Oregon Insurance Exchange - What You Need to Know


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The 10 most asked questions about how Oregon's new healthcare exchange, CoverOregon.com

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  • If you have questions about the Affordable Care Act or Oregon's Insurance Exchange (Cover Oregon www.coveroregon.com) visit www.greenberg-associates.com for answers.
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Oregon Insurance Exchange - What You Need to Know

  1. 1. 2014 Health Reform Oregon’s Insurance Exchange
  2. 2. 10 MOST-ASKED QUESTIONS  What is health care reform?  What do I need to do now?  What are the Health Insurance Marketplaces?  Do I have to buy from the Exchange?  Who has to buy health insurance?  What if I can‘t afford to buy health care coverage?  What if I don‘t buy health care coverage?  Can anyone get health care coverage?  What services will be covered?  What does a ―grandfathered‖ plan mean?
  3. 3. What is health care reform?  The term ―health care reform‖ refers to the Affordable Care Act — the federal law that was passed in March 2010 —as well as any state laws passed to implement. These laws are intended to give more people access to affordable health care coverage and receive better medical care.  Some changes include preventive care without any out of pocket cost, such as annual routine physical exams and immunizations, the removal of pre-existing waiting periods, and no longer denying coverage based on health conditions.
  4. 4. What do I need to do now?  If you have individual medical coverage or no medical coverage, you need to take action this fall. The Open Enrollment Period for the Health Insurance Marketplaces, or Exchanges, starts October 1st for coverage beginning January 1st. You will want to learn what options you will have through the Exchange, and how any current health coverage you may have will be affected. You will have many decisions to make. Keep in mind as you explore your options we are here to help you!  Businesses employing > 50 full time employees are mandated to offer health coverage beginning in 2014, however penalties for not doing so have been delayed until 2015.
  5. 5. What is the Health Insurance Marketplace? Marketplaces, aka ―Exchanges‖, will be a state or federally run website where many people can secure health care coverage. The Exchange will be available to people who are uninsured or acquire insurance on their own. You will be able to compare and choose health plans offered by private companies and find out if you are eligible for financial assistance or the Oregon Health Plan (Medicaid). The Exchange will also operate a Small Business Health Options Program (SHOP) for employers with 50 or fewer employees to provide a variety of group plans. Employees may be able to choose from plans the employer selects or from all plans available. The Exchange Open Enrollment begins October 1, 2013, and coverage effective dates will be January 1, 2014.
  6. 6. Oregon’s Insurance Exchange WWW.COVEROREGON.COM  Cover Oregon will be the health insurance marketplace for individuals, families, and small businesses located in Oregon.  It will allow Oregonians to compare health plans, find out if they are eligible for financial assistance, and enroll in a health plan.  Initially Cover Oregon will only be open to individuals, families and small businesses with 50 or fewer full-time employees. It will expand to companies with up to 100 employees in 2017.
  7. 7. APPROVED COVER OREGON CARRIERS Individual Medical Companies: Atrio Health Plans BridgeSpan Health Company HealthNet of Oregon Health Republic Kaiser Permanente Lifewise Health Plan Moda Health (ODS Companies) Oregon’s Health CO-OP PacificSource Health Plans Providence Health Plans Trillium Community Health Plan Individual Dental Companies: Best Life Dental Health Services Dentegra Insurance Company Kaiser Permanente Moda Health (ODS Companies) PacificSource Health Plans Trillium Community Health Plan Willamette Dental Insurance No Stand Alone Dental Offered SHOP/GROUP Medical & Dental Companies: Atrio Health Plans, Health Republic, Kaiser Permanente, Moda Health, Oregon‘s Health CO-OP, PacificSource, Providence, Trillium, Best Life, Dental Health, Dentegra, Guardian Life, Willamette Dental
  8. 8. SOMETHING NEW! Coordinated Care Organizations (CCO’s)  Coordinated Care Organizations (CCO‘s) are local health care entities that bring together all aspects of care: doctors, hospitals, dental care, mental health care and public health. The goal of CCO‘s is to work for better health care and lower costs by focusing on prevention, chronic disease management, earlier interventions and reduction of waste and inefficiency in the health system.  Coordinated Care Organizations (CCO‘s) are a new health care delivery model being used by the Oregon Health Plan. They are the umbrella organizations that govern and administer care for OHP members in their local communities. CCO‘s must be accountable for health outcomes of the population they serve. They will have one budget that grows at a fixed rate for mental, physical and ultimately dental care. CCO‘s will bring forward new models of care that are patient-centered and team-focused. They will have flexibility within the budget to deliver defined outcomes. They will be governed by a partnership among health care providers, community members, and stakeholders in the health systems that have financial responsibility and risk.
  9. 9.  www.familycareinc.org & www.healthshareoregon.org These are two CCO‘s that will serve members on the Oregon Health Plan, that live in Multnomah County. Coordinated Care Organizations (CCO’s) continued
  10. 10. Do I have to buy from the Exchange? No. The Exchange is just one of the ways people can shop for health coverage. People can still get coverage through their employer or directly from an insurance company. If currently covered by an individual health plan, your insurance company will be making changes to your plan as of January 1st to comply with the new laws & will update you later this fall on those changes. To qualify for individual & family premium tax credits & cost sharing, however, you are required to enroll through Cover Oregon. Also, to receive the Small Business Tax credit, small employers are also required to enroll through Cover Oregon.
  11. 11. Who has to buy health insurance? The Affordable Care Act requires most U.S. citizens and legal immigrants to have a basic level of health coverage starting January 1, 2014. Some people are excluded from this mandate.  People with certain religious beliefs,  Members of Native American tribes,  Undocumented immigrants,  Inmates,  People with income below a certain level
  12. 12. What if I can’t afford to buy health care coverage? The government will provide financial assistance through premium tax credits & cost sharing to help some people pay for health coverage. This is determined by a person‘s income level and family size. You will be able to find out if you qualify for financial assistance when Cover Oregon launches in October. If your spouse has group health coverage through their employer, and you are eligible to enroll, you are not eligible to receive a subsidy or tax credit. However, dependent children whose Household income is up to 250% of the FPL will qualify for coverage through the Exchange even if they have the option to enroll through their parent‘s group health plan.
  13. 13. Income Ranges that Qualify for Assistance  If you’re single, the range of income qualifying for assistance is between $11,490 and $45,960.  For couples, the range of combined income qualifying for assistance is between $15,510 and $62,040.  For a family of four, the range of combined income qualifying for assistance is between $23,550 and $94,200.
  14. 14. Health Insurance Assistance Chart Federal Poverty Level 2013 Family Size 100%* 138%** 150% 200% 250% 300% 400% 1 $11,490 $15,856 $17,235 $22,980 $28,725 $34,470 $45,960 2 $15,510 $21,404 $23,265 $31,020 $38,775 $46,530 $62,040 3 $19,530 $26,951 $29,295 $39,060 $48,825 $58,590 $78,120 4 $23,550 $32,499 $35,325 $47,100 $58,875 $70,650 $94,200 * Medicaid Eligible Currently ** Medicaid Eligible Effective January 1, 2014 due to ACA Medicaid Expansion
  15. 15. Single Person with $40,000 annual income
  16. 16. Family of 4 with $45,000 annual income
  17. 17. Family of 4 with $90,000 annual income
  18. 18. What if I don’t buy health care coverage?  If you don‘t buy coverage and go without it for three months or longer, you‘ll be charged a tax penalty by the government.  Penalty is $95 per adult and $47.50 per child (up to $285 for a family) or 1.0% of family income, whichever is greater, for 2014.
  19. 19. 2015 & 2016 tax penalties (Individuals & Families)  2015: Penalty is $325 per adult and $162.50 per child (up to $975 for a family) or 2.0% of family income, whichever is greater.  2016: Penalty is $695 per adult and $347.50 per child (up to $2,085 for a family) or 2.5% of family income, whichever is greater.
  20. 20. Can anyone get health care coverage? Yes, anyone can get coverage. As of January 1st 2014, insurance companies can no longer deny coverage to anyone who has a medical condition, and you don‘t have to pass a medical exam to qualify for coverage. Pre-existing conditions will be a thing of the past.
  21. 21. What services will be covered? EHB’s (Essential Health Benefits)  Ambulatory patient services, which includes doctor office visits and other same-day outpatient care  Emergency services  Hospitalizations  Maternity and newborn care  Mental health and substance use disorder services, including behavioral health treatment  Prescription drugs  Rehabilitative and habilitative services and devices  Laboratory services  Preventive and wellness services and chronic disease management  Pediatric services, including oral and vision care
  22. 22. What does a “grandfathered” plan mean? Health plans that were in effect on or before March 23, 2010, are exempt from many changes required under the Affordable Care Act. You can find out if your insurance is grandfathered by reviewing your health plan documents. However, if you are covered on an individual health plan chances are it is not a grandfathered plan. Also, the majority of group medical plans are no longer grandfathered due to changes made by employers since March 23, 2010. Therefore, the vast majority of all plans currently in force are no longer grandfathered.
  23. 23. Moving on..  Who  What  Where  When  Why  How
  24. 24. Who is affected by Health Reform?  Individuals & Families with private, individual health insurance  Individuals & Families with NO health insurance  Individuals on Portability, COBRA and OMIP  Children covered by Healthy Kids  Individuals covered by Oregon Health Plan
  25. 25. Who is affected, cont’d.  Small Business Owners offering group health coverage. They can keep existing coverage, outside of the Exchange.  Small Businesses can shop through Cover Oregon, and possibly receive a tax credit.  Or they cancel their group plan & have employees go to Cover Oregon directly to see if they qualify for premium tax credits & cost sharing.
  26. 26. What decisions do you need to make?  If you qualify for a tax credit and/or cost sharing, to assist you in paying for insurance and with reduced copayments, you‘ll want to sign up through Cover Oregon‘s Exchange.  If not, you can either secure coverage inside or outside of the Exchange. Outside of the Exchange there will be a wide range of health plan options to choose from, which will also be subject to all of the ACA requirements, i.e. no medical underwriting, no waits on pre-existing conditions.  Talk with us about your situation. We will help guide you and narrow down the best options for you. Remember, there is no cost to work with an agent!
  27. 27. Remember, incomes that qualify for assistance: Federal Poverty Level 2013 Family Size 100%* 138%** 150% 200% 250% 300% 400% 1 $11,490 $15,856 $17,235 $22,980 $28,725 $34,470 $45,960 2 $15,510 $21,404 $23,265 $31,020 $38,775 $46,530 $62,040 3 $19,530 $26,951 $29,295 $39,060 $48,825 $58,590 $78,120 4 $23,550 $32,499 $35,325 $47,100 $58,875 $70,650 $94,200 * Medicaid Eligible Currently ** Medicaid Eligible Effective January 1, 2014 due to ACA Medicaid Expansion Eligible for OHP / Healthy Kids
  28. 28. What do the plans in Cover Oregon look like? Plan Type Plan Covers Member‘s Responsibility Bronze 60% 40% Silver 70% 30% Gold 80% 20% Platinum 90% 10%
  29. 29. What rates may look like for metal plans Catastrophic Plan 21-year-old, single, non-tobacco user $120 Standard Bronze Plan  21-year-old, single, non-tobacco user $130  40-year-old, single, non-tobacco user $166  60-year-old, single, non-tobacco user $352 Standard Silver Plan  21-year-old, single, non-tobacco user $173  40-year-old, single, non-tobacco user $221  60-year-old, single, non-tobacco user $469 Standard Gold Plan  21-year-old, single, non-tobacco user $212  40-year-old, single, non-tobacco user $271  60-year-old, single, non-tobacco user $575
  30. 30. For the young invincibles…  There will be a ‗catastrophic‘ plan available to people up to age 30, through the Cover Oregon Exchange.  No subsidies are offered for this plan, but it satisfies the Individual Mandate to obtain health insurance.
  31. 31. Annual Income $15,856 - $17,234 $17,235 - $22,979 $22,980 - $28,724 $28,725 - $45,960 Maximum Monthly Amount you Pay $40 - $57 $57 - $121 $121 - $193 $193 - $364 Combined Deductible (Medical and Drug) $100 $750 $2,500 $2,500 Preventive Service No Cost No Cost No Cost No Cost Primary Care Visit Copayment $10 $15 $35 $35 Specialty Care Visit Copayment $20 $30 $70 $70 Urgent Care Visit Copayment $30 $40 $90 $90 Inpatient Coinsurance 10% 10% 30% 30% Generic/Preferred/ Specialty Drug Copay $5 / $10 / 25% $10 / $25 / 50% $15 / $50 / 50% $15 / $50 / 50% Maximum Out-of- Pocket $750 $1,500 $4,250 $6,350 Every carrier offering insurance plans through Cover Oregon must offer a standard silver plan. Individuals under certain income levels will be eligible for premium assistance; the amount of assistance will be based on the second-lowest cost silver plan. In addition, some individuals will receive help paying for co-pays and co-insurance if they buy a silver plan. Costs are estimated below.
  32. 32. Where to go for information?  www.greenberg-insurance.com Our website will help you enroll directly on a Cover Oregon plan when the time comes. In the meantime, our website offers a wealth of information and resources for you to learn more.  www.coveroregon.com Cover Oregon‘s website is currently providing information on health reform, subsidy calculators and what you can expect.  Take a step by step guide on your way out. Call or email us for help! We work one on one with individuals, families & small businesses with no cost to you.
  33. 33. Cover Oregon Open Enrollment dates For 2013 Initial Enrollment: You can enroll from October 1st 2013 – March 31st 2014. For 2014 and beyond, Open Enrollment runs from: October 15th 2014 through December 7th 2014. If you miss your opportunity to enroll, you will have to wait until the following year‘s open enrollment, unless you have a ‗Qualifying Event‘ (birth of child, change in family status).
  34. 34. When do you need to take action For those with no current coverage: October 1, 2013: Open enrollment in Cover Oregon begins. Coverage starts January 1, 2014. For those with existing health insurance: October 1, 2013 is when your insurance company will be sending you information on their upcoming plan and rate changes affecting you. Decide whether to keep the new coverage, or enroll with Cover Oregon through the March 31st 2014 initial open enrollment period.
  35. 35. Why does this matter to you?  Health Insurance Companies have specific rules as to when you can sign up for coverage and make changes. You want to make the right decision up front.  The only way to obtain premium assistance is to enroll in Cover Oregon.  You need to compare and contrast your options before the end of this year, so you are not stuck in a health plan you don‘t like for an entire year.
  36. 36. How will enrollment take place?  After October first, you‘ll go to www.CoverOregon.com  You‘ll have the option to elect an Insurance Agent from the drop down box.  Greenberg & Associates Insurance  Sharon Greenberg, License #676714  Adrienne Hutchins, License # 7373957  Ethel Sly, License #16382850  Describe your household; you‘ll need to have: Birthdates, Social Security Numbers, Family Income, All Household members & relationships, Home address/Oregon residency information, tobacco use, whether anyone is currently pregnant, your tax filing information (who is a dependent on your tax return)
  37. 37. Enrollment, continued.  When applying for financial subsidies or tax credits:  Enter Household Income. Have last year‘s tax return handy, your recent paystubs and who has income in your household. You‘ll enter your gross estimated income for 2014.  You‘ll be asked if any family members are blind, disabled or have special needs.  You‘ll be asked if you have current medical & dental coverage.  Review your application and confirm your identity. Move on to the Final Steps.
  38. 38. Finding a Medical & Dental plan  1) Household plan for all family members  2) One plan per person  3) Defined groups  Set your Preferences, like what benefits you want and which doctors you‘d like to see.  Choose a Plan and then review your plan selections.  Tax Credit Allocations. Choose up front monthly subsidy, or a tax credit at the end of the year.  E sign and submit for enrollment.  You can make a plan change before January 1st if you‘ve not paid your first premium.
  39. 39. Financial Assistance Notice  If your financial situation changes during the year, contact Cover Oregon right away for a redetermination of your subsidy, so you will not be asked to refund any portion of your subsidy at the end of the year if your income increased.
  40. 40. In conclusion ….  Decide whether to stay with your current insurance company, or enroll through the Cover Oregon Exchange.  Use the step by step guide to enroll in Cover Oregon online.  Majority of enrollments will be online and web based, but paper applications are still available.  We will be able to assist you with enrollment and coverage questions.
  41. 41. ~The Benefits of Working with an Agent~  They‘re free!! There is no charge for working with an agent. Premiums will be the same on all plans in or outside the Exchange whether you work with an agent or not.  We‘re able to show you health plans from many insurance carriers, both in and out of the Exchange.  We share our knowledge and experience with you.  We help you understand your benefits.  We help you enroll and obtain coverage from start to finish.  We are your advocate! We help with claims, benefits issues and questions all year long.
  42. 42. We at Greenberg & Associates are part of the Cover Oregon team and are available to answer questions and assist you with enrollment. If you are a current client, please contact us this fall for help with your options for January. If you aren‘t working with us, but would like us to help with your situation, be sure to write down your name, phone # & email address on our contact sheet as you leave. Be sure to take a step by step guide on enrolling in Cover Oregon.
  43. 43. Thank you for coming! Call or email us if you have questions or would like to discuss your situation in greater detail. Adrienne Hutchins Greenberg & Associates Insurance, LLC. adrienne@greenberg-insurance.com 503-297-8078 3439 NE Sandy Blvd., #378 Portland, OR 97232