navigating the affordable care act
TRANSCRIPT
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 [email protected] [email protected]
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 [email protected] [email protected]
Group Phone #: (703) 647-4748
QUESTIONS?
Thank you!