NAVIGATING AFFORDABLE HEALTH CARE
Personal Assistance Within Reach

Thursday, October 31, 13
Mountain Projects Inc.
Graham County Presentation
October 29, 2013
6-7:30 pm
Graham and Swain County
Navigator: Julia Buck...
Today’s Topics
Mountain Project's Role
The MarketPlace
Personalized assistance
Privacy and Protection
Eligibility and Enro...
Mountain Projects Inc.
A Community Action Agency
MPI awarded a grant to implement a Navigator program in the
seven countie...
FINDING A CERTIFIED NAVIGATOR?
Far -Western North Carolina

Thursday, October 31, 13
FINDING A CERTIFIED NAVIGATOR?
Far -Western North Carolina

Jan Plummer: Project Coordinator &
Haywood
Julia Buckner:
Grah...
How do Mountain Projects’
Navigators Assist You?
Certified to assist through
enrollment 
Explain insurance
terminology; ch...
Navigator Assistance
Unbiased, free, impartial
Individuals or Small Employers
Assigned to Counties
Block Times at partner
...
Provisions of the ACA
GOAL: Affordable health care for millions
TOOLS: The Marketplace/An Insurance Exchange
Shop, compare...
Affordable Care Act
Protections
Prohibits higher premiums due
to health/gender
Extend coverage for
dependents up to age 26...
Marketplace Consumers
Individuals
Need health insurance
Have health insurance they
can't afford
Have dependents or a spous...
MARKETPLACE DETAILS
Insurance Affordability

Transparency, Competition, and Choice

APTC

Advanced
Premium
Tax Credits

Th...
MARKETPLACE DETAILS
Insurance Affordability Programs

Transparency, Competition, and Choice

APTC

NEW federal program tha...
MARKETPLACE DETAILS
Insurance Affordability Programs

Transparency, Competition, and Choice

NEW federal program
CSR

Cost...
MARKETPLACE DETAILS
Insurance Affordability Programs

Transparency, Competition, and Choice

MEDICAID

Existing federal-st...
MARKETPLACE DETAILS
Insurance Affordability Programs

Transparency, Competition, and Choice

CHIP

Existing federal-state ...
Eligibility and Enrollment
Started October 1, 2013 
Enroll by December
15,2013 coverage begins
January 1, 2014

Premium by...
How to Prepare
Individuals

Employer

SSN for Household/
Birthdates

Expected enrollment

Pay Stubs/W2 Tax
Information for...
Qualified Health Plans
Minimum Essential Benefits
Ambulatory Patient Services
Emergency Services
Hospitalization
Maternity...
Health Plan Categories
BRONZE: Minimum Essential Benefits/Insurance
pays 60% of covered expenses
SILVER:  Minimum Essentia...
Health Plan Categories
BRONZE: Minimum Essential Benefits/
Insurance pays 60% of covered expenses
SILVER:  Minimum Essenti...
Options to Lower Costs
Premium Tax Credits 
Lower monthly premiums/HH income, size, cost of
available plans
Cost Sharing R...
Exemptions to Individual
Responsibility Requirement
Investigate first
Hardships:  Homelessness, eviction, foreclosure, uti...
HOW THE MARKETPLACE
WORKS

Thursday, October 31, 13
WWW.HEALTHCARE.GOV

Thursday, October 31, 13
Window Shopping
www.healthcare.gov
Look at Plans
Kaiser Health Calculator
BCBS Site: http://
www.bcbsnc.com/content/
provi...
KAISER SUBSIDY
CALCULATOR

Thursday, October 31, 13
Thursday, October 31, 13
FEDERAL POVERTY LEVELS

Thursday, October 31, 13
OPTIONS TO LOWER COSTS

Thursday, October 31, 13
NC Medicaid Eligibility
NC Medicaid covers only 30% of adults in
poverty

100

Medicaid for Families** & Medicaid
for Aged...
NC Medicaid Expansion
Many more can get Medicaid/
CHIP, due to higher income
limits, income exclusions,
choices re claimin...
NC Coverage Gaps
Consumers not eligible for Medicaid/
Chip will not receive tax credits unless
their projected 2014 income...
TAX CREDITS
How much will this cost?

Thursday, October 31, 13
EXPECTED FAMILY $$
How much will this cost?

Thursday, October 31, 13
BENCHMARK PLANS
How much will this cost?
REMEMBER: The size of the tax
credit equals the silver benchmark
plan minus a fam...
FINDING A CERTIFIED NAVIGATOR?
Far -Western North Carolina

Personal Assistance
Within Reach
www.mountainprojects.org
828-...
MOUNTAIN PROJECTS
Serving the Community since 1965

Thursday, October 31, 13
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Navigating Affordable Health Care

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Navigating Affordable Health Care

  1. 1. NAVIGATING AFFORDABLE HEALTH CARE Personal Assistance Within Reach Thursday, October 31, 13
  2. 2. Mountain Projects Inc. Graham County Presentation October 29, 2013 6-7:30 pm Graham and Swain County Navigator: Julia Buckner Thursday, October 31, 13
  3. 3. Today’s Topics Mountain Project's Role The MarketPlace Personalized assistance Privacy and Protection Eligibility and Enrollment Preparing for an Appointment Contact Information Thursday, October 31, 13
  4. 4. Mountain Projects Inc. A Community Action Agency MPI awarded a grant to implement a Navigator program in the seven counties in WNC Counties: Clay, Cherokee, Haywood, Graham, Jackson, Swain, Macon  Local and personal assistance Community education and partnership agencies 5.5 employees- covering the 7 counties of WNC-Navigators Volunteers trained and more needed Thursday, October 31, 13
  5. 5. FINDING A CERTIFIED NAVIGATOR? Far -Western North Carolina Thursday, October 31, 13
  6. 6. FINDING A CERTIFIED NAVIGATOR? Far -Western North Carolina Jan Plummer: Project Coordinator & Haywood Julia Buckner: Graham & Swain Patti DeRidder and Claire Tiernan: Cherokee & Clay Thursday, October 31, 13 Jane Harrison: Haywood & Jackson Rebecca Mathis: Jackson Cindy Solesbee: Macon Personal Assistance Within Reach www.mountainprojects.org
  7. 7. How do Mountain Projects’ Navigators Assist You? Certified to assist through enrollment  Explain insurance terminology; choices; implications Unbiased, impartial, and free Privacy/Confidentiality  Thursday, October 31, 13 No rush, no pressure, no affiliation Resource for questions May complete on-line or paper applications
  8. 8. Navigator Assistance Unbiased, free, impartial Individuals or Small Employers Assigned to Counties Block Times at partner Agencies, i.e. DSS, Mountain Projects Thursday, October 31, 13 Community Events Can not go door to door Refer to state agencies if appropriate Appointments available
  9. 9. Provisions of the ACA GOAL: Affordable health care for millions TOOLS: The Marketplace/An Insurance Exchange Shop, compare and purchase insurance based on income and household size. Medicaid Expansion: NC did not expand Individual Mandate beginning 2014/Exemption Employer Shared Responsibility:  Must offer a plan that meets ACA minimum essential benefits or pay a fee (ESRP) Thursday, October 31, 13
  10. 10. Affordable Care Act Protections Prohibits higher premiums due to health/gender Extend coverage for dependents up to age 26 Prohibits discrimination against consumers seeking coverage with pre-existing conditions Eliminated Insurance Annual Coverage Limits  Thursday, October 31, 13
  11. 11. Marketplace Consumers Individuals Need health insurance Have health insurance they can't afford Have dependents or a spouse that make insurance unaffordable Employed by a small employer getting health insurance through the Marketplace Thursday, October 31, 13 Small Businesses Investigate coverage for employees Explore options via the Marketplace Questions about exemptions and penalties Have 50 FTE's or equivalent 
  12. 12. MARKETPLACE DETAILS Insurance Affordability Transparency, Competition, and Choice APTC Advanced Premium Tax Credits Thursday, October 31, 13 CSR MEDICAID CHIP Cost Sharing Reductions Medicaid Children’s Health Insurance Program
  13. 13. MARKETPLACE DETAILS Insurance Affordability Programs Transparency, Competition, and Choice APTC NEW federal program that uses tax credits to reduce premium costs for QHP enrollees. For people who meet financial criteria and don’t have access to other coverage. Advanced Premium Tax Credits Thursday, October 31, 13 Can be paid in “advance” to provide immediate help in paying premiums. IRS reconciles over/under payments of advance premium tax credits when people file taxes.
  14. 14. MARKETPLACE DETAILS Insurance Affordability Programs Transparency, Competition, and Choice NEW federal program CSR Cost Sharing Reductions Thursday, October 31, 13 Helps reduce out-of-pocket costs for enrollees in QHPs. Payments are made directly to issuers to reduce deductibles, co-insurance, and/or copayments (out-of-pocket) costs.
  15. 15. MARKETPLACE DETAILS Insurance Affordability Programs Transparency, Competition, and Choice MEDICAID Existing federal-state health insurance program for low income people. Expanded to more low-income adults by the ACA. States can opt out of expansion. Medicaid Thursday, October 31, 13 Provides comprehensive health care benefits. Minimal out-of-pocket costs.
  16. 16. MARKETPLACE DETAILS Insurance Affordability Programs Transparency, Competition, and Choice CHIP Existing federal-state health insurance program for low- and moderate-income children. Provides comprehensive health care benefits. Children’s Health Insurance Program Thursday, October 31, 13 Modest out-of-pocket costs.
  17. 17. Eligibility and Enrollment Started October 1, 2013  Enroll by December 15,2013 coverage begins January 1, 2014 Premium by Dec. 15 Ends March 31, 2014 Special Enrollment Periods Coverage by Jan. 1 Thursday, October 31, 13
  18. 18. How to Prepare Individuals Employer SSN for Household/ Birthdates Expected enrollment Pay Stubs/W2 Tax Information for 2013/ estimate2014 Age of Spouse Employer insurance information (handout) Additional HH income information Thursday, October 31, 13 Existing health coverage? Dependent information Agent may help enroll/ explore
  19. 19. Qualified Health Plans Minimum Essential Benefits Ambulatory Patient Services Emergency Services Hospitalization Maternity and Newborn Care Mental Health/Substance Abuse/Behavioral Health Treatment Prescription Drugs Thursday, October 31, 13 Rehabilitation: physical or mental Labs Wellness/Chronic Disease Management (Asthma, diabetes) Pediatric Services including dental
  20. 20. Health Plan Categories BRONZE: Minimum Essential Benefits/Insurance pays 60% of covered expenses SILVER:  Minimum Essential Benefits/Insurance pays 70% of covered expenses GOLD:  Minimum Essential Benefits/Insurance pays 80% of covered expenses PLATINUM:  Minimum Essential Benefits/ Insurance pays 90% of covered expenses CATASTROPHIC: Meet all QHP requirements but only cover 3 primary care visits annually until deductible is met. Must be under 30 or receive a hardship exemption.  Thursday, October 31, 13 Silver 30% you 70% insurance
  21. 21. Health Plan Categories BRONZE: Minimum Essential Benefits/ Insurance pays 60% of covered expenses SILVER:  Minimum Essential Benefits/ Insurance pays 70% of covered expenses GOLD:  Minimum Essential Benefits/ Insurance pays 80% of covered expenses Premiums increase Thursday, October 31, 13 PLATINUM:  Minimum Essential Benefits/Insurance pays 90% of covered expenses Out of Pocket increase
  22. 22. Options to Lower Costs Premium Tax Credits  Lower monthly premiums/HH income, size, cost of available plans Cost Sharing Reductions  Limits out-of-pocket costs (deductibles and co-pays)/ HH income/size  MAY REQUIRE SILVER PLAN SELECTION Competition in the Marketplace: Blue Cross & CoventryOne Thursday, October 31, 13
  23. 23. Exemptions to Individual Responsibility Requirement Investigate first Hardships:  Homelessness, eviction, foreclosure, utility shut-off, domestic violence victim, death of close family member, recent bankruptcy, unexpected caretaker expenses, eligibility denials, coverage exceeding 8% of projected annual income, ineligible for Medicaid/no state expansion Navigators can not assist with the exemption application. (IRS) Incarceration                                    Past months Indian Status                                    Past and Future Religious Conscience                   Complete IRS Form 4029 Health Care Sharing Ministry     Past months Thursday, October 31, 13
  24. 24. HOW THE MARKETPLACE WORKS Thursday, October 31, 13
  25. 25. WWW.HEALTHCARE.GOV Thursday, October 31, 13
  26. 26. Window Shopping www.healthcare.gov Look at Plans Kaiser Health Calculator BCBS Site: http:// www.bcbsnc.com/content/ providersearch/index.htm Coventry Site: http:// nc.coventryproviders.com Thursday, October 31, 13
  27. 27. KAISER SUBSIDY CALCULATOR Thursday, October 31, 13
  28. 28. Thursday, October 31, 13
  29. 29. FEDERAL POVERTY LEVELS Thursday, October 31, 13
  30. 30. OPTIONS TO LOWER COSTS Thursday, October 31, 13
  31. 31. NC Medicaid Eligibility NC Medicaid covers only 30% of adults in poverty 100 Medicaid for Families** & Medicaid for Aged, Blind, Disabled 75 50 21-64: nondisabled, no child, 25 No Medicaid 0 Medicaid Eligibility The Affordable Care Act, as written, expands Medicaid eligibility to all US citizens under 138% of the Federal Poverty Line (FPL). Because ACA assumed Medicaid expansion, those under 100% of FPL do not qualify for APTC. COVERAGE GAPS Thursday, October 31, 13
  32. 32. NC Medicaid Expansion Many more can get Medicaid/ CHIP, due to higher income limits, income exclusions, choices re claiming dependents. A few will LOSE Medicaid/ CHIP due to changes. First recertification after 3/31/14. e.g. stepparent with income, sibling with taxable income, separated but file jointly. Thursday, October 31, 13 Often child will be enrolled in Medicaid or CHIP while parent is enrolled in private insurance. This will lead to different provider networks, different coverage, and different copays/ deductibles (which are very low for Medicaid and CHIP) for parent vs. child.
  33. 33. NC Coverage Gaps Consumers not eligible for Medicaid/ Chip will not receive tax credits unless their projected 2014 income is higher than 100% of FPL. There is no risk (and significant benefit) to honestly, reasonably projecting 2014 income over 100% of FPL. IRS will waive overpayment if actual 2014 income turns out to be under 100% of FPL. Federal Poverty Levels Thursday, October 31, 13
  34. 34. TAX CREDITS How much will this cost? Thursday, October 31, 13
  35. 35. EXPECTED FAMILY $$ How much will this cost? Thursday, October 31, 13
  36. 36. BENCHMARK PLANS How much will this cost? REMEMBER: The size of the tax credit equals the silver benchmark plan minus a family’s expected contribution. The higher the cost of the benchmark plan, the larger the APTC. Benchmark plan costs will change based on where the family lives, the ages of the family members seeking coverage,and the number of household members enrolled in QHP. Even when the benchmark plan changes, the family’s expected contribution amount remains the same. Thursday, October 31, 13
  37. 37. FINDING A CERTIFIED NAVIGATOR? Far -Western North Carolina Personal Assistance Within Reach www.mountainprojects.org 828-452-1447, ext. 115 1-800-627-1548 All NC Counties: 1-855-733-3711 Health Insurance Marketplace: 1-800-318-2596 Thursday, October 31, 13
  38. 38. MOUNTAIN PROJECTS Serving the Community since 1965 Thursday, October 31, 13
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