Patient Protection and Affordable Care Act (ACA): Resources for Frequently Asked Questions Updated May 5, 2020 Congressional Research Service https://crsreports.congress.gov R43215 Patient Protection and Affordable Care Act (ACA) Summary The Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended) had numerous provisions affecting private health insurance and public health coverage programs. This report provides resources to help congressional staff respond to constituents’ frequently asked questions (FAQs) about the ACA. It lists selected resources regarding consumers, employers, and other stakeholders, with a focus on federal sources. It also lists Congressional Research Service (CRS) reports that summarize the ACA’s provisions. The Coronavirus Disease 2019 (COVID-19) pandemic has raised questions among some constituents about how to obtain and use health coverage. The ACA had several provisions to expand health coverage for certain eligible individuals. For example, the ACA established exchanges (sometimes called marketplaces) to provide eligible individuals with access to private health plans; it provides many exchange enrollees with subsidies to help pay for premiums, cost- sharing, or both. In addition, under the ACA, some states have expanded Medicaid eligibility. This report begins with contacts for constituents’ specific questions on obtaining and using health coverage (such as contact information for exchanges, state Medicaid agencies, organizations providing enrollment assistance, state insurance departments, and the U.S. Department of Labor’s consumer hotline for questions on employer-based coverage). These contacts can help constituents determine their health coverage options. The report also provides contacts for questions about health issues, and sources for congressional staff to contact federal agencies with ACA questions. The report then provides basic consumer sources, including a glossary of health coverage terms and sources for obtaining the law’s full text. The next sections focus on private health insurance, exchanges, and employer-sponsored coverage. These are followed by information on public health care programs, such as Medicaid, the State Children’s Health Insurance Program (CHIP), and Medicare. The report also provides sources on the ACA’s provisions on specific populations: women’s health care, Indian health care, veterans’ and military health care, and the treatment of noncitizens under the ACA. These are followed by sources on behavioral health (mental health and substance use disorders); public health, workforce, and quality; and state innovation waivers. Finally, the report lists sources on taxes, congressional efforts to repeal or amend the ACA, ACA agency audits and investigations, cost estimates and spending, insurance coverage statistics, and legal and regulatory issues. This list is not a comprehensive directory of all resources on the ACA but rather is intended to address some questions that may arise frequently. Congressional Research Service Patient Protection and Affordable Care Act (ACA) Contents Contacts for ACA Assistance........................................................................................................... 1 Help with Obtaining and Using Health Coverage ..................................................................... 1 Help with Health and Health Care Questions ........................................................................... 2 Help with Taxes ......................................................................................................................... 2 Assistance for Congressional Staff ........................................................................................... 3 Basic Consumer Sources ................................................................................................................. 3 ACA Text ......................................................................................................................................... 4 The Individual Mandate .................................................................................................................. 5 Private Health Insurance.................................................................................................................. 5 Overviews ................................................................................................................................. 5 Dependent Coverage ................................................................................................................. 6 Essential Health Benefits .......................................................................................................... 6 Risk Mitigation.......................................................................................................................... 7 Statistics .................................................................................................................................... 7 Exchanges ........................................................................................................................................ 8 Getting Exchange Coverage ...................................................................................................... 8 Using Exchange Coverage ........................................................................................................ 9 Exchange Subsidies ................................................................................................................. 10 Exchange Statistics and Research ............................................................................................ 11 Enrollment Statistics .......................................................................................................... 11 Additional Exchange Statistics................................................................................................ 17 Coverage of Abortion Services by Exchange Plans ................................................................ 20 Employer-Sponsored Coverage ..................................................................................................... 21 Sources for Employees and Their Families ............................................................................. 21 Overviews ......................................................................................................................... 21 Federal Employee Health Benefits Program ..................................................................... 21 Members of Congress and Congressional Staff ................................................................ 22 Sources for Employers ............................................................................................................ 22 Overviews ......................................................................................................................... 22 Employer Penalties ........................................................................................................... 23 Employer Wellness Programs and Genetic Information ................................................... 23 Small Businesses ............................................................................................................... 23 Medicaid and the State Children’s Health Insurance Program ...................................................... 24 Medicare ........................................................................................................................................ 26 Specific Populations ...................................................................................................................... 27 Women’s Health Care ............................................................................................................. 27 Preventive Services ........................................................................................................... 27 Contraceptive Coverage .................................................................................................... 28 Indian Health Care .................................................................................................................. 29 Veterans and Military Health Care .......................................................................................... 29 Noncitizens .............................................................................................................................. 30 Behavioral Health .......................................................................................................................... 30 Public Health, Workforce, Quality, and Related Provisions .......................................................... 31 State Innovation Waivers ............................................................................................................... 32 Congressional Research Service Patient Protection and Affordable Care Act (ACA) Taxes .............................................................................................................................................. 33 Tax Filing Resources ............................................................................................................... 33 Contacts for Tax Filing Assistance .......................................................................................... 33 Tax Provisions ......................................................................................................................... 34 Overviews ......................................................................................................................... 34 Tax Statistics ..................................................................................................................... 34 Medical Device Tax .......................................................................................................... 34 Excise Tax on High-Cost Employer-Sponsored Health Coverage .................................... 35 Congressional Efforts to Repeal or Amend ACA .......................................................................... 35 Agency Audits and Investigations ................................................................................................. 36 Cost Estimates and Spending ........................................................................................................ 37 Statistics on Insurance Coverage ................................................................................................... 38 Census Bureau Statistics ......................................................................................................... 38 U.S. Department of Health and Human Services Statistics .................................................... 39 Legal and Regulatory Issues .......................................................................................................... 41 Tables Table 1. Pre-effectuated Enrollment Data Sources ........................................................................ 13 Table 2. Point-in-Time Effectuated Enrollment Reports ............................................................... 14 Table 3. Average Monthly Effectuated Enrollment Reports .......................................................... 16 Table 4. Average Effectuated Enrollment for First Half of the Year Reports ................................ 17 Contacts Author Information ........................................................................................................................ 41 Congressional Research Service Patient Protection and Affordable Care Act (ACA) T his report provides resources to help congressional staff respond to constituents’ frequently asked questions (FAQs) about the Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended). The report lists selected resources regarding consumers, employers, and other stakeholders, with a focus on federal sources. It also lists Congressional Research Service (CRS) reports that summarize the ACA’s provisions. The resources are arranged by topic. This list is not a comprehensive directory of all resources on the ACA but rather is intended to address some questions that may arise frequently. Contacts for ACA Assistance Help with Obtaining and Using Health Coverage Contact Us (U.S. Department of Health and Human Services, HealthCare.gov) https://www.healthcare.gov/contact-us/ HealthCare.gov is the official federal portal for ACA consumer information. It has questions and answers on options for obtaining coverage and other health insurance questions. The website offers a 24/7 consumer hotline, 1-800-318-2596 (TTY: 1-855-889-4325).1 For translation assistance in other languages, constituents may call the HealthCare.gov hotline or visit the website at https://www.healthcare.gov/language-resource. Find Local Help (U.S. Department of Health and Human Services, HealthCare.gov) https://localhelp.healthcare.gov A directory of state and local organizations trained to provide enrollment assistance and help constituents understand their health coverage options. The directory also includes insurance agents and brokers. Consumer Assistance Program (The Center for Consumer Information and Insurance Oversight) https://www.cms.gov/CCIIO/Resources/Consumer-Assistance-Grants/ A clickable map directory of consumer assistance programs and other state agencies that can answer constituent questions on ACA and health insurance, including options for obtaining coverage. Contact Your State With Questions (Centers for Medicare & Medicaid Services) https://www.medicaid.gov/about-us/contact-us/contact-your-state-questions/index.html A directory of state Medicaid contacts. Individuals can apply for Medicaid coverage any time of the year. InsureKidsNow.gov (Centers for Medicare & Medicaid Services) https://www.insurekidsnow.gov/ Families interested in Medicaid or State Children’s Health Insurance Program (CHIP) coverage may call 1-877-KIDS-NOW (1-877-543-7669). Map of NAIC States & Jurisdictions (National Association of Insurance Commissioners) http://www.naic.org/state_web_map.htm 1 A teletypewriter (TTY) is a communication device used by persons who are deaf, hard-of-hearing, or have severe speech impairments, according to “TTY,” Glossary (U.S. Department of Health and Human Services, HealthCare.gov), at https://www.healthcare.gov/glossary/tty/. Congressional Research Service 1 Patient Protection and Affordable Care Act (ACA) States are the primary regulators of health insurance. Constituents with health insurance questions and problems may contact state insurance departments for assistance. The map links to each insurance department’s website. Ask EBSA (U.S. Department of Labor, Employee Benefits Security Administration) https://www.dol.gov/agencies/ebsa/about-ebsa/ask-a-question/ask-ebsa Constituents with questions about job-based health coverage can speak with benefits advisors at 1-866-444-3272. Benefits advisors can also answer questions about COBRA continuation coverage, which “gives workers and their families who lose their health benefits the right to choose to continue group health benefits provided by their group health plan for limited periods of time under certain circumstances such as voluntary or involuntary job loss, reduction in the hours worked, transition between jobs, death, divorce, and other life events.” See https://www.dol.gov/general/topic/health-plans/cobra. State Health Insurance Assistance Programs (SHIPs) (Centers for Medicare & Medicaid Services) https://www.medicare.gov/contacts/#resources/ships SHIPs offer personalized health insurance counseling for Medicare beneficiaries Health plan enrollees may contact insurers directly to verify enrollment or to ask about coverage of particular drugs, medical services, and health care providers. Enrollees can find their health plan’s customer service phone number on their insurance card, on the insurer’s website, or by calling the HealthCare.gov hotline, 1-800-318-2596 (TTY: 1-855-889-4325). Help with Health and Health Care Questions Federal Health Information Centers and Clearinghouses (U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion) https://health.gov/our-work/health-literacy/resources/national-health-information- center/clearinghouses/topic A directory of federal hotlines and information clearinghouses related to health and health care. Health Info Lines (National Institutes of Health) https://www.nih.gov/health-information/health-info-lines A directory of hotlines for health information. The resources above do not provide medical advice. Constituents should contact their own health care providers for medical advice. Find Doctors and Medical Facilities (USA.gov) https://www.usa.gov/doctors A compilation of tools for finding providers (such as physicians) and health care facilities (such as hospitals). Some of the listed directories incorporate quality measures. Health plan enrollees should also check their health plan’s website for a provider directory. Help with Taxes Telephone Assistance (Internal Revenue Service) https://www.irs.gov/help/telephone-assistance Congressional Research Service 2 Patient Protection and Affordable Care Act (ACA) The IRS is implementing many of the ACA’s tax provisions, including premium tax credits and employer shared responsibility penalties. The Internal Revenue Service (IRS) has a Healthcare Hotline for ACA questions (1-800-919-0452) and other telephone hotlines to answer questions from individuals and employers. Assistance for Congressional Staff Congressional Marketplace Hotline (U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services) A dedicated hotline exclusively for Members of Congress and congressional staff with questions about ACA implementation and exchanges: 202-690-8004, [email protected]. CRS Report 98-446, Congressional Liaison Offices of Selected Federal Agencies The CRS report lists congressional liaison offices at federal agencies, including those that work on ACA issues, such as the Department of Health and Human Services (HHS); HHS’s Centers for Medicare & Medicaid Services, which administers the ACA’s private health insurance, Medicare, and Medicaid provisions; the IRS, which administers the ACA’s revenue (tax) provisions; the Department of Labor, which administers ACA provisions related to employer-sponsored coverage; and the Congressional Budget Office. Congressional liaison offices answer questions from Members of Congress and congressional staff; they usually do not assist constituents directly. Assistant Secretary for Legislation (ASL) Offices (U.S. Department of Health and Human Services) https://www.hhs.gov/about/agencies/asl/about-asl/asl-offices/index.html Lists contact information and subject area portfolios for HHS congressional liaison staff. CRS reports on ACA and other health policy issues are at CRS.gov: Issue Area: Health Care http://www.crs.gov/iap/health-care Click “All Subissues” for reports on “Health Care Reform,” “Private Health Insurance,” and “Medicaid & CHIP,” among other health-related topics. Each report has author contact information. CRS authors are available to answer questions from Members of Congress and congressional staff. CRS provides research and analysis exclusively to Congress. CRS authors are unable to assist constituents directly. Basic Consumer Sources HealthCare.gov (U.S. Department of Health and Human Services) http://www.healthcare.gov The official federal portal for ACA consumer information. Click “Get Answers” for frequently asked questions and answers, including options for obtaining coverage. Click “See Topics”: “Browse all topics” for sources tailored to specific populations, such as unemployed people, self-employed people, people under 30, people with disabilities, veterans, American Indians and Alaska Natives, immigrants, pregnant women, same-sex married couples, transgender people, retirees, and incarcerated people. Marketplace coverage & Coronavirus covers topics such as “If I lost my job or experienced a reduction in hours due to COVID-19” https://www.healthcare.gov/coronavirus/. A Spanish-language version of HealthCare.gov is at http://www.CuidadoDeSalud.gov. Congressional Research Service 3 Patient Protection and Affordable Care Act (ACA) Affordable Care Act Tax Provisions for Individuals and Families (Internal Revenue Service) https://www.irs.gov/affordable-care-act/individuals-and-families Explains ACA tax provisions for consumers, including provisions on premium tax credits. FAQs are at https://www.irs.gov/affordable-care-act/affordable-care-act-tax-provisions- questions-and-answers. Glossary (U.S. Department of Health and Human Services, HealthCare.gov) http://www.healthcare.gov/glossary/index.html Plain-language definitions of health care and health insurance terms. Roadmap to Better Care (Centers for Medicare & Medicaid Services) https://www.cms.gov/About-CMS/Agency-Information/OMH/equity- initiatives/c2c/consumerresources/roadmap-to-better-care.html Consumer booklets on how to read an insurance card, how to choose a provider, how to set up and prepare for a health care appointment, and more. Some resources have been translated to other languages. CRS Report R45244, Legislative Actions to Modify the Affordable Care Act in the 111th-115th Congresses Includes “A Brief Overview of the ACA.” Find Doctors and Medical Facilities (USA.gov) https://www.usa.gov/doctors A compilation of tools for finding providers (such as physicians) and health care facilities (such as hospitals). Some of the listed directories incorporate quality measures. Health plan enrollees should also check their health plan’s website for a provider directory. MedlinePlus (U.S. National Library of Medicine, National Institutes of Health) https://medlineplus.gov/ Plain-language information on numerous health topics, drugs, and supplements. Some materials are in Spanish at https://medlineplus.gov/spanish/. ACA Text The following resources can help with constituent requests for the text of the ACA. Compilation of the Patient Protection and Affordable Care Act (U.S. House of Representatives, Office of the Legislative Counsel) http://legcounsel.house.gov/HOLC/Resources/comps_alpha.html The ACA compilation is listed under “P” on this website. The House Office of the Legislative Counsel compiled the text of the ACA, consolidated with amendments made by subsequent laws. The compilation is unofficial. It is updated periodically. P.L. 111-148, Patient Protection and Affordable Care Act (Government Publishing Office, March 23, 2010, 124 Stat. 119) http://www.gpo.gov/fdsys/pkg/PLAW-111publ148/pdf/PLAW-111publ148.pdf Unlike the unofficial compilation above, this is the official publication of the ACA as enacted on March 23, 2010. However, this does not reflect current law, as the ACA has since been amended by several subsequent laws, including P.L. 111-152, Health Care and Education Congressional Research Service 4 Patient Protection and Affordable Care Act (ACA) Reconciliation Act of 2010, http://www.gpo.gov/fdsys/pkg/PLAW-111publ152/pdf/PLAW- 111publ152.pdf. The Individual Mandate See also “Tax Statistics” CRS Report R44438, The Individual Mandate for Health Insurance Coverage: In Brief Basic background and state-level statistics on the individual mandate, the requirement that most individuals have minimum essential health coverage or else pay a tax penalty. The report also discusses how the Tax Cuts and Jobs Act (P.L. 115-97) effectively eliminated the individual mandate penalty beginning in 2019. The fee for not having health insurance (U.S. Department of Health and Human Services, HealthCare.gov) https://www.healthcare.gov/fees/ Details on the federal individual mandate penalty, which no longer applies beginning with plan year 2019. Although the federal penalty has been eliminated, some states have enacted their own individual mandate laws. Private Health Insurance See also “Exchanges” and “Employer-Sponsored Coverage.” Overviews CRS Report R45146, Federal Requirements on Private Health Insurance Plans Table 1 shows which federal requirements apply to which health plans, depending on whether they are sold in the large group, small group, or individual market; and whether plans are fully insured or self-insured. Table A-1 compares requirements pre-ACA and under current law. CRS Report RL32237, Health Insurance: A Primer A basic overview of health insurance: key definitions and principles, the regulation of health insurance, and sources of health insurance. CRS Insight IN10969, Consumer Protections in Private Health Insurance for Individuals with Preexisting Health Conditions A brief overview of preexisting condition protections, pre-ACA and under current law. Health coverage rights and protections (U.S. Department of Health and Human Services, HealthCare.gov) https://www.healthcare.gov/health-care-law-protections/ Summarizes consumer protections under ACA, such as coverage for preexisting conditions, the requirement that insurers provide a plain-language Summary of Benefits and Coverage, and restrictions on lifetime and annual limits. Fact Sheets and Frequently Asked Questions (FAQs) (The Center for Consumer Information and Insurance Oversight) http://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/index.html Congressional Research Service 5 Patient Protection and Affordable Care Act (ACA) The federal Center for Consumer Information and Insurance Oversight is charged with implementing the ACA’s private health insurance reforms. The page provides information for stakeholders, including state officials, health insurance companies, and consumers. Private health insurance resources include, for example, Coronavirus Disease 2019 (COVID-19) Guidance, https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/index#COVID-19 and FAQs About Families First Coronavirus Response Act and Coronavirus Aid, Relief, and Economic Security Act Implementation (April 11, 2020), https://www.cms.gov/files/document/FFCRA-Part-42-FAQs.pdf. CRS In Focus IF11359, Applicability of Federal Requirements to Selected Health Coverage Arrangements: An Overview In general, private health insurance plans must comply with certain federal health insurance requirements, including some requirements enacted by ACA as amended. However, some health coverage arrangements, including certain exempted health coverage arrangements and noncompliant health coverage arrangements (as termed for purposes of this report), do not comply with federal health insurance requirements. This report gives a brief overview of these arrangements. More details are in CRS Report R46003, Applicability of Federal Requirements to Selected Health Coverage Arrangements. CRS In Focus IF11523, Health Insurance Options Following Loss of Employment Two-page overview of potential health coverage options following job loss, including private health insurance options such as exchange coverage. Due to the COVID-19 pandemic’s economic impact, many Americans may lose jobs through which they receive health insurance. Dependent Coverage Young Adults and the Affordable Care Act: Protecting Young Adults and Eliminating Burdens on Businesses and Families FAQs (Employee Benefits Security Administration) https://www.dol.gov/agencies/ebsa/about-ebsa/our-activities/resource-center/faqs/young-adult- and-aca Questions and answers on the ACA’s dependent coverage provision. Under the ACA, if a health plan provides for dependent coverage of children, the plan must make such coverage available for adult children under the age of 26. Essential Health Benefits CRS In Focus IF10287, The Essential Health Benefits (EHB) Two-pager gives brief background and infographics on EHB. CRS Report R44163, The Patient Protection and Affordable Care Act’s Essential Health Benefits (EHB) Describes EHB, interstate and intrastate variations in EHB coverage, the applicability of EHB requirements to health plans, and how other ACA provisions apply to EHB. Information on Essential Health Benefits (EHB) Benchmark Plans (The Center for Consumer Information and Insurance Oversight) https://www.cms.gov/cciio/resources/data-resources/ehb.html Describes current requirements and options for states to select their EHB benchmark plans; summarizes other requirements related to the EHB; and links to all states’ benchmark plan Congressional Research Service 6