Navigating the Affordable Care Act

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  • Stay on parents’ plans until age 26
    People on Medicare who can get free preventive care and savings on prescription drugs when hit coverage gap “donut hole”
    Recommended preventive care without copay or deductible
    Removal of annual and lifetime limits on coverage
    Can no longer be turned away or charged a higher premium due to pre-existing condition
  • Now, insurance companies cannot raise the costs of premiums more than 10% without giving a reasonable explanation.
    Insurance companies can no longer spend almost half your premium on overhead or marketing instead of actual health care services. They must spend 80% on health care and no more than 20% can go to profits or administrative costs.
  • Enrollment in the Marketplace begins October 1, 2013. Coverage can begin as early as January 1, 2014. After that, if you enroll and make your first premium payment by the 15th of the month your coverage will begin on the 1st of the following month. If you enroll and pay after the 15th, your coverage will begin on the 1st of the second following month.
    To be eligible to enroll in a Marketplace, you must live in its service area. You must also be a U.S. citizen or national, or be a non‐citizen who is lawfully present in the U.S. for the entire period for which enrollment is sought.
    You also cannot be incarcerated, unless you are pending disposition of charges. However, those who are incarcerated can apply for Medicaid or CHIP at any time.
  • Streamlined application
    You can apply online, by phone, via mail or in person.
    Then your application is verified (supported by a data services Hub between SSA, the IRS, DHS, and other approved data sources).
    You may be determined eligible for the Marketplace (to purchase and enroll in a QHP through the Marketplace), Medicaid, or FAMIS.
    If you are eligible to enroll in a QHP, you also find out if you are eligible for the Premium Tax Credit and the cost‐sharing reduction.
    You then enroll in the program you are eligible for.
    For individuals/families who appear eligible for Medicaid, Plan First, FAMIS – filing with state first could be better / faster
    Health Insurance Marketplace must “assess” for Medicaid/FAMIS eligibility
    But HIM it is not transferring applications assessed as Medicaid/FAMIS eligible until after Nov. 1
    State “Cover Virginia”
    Call center – 855-242-8282
    Website –
  • The Health Care Law provides for the establishment of an Essential Health Benefit (EHB) package that includes coverage of EHBs . The law directs that EHBs be equal in scope to the benefits covered by a typical employer plan and cover at least the following 10 general categories
  • 15 insurance companies have been certified in Virginia. 9 individual. 6 for SHOP exchange.
    Actuarial value, or AV, in the aggregate for a standard population, can be considered a general summary measure of health plan generosity.
    For example, if a plan has an actuarial value of 70%, on average, you would be responsible for 30% of the costs of all covered benefits. However, you could be responsible for a higher or lower percentage of the total costs of covered services for the year, depending on your actual health care needs and the terms of your insurance policy.
    While premiums are not taken into account to calculate the actuarial value, generally plans with a higher actuarial value and more generous cost‐sharing tend to have higher premiums.
    The Health Care Law requires that plans meet certain levels of coverage referred to as “metal tiers.” Each of these levels of coverage is associated with an actuarial value, which section 1302(d) of the statute requires be calculated based on the provision of the Essential Health Benefits to a standard population (and without regard to the population the plan may actually provide benefits to).
  • QHPs in the Marketplace can vary, for instance:
    Some plans may cover additional benefits
    You may have to see certain providers or use certain hospitals
    The premiums, copays, and coinsurance will be different in different plans
    The quality of care can vary, but quality data will be available
    Some plans will be structured differently, like high‐deductible plans
    Remember, all plans must cover the Essential Health Benefits.
    QHPs will be available with different levels of cost sharing. A plan will offer the same package of benefits in each level. What varies is how much the plan pays, and how much you will pay (cost sharing).
  • The Premium Tax Credit can vary based on the following:
    The amount of your household income (actual household income as reported on your income tax return) as a percentage of the Federal Poverty Level (FPL) and family size. It is based on a sliding scale. Higher household income  higher contribution
    The amount of the premium for the second lowest cost silver level Qualified Health Plan in your Marketplace.
  • The premium tax credit is generally available to individuals and families with incomes between 100% and 400% of the Federal Poverty Level ($23,550 – $94,200 for a family of four in 2013) who do not have access to certain other types of minimum essential coverage (MEC).
    What is MEC will be addressed on the next slide…
  • MEC includes government‐sponsored coverage (like Medicare, Medicare, CHIP, some VA coverage, and TRICARE, affordable employer‐sponsored insurance [meaning the cost for the employed individual is no more than 9.5% of their income], and certain other coverage).
  • With most tax credits, you have to wait until you file your taxes to get the credit. However, the new APTC lets you reduce your premiums right away or wait to receive the PTC until tax time.
    NOTE: Any changes in financial circumstances or family size should be reported immediately. Double‐check the information you put on your application. If you earn more income than the qualifying household income amount, the amount of savings for which you are eligible will be lower when you file your tax return. In this case, you might owe money at the end of the year. But if you make less than you expected, you may be eligible to receive a refund based on a higher PTC at the end of the year. You would do this on your next tax return. If you think a mistake was made when you get your savings decision determination in the Marketplace, you have the right to appeal (the application explains).
    There are special rules in case of divorce. If you get married, the savings amount is computed by month.
  • Cost‐sharing reductions are also available to help reduce out‐of‐pocket expenses.
    To be eligible for cost‐sharing reductions, you must have a household income that is less than or equal to 250% of the Federal Poverty Level (FPL) which is $58,875 annually for a family of four in 2013; meet the requirements to enroll in a health plan through the Marketplace and receive the new tax credit; and enroll in a silver‐level plan through the Marketplace.
    Members of a Federally‐recognized Indian tribe may also be eligible for special cost‐sharing reductions.


  • 2. Where Americans Get Health Coverage
  • 3. Affordable Care Act “Obamacare” Goals: oAffordable Insurance Coverage o Private Insurance Reform o 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
  • 4. 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
  • 5. Ensuring Reasonable Premiums   Premiums can be based on age,  geography,  smoking – not sex or health status   Annual Rate Review ◦ Federal and state governments insurance premium increases ≥ 10%    Medical Loss Ratio (MLR) ◦ Insurers must pay out 80¢ - 85¢ of each $1 premium for medical benefits -- or pay rebates to consumers. o Virginia’s 2012 rebates = $43 million to  over 685,000 residents
  • 6. 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
  • 7. Insurance Marketplace How to Apply   Multiple “doors” for applications ◦ Online – ◦ Phone –  ◦ Federal - 1-800-318-2596 ◦ Virginia call center – 1-888-392-5132 ◦ Website:  ◦ Virginia Local Departments of Social Services ◦ DSS  - “CommonHelp” - Online applications ◦   Federal Paper Application -
  • 8. 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
  • 9. 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
  • 10. 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
  • 11. Coverage Level Options in the Exchange Average % covered by plan & by enrollee Platinum 90% Gold 80% Silver Bronze 0% 20% 70% 60% 40% 60% 10% 20% 30% 40% 80% 100%
  • 12. Plans Offered in Northern Virginia
  • 13. Possible* Premium Rates for “Most Popular” Plans Company presentations to Virginia SCC on 7/16/2013: ◦ Single male age 29 ◦ Parents age 45 + 2 kids ◦ Couple age 60 $186 - $338 $690 - $1257 $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 and the Kaiser Family Foundation subsidy calculator
  • 14. Subsidies on the Marketplace PREMIUM 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)
  • 15. Insurance Marketplace - Tax redits 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%
  • 16. 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
  • 17. 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
  • 18. 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)
  • 19. 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 -
  • 20. 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)
  • 21. 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 OOP Individual Maximum OOP Family 100-200% FPL $2,063 $4,125 200-300% FPL $3,125 $6,250 300-400% FPL $4,125 $8,250
  • 22. 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 immigrants o Incarcerated persons o Those uninsured for less than 3 months.
  • 23. Minimum Coverage Requirements Tax 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]
  • 24. 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
  • 25. 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
  • 26. What Navigators Do • 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
  • 27. Contact Us! Carlon M. Ocel, Esq. Jessica R. Killeen Health Insurance Navigator with ENROLL Virginia! Health Insurance Navigator with ENROLL Virginia! 8305 Richmond Highway, Suite 17B 3401 Columbia Pike, Suite 301 Alexandria, VA 22309 Arlington, VA 22204 Direct: (703) 647-4744 Direct: (703) 647-4742 Main: (571) 482-2694 Main: (703) 532-3733 Fax: (703) 778-3455 Fax: (703) 685-1011 Group Phone #: (703) 647-4748
  • 28. QUESTIONS? Thank you!