navigating the affordable care act

VIRGINIA’S HEALTH INSURANCE MARKETPLACE--THE BASICS--

Where Americans Get Health Coverage

Affordable Care Act“Obamacare”

Goals:oAffordable Insurance Coverageo Private Insurance Reformo Better Health Delivery Systems In Virginia:◦ One Million Uninsured Virginians

o 60% have incomes ≤ 200% FPL .o 75% are from families where someone works full or part-time.

 Coverage changes on January 1, 2014:◦ State Option for Medicaid Adult Coverage (no decision yet)◦ New Insurance Marketplace – Affordable Private Coverage ◦ People/Businesses Required to Have/Provide Insurance

Private Health Insurance “Patient’s Bill of Rights”

  Allows children to stay on parent’s plan until 26th birthday (even if married).*◦ 66,000 in Virginia

  Ends lifetime dollar caps & phases out annual limits  Ends denial of coverage and increase of premiums for people with 

pre-existing conditions.*  Ends increase of premiums based on gender  Ends co-pays or other out-of-pocket expenses for Preventive Care*

◦ Required preventive health services for women

*Some exceptions apply

Ensuring Reasonable Premiums

  Premiums can be based on age, geography,  smoking – not sex or health status

  Annual Rate Review◦ Federal and state governmentsinsurance premium increases ≥ 10% 

  Medical Loss Ratio (MLR)◦ Insurers must pay out 80¢ - 85¢of each $1 premium for medicalbenefits -- or pay rebates to consumers.o Virginia’s 2012 rebates = $43 million to 

over 685,000 residents

Open Enrollment October 1,2013 – March 31,2014

•If enrolled by December 15, coverage can begin January 1, 2014

•“Special Enrollment” after March to enroll in or change QHPs (45 CFR §155.420).  For example:• Loss of other coverage (except for non-payment, rescission)• Birth, adoption, marriage• Change in immigration status• Error by FFM• Other exceptional circumstances

•Note: Medicaid/FAMIS applications accepted & processed all year

Insurance MarketplaceHow to Apply

 Multiple “doors” for applications◦ Online – www.healthcare.gov◦ Phone – 

◦ Federal - 1-800-318-2596

◦ Virginia call center – 1-888-392-5132◦ Website: www.enroll-Virginia.com ◦ Virginia Local Departments of Social Services

◦ DSS  - “CommonHelp” - Online applications◦ https://commonhelp.virginia.gov/access/

 Federal Paper Application - http://www.cms.gov/CCIIO/Resources/Forms-Reports-and-Other-Resources/Downloads/marketplace-app-standard.pdf

Information Needed to Apply

  Availability of Employer-based Coverage

  Identity of applicants◦ Name and contact info◦ Social Security Number◦ Immigration Status

  Household Size◦ Using tax code principles & expected HH in 2014

  Countable Income◦ Using tax code principles & expected income in 2014

  Data bases will verify a lot of information◦ Paper documents last resort

Qualified Health Plans (QHPs)

Covered Services  Standardized coverage - “Essential Health Benefits”  (EHB)

1.Ambulatory patient services 2.Emergency services 

3.Hospitalization 

4.Maternity & newborn care 

5.Mental health & substance use disorder services, including behavioral health treatment 

6.Prescription drugs 

7.Rehabilitative & habilitative services & devices 

8.Laboratory services 

9.Preventive & wellness services & chronic disease management, & 

10.Pediatric services, including oral & vision care 

QHPs Grouped by “Value” Premium Rates & Cost-sharing establish “actuarial value” (AV) of

each plan:◦ 4 Tiers of Coverage◦  Bronze – 60% AV - low overall coverage, lower premiums but higher out-of-pocket costs

◦  Silver – 70% AV

◦  Gold – 80% AV

◦  Platinum – 90% AV - best coverage, highest premiums◦ Catastrophic coverage for people under age 30◦  Very high deductible

Coverage Level Options in the Exchange

40%

30%

20%

90%

80%

70%

60%

10%

0% 20% 40% 60% 80% 100%

Average % covered by plan  &  by enrollee          

Platinum

  Bronze

Gold

Silver

Plans Offered in Northern Virginia

Possible* Premium Rates for “Most Popular” Plans

 Company presentations to Virginia SCC on 7/16/2013:◦ Single male age 29    $186 - $338◦ Parents age 45 + 2 kids  $690 - $1257◦ Couple age 60  $902- $1574

* These numbers may not be for same metal tier and do not show geographic variables or tobacco ratings. They also do not factor in potential financial assistance.

 Various tools to calculate rates in your area and factor in estimated Premium Tax Credit

https://www.healthcare.gov/find-premium-estimates/   and the Kaiser Family Foundation subsidy calculator

Subsidies on the MarketplacePREMIUM TAX CREDITS

  Income between 100%-400% federal poverty line◦ Some legal immigrant under 100% 

FPL can get tax credits IF not eligible for current Medicaid because of immigration status.

◦ Most under 100% FPL will fall into Virginia’s Medicaid GAP until expansion.

COST SHARING SUBSIDIES 

  Income between 100% and 250% of the federal poverty line

 Only applies if Silver Plan is purchased◦ Effectively increases Actuarial 

Value of Silver Plan to: ◦ 94% AV (income 100%-150% 

FPL)◦ 87% AV (income 150%-200% 

FPL)◦ 73% AV (income 200%-250% 

FPL)

Insurance Marketplace - TaxCredits Reduce Premium

Costs Financial assistance (tax credits)

 Based on family’s income and cost of the 2nd lowest cost silver plan. 

 Maximum contribution towards premium Income Level (FPL)

Contribution From Income

Up to 133% 2%

133  -  150% 3 – 4%

150  -  200% 4 – 6.3%

200 -  250% 6.3 – 8.05%

250  - 300% 8.05 – 9.5%

300  - 400%  9.5%

Basic Eligibility for Marketplace Insurance with

Premium Tax Credits  Income between 100%-400% federal poverty line

◦ Some legal immigrants under 100% FPL can get tax credits IF not eligible for current Medicaid because of immigration status.

◦ Most under 100% FPL will fall into Virginia’s Medicaid GAP until expansion.

Family Size

100% FPL 400% FPL

1 $11,490 $45,960

2 $15,510 $62,040

3 $19,530 $78,120

4 $23,550 $94,200

Basic Eligibility for Marketplace Insurance with

Premium Tax Credits Not receiving or eligible for “minimum essential coverage”:◦ Medicaid,  FAMIS, Medicare

◦ “Affordable & Adequate ” job-based coverage

 Job-based coverage is not affordable/adequate  if  employee-only plan:◦  costs ↑9.5% family income; or◦  covers ↓60% costs

Premium Tax Credit Example

John is 32-year old single male

Annual Income of $17, 200/year  (150% FPL)

Maximum Contribution 4% Income = $688/ yr

Cost of 2nd lowest Silver Plan $4,000  ($333.33/mo.)

Subtract Contribution - $688

Annual Federal Tax Credit $3,312

John pays  $  57.33/mo

Tax Credit  $276.00/mo (goes to QHP)

Using the Tax Credits

 Can use same tax credit for other tier plans Tax credit is fully “refundable” with tax return (even if no taxes owed) Or you can receive credit (or partial credit) in advance to help pay monthly premiums.  

◦ Must report changes in income / family size to adjust during year◦ “Reconciliation” at tax time

 Subsidy Calculator - http://kff.org/interactive/subsidy-calculator/

Limits on Out-Of-Pocket Costs for Low Income People

 Special cost-sharing protections for those with income under 250% FPL

 Only applies if Silver Plan is purchased◦ Effectively increases Actuarial Value of Silver Plan to: ◦ 94% AV (income 100%-150% FPL)◦ 87% AV (income 150%-200% FPL)◦ 73% AV (income 200%-250% FPL)

Other Limits on Out-Of-Pocket Costs

 Overall limits on total cost-sharing for Essential Health Benefits.

  Tied to out-of-pocket limits for Health Savings Accounts.

 Estimates based on 2013 HSA maximums

Income Level Maximum OOPIndividual

Maximum OOPFamily

100-200% FPL $2,063 $4,125

200-300% FPL $3,125 $6,250

300-400% FPL $4,125 $8,250

Minimum Coverage Requirements

  Affordability requires spreading risk over large pool that includes healthy people

  Mandates Apply to Individuals & Large Employers (over 50 FTE employees)

  Who Is Exempt from Individual Mandate?  o Lowest-price Exchange plan costs > 8% of family income o Income below tax filing threshold (e.g. $10,000 single/$20,000 couple in 2013)o Excused for other financial hardship o Religious objectors o Native Americans o Undocumented immigrantso Incarcerated persons o Those uninsured for less than 3 months.

Minimum Coverage RequirementsTax Penalties

•Individual / Family penalty is much less than cost of insurance.  

•Penalty is the greater of:◦ 2014 - $95 /adult + $47.50 /child (up to $285) or 1% family income*◦ 2015 - $325/adult + $165.50/child (up to $975) or 2% family income*◦ 2016 - $695/adult + $347.50/child (up to $2085) or 2.5% family income*

•Large Employer Penalty

in 2015 if affordable coverage

not offered.[*Income is amount over tax

filing threshold]

Who Will Still Be Uninsured?

U.S. Citizens◦ Those in the Medicaid gap due to expansion delay◦ Exempt from the mandate (no penalty)◦ People who choose not to be covered (penalty may apply) 

Low Income Legal Immigrants ◦ Many are ineligible for Virginia’s Medicaid program◦ Can’t afford Exchange products

Undocumented ◦ Not covered by Medicaid (except for emergencies), FAMIS or the Exchange

Outreach & Enrollment Assistance

 Extremely important!

 Many opportunities:◦ Federal $ for Virginia Navigators  ($1.4 million)◦ Federal $ for 22 Virginia community health centers ($2.5 m)◦ Similar role for “Certified Application Counselors” ◦ Application “Assistors” ◦ Agents & Brokers

• Conduct outreach and public education on Marketplace coverage options and financial assistance

• Distribute fair and impartial information on enrollment, plan options, and subsidies.  This includes options from the Marketplace as well as public programs, such as Medicaid and FAMIS

• Facilitate enrollment in Marketplace health plans

• Provide referrals for any grievance, complaint, or question about their health plan, post-enrollment. 

• Provide information that is culturally and linguistically appropriate, and accessible to those with disabilities

What Navigators Do

Contact Us!   Carlon M. Ocel, Esq.  Health Insurance Navigator with ENROLL Virginia!

  8305 Richmond Highway, Suite 17B  Alexandria, VA 22309  Direct: (703) 647-4744 Main: (571) 482-2694  Fax: (703) 778-3455  cocel@lsnv.org  cocel@enroll-virginia.com

  Jessica R. Killeen  Health Insurance Navigator with ENROLL Virginia!

  3401 Columbia Pike, Suite 301  Arlington, VA 22204  Direct: (703) 647-4742 Main: (703) 532-3733  Fax: (703) 685-1011  jkilleen@lsnv.org  Jessica@enroll-virginia.com

Group Phone #: (703) 647-4748

QUESTIONS?

Thank you!