Each state will write its own Essential Health Benefits policy. If the state does not comply, it will more than likely take on the federal policy.

Women and the ACA

Starting August 1, 2012, NO CO-PAY for:

• Well Woman Visits: annual visits are covered.
• Lactation Counseling: Pregnant and post-partum women have access to comprehensive lactation support and counseling from trained providers as well as breastfeeding equipment to give moms and little ones the best start.
• DNA Testing for Cervical Cancer: Women who are 30 or older will have access to HPV testing every three years, even if previous pap tests were normal.
• Contraceptive Counseling: Women will have access to all FDA approved contraceptive methods and patient education/counseling.
• STI and HIV Screenings & Counseling: Women will have access to annual testing and counseling on HIV and Sexually Transmitted Infections (STI).
• Gestational Diabetes Screenings: Screenings will be performed at 24 - 28 weeks pregnant and for those at high risk.
• Domestic Violence Screening: Screening and counseling for domestic and partner violence will be provided for all women.

Seniors and Persons with Disabilities:

• Seniors and person with disabilities on Medicare are already receiving free screenings and preventive care.
• Closing the Medicare prescription “doughnut hole,” by making prescription drugs more affordable.
  • In Texas in 2011, the average savings was approximately $639 for each person who fell into the doughnut hole.
  • Completely close the prescription doughnut hole by 2020

Small Business Owners

Many small business owners have access to new tax credits to help them buy health insurance for their employees, if they choose.

• Currently 35 percent tax credit
• 2014 tax credit will raise up to 50 percent
• No penalties or obligations for small business owners (50 or fewer employees) who choose not to provide insurance.
• For those who do provide insurance, the ACA makes it easier to buy and afford insurance through Small Business Health Insurance Exchange.

Individual Mandate

If an individual is uninsured through work, Medicaid, or Medicare, the person must purchase insurance or pay a fine. The individual is exempt if the cost of coverage is more than eight percent of the person’s house-hold income. Currently, the law does not clearly state if this is gross or net income.

Health Insurance Exchange

How will individuals choose a plan?

• An online marketplace where plans will compete side-by-side.
  • Subsidies are available to people who can’t afford it by percent of federal poverty level.
  • The government is making subsidies available to people with moderate incomes – if you earn $92,000 or less (for a family of four), you’ll receive sliding scale discounts to the cost of your insurance policy.
  • Precious metals scale (choose from gold, silver, bronze plans)– you can choose which plan fits your situation the best.

Medicaid Expansion

• In 2014, anyone at 138 percent of federal poverty level should become eligible for Medicaid,
• In Texas, 2.5 million kids are covered under Medicaid now, but only 225,000 of their parents are. Under new rules 1.5-2 million Texans could qualify,
• Texas will have to “opt in” to the Medicaid expansion. First three years are free. Then a 1:9 matching rate,
• Still a problem of getting providers to enroll, federal government is helping for the first two years by raising reimbursement rates to the Medicare level.

Individuals currently living with pre-existing conditions

If an adult cannot get insurance right now because of a pre-existing condition, and they don’t qualify for Medicaid or Medicare - until 2014.

• ACA has a high risk pool, called the Pre-existing Condition Insurance Plan (PCIP)
• You are eligible for PCIP if you meet the following criteria:

1. You are a citizen or national of the United States or reside in the U.S. legally,
2. You have a pre-existing condition or have been denied coverage because of your health condition and
3. You have been without health coverage for the last six months or more prior to enrolling.

80/20 Rule

The ACA’s 80/20 rule to keep health insurers from abusing premium spending. Insurers have to spend 80 percent of your premiums on your health care, only 20 percent can go to overhead and profits. Any health insurance company’s increase of 10 percent or more goes through an automatic review process on whether or not it is justified.

Costs

• The price tag: $938 billion over 10 years.
• In other words: two percent of the federal budget, and only three percent of what the U.S. will spend on health care overall.
• A combination of new taxes, cost saving measures and incentive programs will lead to a $124 billion reduction in federal deficit over next 10 years.

Mimi Garcia of Engage Texas and Texas Well and Healthy organizing director spoke about outreach initiatives and how individuals can advocate for the ACA for better health outcomes and access. She explained that details continue to be developed. Garcia talked about the ongoing process to challenge those against healthcare reform and past initiatives. For example, providers attempted to receive waivers for medical loss ratio protection. Garcia explained that some insurance providers would spend less than 50 percent on premiums to provide services. Engage Texas mobilized a petition sent to Health and Human Services. Ultimately the waiver was stopped and now rebates are going to Texans for overpayment. Garcia also distributed a pamphlet promoting the ACA.

Question and Answer

Moderated by Mimi Garcia and Cheasty Anderson

Question: What does the law say about providing proof that someone tried to find appropriate insurance?

Answer (Cheasty Anderson): Co-insurance will answer this. You can purchase different level plans that have different cost shares "precious metals" (gold, silver, bronze). The most affordable will be the bronze level plans. Plans will compete side-by-side in an online marketplace.

Question: How will the mental health parity law be involved with the essential health benefit services?

Answer (Cheasty Anderson):  The parity will enhance the benefit for mental health. It will equate mental health and physical health. For example, if the plan outlines 20 physical therapy sessions, there will also be 20 mental health sessions.

Mimi Garcia: The essential health benefits are a floor not a cap. Think of it as a baseline, but there can be more services added to it.

Question: How much power does Governor Perry have on whether Texas will opt in or not?

Answer (Mimi Garcia): It’s not an executive decision, but a legislative decision. People will have to put pressure on our legislatures.

Question: What limits are set for provider fees, services and session limits etc.

Answer (Cheasty Anderson):  There will be more mandates and providers may have to change models of care and practices.

Question: If a person is grandfathered in their current insurance plan, what is the process to take advantage of the new law?

Answer (Cheasty Anderson):  A person would change providers and get a new plan. If the individual cannot change plans, they may have to wait until 2014.

Mimi Garcia: Also check with employer and insurance plan. Some insurance providers are opting to cover these services already.

Question: What are the efforts to entice providers to accept Medicaid?

Answer (Cheasty Anderson): The federal government is raising reimbursement rates for Medicaid for primary care to Medicare levels for two years.

Question:  What has been discussed for those left uninsured?

Answer (Cheasty Anderson): undocumented immigrants would be uninsurable. I don't think anyone is estimating cost for the healthcare needs for those communities.

Question: What about healthcare cooperatives insurance policies?

Answer (Cheasty Anderson):  They will still be cooperatively owned. More details are coming down the pipeline.

Anderson and Garcia ended the question and answer period by encouraging individuals to share their healthcare reform story and remember the law doesn’t fix everything, but it is a leap forward. John McNabb, One Voice Central Texas president concluded the forum by encouraging the group to stay engaged and illuminate this issue to family and friends saying, “This is one of the major changes we will see in our lifetime. Thanks to Iliana Gilman and Integral Care for hosting this forum.”