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Payments for Affordable Care Act (ACA) Cost-Sharing Reductions [October 25, 2017]
"Funding for the cost-sharing reduction (CSR) payments established under the Patient Protection and Affordable Care Act (ACA) has been the subject of hearings about the individual insurance market, numerous press articles, and analyses from actuaries to consultants. Insurers have warned that they may leave the market or raise premiums without a commitment to sustained funding. On October 13, the Trump Administration filed a notice announcing it would terminate payments for CSRs beginning with the payment that was scheduled for October 18, potentially affecting 2017 and 2018 plan options and premiums. Payment termination may affect not only consumers who receive CSRs and insurers who provide them, but also have secondary effects on the broader individual market, non-CSR consumers, and the federal budget. To understand the concern about funding CSR payments, it is important to understand the context in which CSRs are provided, beginning with premiums."
Library of Congress. Congressional Research Service
Fernandez, Bernadette
2017-10-25
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American Rescue Plan Act of 2021 (P.L. 117-2): Private Health Insurance, Medicaid, CHIP, and Medicare Provisions [April 27, 2021]
From the Introduction: "The American Rescue Plan Act of 2021 (ARPA; P.L. 117-2), enacted on March 11, 2021, is the latest in a series of Coronavirus Disease 2019 (COVID-19)-related relief and economic stimulus legislation. [...] The ARPA includes provisions addressing a number of issues, such as tax credits, unemployment benefits, state fiscal relief, health, housing, education, and food assistance, among others. This report provides information about the ARPA provisions related to private health insurance, Medicaid, the State Children's Health Insurance Program (CHIP), and Medicare. The report begins with a summary of the reconciliation process for the ARPA. Then, the report provides high-level summaries of the provisions in the ARPA under the following headings: private health insurance, Medicaid and CHIP, Medicare, and Medicare and Medicaid. The high-level summaries are followed by a table with abbreviated summaries of each provision. The sections following the table provide more detailed summaries of these provisions. The 'Appendix' includes a table with a list of the abbreviations used in this report."
Library of Congress. Congressional Research Service
Mitchell, Alison; Baumrucker, Evelyne P.; Binder, Cliff . . .
2021-04-27
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Division A of H.R. 3922: The Championing Healthy Kids Act [November 07, 2017]
"On October 30, 2017, the House Rules Committee posted an amendment in the nature of a substitute for the Community Health And Medical Professionals Improve Our Nation Act of 2017 (CHAMPION Act, H.R. 3922). [...] The amendment in the nature of a substitute is entitled the Continuing Community Health And Medical Professional Programs to Improve Our Nation, Increase National Gains, and Help Ensure Access for Little Ones, Toddlers, and Hopeful Youth by Keeping Insurance Delivery Stable Act of 2017 (CHAMPIONING HEALTHY KIDS Act). In revising the language of the CHAMPION Act, the CHAMPIONING HEALTHY KIDS Act includes revised language for the CHAMPION Act in Division A. Division A would extend funding for several public health programs that had received directed appropriations through FY2017. It would also make a number of changes to these programs and would provide offsets for the proposed funding extensions. Division B of this act would, among other things, extend funding for the State Children's Health Insurance Program (CHIP). [...] This report summarizes provisions in Division A of the CHAMPIONING HEALTHY KIDS Act. CRS Report R44989, 'Comparison of the Bills to Extend State Children's Health Insurance Program (CHIP) Funding', summarizes provisions in Division B."
Library of Congress. Congressional Research Service
Heisler, Elayne J., 1976-; Fernandes-Alcantara, Adrienne L.; Fernandez, Bernadette . . .
2017-11-07
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Use of Modified Adjusted Gross Income (MAGI) in Federal Health Programs [December 6, 2018]
"Certain portions of federal health programs rely on means testing for eligibility and other purposes. Medicare premiums, the individual mandate exemptions and penalties, eligibility and amounts for tax credits for health insurance exchange coverage, and Medicaid eligibility are determined, in part, using modified adjusted gross income (MAGI). MAGI is a concept that is used throughout federal tax law and certain federal programs. There is no uniform definition of MAGI; rather, the term has different definitions depending on the purpose for which it is being calculated. For each of these federal health programs, MAGI begins with adjusted gross income (AGI) as calculated for tax purposes. From there, various types of income are included (or, in the case of Medicaid, subtracted) to calculate MAGI for each particular program. The different health programs do not necessarily define household income using the same groupings of people. For example, married couples living together are counted as the same Medicaid household regardless of whether they file a joint tax return. By contrast, married couples must file a joint tax return to be eligible for premium credits."
Library of Congress. Congressional Research Service
Baumrucker, Evelyne P.; Davis, Patricia A.; Fernandez, Bernadette . . .
2018-12-06
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Health Insurance Options Following Loss of Employment [Updated May 4, 2020]
From the Document: "Many Americans have health insurance coverage that is provided through an employment setting. In light of the economic repercussions of the COVID-19 [coronavirus disease 2019] pandemic, many Americans may lose the jobs through which they receive health insurance. Such individuals may need to identify another source of health insurance to remain enrolled in plans that cover COVID-19-related services. Three potential comprehensive coverage options for these individuals include the Consolidated Omnibus Budget Reconciliation Act (COBRA) continuation coverage, individual health insurance coverage, and Medicaid. An individual's eligibility for these coverage options depends on a number of factors (e.g., economic circumstances, family composition, federal/state policies). Even if an individual is eligible for such coverage, the costs associated with some options may be prohibitive given the individual's loss of income due to unemployment. This In Focus provides a brief overview of eligibility, benefits, and costs associated with these different health insurance coverage types."
Library of Congress. Congressional Research Service
Rosso, Ryan J.; Fernandez, Bernadette; Baumrucker, Evelyne P.
2020-05-04
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Federal Requirements on Private Health Insurance Plans [March 29, 2018]
"A majority of Americans have health insurance from the private health insurance (PHI) market. Health plans sold in the PHI market must comply with requirements at both the state and federal levels; such requirements often are referred to as market reforms. The first part of this report provides background information about health plans sold in the PHI market and briefly describes state and federal regulation of private plans. The second part summarizes selected federal requirements and indicates each requirement's applicability to one or more of the following types of private health plans: individual, small group, large group, and self-insured. The selected market reforms are grouped under the following categories: obtaining coverage, keeping coverage, developing health insurance premiums, covered services, cost-sharing limits, consumer assistance and other patient protections, and plan requirements related to health care providers. Many of the federal requirements described in this report were established under the Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended); however, some were established under federal laws enacted prior to the ACA."
Library of Congress. Congressional Research Service
Mach, Annie L.; Fernandez, Bernadette
2018-03-29
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Health Insurance Premium Tax Credits and Cost-Sharing Subsidies [March 29, 2018]
"Certain individuals without access to subsidized health insurance coverage may be eligible for premium tax credits, as established under the Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended). The dollar amount of the premium credit varies from individual to individual, based on a formula specified in statute. Individuals who are eligible for the premium credit, however, generally are still required to contribute some amount toward the purchase of health insurance. In order to be eligible to receive premium tax credits, individuals must have annual household income at or above 100% of the federal poverty level (FPL) but not more than 400% FPL; not be eligible for certain types of health insurance coverage, with exceptions; file federal income tax returns; and enroll in a plan through an individual exchange. Exchanges are not insurance companies; rather, exchanges serve as marketplaces for the purchase of health insurance. They operate in every state and the District of Columbia (DC)."
Library of Congress. Congressional Research Service
Fernandez, Bernadette
2018-03-29
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Health Insurance Premium Tax Credits and Cost-Sharing Subsidies [April 24, 2018]
"Certain individuals without access to subsidized health insurance coverage may be eligible for premium tax credits, as established under the Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended). The dollar amount of the premium credit varies from individual to individual, based on a formula specified in statute. Individuals who are eligible for the premium credit, however, generally are still required to contribute some amount toward the purchase of health insurance. In order to be eligible to receive premium tax credits, individuals must have annual household income at or above 100% of the federal poverty level (FPL) but not more than 400% FPL; not be eligible for certain types of health insurance coverage, with exceptions; file federal income tax returns; and enroll in a plan through an individual exchange. Exchanges are not insurance companies; rather, exchanges serve as marketplaces for the purchase of health insurance. They operate in every state and the District of Columbia (DC)."
Library of Congress. Congressional Research Service
Fernandez, Bernadette
2018-04-24
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Federal Requirements on Private Health Insurance Plans [May 1, 2018]
"The first part of this report provides background information about health plans sold in the PHI [Private Health Insurance] market and briefly describes state and federal regulation of private plans. The second part summarizes selected federal requirements and indicates each requirement's applicability to one or more of the following types of private health plans: individual, small group, large group, and self-insured. The selected market reforms are grouped under the following categories: obtaining coverage, keeping coverage, developing health insurance premiums, covered services, cost-sharing limits, consumer assistance and other patient protections, and plan requirements related to health care providers. Many of the federal requirements described in this report were established under the Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended); however, some were established under federal laws enacted prior to the ACA."
Library of Congress. Congressional Research Service
Mach, Annie L.; Fernandez, Bernadette
2018-05-01
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Eligibility and Determination of Health Insurance Premium Tax Credits and Cost-Sharing Subsidies: In Brief [November 16, 2016]
"Certain individuals without access to subsidized health insurance coverage may be eligible for premium tax credits, as established under the Patient Protection and Affordable Care Act (ACA; P.L. [Public Law] 111-148, as amended). The dollar amount of the premium credit varies from individual to individual, based on a formula specified in statute. Individuals who are eligible for the premium credit, however, generally are still required to contribute some amount toward the purchase of health insurance. [...] Individuals who receive premium credits also may be eligible for subsidies that reduce cost-sharing expenses. The ACA established two types of cost-sharing subsidies. One type of subsidy reduces annual cost-sharing limits; the other directly reduces cost-sharing requirements (e.g., lowers a deductible). Individuals who are eligible for cost-sharing subsidies may receive both types."
Library of Congress. Congressional Research Service
Fernandez, Bernadette
2016-11-16
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Health Coverage Tax Credit (HCTC): In Brief [December 6, 2016]
From the Summary: "The Health Coverage Tax Credit (HCTC) subsidizes most of the cost of qualified health insurance for eligible taxpayers and their family members. Potential eligibility for the HCTC is limited to two groups of taxpayers. One group is comprised of individuals eligible for Trade Adjustment Assistance (TAA) allowances because they experienced qualifying job losses. The other group consists of individuals whose defined-benefit pension plans were taken over by the Pension Benefit Guaranty Corporation (PBGC) because of financial difficulties. HCTC-eligible individuals are allowed to receive the tax credit only if they either could not enroll in certain other health coverage (e.g., Medicaid) or are not eligible for other specified coverage (e.g., Medicare Part A). To claim the HCTC, eligible taxpayers must have qualified health insurance (specific categories of coverage, as specified in statute). Several of those categories, known as state-qualified health plans, are available only after being established by state action. The HCTC is refundable, so eligible taxpayers may receive the full credit amount even if they had little or no federal income tax liability. The credit is also advanceable, so taxpayers may receive the credit on a monthly basis to coincide with the payment of premiums. The HCTC has a sunset date of January 1, 2020."
Library of Congress. Congressional Research Service
Fernandez, Bernadette
2016-12-06
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Potential Impacts of Uncertainty Regarding Affordable Care Act (ACA) Cost-Sharing Reduction Payments [September 25, 2017]
"Funding for the cost-sharing reduction (CSR) payments established under the Affordable Care Act (ACA; P.L. 111-148, as amended) has been the subject of recent hearings about the individual insurance market, numerous press articles, and analyses from actuaries to the Congressional Budget Office (CBO). The continuation of CSR payments has come into question, and insurers warn that they may leave the market or raise premiums without a commitment to sustained funding. To understand the concern about funding CSR payments, it is important to understand the context in which CSRs are provided, beginning with insurance premiums."
Library of Congress. Congressional Research Service
Fernandez, Bernadette
2017-09-25
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Overview of Health Care Changes in the FY2014 Budget Proposal Offered by House Budget Committee Chairman Ryan [March 22, 2013]
"On March 12, 2013, House Budget Committee Chairman Paul Ryan released the chairman's mark of the FY2014 House budget resolution together with his report entitled 'The Path to Prosperity: A Responsible Balanced Budget', which outlines his budgetary objectives. The House Budget Committee considered and amended the chairman's mark on March 13, 2013, and voted to report the budget resolution to the full House. H.Con.Res. [House Concurrent Resolution] 25 was introduced in the House March 15, 2013, and was accompanied by the committee report (H.Rept. [House Report] 113-17). H.Con.Res. 25 was agreed to by the House on March 21, 2013. [...] This report summarizes the proposed changes to Medicare, Medicaid, and private health insurance as described in H.Con.Res. 25, the accompanying committee report, and Chairman Ryan's 'Path to Prosperity' report. Additionally, it briefly examines the potential impact of the proposed changes on health care spending and coverage."
Library of Congress. Congressional Research Service
Davis, Patricia A.; Fernandez, Bernadette; Mitchell, Alison
2013-03-22
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Overview of Health Care Changes in the FY2015 House Budget [April 16, 2014]
"On April 1, 2014, House Budget Committee Chairman Paul Ryan released the chairman's mark of the FY2015 House budget resolution together with his non-binding report entitled 'The Path to Prosperity: Fiscal Year 2015 Budget Resolution,' which outlines his budgetary objectives. The House Budget Committee considered and amended the chairman's mark on April 2, 2014, and voted to report the budget resolution to the full House. H.Con.Res. 96 was introduced in the House April 4, 2014, and was accompanied by the committee report (H.Rept. 113-403). H.Con.Res. 96 was agreed to by the House on April 10, 2014. Once it is agreed to by both chambers of Congress, a budget resolution provides enforceable budgetary parameters; however, it is not a law. [...] Committee documents also suggest restructuring Medicaid from an individual entitlement program to a block grant program. In addition, beginning in 2024, the budget assumes the conversion of Medicare to a fixed federal contribution ('premium support') program. This report summarizes the proposed changes to Medicare, Medicaid, and private health insurance as described in H.Con.Res. 96 and accompanying documents, including the committee report and Chairman Ryan's 'Path to Prosperity' report."
Library of Congress. Congressional Research Service
Davis, Patricia A.; Mitchell, Alison; Fernandez, Bernadette
2014-04-16
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Overview of Health Care Changes in the FY2013 Budget Proposal Offered by House Budget Committee Chairman Ryan [March 29, 2012]
"On March 20, 2012, House Budget Committee Chairman Paul Ryan released the Chairman's mark of the FY2013 House budget resolution together with his report entitled 'The Path to Prosperity: A Blueprint for American Renewal,' which outlines his budgetary objectives. On the same day, CBO [Congressional Budget Office] issued an analysis of the long-term budgetary impact of Chairman Ryan's budget proposal based on specifications provided by House Budget Committee staff. The House Budget Committee considered and amended the Chairman's mark on March 21, 2012, and voted to report the budget resolution to the full House. H.Con.Res. 112 was introduced in the House March 23, 2012, and was accompanied by the committee report H.Rept. 112-421. H.Con.Res. 112 was agreed to by the House on March 29, 2012. [...] This report summarizes the proposed changes to Medicare, Medicaid, and private health insurance as described in H.Con.Res. 112, the accompanying committee report, Chairman Ryan's 'Path to Prosperity' report, and the CBO analysis. Additionally, it briefly examines the potential impact of the proposed changes on health care spending and coverage."
Library of Congress. Congressional Research Service
Fernandez, Bernadette; Mitchell, Alison; Davis, Patricia A.
2012-03-29
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Delay in Implementation of Potential Employer Penalties Under ACA [July 16, 2013]
"The Patient Protection and Affordable Care Act (ACA, P.L. 111-148), as amended, attempts to increase access to health insurance coverage, expands federal private health insurance market requirements, and requires the creation of health insurance exchanges to provide certain individuals and small employers with access to insurance. To ensure that employers continue to provide some degree of coverage, ACA includes a 'shared responsibility' provision. This provision does not explicitly mandate that an employer offer employees health insurance; instead, ACA imposes penalties on 'large' employers if at least one of their full-time employees obtains a premium credit through the newly established exchange. A companion provision to the employer requirements is the ACA requirement for most individuals to maintain health insurance coverage ('individual mandate') or pay a penalty, with exceptions. These provisions are effective in 2014 according to the ACA statute. On July 2, 2013, the Obama Administration announced that it is going to delay, until 2015, enforcement and associated reporting requirements relating to potential employer penalties under ACA. On July 11, 2013, the IRS [Internal Revenue Service] released Notice 2013-45, which provided more detailed information on this decision. This delay may have implications for the individual mandate and eligibility for tax assistance provided through the exchanges. It also may have some impact with respect to federal spending and revenues. This report summarizes some of these issues; however, it does not attempt to identify all possible implications of this delay. This report does not address whether the Obama Administration has legal authority to delay implementation of ACA reporting requirements and enforcement of the employer penalty."
Library of Congress. Congressional Research Service
Mulvey, Janemarie; Fernandez, Bernadette; Mach, Annie L.
2013-07-16
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Delay in Implementation of Potential Employer Penalties Under ACA [July 22, 2013]
"The Patient Protection and Affordable Care Act (ACA, P.L. [Public Law] 111-148), as amended, attempts to increase access to health insurance coverage, expands federal private health insurance market requirements, and requires the creation of health insurance exchanges to provide certain individuals and small employers with access to insurance. To ensure that employers continue to provide some degree of coverage, ACA includes a 'shared responsibility' provision. This provision does not explicitly mandate that an employer offer employees health insurance; instead, ACA imposes penalties on 'large' employers if at least one of their full-time employees obtains a premium credit through the newly established exchange. A companion provision to the employer requirements is the ACA requirement for most individuals to maintain health insurance coverage ('individual mandate') or pay a penalty, with exceptions. These provisions are effective in 2014 according to the ACA statute."
Library of Congress. Congressional Research Service
Mulvey, Janemarie; Fernandez, Bernadette; Mach, Annie L.
2013-07-22
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Health Insurance Premium Credits in the Patient Protection and Affordable Care Act (ACA) [July 31, 2013]
"New federal tax credits were authorized in the Patient Protection and Affordable Care Act (ACA, P.L. 111-148, as amended), to help certain individuals pay for health insurance coverage, beginning in 2014. The tax credits will go toward covering premiums for health insurance offered through exchanges--marketplaces offering private health plans. ACA also establishes subsidies to reduce cost-sharing expenses. ACA requires exchanges to be established in every state by January 1, 2014, either by the state itself or by the Secretary of Health and Human Services (HHS). Exchanges will not be insurers, but will provide eligible individuals and small businesses with access to private health insurance plans. Generally, the plans offered through the exchanges will provide comprehensive coverage and meet all ACA market reforms, as applicable. The new premium credits established under ACA will be advanceable and refundable, meaning taxpayers need not wait until the end of the tax year in order to benefit from the credit, and may claim the full credit amount even if they have little or no federal income tax liability. Although the premium credits will not be available until 2014, the examples provided in this report estimate premium credit amounts by income levels and age, if the credits were available in 2013. Under ACA, the amount received in premium credits is based on income tax returns. These amounts are reconciled in the next year and can result in overpayment of premium credits if income increases, which must be repaid to the federal government. ACA limited the amount of required repayments. Since the enactment of ACA, these limits have been amended twice, under P.L. 111-309 and P.L. 112-9."
Library of Congress. Congressional Research Service
Fernandez, Bernadette; Gabe, Thomas
2013-07-31
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Summary Cost Data for Federally-Facilitated Exchanges, 2014 [August 8, 2014]
"The Patient Protection and Affordable Care Act (ACA, P.L. [Public Law] 111-148, as amended) contains a number of provisions that may affect the individual health insurance market. These provisions will alter the amount that individuals and families can expect to pay for plans sold through the health insurance exchanges ('marketplaces') established under ACA, both in terms of premiums and cost-sharing measures. In general, the ACA provisions that may affect exchange premiums and cost-sharing requirements may also affect plans sold to individuals and families outside of exchanges." This report contains links to ACA fact sheets for each U.S. state.
Library of Congress. Congressional Research Service
Fernandez, Bernadette; Mach, Annie L.
2014-08-08
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Health Insurance Premium Credits in the Patient Protection and Affordable Care Act (ACA) [March 12, 2014]
"New federal tax credits were authorized in the Patient Protection and Affordable Care Act (ACA, P.L. 111-148, as amended), to help certain individuals pay for health insurance coverage, beginning in 2014. The tax credits apply toward premiums for private health plans offered through 'exchanges' (also referred to as health insurance marketplaces). ACA also establishes subsidies to reduce cost-sharing expenses. This report describes the eligibility criteria applicable to the premium tax credits and cost-sharing subsidies, and the calculation method for the credit and subsidy amounts. It also highlights selected issues addressed in the final regulation on premium credits."
Library of Congress. Congressional Research Service
Fernandez, Bernadette
2014-03-12
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Summary Cost Data for Federally-Facilitated Exchanges, 2014 [April 16, 2014]
"The Department of Health and Human Services established a data website that makes premium and cost-sharing data, for plans offered through federally-facilitated exchanges (FFEs), available to researchers and the general public. CRS developed a fact sheet for each of the 34 FFEs that offer private health plans to individuals and families. Each fact sheet provides summary data about the range of costs and options for plans in a specific state's marketplace. Given that these fact sheets are data documents, they do not discuss the factors that insurance carriers consider when developing premium rates or cost-sharing requirements. For example, medical claims represent the largest component of premiums by far, but claims costs are subject to a variety of factors, which may range from being plan-specific (e.g., limited provider network) to more general (e.g., market power of the carrier in negotiations with providers). Likewise, there are multiple considerations represented in cost-sharing requirements. For example, a given medical deductible may reflect heavy use of managed care techniques (as is the case in a traditional health maintenance organization [HMO], for example); presence of a separate prescription drug deductible; emphasis on consumer incentives to manage their use of health care services (e.g., a high-deductible plan that is paired with a health savings account [HSA]; and other plan features. Given the variability in the factors underlying both premiums and cost sharing, caution should be used when comparing amounts across geographic areas and, in certain instances, across plans in the same area."
Library of Congress. Congressional Research Service
Elan, Nicholas; Mach, Annie L.; Fernandez, Bernadette
2014-04-16
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Summary Cost Data for Health Plans Available in Maine's Exchange, 2014: Fact Sheet [May 1, 2014]
"The Patient Protection and Affordable Care Act (ACA, P.L. [Public Law] 111-148, as amended) contains a number of provisions that may affect the individual health insurance market. These provisions may alter the amounts that individuals and families can expect to pay for insurance plans sold on Maine's exchange. This fact sheet provides a look at selected costs and options for individual and family plans in Maine's exchange. (For background information, see the related overview report, CRS [Congressional Research Service] Report R43484, 'Summary Cost Data for Federally-Facilitated Exchanges, 2014'). A state resident interested in purchasing an individual plan in his or her exchange may have a choice of plans that vary in characteristics, such as the share of medical spending the plan will cover ('actuarial value,' or AV), the scope of the benefits package (e.g., types of services and providers covered), and other plan features. Under ACA, each plan that meets a specific AV is designated by a precious metal: platinum, gold, silver, or bronze. Exchanges are also allowed to offer catastrophic plans, with AVs below 60%; such plans are available only to individuals under the age of 30 and certain others who are exempt from ACA's individual mandate. Given this potential range in plans, this fact sheet displays premium and cost-sharing data tables for five categories of health plans, in order of decreasing actuarial value: platinum to catastrophic."
Library of Congress. Congressional Research Service
Mach, Annie L.; Fernandez, Bernadette; Elan, Nicholas
2014-05-01
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Child Welfare: Health Care Needs of Children in Foster Care and Related Federal Issues [November 19. 2014]
"Children who are placed in foster care are at a higher risk of having a medical, social, or behavioral disability than children in the general population. The abuse or neglect most experience before entering foster care can create physical and mental health issues, and the trauma of being removed from their parents may also incline children in foster care to social or behavioral health concerns. The Social Security Act addresses some of the health care needs of children in foster care-through provisions in titles pertaining to child welfare (Titles IV-B and IV-E) and those in the title pertaining to the Medicaid program (Title XIX). Federal child welfare policy expects state child welfare agencies to maintain health care records of children in foster care and to develop a strategy that addresses the health care needs of each child. States must provide Medicaid coverage to children who are eligible for the Title IV-E federal foster care program or, if applicable, eligible through other Medicaid eligibility pathways. […] This report begins with a discussion of major findings. It then briefly describes the foster care population and their unique health-related issues. Next is an overview of the federal programs and policies in three areas-child welfare, Medicaid, and private health insurance-that directly or indirectly address some of the health care needs of such children and young adults"
Library of Congress. Congressional Research Service
Fernandez, Bernadette; Fernandes-Alcantara, Adrienne L.; Baumrucker, Evelyne P. . . .
2014-11-19
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Private Health Plans Under the ACA: In Brief [September 19, 2013]
"The Patient Protection and Affordable Care Act (ACA, P.L. 111-148), as amended, expands federal private health insurance market requirements, and requires the creation of health insurance exchanges (marketplaces) to provide certain individuals and small employers access to private insurance, among other provisions. While some of ACA's private insurance provisions have already become effective, full implementation begins in 2014 and beyond. Given the breadth of ACA's reforms to the existing private insurance market and creation of new health insurance marketplaces, there is interest in understanding what types of health plans may be offered once these ACA provisions are fully implemented. This report provides short descriptions of health plans that may be offered inside and outside of exchanges, and includes information about interaction with other selected ACA provisions. The descriptions are displayed in a side-by-side format to facilitate comparison of exchange and nonexchange plans. This report does not attempt to identify all forms of health insurance coverage, but does address all plan types specified under ACA's exchange provisions, as well as major medical plans and certain limited benefit plans offered outside of exchanges. In addition, this report indicates the applicability of ACA's market reforms to plans offered in the private market."
Library of Congress. Congressional Research Service
Mach, Annie L.; Fernandez, Bernadette
2013-09-19
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Timeline Related to Health Insurance and Exchange Rules: Backdrop to 'King v. Burwell' [June 19, 2015]
"The Supreme Court is expected to issue a decision in 'King v. Burwell' by the end of June. The central issue in the case is whether the Affordable Care Act (ACA; P.L. 111-148, as amended) gives authority to the U.S. Department of the Treasury to make premium tax credits available to eligible individuals in every state (including the District of Columbia) or just the states that choose to establish their own health insurance exchanges (state-based exchanges, or SBEs). As of the date of this report, the direction and scope of the Court decision is unknown. However, it is generally agreed that a Court decision favoring the plaintiffs would affect the health insurance options of millions of consumers, as loss of premium tax credits would affect the affordability of health insurance for the consumers who no longer have the credits. Such a decision and its effects may motivate insurers, consumers, legislators, and others (referred to as 'stakeholders' in this report) to act. To the extent stakeholders are motivated to respond to the Court's decision, this report provides a timeline that identifies selected 2015 dates related to exchange establishment and operation, legislative calendars, and regulation of the individual health insurance market, among other issues. This information may be useful for setting parameters around potential stakeholder actions."
Library of Congress. Congressional Research Service
Fernandez, Bernadette; Mach, Annie L.; Uberoi, Namrata K.
2015-06-19
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Framework for Understanding Health Insurance Consolidations [September 22, 2015]
From the Background: "Like any viable business sector, the health insurance industry is dynamic. Insurers employ numerous strategies to achieve enterprise objectives, including mergers and acquisitions (M&A). While the specific motivations for each transaction vary, insurers pursue M&A to enhance (predicted) value, such as larger revenues or greater efficiencies. Consolidation concerns are rooted in the concept of market power (i.e., the ability to raise prices by affecting supply, demand, or both). Insurers exert market power as buyers of services from health care providers and as sellers of health plans to purchasers (individuals, employers, and governments). To the extent that any one insurer may dominate a market (market concentration), it may influence negotiations with providers, affecting payments for services. Insurers incorporate these payments in the determination of premiums. Since the majority of premium revenue is spent on medical claims, a change in provider payments may lead to premium adjustments. Thus, the final premiums charged to purchasers may reflect an insurer's market power. Concerns about market power underlie the pending mergers that involve several of the largest U.S. health insurers: Aetna, Inc. and Humana, Inc., and Anthem, Inc. and Cigna Corporation. Aetna and Humana each already has national presence, and a combined Anthem and Cigna would create the largest insurer, by health enrollment. However, health care generally is obtained at the local level, focusing attention on the impact of mergers in local health insurance markets (a notable exception is a multistate market for 'administrative services only' services for large businesses that self-insure)."
Library of Congress. Congressional Research Service
Fernandez, Bernadette
2015-09-22
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Use of Modified Adjusted Gross Income (MAGI) in Federal Health Programs [February 25, 2016]
"The Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended) created Section 36(B) of the Internal Revenue Code (IRC) to define household income, based on modified adjusted gross income (MAGI). MAGI is used to determine (1) penalty amounts owed if a person does not comply with the individual mandate or whether an individual is exempt from the individual mandate; (2) eligibility for and the amount of a premium credit to purchase coverage through a health insurance exchange; and (3) Medicaid income eligibility for certain populations. MAGI is also used to determine which Medicare beneficiaries pay high-income premiums. However, MAGI has many different definitions, depending on the purpose for which it is being calculated. For these government health programs, MAGI begins with adjusted gross income (AGI) as calculated for tax purposes. From there, various types of income are included (or, in the case of Medicaid, subtracted) to calculate MAGI for each particular program. Although the different health programs use the word 'household,' they do not necessarily refer to the same groupings of people. For example, married couples living together are counted as the same Medicaid household regardless of whether they file a joint tax return. By contrast, married couples must file a joint tax return to be eligible for premium credits. This report explores the different MAGI definitions across health programs, including Medicare, the health insurance exchanges under the ACA, and Medicaid. It also addresses why MAGI is used, and how it is applied, specific to each program."
Library of Congress. Congressional Research Service
Baumrucker, Evelyne P.; Davis, Patricia A.; Fernandez, Bernadette . . .
2016-02-25
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Eligibility and Determination of Health Insurance Premium Tax Credits and Cost-Sharing Subsidies: In Brief [March 23, 2016]
"Certain individuals without access to subsidized health insurance coverage may be eligible for premium tax credits, as established under the Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended). The dollar amount of the premium credit varies from individual to individual, based on a formula specified in statute. Individuals who are eligible for the premium credit, however, generally are still required to contribute some amount toward the purchase of health insurance. The premium credit may be applied only toward the cost of purchasing private health plans through health insurance exchanges. Exchanges are not insurance companies; rather, exchanges serve as marketplaces for the purchase of health insurance. They operate in every state and the District of Columbia (DC). The premium credit is refundable, so individuals may claim the full credit amount when filing their taxes, even if they have little or no federal income tax liability. The credit also is advanceable, so individuals may choose to receive the credit on a monthly basis to coincide with the payment of insurance premiums. Individuals who receive premium credits also may be eligible for subsidies that reduce cost-sharing expenses. The ACA established two types of cost-sharing subsidies. One type of subsidy reduces annual cost-sharing limits; the other directly reduces cost-sharing requirements (e.g., lowers a deductible). Individuals who are eligible for cost-sharing subsidies may receive both types."
Library of Congress. Congressional Research Service
Fernandez, Bernadette
2016-03-23
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Health Coverage Tax Credit (HCTC): In Brief [February 18, 2016]
"The Health Coverage Tax Credit (HCTC) subsidizes most of the cost of qualified health insurance for eligible taxpayers and their family members. Potential eligibility for the HCTC is limited to two groups of taxpayers. One group is comprised of individuals eligible for Trade Adjustment Assistance (TAA) allowances because they experienced qualifying job losses. The other group consists of individuals whose defined-benefit pension plans were taken over by the Pension Benefit Guaranty Corporation (PBGC) because of financial difficulties. HCTC-eligible individuals are allowed to receive the tax credit only if they either could not enroll in certain other health coverage (e.g., Medicaid) or are not eligible for other specified coverage (e.g., Medicare Part A). To claim the HCTC, eligible taxpayers must have 'qualified health insurance' (specific categories of coverage, as specified in statute). Several of those categories, known as 'state-qualified health plans', are available only after being established by state action. The HCTC is refundable, so eligible taxpayers may receive the full credit amount even if they had little or no federal income tax liability. The credit is also advanceable, so taxpayers may receive the credit on a monthly basis to coincide with the payment of premiums. The HCTC has a sunset date of January 1, 2020."
Library of Congress. Congressional Research Service
Fernandez, Bernadette
2016-02-18
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Overview of Health Insurance Exchanges [July 1, 2016]
"The Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended) requires health insurance exchanges (also known as marketplaces) to be established in every state. ACA exchanges are marketplaces in which individuals and small businesses can shop for and purchase private health insurance coverage. Exchanges are intended to simplify the experience of providing and obtaining health insurance. They are not intended to supplant the private market outside of the exchanges but to provide an additional source of private health insurance coverage. This report provides an overview of the various components of the health insurance exchanges. The report includes summary information about how exchanges are structured, the intended consumers for health insurance exchange plans, and consumer assistance available in the exchanges, as specified in the ACA. The report also describes the availability of financial assistance for certain exchange consumers and small businesses and outlines the range of plans offered through exchanges. Moreover, the report provides a brief summary of the implementation and operation of exchanges since 2014. While the report provides a high-level description of exchanges, it also includes references to other CRS [Congressional Research Service] reports that provide further information."
Library of Congress. Congressional Research Service
Uberoi, Namrata K.; Mach, Annie L.; Fernandez, Bernadette
2016-07-01
