved for purchase of over-the-counter medicines. Penalties apply in HSAs and Archer MSAs. Includes grandfathered plans Effective Year 2011.

30. Industry Taxes • Insurance Industry • 2014 - $8 Billion • 2015 - $11.3 Billion • 2018 - $14.3 Billion • Pharmaceutical • 2011 - $2.5 Billion • 2018 - $4.1 Billion • 2019+ $2.8 Billion • Medical Device Industry • Excise tax of 2.3% on all taxable sales

31. Legal Challenges to PPACA…

32. First Challenge to the ACA • Who initiated the challenge? • Florida • 25 other states • Basis for challenge? • Where? • Florida District Court; 4th Circuit; SCOTUS • When?

33. Supreme Court Decision • Oral Arguments (March, 2012) • Opinion Issued (June 28, 2012) • Divided Court • Four Issues Addressed • Anti-Injunction Act • Individual Mandate • Medicaid Expansion • The Rest of the Law

34. Individual Mandate • Question – Is the Mandate Constitutional? • Commerce Clause • Regulation vs. Requiring Commerce • Healthcare vs. Broccoli • Spending/Taxing Power • Penalty is a Tax. • Congress can do it. • Essentially – the “mandate” is now an option. • Buy insurance, OR • Shared responsibility payment

35. Medicaid Expansion • In a word, it’s OPTIONAL

36. The Rest… ALL STANDS (Don’t reach question of severability)

37. Oral Arguments http://www.supremecourt.gov/oral_arguments/argument_audio.aspx

38. More Challenges Ahead…

39. The Next Challenges: Exchanges • The Argument • Employer penalties are triggered when employee goes to Exchange and qualifies for subsidy • Subsidies are available, per ACA 1311, to employees who enroll through “state established exchange.” • So, if a State doesn’t have an SBE, but only an FFE, then no subsidies and no employer penalties. • Thus, ALL STATES should refuse to establish SBEs. • ACA Drafters: We made an error. • IRS: We will fix that.

40. The Next Challenges: Contraceptives • PPACA says: • Employee group plans must cover preventive care • Contraceptives (sterilization, abortifacients) • No copay or cost-sharing • August, 2011 – interim final rule • Coverage mandate effective 8/1/12 • The Challenge: • Archbishop, Notre Dame • 40+ Catholic organizations in various states

41. The Next Challenges: Contraceptives • The Argument • Violates First Amendment to Constitution • Violates Religious Freedom Restoration Act • Government’s Response • Exemption of “religious employers” • Plaintiffs say exemption is meaningless • Definition of “religious employer” • Relief sought