After open enrollment period ends, what?

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Open Enrollment (Year 2)

Report a Life Change File for an Exemption File for an Appeal Federal Poverty Level Guidelines for

2014 Shared Responsibility Penalty Estimator

Insurance 101

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Open Enrollment Period

NOVEMBER 01, 2015 -

JANUARY 31, 2016

Sign up between:

Nov 1, 2015-Dec 15, 2015, your plan will start on Jan 1, 2016

Dec 16, 2015 - Jan 15, 2016, your plan will start Feb 1st

Jan 16, 2016-Jan 31, 2016, your plan will start Mar 1st

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Next Open Enrollment Period

Report a Life Change

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Type of Life Change/Change in Circumstance: Where to Report New person on the application (e.g., birth, marriage) Marketplace Relocation to a new zip code or county Marketplace Loss of access to other coverage (e.g., employer coverage) Marketplace Release from incarceration Marketplace Change in citizenship or immigration status Marketplace Removal of a person from the application (e.g., death, divorce) Marketplace Become incarcerated Marketplace New access to other coverage (e.g., employer coverage) Marketplace Pregnancy Marketplace Change in tax filing status/tax household composition Marketplace Change in status as an American Indian/Alaska Native or tribal Marketplace Change in disability status Marketplace Correction to name, DOB, or Social Security number Marketplace Increase or decrease in income Marketplace Change in contact information, like: Relocation within the same zip code and county Marketplace AND Email address Insurance Company Phone number Add or remove phone text alert Mailing of paper notices

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Reportable Changes

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Report your Change on your account online

EXEMPTIONS

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Exemptions from the Payment Under certain circumstances, you won’t have to make the individual shared responsibility payment (tax penalty). This is called an “exemption.”

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You may qualify for an exemption if: You’re uninsured for less than 3 months of the year

The lowest-priced coverage available to you would cost

more than 8% of your household income

You don’t have to file a tax return because your income is too low

You’re incarcerated, and not awaiting the disposition of charges against you

You’re not lawfully present in the U.S. and many more

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If you have any of the circumstances below that affect your ability to purchase health insurance coverage, you may qualify for a “hardship” exemption: You were homeless. You were evicted in the past 6 months or were facing eviction or

foreclosure. You received a shut-off notice from a utility company. You recently experienced domestic violence. You recently experienced the death of a close family member. You experienced a fire, flood, or other natural or human-caused disaster

that caused substantial damage to your property. You filed for bankruptcy in the last 6 months. You had medical expenses you couldn’t pay in the last 24 months. You experienced unexpected increases in necessary expenses due to caring

for an ill, disabled, or aging family member. Many more…

Hardship Exemptions

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1. You can claim some exemptions

when you fill out your 2014 federal tax return, which is due in April 2015.

How to Apply for Exemptions

2. You can apply for some exemptions, by mailing in the right form.

You have 2 options, depending on which type of exemption you’re asking for:

All exemption application forms can be found here: https://www.healthcare.gov/exemptions/

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APPEALS

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You may file a Marketplace eligibility appeal in two ways.

1st: Print the form that can be found on the eligibility appeals website:

https://www.healthcare.gov/can-i-appeal-a-marketplace-decision/ You should download the paper form, complete it and mail it in. While the form looks complicated and has many pages, only two pages or so need to be completed and it’s not hard to fill in or contact a local navigator or certified application counselor for in-person assistance.

2nd: Write a letter. You should include the reason you’re appealing, and they

strongly urge you to attach a copy of your eligibility determination letter to the appeal. Consumers should send the letter to: Health Insurance Marketplace Attn: Appeals Department 465 Industrial Blvd. London, KY 40750-0061

How to submit an Eligibility Appeal

Appeal Decisions

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The government will let appellants know of their decision, including whether you are eligible to obtain health insurance coverage through the Marketplace, and whether you qualify for any subsidies. If you receive a favorable eligibility appeal decision, you will be given a special enrollment period to enroll in or to switch plans within the Marketplace.

Retroactive enrollment - If the decision is favorable and retroactive coverage is judged to be appropriate, you may choose to have your insurance coverage and any subsidies retroactively. You may be able to select a retroactive date based upon the date of your application to the Marketplace.

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NEW FPL GUIDELINES FOR SUBSIDY ELIGIBILITY

FOR 2014

2014 Federal Income Level Guidelines

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Household Size 100% 133% 150% 200% 250% 300% 400%

1 $11,670 $15,521 $17,505 $23,340 $29,175 $35,010 $46,680

2 15,730 20,921 23,595 31,460 39,325 47,190 62,920

3 19,790 26,321 29,685 39,580 49,475 59,370 79,160

4 23,850 31,721 35,775 47,700 59,625 71,550 95,400

5 27,910 37,120 41,865 55,820 69,775 83,730 111,640

6 31,970 42,520 47,955 63,940 79,925 95,910 127,880

7 36,030 47,920 54,045 72,060 90,075 108,090 144,120

8 40,090 53,320 60,135 80,180 100,225 120,270 160,360

AFFORDABLE CARE ACT

1) ADVANCE PREMIUM TAX CREDIT (APTC) • APTC lowers the monthly premium owed by the consumer. • Marketplace determines eligibility for APTC and the

amount allowed. • Any APTC paid on an advance basis is reconciled at the end

of the year when you file your taxes. • The amount of APTC is based on income and can be

adjusted by the consumer, at the time of plan selection. • To receive APTC a consumer must file a tax return at the

end of the year.

2) COST SHARING REDUCTION (CSR) • Cost Sharing Reductions limit consumers’ max out-of-

pocket cost (i.e. deductibles, coinsurance or copayments).

• Marketplace determines eligibility for CSR. • Consumers cannot adjust the amount of CSR assistance

received. • In general, if a consumer is eligible for cost sharing

reductions, they must enroll in a silver plan.

Two Types of Government Financial Assistance Available:

Redetermination Process For individuals who are enrolled with advance

payments of the premium tax credit (APTC) or cost-sharing reductions (CSR) and who have authorized the Marketplace to request updated tax data, the Marketplace will automatically request updated tax return information from IRS.

The Marketplace sends notices containing information about the annual redetermination process to qualified individuals and enrollees (paper or electronic, depending on the consumer’s preference)

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Standard Insurance Company Notices

Individual insurance companies must provide written notice of renewals and any product discontinuances.

This notice should inform the individual if their plan will be available, any changes to the plan, and if the plan won’t be available, what plan the consumer will be enrolled in. This notice will also be required to contain additional information, including information on premiums and APTC.

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No Action taken by Consumer Scenario 1

John applied through the Marketplace and has a household income of $20,000. He was determined eligible for $100 of APTC, and selected a plan on 12/10/13. On his application he allowed the Marketplace to access tax return information for redetermination.

He will receive two notices: 1) Marketplace 2) Insurance Co. telling him his plan will remain available and his premium will be $200 (a total of $300 minus the $100 APTC he is eligible for in 2014.)

If he does not contact the Marketplace, he’s renewed in the plan with $100 APTC (his 2014 eligibility) effective 1/1/15. APTC for 2015 could be more!

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SHARED RESPONSIBILITY PAYMENT (TAX PENALTY)

The fee in 2014 and beyond The tax penalty in 2014 is calculated one of 2 ways.

If you or your dependents don’t have insurance that qualifies as Minimal Essential Coverage (MEC) you'll pay whichever of these amounts is higher:

1% of your yearly household income. (Only the amount of income above the tax filing threshold, $10,150 for an individual, is used to calculate the penalty.) The maximum penalty is the national average premium for a bronze plan.

$95 per person for the year ($47.50 per child under 18). The maximum penalty per family using this method is $285.

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How is the penalty calculated The way the penalty is calculated, a

single adult with household income below $19,650 would pay the $95 flat rate. A single adult with household income above $19,650 would pay an amount based on the 1% rate. (If income is below $10,150, no penalty is owed.)

If you’re uninsured for just part of the year, 1/12 of the yearly penalty applies to each month you’re uninsured. If you’re uninsured for less than 3 months, you don’t have to make a payment.

You’ll pay the fee on your 2014 federal income tax return. Most people will file this return in 2015.

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The penalty increases every year. In 2015 it’s 2% of income or $325

per person.

In 2016 and later years it’s 2.5% of income or $695

per person.

After that it's adjusted for inflation.

2014 IRS Federal Tax Filing Thresholds Filing Status Age

Must File a Return If Gross Income Exceeds

Single Under 65 $10,150

65 or older $11,700

Head of Household Under 65 $13,050

65 or older $14,600

Married Filing Jointly Under 65 (both spouses) $20,300

65 or older (one spouse) $21,500

65 or older (both spouses) $22,700

Married Filing Separately Any age $3,950

Qualifying Widow(er) with Dependent Children

Under 65 $16,350

65 or older $17,550

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Examples of the Tax Penalty

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Example 1: Single individual with $40,000 income Jim, an unmarried individual with no dependents, does not have minimum essential coverage for any month during 2014 and does not qualify for an exemption. For 2014, Jim’s household income is $40,000 and his filing threshold is $10,150.

To determine Jim’s payment using the income formula:

$40,000 Household Income

- $10,150 filing threshold

$29,850 Income left

x 1% Tax Penalty

$298.50 Jim’s Tax Penalty

Jim’s flat dollar amount would be $95. Because $298.50 is greater than $95 (and is less than the national average premium for bronze level coverage for 2014), Jim’s shared responsibility payment for 2014 is $298.50, or $24.87 for each month he is uninsured (1/12 of $298.50 equals $24.87).

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Jim will make his $298.50 shared responsibility payment when he files his 2014 income tax return, which is due in April 2015.

Examples of Tax Penalty

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Example 2: Married couple with 2 children, $70,000 income Eduardo and Julia are married and have two children under 18. They do not have minimum essential coverage for any family member for any month during 2014 and no one in the family qualifies for an exemption. For 2014, their household income is $70,000 and their filing threshold is $20,300.

To determine their payment using the income formula: $70,000 Household Income - $20,300 Filing threshold $49,700 Income left x 1% Tax Penalty $497 Family’s Tax Penalty

Eduardo and Julia’s flat dollar amount is $285, or $95 per adult and $47.50 per child. The max total of $285 is the flat dollar amount in 2014.

Because $497 is greater than $285 (and is less than the national average premium for bronze level coverage for 2014), Eduardo and Julia’s shared responsibility payment is $497 for 2014, or $41.41 per month for each month the family is uninsured (1/12 of $497 equals $41.41).

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Eduardo and Julia will make their $497 shared responsibility payment when he files their 2014 income tax return, which is due in April 2015.

IRS and Marketplace Forms IRS Form 1095-A is like the W-2 from your employer or the

statement from your bank. IRS Form 1095-A is completed and sent to enrolled consumers

by the Marketplace. If the consumer has not received it or loses it, a duplicate can be downloaded from the consumer's Marketplace account.

Consumers must review the accuracy of the information on IRS Form 1095-A and use it to complete IRS Form 8962 and/or IRS Form 8965 as part of their income tax return.

Use Form 8962 if you received tax credit (financial aid)

Use Form 8965 if you have Exemption for not having health coverage

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INSURANCE

Insurance Card Details

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TERMS-TO-KNOW

Co-insurance- amount you may be required to pay as your share of cost for services after you pay any deductibles. Coinsurance is usually a percentage (for example, 20%)

Co-payment- amount required to pay for services, usually a set amount; $10 or $20 for a doctor’s visit or prescription

Deductible- amount you must pay for health care or prescriptions before your prescription drug plan, or your other insurance begins to pay.

Excluded Services- services that your insurance plan doesn’t pay for or cover.

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Terms-To-Know continued…

Out-of-Network-provider who doesn’t have a contract with your health insurer or plan to provide services to you. You’ll pay more to use them.

Out-of-pocket Maximum- limit you must reach (using the deposit from the plan and/or your own money) before your plan will cover your expenses. The out-of-pocket maximum includes the yearly deductible and may also include any cost sharing you have after the deductible.

Premium- A fixed monthly payment to an insurance company.

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Open enrollment through the Marketplace will begin again:

NOVEMBER 01, 2015 to

JANUARY 31, 2016

When is next open enrollment?

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• Marketplace: www.Healthcare.gov (800) 318-2596

• In person help with a Navigator: (for outside West Volusia County)

(866) 295-5955 • In person help with a Certified

Application Counselor: (for West Volusia County)

Deltona area: (386) 532-1101 Deland area: (386) 734-1026

HOW TO GET HELP