Health Care



Hardship Exemptions to the Individual Shared Responsibility Provision of the
Affordable Care Act (ACA)

Any individual whom the Secretary of the Department of Health & Human Services (HHS) determines has suffered a hardship with respect to the capability to obtain health insurance coverage will receive a hardship exemption. Through regulations and guidance, HHS has identified a number of circumstances that would allow individuals to receive a hardship exemption:

(1)    an individual experiences financial, domestic, or other circumstances that prevent him/her from obtaining coverage or the expense of purchasing coverage would have caused him/her to experience serious deprivation of food, shelter, clothing, or other necessities;

(2)    an individual is unable to afford coverage based on projected household income, where coverage would exceed 8% of projected household income;

(3)    an individual whose income is below the filing threshold (and therefore eligible for the filing threshold exemption), except that the individual claimed a dependent with a filing requirement and had household income exceeding the filing threshold as a result;

(4)    an individual is ineligible for Medicaid based on a state's decision not to carry out the ACA expansion;

(5)    an individual is identified eligible for affordable self-only employer-sponsored insurance (ESI), but the aggregate cost of the ESI for all the employed members of the family exceeds 8% of household income;

(6)    an individual is an Indian eligible for services through an Indian health care provider, but is not eligible for an exemption based on being a member of an Indian tribe, or is eligible for services through the Indian Health Service;

(7)    an individual who enrolls in a plan offered through an exchange prior to the close of the open enrollment period (March 31, 2014) will be able to claim a hardship exemption for the months prior to the effective date of the individual's coverage; or

(8)    an individual has been notified that his/her plan will not be renewed and believes that the available plan options are more expensive than the plan that was not renewed.

Individuals who claim hardship exemptions are eligible to purchase catastrophic plans. Under ACA, catastrophic plans must cover a comprehensive set of benefits, but they do not have to comply with the same cost-sharing requirements with which other plans must comply under ACA. As a result, these plans typically have lower premiums because they have higher cost-sharing. Only individuals who are either under age 30 or eligible for a hardship or affordability exemption from the individual mandate are eligible to enroll in catastrophic plans.

Instructions for taxpayers on how to report health care coverage and/or exemption will be available closer to the start of the 2015 filing season.
•    When it becomes available, the IRS will first release draft forms and instructions here: Draft forms and instructions
•    Taxpayers may also submit comments on draft forms and instructions here: Form for commenting on draft forms and instructions

 

Patient Protection and Affordable Care Act (ACA)
In March 2010, Congresswoman Speier proudly cast her vote in favor of the Patient Protection and Affordable Care Act (ACA), a historic measure that was nearly 60 years in the making.

Congresswoman Speier, an avid supporter and advocate of the ACA, has forcefully opposed the ongoing efforts by some members of Congress to undermine the new health benefits for millions of Americans, and voted against repealing the law—for the 45th time. In stark contrast to such obstructionist tactics, Speier has been working to make sure Americans know about the new opportunities for affordable, quality health insurance coverage, and their rights and benefits under the law that take effect on January 1, 2014.

Speier, alongside California’s health care exchange - Covered California - will be holding a number of educational ACA events for seniors, small businesses, individuals and families in the District in the coming months. The events will be focused on dispelling the myths about the health care law informing constituents about the upcoming changes to health care in 2014, and providing residents with the tools and resources they need to take advantage of the Covered California marketplace.

http://www.youtube.com/watch?v=vNeui23joF0

Speier kicked-off her ACA educational tour on August 21st, 2013 at the Pacifica Chamber of Commerce’s ACA Lunch N’ Learn at Sharp Park Golf Course Restaurant. There, she spoke to over 50 small business owners in her district about the upcoming changes under the ACA, and what it will mean for them. Speier along with Shawn Balsdon, Director of Covered California’s Small Business Health Options Program (SHOP) sales, was able to dispel some of the false information circulating on ‘Obamacare’, and provided them with the facts they need to provide health insurance for their employees.

There will be more ACA events in the 14th District to come, including telephone town halls. To participate in these events, sign up for Jackie’s Journal here.

ACA By The Numbers
Since its passage, Americans have already seen some of the benefits the ACA has to offer. In Speier’s district alone:

  • 97,000 Medicare beneficiaries have experienced improved benefits, including free preventive and wellness care and improved primary and coordinated care.

  • 11,300 patients who fall into the Part D prescription drug "donut hole" each year are already experiencing much needed relief. In 2010, these beneficiaries all received a $250 rebate and are purchasing their brand name drugs at a 50% discount this year. Further, seniors who hit the donut hole this year will save more than $600 on average. The Affordable Care Act will close the donut hole by 2020.

  • 44,000 young adults can now remain on their parents’ policies until they turn 26.

  • The 472,000 residents who receive coverage from their employer or through policies purchased on the individual market cannot lose their coverage should they become sick with a costly disease or condition or be limited by lifetime benefit limits.

  • Insurers can no longer charge a woman more than a man, simply for being a woman.

  • Further, insurance companies are now limited in how much of the premiums dollars received can be spent on administrative expenses, profits and other overhead, rather than actual health care. The ACA’s rate review and medical loss ratio provisions have already helped save Americans an estimated $2.1 billion on their premiums.

In addition to providing improved care for millions of Americans, the ACA is also fiscally responsible. It has extended the Medicare trust fund solvency by over seven years, while at the same time reducing the deficit by over $1.3 trillion in the next two decades.

ACA For Individuals and Families
Beginning in 2014, a new “Health Insurance Marketplace” will operate in each state. In California, that marketplace is called Covered California.

  • Covered California will provide individuals and families a choice among numerous quality private health insurance plans; and will also make premiums affordable through sliding-scale premium tax credits.
  • Every health insurance plan in the new Marketplaces will offer comprehensive coverage, from doctors to medications to hospital visits.
  • Individuals will be able to easily compare their insurance options based on premiums, benefits, quality and other features important to them.
  • The vast majority (over 80%) of Americans, who have coverage through their employer or through such programs as Medicare and Medicaid, will not need to purchase insurance through the new Marketplaces.
  • Those in the marketplace will have better benefits than virtually everyone buying insurance in the individual market today.
  • In the marketplace, health insurance companies will compete on a level playing field, promoting competition.
  • Premium tax credits will make coverage in the marketplaces affordable
  • About 85 percent will qualify for premium tax credits.Tax credits will be available for individuals and families with incomes between $23,500 to $94,200 for a family of four in 2013 who are not eligible for Medicaid, employer-sponsored insurance, or other acceptable coverage.
  • In addition to these premium tax credits, individuals and families with incomes up to 250% of the federal poverty level are also eligible for reduced cost sharing, to help them afford the insurance coverage they bought through the Marketplaces.
  • Americans with pre-existing conditions can no longer be denied coverage and premiums will be fair.
  • There will be consumer enrollment assistance.

You can apply for enrollment in the Marketplace in numerous ways, including: online, by phone, by mail, or in person. The help available in each Marketplace to help individuals and families choose the best private health plan for them will include:

  • Covered CA toll-free call center
  • The Covered CA website
  • Covered CA Navigators, such as community-based organizations;
  • Covered CA In-Person Assisters
  • Covered CA Certified Enrollment Entities

 

ACA For Small Businesses
The Affordable Care Act includes key provisions that will give you and other of America’s small business owners new options for providing quality, affordable health coverage to your employees if you so choose.

If you own a business with fewer than 50 employees – 96 percent of America’s businesses – you will have NO employer responsibility requirement, when the requirement goes into effect in 2015. That is, you will NOT face penalties for not offering affordable coverage to your employees.

The provisions in the health care law will be an improvement over the current market where small businesses have had many problems obtaining affordable insurance up until now. For example, currently small businesses pay 18 percent more in premiums than large firms for the same benefits. Also, today, premiums for a small business can rise exponentially simply because one of your employees gets cancer or has a serious heart attack. 

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Businesses with Fewer than 25 Employees (Beginning 2014):

      • There is no employer responsibility requirement.

      • There is a sliding-scale tax credit to help you afford to offer employee health insurance coverage, if you have average annual wages of less than $50,000. The credit is worth up to 50 percent of your small business’s premium costs.

      • There is a Small Business Health Options Program (SHOP) in each state – a Health Insurance Marketplace for small businesses – to make health insurance affordable and accessible for small businesses with 50 or fewer employees.

      • With the SHOPs, by being given the ability to join a large pool, you and other small businesses will now have access to the same types of quality, affordable coverage that only large firms have today.

      • The SHOPs will reduce premiums for you and other small businesses through lower administrative costs, increased competition among insurers, increased transparency of costs, and better risk pooling.

Businesses with 25-49 Employees (Beginning 2014):

      • There is no employer responsibility requirement.

      • There is a SHOP in each state – a Health Insurance Marketplace for small businesses – to make health insurance affordable and accessible for small businesses with 50 or fewer employees.

      • With the SHOPs, by being given the ability to join a large pool, you and other small businesses will now have access to the same types of quality, affordable coverage that only large firms have today.

      • The SHOPs will reduce premiums for you and other small businesses through lower administrative costs, increased competition among insurers, increased transparency of costs, and better risk pooling.

Businesses with 50 or more Employees (Beginning in 2015):

      • There is a shared responsibility requirement for businesses with 50 or more employees. Under the requirement, businesses with 50 or more employees that don’t offer affordable health coverage and have at least one full-time employee receiving a premium tax credit in the new Marketplaces will have to pay a penalty.

      • However, the vast majority of these businesses already voluntarily offer health coverage. Currently, 94 percent of firms with 50-199 employees already offer coverage to their employees and 98 percent of firms with 200 or more employees do so.

      • Beginning in 2016, the SHOPs will be open to employers with 100 or fewer employees

ACA dates to know:

Mid-September 2013 The health plans to be offered in the Marketplaces of the 34 states without State-Based Marketplaces are unveiled.
October 1, 2013 Enrollment begins for individuals in the marketplaces and for small businesses in the SHOPs.
January 1, 2014 Coverage begins for individuals in the Health Insurance Marketplaces and for small businesses in the SHOPs.
  • To make coverage affordable in the Marketplaces, premium tax credits become available for those with incomes between 100% to 400% of the poverty level (between $23,500 to $94,200 for a family of four in 2013).
  • For those states that choose, Medicaid is expanded to cover all those with incomes up to 138% of the poverty level, with the federal government paying 100% of the cost for first three years, phasing down to 90% of the cost by 2020 and beyond.
  • A prohibition on all discrimination by insurance companies against Americans due to pre-existing conditions begins.
  • A prohibition against all discrimination by insurance companies against women begins.
  • The elimination of all annual limits on insurance coverage begins.
  • A cap on a consumer’s out-of-pocket costs in health plans begins, providing an additional vital new protection for consumers.
  • The small business health insurance tax credit increases from covering 35% of a business’s premium costs to 50% of a business’s premium costs.
March 30, 2014 The enrollment period ends for calendar year 2014 for individuals enrolling in Individual Health Marketplaces and for small businesses enrolling in SHOPs.
January 1, 2015 New provisions go into effect beginning to tie physician payments to the value of the care they provide, not simply the volume.

ACA Resources
Healthcare.gov : What health care plans am I eligible for?

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Request for Enrollment Assistance with Covered CA

Covered CA Potential Insurance Cost Calculator

Frequently Asked Questions

Medicare
More than forty years ago, our nation created the Medicare system and entered into an agreement with every single American - if you work hard and pay into the system, you are entitled to Medicare benefits when you turn 65 or become disabled. Today, more than 47 million people receive Medicare benefits - nearly 50% of who earn less than $23,000 each year. Congresswoman Speier considers this system to be absolutely sacred and is committed to doing all she can to ensure that it is here for decades to come. That said, Medicare is certainly in the line of fire these days.

The Republicans, under the leadership of Paul Ryan, have proposed a Medicare plan which would replace traditional Medicare with a voucher system beginning in 2022. The voucher would grow more slowly than health care costs leaving seniors at the mercy of insurance companies and facing higher out of pocket costs. In fact, the non-partisan Congressional Budget Office estimates that by 2030, seniors would be paying nearly 70% of their health care costs, with the voucher only picking up 30% of the tab. A 54 year old today will need to have an additional $182,000 in their IRA or 401(k) just to cover these additional expenses. This is not what seniors have worked for and deserve, nor what Congress envisioned when it created the program decades ago. That is why Speier has consistently voted against efforts to cut Medicare benefits or transfer it into a voucher system, and will continue to oppose these efforts.

Speier believes we must do more to protect the Medicare system, not undermine it. As the baby boomers age, there are fewer contributing workers for each eligible Medicare recipient. Currently, there are nearly 4 workers paying Medicare taxes for every American receiving services but only 2.4 workers will be contributing by 2030. Furthermore, while health reform extended the solvency of the Medicare trust fund by seven years, it will still face funding challenges by 2024.

This is why Speier is committed to implementing common sense reforms that will ensure adequate access to care, increased efficiency and a Medicare system that is available for decades to come. She believes we must do more to eliminate Medicare fraud which costs our nation nearly $60 billion each year, reduce medical errors and infections which not only cost our system $45 billion annually but lead to 100,000 deaths each year, and build on the measures included within health reform which ensure that doctors operate more efficiently while continuing to make quality patient care their number one priority.

One reform to Medicare Speier is championing is the end to physician self-referrals. She will soon introduce the Promoting Integrity in Medicare Act, legislation that will cut wasteful Medicare spending on unneeded or even harmful CTs, MRIs, lab tests, radiation treatments, or physical therapy. Current law bars physicians from referring Medicare patients for certain health care services in which they have a financial interest, but the in-office ancillary services exception allows physicians to be reimbursed for some services, including CT, MRI and PET scans, anatomic pathology, radiation oncology and physical therapy that they provide within their own offices.  Today, many physicians purchase expensive advanced imaging machines or bring pathologists or physical therapists in house because with a fee for service payment system, they know that they are big profit drivers.  A recent Government Accountability Office report has confirmed that physician self-referral for advanced imaging services is costing Medicare more than $100 million in unnecessary spending each year.

The in office exception was originally created so that physicians could continue to render non-complex services, like X-Rays, within their offices at the same time as the patient’s visit, and was never intended to include these complex and costly services.  Instead, this exception has created perverse incentives and led to overutilization:

•    Doctor-owned imaging machines have been used four times more than those used by radiologists since 2000.

•    Self-referring non-radiologist physicians perform up to eight times as many imaging studies as physicians who refer their patients to radiologists.

•    Between 1998 and 2005, the number of physicians referring patients for radiological testing within their own practices grew at triple the rate of the same exams in other settings.

•    Only 10% of advanced imaging services are performed on the same day as an office visit.

Childhood Cancer
For many cancer survivors and their families, geographic distance from cancer centers is a barrier to receiving appropriate specialized care. Her bill adopts many of the IOM recommendations for improving follow-up care for cancer survivors. It also expands cancer control programs, including surveillance and comprehensive control programs within the CDC that will support states’ efforts in this area. In addition, it establishes grants at the National Institutes of Health so that research can be conducted on disparities in survivorship and the development of systems to monitor and care for cancer survivors. Of particular importance, it creates grants to establish and operate childhood cancer clinics so that comprehensive long-term follow up services are available for a larger number of childhood cancer survivors.

While we are making progress towards the elimination and more effective treatment of children's cancer, we must also dedicate greater effort towards effectively addressing the long-term effects of these conditions. This bill would help ensure that those who have bravely struggled and conquered cancer as children have access to the resources and infrastructure they need as the longer term consequences of their illness surface, sometimes years down the road.