**Transcript of Cyberseminar**

**Spotlight on Womens Health**

**Women’s Health Care:  The Implications of the Affordable Care on Coverage and Access**

**Presenter: Alina Salganicoff, Ph.D.**

**October 3, 2013**

*This is an unedited transcript of this session. As such, it may contain omissions or errors due to sound quality or misinterpretation. For clarification or verification of any points in the transcript, please refer to the audio version posted at www.hsrd.research.va.gov/cyberseminars/catalog-archive.cfm or contact Alina Salganicoff at**alinas@kff.org**.*

**Facilitator:**We're at the top of the hour so at this time I'd like to [audio break 0:00:03] over to Dr. Elizabeth Yano to introduce our speaker.

**Moderator:**Thank you so much, Molly.  Presumably most of you know who I am by now.  I'm the Director of the VA Women's Health Research Consortium in VA HSR&D Service.  I have the great pleasure of introducing Dr. Alina Salganicoff.  She is Vice President and Director of Women's Health Policy for the Kaiser Family Foundation, which is a non-profit, private operating foundation, focused on the major healthcare issues facing the United States as well as the U.S., world, and global health policy and is not affiliated with Kaiser Permanente or Kaiser Industries.

Dr. Salganicoff is widely regarded as a national expert on women's health policy and healthcare reform and has also written and lectured extensively on healthcare access and financing for women.  Dr. Salganicoff has served as an advisor to several federal and state agencies and non-profits.  She was also appointed to serve on the Institute of Medicine Committee on Women's Health Research and the Institute of Medicine Committee on Preventive Services for Women.

I am very grateful for her service on the Executive Steering Committee for the Administration of Women's Health Research Consortium.  Thank you again, Dr. Salganicoff and let's go from there.

**Dr. Salganicoff:**Great.  I am just delighted to be able to join you all here today.  What I want to do—let me see if I'm going to try to advance my slides here.  Here we go.  Great.  What I want to do today is talk a little bit about what's been going on with the Affordable Care Act.  It's been so much in the news in the past week.  Still many people are confused and even those of us who work on these issues on a daily basis are still learning new things about the Affordable Care Act.  I was very excited to have this opportunity to talk to a VA audience about what this might mean for women.

As many of you know, people are extremely confused about what's going on.  This data here is from a monthly tracking poll that the Kaiser Family Foundation does about the state of knowledge about a wide range of healthcare issues.  This specifically was focused on the Affordable Care Act as have been most of our polls over the past couple of years.

We asked individuals, "As you may know the healthcare bill was signed and which comes closest to describing the current status of the healthcare law?"  As you can see in blue, 57 percent of the population did answer this correctly; however, one-third don't know or refuse to answer and another 8 percent felt like this was repealed by Congress.  Another 5 percent felt that it was overturned by the Supreme Court and no longer a law.  As you can see, there is still quite a bit of confusion out there.

As we think about it, I'm going to go here to the first polling question, "Do you feel that you have enough information about the health reform law now to explain it to a patient or a family member about how it may be affecting them?"  If we could take a minute or two here—

**Facilitator:**Thank you very much.  It looks like the answers are streaming in.  We're getting quite a great response rate, so thank you to our audience members.  This does help us proceed with the presentation.  Still coming in.  I think this is the highest response rate we've ever had.

**Dr. Salganicoff:**People have been thinking about it.

**Facilitator:**I'm sure it's a hot topic this week.  Looks like they've slowed down if you want to go ahead and go over the answers real quick.

**Dr. Salganicoff:**Okay.  Great.  Let me go back.

**Facilitator:**It's okay.  You can just click in or out of full screen mode.  I can read through real quick.  It looks like we have 19 percent that say, "Yes I have enough information."  About 81 percent saying, "No, I do not have enough information."

**Dr. Salganicoff:**All right.  I'm just having a little trouble now getting back here.  Okay.  Great.  When we looked at the American public, people were also extremely confused.  You can see here that we asked 47 percent said that they had enough information.  This was done back in August.  Clearly now people are realizing that you need even more information than you may have anticipated.  Fifty-one percent said that they did not have enough information.  What was also particularly worrisome was that when we looked at people who were low income, those with annual household incomes less than $40,000.00 a year or those who were uninsured who under age 65, basically anywhere from 60 to 62 percent said that they did not have enough information to really figure out how it's going to impact their families.

What I want to do today is spend a little time talking about where we are with the implementation now that we're three years post enactment and talk about some major issues involved in the coverage expansion, particularly related to the Medicaid and the exchanges looking at program eligibility and enrollment, what the benefits and the scope of coverage are, and some of cost and affordability issues.

In addition, what I'd like to do is zero in a little bit on the services of importance to women.  Women have played an important role both in terms of the advocacy in getting the Affordable Care Act passed.  There are some very important improvements as well for women's health coverage as well as potentially their access to care.  Then some considerations as we look forward what may be likely to happen.

Where are we today?  There were some provisions of the law that were actually implemented very quickly right away.  They established temporary high risk pools for people who were uninsurable.  This was done at the state level.  They expanded dependent coverage to age 26.  We've seen a tremendous increase in the number of 19 to 26 year olds who now have insurance coverage, many of them now through their parents' plans.  There have been the elimination of lifetime limits and rescissions and restrictions on annual limits.  We no longer have pre-existing conditions for children.  Starting in January 1st, we will have no longer pre-existing condition exclusions for adults.

The plans are now—their rates of increases need to be reviewed by state insurance commissioners.  We're actually seeing some of these increases being rejected.  That's been really an important change.  As well, some of the plans are now providing rebates because the rates were too high.  Now we also have no cost-sharing for preventive services in private plans.  I’m going to talk a little bit more about that in some detail.  For people who are in new plans or plans that are not grandfathered, that has already taken effect.

This is kind of a pyramid that discusses how health reform should work, particularly around the health coverage expansions.  The law has a lot of health insurance reforms, like the ones that I mentioned around the pre-existing condition exclusions and limits on out-of-pocket costs, but in addition to that one of the main parts of the law was really to expand coverage.

As we look here—I’m going to try to use the arrow.  Here on the bottom of the graphic you can see employer sponsored coverage.  That's supposed to be the foundation of the expansion.  Part of the law was that employers are also now required to cover health insurance for their employees.  That part of the law, as you may have heard, has been postponed to 2015.  The goal was really not to effect or to eliminate employer sponsored coverage, because we really need that.  Over half, I think around 54 percent of Americans have coverage through their employer, although that has been eroding over time.

In addition to that, what we had was for the poorest individuals there was going to be an expansion of Medicaid coverage for low income individuals.  That was going to happen on the state level.  For those who were higher income, those up to 400 percent of the poverty, were going to be able to get their insurance through healthcare marketplaces.  Sometimes they're called exchanges.  Now the new terminology is marketplaces.  Those individuals, we're going to get federal subsidies to get that.  All individuals were required to have an individual mandate.  You must have insurance coverage with a few exceptions.  I'll discuss that.

The goal is universal coverage.  It is unlikely that we will get here, at least in the immediate future, because there are many states that have not moved forward with a lot of the expansions that were initially envisioned.

Initially it was envisioned that the Affordable Care Act will deal with the 20 percent of the uninsured that you see there.  Over half of them had incomes below 138 percent of the poverty level.  This is women, but it's highly reflective of the general population as well.

Another 37 percent, slightly over a third, have incomes between 139 and 399 percent of the poverty level.  These are the individuals who would likely qualify for financial subsidies and would be able to buy their coverage through the exchange.  Ten percent of women had incomes above 400 percent of poverty, so they are uninsured but they will be able to get coverage on the exchange.  They will be required to get coverage, but they will not qualify for federal subsidies.

As you can see here, there are these really tremendous geographic variations across the country in terms of who is likely to benefit.  This is a map that looks at, I think, the county level as to the share of the uninsured with incomes under 400 percent of poverty.  These are people who would likely qualify for Medicaid or also qualify for subsidies under the health exchange.  As you can see in the grayer states, that's less than 15 percent; whereas, in a lot of the border and in the northwest you see that there are a lot of individuals who fall into this category.

As we look at how this initially was envisioned, this is Medicaid eligibility today.  As most of you probably know, just being poor is not enough to qualify for Medicaid.  Medicaid has historically been a categorical as well as an income or means tested program.  People who, in order to qualify for Medicaid, you need to fit into one of the different categories, that's elderly and people with disabilities, children, pregnant women, and parents of dependent children.

Historically single adults and married adults without children have been excluded from Medicaid, no matter how poor they were.  This was a really big gap and part of the goal of the Affordable Care Act was really to fill this gap so that in order to qualify for assistance you would just have to be very low income.

However, that was not the outcome.  After the Supreme Court issued its ruling, which found that the states did not have to expand Medicaid coverage, there was really a dramatic change in how the law was ultimately going to be implemented.  Right now there are 24 states that have expanded their Medicaid eligibility.  At this point, 26 states have decided not to move forward at this time.  There are some states like Tennessee, Pennsylvania, and New Hampshire where there is a possibility that they may move forward and they're still kind of in debate, but at this time they haven't given clear indication that they're going to do that.

What does that mean?  This is a very busy slide, but you can see here, and what's important to see here, are the Medicaid eligibility levels, the current levels, for parents.  You can see here that there's tremendous variation in states like Arkansas, Alabama, Indiana, Texas.  You have to be at 25 percent of the federal poverty level.  That is an extremely low income and a parent in order to qualify.

As you can see here, some of the states and most of the states actually—these are not all of the states.  These are those that have income below 133 percent of the poverty level.  The states that are noted here in gray are where there's going to be gaps.

Let me just walk you through this.  In Louisiana, for example, if your income is up to 24 percent of the federal poverty level, you will be able to get and continue to qualify for Medicaid; however, if your income is anywhere between 24 percent and 100 percent of the federal poverty level, you will not qualify for any Medicaid assistance because the state is not expanding coverage.  You will be barred from getting any subsidies on the exchange.  For these very poor individuals, there will be no difference and no option to get coverage on the exchange.

If your income is above 100 percent of the poverty level, then you will qualify for subsidies on the exchange.  Right now this is a tremendous gap and will really limit the reach of the Affordable Care Act to some of the poorest individuals in the country.

The states also have a choice of how they're going to structure their health insurance marketplaces.  As you can see here, about 17 states and the District of Columbia are operating their own marketplace.  Seven states are having a partnership with the federal government to operate a marketplace.  Twenty-seven states are basically allowing the federal government to operate this marketplace.  Basically the federal government makes all the policies and rules and the access to the health exchanges there.

This is moving now to our next poll question, which is looking at the kind of information that people have on health exchanges.  Let's take a quick poll here if you've seen or read ads.

**Facilitator:**Thank you very much.  I also want to thank everybody for their patience while we lost audio temporarily.  My computer decided to reboot itself.  Not much I could do about that.

**Dr. Salganicoff:**Molly, I'm also having...  like it pops up into—I was not in the full screen and then I'm afraid I'm going to lose the same thing again.  How do I get back into this full screen?

**Facilitator:**It's okay.  It should be located at the top center right of your screen.  Do you see that there?

**Dr. Salganicoff:**I have speakers, audio, set status.  Meeting?

**Facilitator:**Nope.  No.  Just hold on one second and I will get this a little bit smaller.

**Dr. Salganicoff:**Oh great.  Here we go.  Okay.

**Facilitator:**It looks like the poll results are that just over 59 percent answered yes.  Almost 41 percent answered no.  Thank you to our respondents.

**Dr. Salganicoff:**Great.  As you can see here, this is a data that was actually from a Kaiser Health tracking poll just taken last month.  What we found was that 48 percent had not heard at all about this.  This is actually--the date is actually September, not August.  I'll make that correction.  About half had not heard anything about the health exchanges.  One-third had heard a little bit.  Only 14 percent had heard some.  Only 5 percent had heard a lot.  Clearly with the news this past week I think a lot more people have heard about the fact that the exchanges are there, but this is going to really, really require a major, major outreach effort to get people who are needing coverage enrolled and informed about what their coverage options are.

These are all of the different exchanges.  You can look in your state and see if it's there or not.  There's been a lot of work in terms of branding and a lot of the states, I live here in California, and Covered California has been very active in trying to get outreach and enrollment as I'm sure they have been in all of the other states.

How's it going to work?  All of these states have—what they're going to have is a Web site.  Individuals can either apply on paper, which will get put in through the Web site through an assister, or they can call or they can apply themselves.  Individuals will then be identified as eligible for Medicaid or they'll be eligible for a premium or tax credit and be able to buy a plan on the exchange.  Or they will not qualify for any tax credit and they'll get some kind of—they'll get access but without the subsidies.  That's going to be determined presumably in real-time.

You may have been hearing about the problems with the startups with the exchanges and that was very unfortunate.  There was an overwhelming response and the states were moving very, very quickly as were those in HHS trying to get the federal Web site, healthcare.gov, operational.  There was a tremendous response on the first day.

Once you determine your eligibility, you're going to get information on the different types of plan that you qualify for and presumably you're going to be enrolled in your selected plan.  These plans then start on January 1 for people who are covered, I believe it is, you need to be enrolled by December 15.  There is going to be an open enrollment period and that starts now.  It will go through March 31, 2014.

Once you go in, you're going to be asked, once they figure out the subsidy level that you qualify for, you're going to be asked to select a bronze, silver, gold, or platinum, or for those who are under age 30, catastrophic plan.  These plans differ in terms of the actuarial value of what they cover.  That's the actual value of the level of coverage that you'll have.  They'll also vary in terms of the deductibles that you'll have to pay and the co-insurance in terms of the share of visits and the maximum out-of-pocket costs as you can see here.  All of them have a maximum out-of-pocket cost.  This is for an individual that should not exceed $6,350.00.  A family's is double, $12,700.00

How might that work?  This is an example from California.  If you're a single 25 year old and you earn $25,000.00 a year, the overall unsubsidized level is based on the second lowest cost silver plan and annually that's $2,772.00 a year.  Your individual contribution is calculated at $1,021.00.  That's annually.  You will receive a tax credit of $1,751.00.

If you look at the case of the 40 year old parents, a 4-person family, making around $50,000.00, which is around the median income in the United States, their overall cost for the unsubsidized plan is $10,563.00.  They will get a very significant subsidy of $7,198.00 and their contribution here in orange will be $3,365.00.  They will also get basically 70 percent of the cost will be covered through the federal subsidy.

Similarly it operates for this is a 60 year old couple who earns $50,000.00 a year.  They also get a very, very significant tax credit.  You'll notice here that although they can't make your rates based on your health status, they do have age banding.  The premium for the 60 year old couple is considerably higher than the 4-person family.  As you can see, it's over $4,000.00 more, but also their subsidy is also significantly higher.

What are these plans going to cover?  There are ten specified categories of what they call "essential health benefits" that are listed here.  All of the plans are going to be required to cover these ten categories of benefits.  In addition, this will also apply to individual insurance plans that people purchase outside of the exchange.  There will also be a Medicaid expansion group.  They may or may not have the same exact benefits as the traditional Medicaid group, but the benchmark benefits must include these benefits.

One of the really important changes has been the fact that for the first time there are specifications as to what types of benefits insurance must cover.  One of the big changes has been the expansion and requirement for the first time that insurance plans cover preventive services.

I want to be clear that this does not just apply to the plans that are sold and available to the exchange, but it affects basically all private health insurance plans.  Those are plans that you get through your employer as well as the individual plans.  It applies to self-funded plans, that is plans that are self-insured, as well as those plans that individuals buy through the individual insurance marketplace.

Now all new plans, they must cover without cost-sharing all of the U.S. Preventive Services Task Force recommended service that are rated A or B, basically services that are rated as highly effective.  All the immunizations that are recommended by the advisory committee on immunization practices.  For women, that means the HPV vaccine as well as flu vaccines.  For children, all of the Bright Futures guidelines for preventive services and screenings are also included.

In addition, now there are a new set of eight new services that are also included for women.  That includes well-woman visits, screening and counseling for gestational diabetes for pregnant women and HIV and STI for all women, HPV testing, all FDA approved contraceptives, breast feeding support, supplies, and counseling.  That includes breast pump rentals.  For the first time interpersonal domestic screening and counseling services.  That is also an important new expansion that's covered under private plans.

Right now I'm not exactly sure.  We don't know exactly how many people are in plans that are considered grandfathered plans, but it's estimated that over time all individuals will be in plans that have changed in some way or new plans and they will no longer be considered to be grandfathered plans.  We expect most individuals to have coverage, first dollar coverage, for preventive services.

It's a pretty extensive list.  This is just a summary of the adult preventative services to be covered by the private plans.  These must be covered without cost sharing.  Women's preventive services are the ones that are in orange, but as you can see through the list here, many of these services are not—the women's services are just a fraction of the many important services that are now going to e covered.

One of the areas that has gotten the most attention, I would say, on all of these has been contraceptive coverage.  The way the HRSA guidelines interpreted the recommendations that were made by the Institute of Medicine was that it would be contraceptive methods as prescribed.  These are barrier-methods, hormonal, emergency contraception, implanted devices such as IUDs or rods, and sterilization.  It's a pretty, pretty broad swath and it's meant to be very comprehensive.

It should be noted that this only applies if you get your services through an in-network provider.  Women that go out of network may be covered, but they won't be covered without cost-sharing.  This also includes counseling and insertion as well as services related to the follow-up of side effects or for adherence or education or device removal.  There's been some anecdotal evidence that not all of the plans are actually covering all of the services or that women are having difficulty particularly in accessing some of the more expensive contraception options such as the Mirena, or the NuvaRing.

HHS did come out with clarification earlier in the year that says that if a generic would be medically inappropriate, the plan must waive cost-sharing if the provider recommends this brand or a non-preferred brand because the formularies still do apply.  If a generic's not available or would be inappropriate, then it has to cover the brand name drug.

What's important to note is this service, along with all of the other preventive services, are required subject to reasonable medical management.  There is, unfortunately, not a lot of clarity right now as to how plans are describing their medical management or what would be considered to be reasonable.  A lot of the advocates are waiting for some clarification, further clarification, from HHS, but it has not happened yet.

The other area where there's been a tremendous amount of attention around contraceptive coverage relates to the religious exemptions.  Right now, the way the law is written, all houses of worships are completely exempt but only from the contraceptive coverage requirement, if they so wish.  An HHS regulation came for religiously affiliated non-profits, and that's an important distinction, that object.  In those cases, either an insurer or the third party administrator would be required to cover the contraceptive services and supplies, not the employer, thus requiring that women have access to contraceptive coverage without requiring the employer to pay for it if they have an objection.

There have been more than 60 lawsuits, however, filed against HHS, the Department of Labor, and Treasury to block implementation of this particular provision.  This has been filed by non-profits and also for-profits, individuals, and corporations.  The administration has actually asked that the Supreme Court hear this case and we're expecting that to happen possibly in the coming year.  That is one of the big areas that's still unresolved from the courts.

Access to abortion coverage is explicitly addressed in the affordable care act.  It is explicitly banned as an essential benefit.  In the case of Medicaid expansion, Medicaid still is subject to the high limitations.  That means that no federal funds, tax credits, subsidies may be used for abortion coverage expect in the cases of when the pregnancy is a result of rape or incest or life endangerment.  States can use their own funds to cover other medically necessary abortion and 17 states currently do that.

In terms of the state exchanges, the states are actually permitted to ban coverage on the health exchange and currently 23 states have passed laws since the ACA was enacted that ban private plans that are available through the exchange from offering abortion coverage.  If a state is still allowing that coverage, there are special rules that the plans must follow to ensure that the funds are completely segregated so that no federal subsidy even can be used to pay for abortion services.

In terms of maternity care, there have also been some really, really important advances.  Now pregnancy can no longer be defined as a pre-existing condition.  Maternity and newborn care is defined as an essential benefit in plans.  This is really important because historically in the individual insurance market, very few women have had access to maternity coverage.  Through employer plans, through the pregnancy discrimination act, most women in employer plans do have maternity coverage; however, if you end up buying your own coverage you—if you were pregnant you were just banned from coverage because it was considered a pre-existing condition, or in most cases even if you wanted to buy that coverage, it was not available.  Only 12 percent of—National Women's Law Center Analysis found only 12 percent of individual plans even offered maternity coverage.

In addition, now Medicaid, which covers 41 percent of all births naturally—I think there's actually a new study that came out that it's now up to 50 percent of all births—there is now mandatory coverage of tobacco cessation programs for pregnant women and new optional coverage for freestanding birth centers.  Medicaid now covers for one year all newborns who lacked acceptable coverage.

There are new grants for home visiting and post partum depression and new important breast feeding protections for nursing mothers so that employers greater than 50 have to provide a private place that's not a bathroom to express milk and also need to provide women with the adequate break time to do it.

One of the other important advances for women has been looking—now there is a new requirement for a well-woman visit.  This is a list of the potential services that women could get that are just preventive services that is from the IOM report.  As you can see, it's an extremely extensive list.  How do we cover this?  What services are covered?  What does this mean for a primary care medical home?  All are really important questions that we really need to grapple with, I think, in the next stage of this implementation.  What does it mean and who should be doing it?

In addition, I think the Affordable Care Act will have some really important and, in some cases, very positive impacts on practice.  Clearly now, more patients that providers see are going to have insurance coverage, which is going to expand access and affordability of coverage to millions of individuals, as I mentioned earlier.  There's going to be now finally a floor on the scope of coverage which includes all of the essential benefits.  You have first dollar coverage for preventive services.

Now higher reimbursements for primary care.  There is a lot of attention to primary care in the Affordable Care Act.  One of the big concerns has been reimbursed at much lower rates than specialty care, so these are—in the map here you can see that some of the states will have some pretty significant fee increases over this coming year.  They've been a little slow to implement this in some of the states.

There are, I think, some real challenges.  There are still going to be co-insurance and deductibles, which could be very high and still difficult for individuals to pay.  As I mentioned earlier, the "reasonable medical management" definition will be, I think, a challenge for providers to help advocate on behalf of their patients when the plan doesn't cover services that they think they should get.

There are still significant concerns about the primary care work force.  If it's adequate enough to meet the needs of the millions of individuals who are going to be coming into the insurance system.  We still have extremely low reimbursement rates for Medicaid and in some locations very limited provider participation.  In some places, it's very hard to find a provider who will see you if you have Medicaid, particularly if you need specialty care.

We will see a lot of growth in private plans both in terms of Medicaid and the exchange.  There has been some anecdotal reports that in order to keep the premiums low, which is the incentive to make the plans affordable, that provider reimbursements are very low as well.  That is an area of concern.

Also, finally and the really critically important issue, is the involvement of essential community providers could be very limited if they aren't involved in managed care networks or particularly family planning clinics that may not be included where they have traditionally been seeing many uninsured.  Also the adequacy of networks.  Will there be enough specialists?  Will there be enough providers to serve the populations that are enrolled?

As you can see, people need—there's a lot of information there.  People are very overwhelmed.  People really—individuals really are looking to and trust their healthcare providers, federal agencies as a source of information on the Affordable Care Act.  As you can see here, 44 percent said they would trust their doctor or their nurse "a lot."  Thirty-four percent said their federal or state agency.

However, when you see on the other side as where they're getting information in the past 30 days, only 22 percent said they heard something from their doctor or nurse about it.  Mostly where people are getting information is from the news media and most of that information, as you can imagine, kind of focuses on the more sensational and the political aspects and a lot less on the nuts and bolts about how to get enrolled and what types of services that you may be eligible for.

The other area that I think hasn't gotten as much attention is that it is estimated, and the CBO estimates, that in 2019 that 23 million people will still be uninsured across the country.  These are individuals who are undocumented, who are not qualified, who do not qualify for any federal subsidy, cannot purchase coverage on the exchange.  Individuals who may be eligible for Medicaid but don't enroll.  Those who are in states who don't expand Medicaid.  In addition, there are certain individuals who may be exempt from the mandate because they don't have affordable insurance coverage.  That's coverage that exceeds 9.5 percent of your income.  That's going to be a barrier.  It's a lower rate for lower income people or people who just choose to pay the penalty rather than getting coverage.

I think one of the things we know is that most of the remaining uninsured will be low income and will still need a healthcare safety net because they'll still need the services.  As all of you, I'm sure, well know those who are uninsured are much less likely to get recommended preventive services and this goes throughout the healthcare needs.  If you're uninsured, you're much less likely to get the care that you need.

Finally, where are we looking as we look ahead?  Right now we're in the open enrollment period for the marketplaces.  It's going to last six months.  There is a lot of energy right now at trying to get as many people who are eligible enrolled.  There are many elements that are really important for coverage and care for women.  We have an elimination of gender rating.  There are new subsidies and new requirements for benefits including maternity care and contraception.

This is an important opportunity, but there are still going to be many gaps.  I think that that's important to recognize that we are still going to need the healthcare safety net as we move forward.  Individuals are going to be needing assistance in order to get enrolled.  It's designed to be simple, but it's not always simple.  You need to have a lot of documentation ready and some information as well in terms of the type of plans that you'd like to enroll in.  Clearly women, as decision makers for their families, are going to play a critical role here.

Finally, 2014 is not the end.  It is the beginning.  With any luck, we'll keep reforming and strengthening this law so that more and more individuals can get access to the care they need.  Molly?

**Facilitator:**Thank you so much.  I’m still here, don't worry.  I just had to pull up the slide real quick.

**Dr. Salganicoff:**Yeah.  Great.

**Facilitator:**I know a lot of people joined us after the top of the hour, so I just want to let you know to ask a question or give a comment, please use the Q and A box located in the upper right hand corner or your screen and I'll be sure to pass it along in the order that it was received.

So far we've had a lot of questions asking about how to access the slides.  Just refer back to the reminder email you got to enter the session and there is a hyperlink leading directly to the slides.  It will also be posted with the archive.

First off, first question we have what happens after open enrollment for consumers?

**Dr. Salganicoff:**What happens?  Individuals can now go and actually there's a period between now and January where they can actually—I'm sorry.  After the open enrollment period?  Can you ask a question?

**Facilitator:**Yeah, what happens after?

**Dr. Salganicoff:**After the period ends.  Individuals are not going to be able to qualify for the subsidy, so it's really important that they enroll now.  The subsidy qualification ends.  That's a big change from how it was in the past.

**Facilitator:**Thank you for that response.  The next question we have, in the example of the state Louisiana, where between 25 and 100 percent of the poverty line did not receive subsidies for the insurance exchange, why did those individuals not qualify to receive subsidies?

**Dr. Salganicoff:**Through, I'm sorry, what subsidies?

**Facilitator:**It says, at the poverty line did not receive—

**Dr. Salganicoff:**So basically the way the law was setup was that it was structured so that people below 138 percent of the poverty level would only qualify for Medicaid, would qualify for Medicaid.  There was an overlap group of those 100 and 138.  Those over 100 percent of the poverty level could get subsidies, but basically the law is written unfortunately is that those with incomes below 100 percent of the poverty level qualify for Medicaid and not federal subsidies.

What ended up happening is in the states that didn't expand their coverage, there is just a tremendous gap and those individuals don't legally qualify for federal subsidies.  I know it sounds crazy, but that's the way it's structured right now. 

For Louisiana, just so you know, for a percent of the poverty level it's basically working parents who earn more than $4,665.00 a year up to those up to the federal poverty level will not qualify for any assistance.  Those individuals basically are like they are today.  They're just not going to have access to coverage through Medicaid or subsidized care on the exchange.

**Facilitator:**Thank you for that reply.  We do have several more questions pending, but I just want to let you know that several people have written in saying, "Thank you so much for this excellent presentation."  They'll be sure to pass along the resources to their colleagues.

**Dr. Salganicoff:**Oh great.

**Facilitator:**The next question, is there any provisions for those needing insurance prior to January 1st?

**Dr. Salganicoff:**There were provisions.  There were the high-risk pools that I mentioned earlier.  Those provisions were there.  There was small but significant enrollment for people who had pre-existing conditions and couldn't afford it.  In addition, there was the expansion of the eligibility of the dependent coverage so that a lot of young adults now were covered.  The actual expansion does not start until this January.

**Facilitator:**Thank you.  The next question, do people pay the full premium of out-of-pocket with reimbursement at tax time?

**Dr. Salganicoff:**No.  Actually you pay—it's a monthly payment.  The credit is calculated in your payment.  You don’t have to pay the full amount and then get reimbursed.  If you ended up having a lower income then you actually calculated, then at tax time you would actually get a rebate because you would qualify for a lower subsidy.  Conversely, if you ended up and you had a higher income, then you would actually have to pay more at tax time.  They call that the reconciliation.  That will happen—probably the first year that that will happen will be April of 2015.

**Facilitator:**Thank you for that reply.  We do have some great questions coming in.  The next one, for people who have employer insurance, is there anything that person needs to do?

**Dr. Salganicoff:**No.  No.  They are covered.  Basically there is an employer mandate, but any employer sponsored insurance basically, unless it's one of these mini-med plans, basically functions as what they call creditable coverage.  They shouldn't have to do anything.  They might want to find out if they're a grandfathered or not plan because then they will be eligible to have a wide range of preventive services.

**Facilitator:**Thank you for that reply.  The next person has both a comment and a question.  Thank you so much for this incredibly helpful presentation.  When do states that have opted out thus far, for example Pennsylvania, Tennessee, New Hampshire, have to decide whether to opt in?

**Dr. Salganicoff:**States can decide to opt in at any time they want.  The incentive to do it sooner versus later is that the first year that you get full 100 percent federal funding for the expansion population.  As you probably know, Medicaid is a shared federal and state program and the level of the federal match is largely based on the poverty rate in the state.  Some states, like Louisiana, Mississippi, where their poverty rates are high receive an 80 percent federal match for their traditional Medicaid.  With this expansion, they'll get 100 percent the first year and then it goes down to 90 percent in the subsequent years.  If they wait until the second year, they won't get 100 percent.  They'll get the 90 percent, but they can join any time.  We're hoping many of them will change their minds.

**Facilitator:**Thank you for that reply.

**Dr. Salganicoff:**I speak for myself on that one.

**Facilitator:**Probably not just for yourself.  After the initial six months window expires, you said one cannot apply and get subsidies.  What if your employment situation changes, say, seven months from now, like if you don't need the exchange until seven months from now?

**Dr. Salganicoff:**If you have one of these kind of, I don’t know what the terminology is, a life-changing event, you lose your job, you get a job, you get married, you have a baby, then you are allowed to qualify.

**Facilitator:**Thank you.  We do have lots more great questions coming in.  The next one, what about those that have coverage until let's say the end of February 2014?  Should those people apply now or wait until then?

**Dr. Salganicoff:**I think getting information and—you can apply now.  If you have coverage, you probably should wait, but you can pre-enroll.  I think trying to get information and trying to get as knowledgeable as possible is a good idea.

**Facilitator:**Thank you.  If abortion is currently covered in your employer sponsored plan, will it continue to be covered?

**Dr. Salganicoff:**Yes.  It will continue to be covered unless your state passes a law that says that they do not permit abortion coverage in private plans.  If that's the case, then it won't be.  It has nothing to do with the Affordable Care Act, rather it's state policy.

**Facilitator:**Thank you.  Children who are now on parents' insurance until 26 years old, when they get their own insurance can they apply for subsidies?

**Dr. Salganicoff:**Yes.  They can apply for subsidies.  Particularly that particular age group tends to be kind of in the lower earning phase of their life and so they will likely have also, because of the age banding, likely those plans are going to be very affordable for them.

**Facilitator:**Thank you very much.  That is actually the last pending question we have at this time.  I'd like to give you an opportunity to make any concluding comments, if you'd like.

**Dr. Salganicoff:**I think all of us—I think it's really going to be very challenging.  As I mentioned earlier, the more—I always used to say about Medicaid, the more you know the more you know you don't know.  I think this is going to be a similar situation with the Affordable Care Act where it's really the information—there's a lot of information to know.  A lot of it is evolving and decisions are actually still being made in terms of some of the policies.  It is a terrific opportunity for a lot of people who haven't had access to affordable coverage to start getting the care that they need.

**Facilitator:**I would like to thank you so very much for lending your expertise to the field today.  We do have a lot of appreciative attendees.  I also want to thank our attendees for joining us today.  This session has been recorded.  You will receive a follow-up email with a direct link to the archive.  Feel free to share that with any colleagues that you think might be interested or weren't able to come to the live session.

Also, as I close the session, you are going to be redirected automatically to a survey.  Please do give us your feedback on this presentation as it is your feedback that drives this program and helps us decide what topics to provide.  Thank you so much again.

**Dr. Salganicoff:**I just wanted to add one thing.  We have really, at the Kaiser Family Foundation, been trying to crank out as many resources as possible.  In addition to our kind of more wonky work, I would say, we have a lot of consumer information that we are providing that's available if you click on the link on the final slide there, a list of frequently asked questions and video explainers so that if you want to discuss this with others, hopefully it will be helpful in that process.

**Facilitator:**Great.  We really appreciate you making so many resources available.  All right, that does conclude today's HSR&D CyberSeminar.  Once again, I'd like to thank everybody for joining us and please do fill out the survey.  Have a wonderful day.

**Dr. Salganicoff:**Great.  Thank you.

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