The Affordable Care Act
A new age in health care:
Insurance that works,
Navigators to show the way

Kit Wagar
Affordable C...
Enrollment is a marathon, not a sprint


Enrollment schedule:
 The first enrollment period began Oct. 1, and ends on Mar...
Moving ahead



Two benchmarks from the first three weeks:
 Nearly 20 million unique visitors have checked out Healthcar...
Marketplaces – A fairer system
 In 2014, private insurers will no longer deny coverage or charge a

higher price based on...
A fairer market – Essential Health Benefits
 Currently, many plans offered in the individual market leave out
major categ...
Key requirements of a Marketplace


Marketing of policies
These functions include:
 Toll-free phone number

 Website
 ...
Making insurance affordable
Help for the middle class
Beginning in 2014:


Workers without health benefits receive tax credits to help buy
insurance ...
Affordable Health Plans
 Expected contribution to insurance premiums, silver-level plan
 For an individual:
Annual Incom...
Affordable Health Plans
 Expected contribution to insurance premiums, silver-level plan
 For a family of 4:
Annual Incom...
Actual prices in the Missouri Marketplace
Individual policies, lowest-priced plan in each category:
Age
27
27
27
27

Count...
Actual prices in the Missouri Marketplace
Family of 4, lowest-priced plan in each category:
County
Boone
Boone
Boone
Boone...
Calculating your income
 When you apply for lower costs in the Marketplace, you’ll need to
estimate your household income...
Individual responsibility


Beginning in 2014, individuals can choose to:
 carry health insurance, or
 pay a fee to off...
Consumer assistance
No wrong door to enrollment
Healthcare.gov (aka “The Culprit”)
 Links to key questions consumers
have about health insurance,
eligibility & enrollmen...
Marketplace Call Center
Call Center launched in June

1-800-318-2596

TTY/TDD line for hearing-impaired callers:


Helps ...
Help for small employers
Small Business Health Options Program – “The SHOP”
 SHOP Call Center launched in August
TTY/TDD ...
Finding the right health plan
 Once an account is created, the
website offers:
 A comparison tool to evaluate policies
...
In-person assistance
Sources of enrollment help
 Navigators
 Navigators received grants from Marketplace funds
 They must provide community ...
Missouri Navigators
Navigator funding was announced Aug. 15:
Missouri received $1.8 million for navigator organizations
...
Sources of enrollment help
 Application Counselors
 They receive similar, but less extensive, training than Navigators. ...
Becoming a CAC agency
 To apply to be designated as a certified application counselor
agency, go to:
 http://marketplace...
Sources of enrollment help
 Licensed health Insurance agents and brokers
 To enroll individuals, must undergo training o...
Security of personal information
 Navigators and application counselors must:
 comply with the Marketplace privacy polic...
Steps to take now
 Learn about different types of health coverage
 The Marketplace lets you choose a health plan with th...
A final thought

“Opportunity is missed by most people because it
is dressed in overalls and looks like work.“

----Thomas...
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Missouri and The Affordable Care Act in 2014

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Kit Wagar: Outreach Specialist, US Department of Health and Human Services
Missouri Health Policy Summit 2013

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  • In 2014, private insurers will no longer be able to deny coverage because of a person’s health condition. They also won’t be able to charge a higher price because of a person’s medical history. Prices will vary only based on four criteria:Age – insurers can charge a maximum of 3 times the price of younger applicantsTobacco use – insurers can charge a maximum of 50 percent higher than non-smokersLocation – states can establish rating areasFamily size – insurers can charge more for larger familiesIn 2014, insurers will no longer be able to discriminate against half the nation’s population. Currently, young women are often charged up to 50 percent more than men the same age simply because they could become pregnant. This kind of discrimination will no longer be allowed.
  • As we’ve discussed, the new marketplaces are a web-based supermarket for health insurance. There are several duties that these marketplaces have to help people find the insurance plan that works best for them. They will have a toll-free phone number and a website. Some may have storefront offices. They will present benefits in a standardized format for easy comparison. And the website will have a calculator so that people can figure out, based on their income, how much help they will receive to pay for insurance and how much they will have to pay out of pocket for the policy. We’ve talked about how families with incomes below 400 percent of the poverty level can get part of their insurance premium paid by the federal government. In addition, families with incomes below 250 percent of the poverty level can get lower co-payments and deductibles to help them afford medical care.Marketplaces will also determine whether applicants qualify for Medicaid or whether their kids qualify for the Children’s Health Insurance Program, which provides Medicaid coverage for kids from households modestly above the poverty level. The marketplace also must determine which policies are eligible to be sold through the marketplace. Most marketplaces are expected to be passive marketplaces, also called a clearinghouse. They will simply list all qualified insurance plans available for sale. But some states are adopting “active marketplaces.” In those cases, the marketplaces will act like an employer and take bids from insurance companies on their best plans. Only the plans offering the most value will be sold through the marketplace. Insurers are likely to compete vigorously on both price and service to be able to offer their plans through the marketplaces.
  • ‘‘In the case of household income (expressedas a percent of poverty line)within the following income tier: The initial premium % is— The final premium % is—Up to 133% 2.0% 2.0%133% up to 150% 3.0% 4.0%150% up to 200% 4.0% 6.3%200% up to 250% 6.3% 8.05%250% up to 300% 8.05% 9.5%300% up to 400% 9.5% 9.5%Based on the second lowest cost silver plan.
  • In Boone County, the second-lowest-priced silver plan costs $252. Therefore, the subsidy equals $252 minus the “maximum payment based on income” of $86. In St. Louis County, the second-lower-priced silver plan costs $216. Therefore, the subsidy equals $216 minus $86, which equals $130.
  • In Boone County, second-lowest-priced silver plan is $852. Therefore, the subsidy equals $852 minus the “maximum payment based on income” of $177, or $675. In St. Louis County, the second-lowest-priced silver plan is $730. Therefore, the subsidy equals $730 minus the “maximum payment based on income” of $177, or $675.
  • The tax filing threshold in 2012 is $9,750 for an individual and $19,500 for a married couple. This is the sum of the personal exemption plus the amount below the point at which tax rates start.
  • In-person assisters can be used in state-based exchanges and partnership exchanges where the state runs the consumer assistance portion. See August 2012 exchange application guidance. http://www.cciio.cms.gov/resources/files/hie-blueprint-081312.pdf
  • FFMs will designate organizations, which will certify their employees or volunteers after they have passed the test. SBMs can choose either to 1) certify individual application counselors; 2) designate organizations to certify their employees and volunteers; or 3) do both.
  • Missouri and The Affordable Care Act in 2014

    1. 1. The Affordable Care Act A new age in health care: Insurance that works, Navigators to show the way Kit Wagar Affordable Care Act Specialist U.S. Department of Health and Human Services Region 7 – Missouri, Kansas, Iowa, Nebraska 1
    2. 2. Enrollment is a marathon, not a sprint  Enrollment schedule:  The first enrollment period began Oct. 1, and ends on March 31, 2014  We are in only the fourth week of a six-month enrollment period  Coverage through the Marketplaces begins as early as Jan. 1, 2014  Must be enrolled by Dec. 15, 2013, for coverage to begin in January  In subsequent years, enrollment runs from October 15 to December 7
    3. 3. Moving ahead  Two benchmarks from the first three weeks:  Nearly 20 million unique visitors have checked out Healthcare.gov  Nearly 700,000 people have completed online applications nationwide  But the health reform law is not just a website:  It’s a new approach that makes health insurance more affordable and health care more accessible to everyone
    4. 4. Marketplaces – A fairer system  In 2014, private insurers will no longer deny coverage or charge a higher price based on a person’s medical history  Prices for individuals will vary based only on four criteria:  Age – a maximum of 3 times the price of younger applicants  Tobacco use – a maximum of 50 percent higher than non-smokers  Location states can establish rating areas –  Family size  Ending gender discrimination  Women will no longer be charged more than men the same age  Currently, 22-year-old women are often charged 50 percent more than men their age simply because women bear children
    5. 5. A fairer market – Essential Health Benefits  Currently, many plans offered in the individual market leave out major categories of coverage  Consumers often don’t realize the omission until they need the coverage  62 percent don’t have maternity benefits  34 percent don’t cover substance abuse  18 percent don’t provide mental health coverage  9 percent don’t cover prescription medication In 2014, all health insurance plans must cover the following services:      Ambulatory patient services Emergency Services Hospitalization Maternity and newborn care Mental health and substance abuse 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
    6. 6. Key requirements of a Marketplace  Marketing of policies These functions include:  Toll-free phone number  Website  Presenting benefits in a standardized format  Single application for Medicaid/CHIP/private insurance  Providing electronic calculator to determine actual cost of policy  Includes premium subsidies for less than 400% of poverty level  Cost-sharing reductions for households at less than 250% of poverty  Determining eligibility for Medicaid and CHIP  Certifying people too poor to make personal responsibility payments  Review insurance plans for eligibility in the marketplace  In Kansas & Missouri, insurers had to file their proposed plans and rates by May 3  They were reviewed last summer and approved in September
    7. 7. Making insurance affordable
    8. 8. Help for the middle class Beginning in 2014:  Workers without health benefits receive tax credits to help buy insurance through the marketplaces  Credits will be available up to 400 percent of the poverty level  Maximum income of:  $45,960 for 1 person  $94,200 for family of 4  The IRS estimates the average credit will be more than $5,000 These credits:  allow family farmers and the self-employed to obtain health insurance as if they had an employer helping them buy it  help small business owners that can’t afford health insurance to compete for employees with large companies that provide generous benefits
    9. 9. Affordable Health Plans  Expected contribution to insurance premiums, silver-level plan  For an individual: Annual Income % of FPL  $13,788 120*  $16,200 141  $20,107 Expected Contribution 2% of income Maximum Monthly Premium Reduction in Out-of-Pocket Maximum Consumer’s Portion of Total costs $23 2/3 6% 3.5% $47 2/3 6% 175 5.15% $86 2/3 13%  $25,852 225 7.18% $155 1/2 27%  $31,597 275 8.78% $231 0 30%  $40,215 350 9.5% $318 0 30%  Incomes below 250% of the poverty level qualify for lower co-pays and deductibles * This level of income would be eligible for Medicaid in states that expand their programs in accordance with the Affordable Care Act
    10. 10. Affordable Health Plans  Expected contribution to insurance premiums, silver-level plan  For a family of 4: Annual Income % of FPL  $28,260 120*  $33,205 141  $41,212 Expected Contribution 2% of income Maximum Monthly Premium Reduction in Out-of-Pocket Maximum Consumer’s Portion of Total costs $47 2/3 6% 3.5% $97 2/3 6% 175 5.15% $177 2/3 13%  $52,987 225 7.18% $317 1/2 27%  $64,762 275 8.78% $474 0 30%  $82,425 350 9.5% $653 0 30%  Incomes below 250% of the poverty level qualify for lower co-pays and deductibles * This level of income would be eligible for Medicaid in states that expand their programs in accordance with the Affordable Care Act
    11. 11. Actual prices in the Missouri Marketplace Individual policies, lowest-priced plan in each category: Age 27 27 27 27 County Boone Boone Boone Boone Annual income $20,107 $20,107 $25,852 $25,852 27 27 27 27 St. Louis St. Louis St. Louis St. Louis $20,107 $20,107 $25,852 $25,852 Plan Monthly level premium Silver $242 Bronze $195 Silver $242 Bronze $195 Silver Bronze Silver Bronze $196 $147 $196 $147 Actual payment $76 $29 $145 $98 $66 $17 $135 $86 Size of Discount $166 $166 $97 $97 $130 $130 $61 $61 Many rural areas, which traditionally have higher insurance prices than urban areas, get bigger discounts to even out the costs
    12. 12. Actual prices in the Missouri Marketplace Family of 4, lowest-priced plan in each category: County Boone Boone Boone Boone Annual Income $41,212 $41,212 $52,987 $52,987 Plan Monthly level premium Silver $816 Bronze $659 Silver $816 Bronze $659 St. Louis St. Louis St. Louis St. Louis $41,212 $41,212 $52,987 $52,987 Silver Bronze Silver Bronze $663 $496 $663 $496 Actual payment $141 $0 $281 $124 Size of Discount $675 $675* $535 $535 $110 $0 $250 $83 $553 $553** $413 $413 * In Boone County, 1 plan would produce a $0 monthly premium; 1 plan would produce a monthly premium of $5. **In St. Louis County, 2 bronze plans would produce a $0 monthly premium
    13. 13. Calculating your income  When you apply for lower costs in the Marketplace, you’ll need to estimate your household income for 2014  Most people can use their household’s adjusted gross income for this estimate  If you know your 2013 adjusted gross income, use that and take into account any changes you expect in 2014  You could also add up the following items for everyone in your household, based on what you think they’ll receive in 2014:  Wages  Salaries  Tips  Net income from any self-employment or business  Unemployment compensation  Social Security payments  Other kinds of income to include when estimating your 2014 income are:  rental income, interest, dividends, capital gains, annuities, alimony, and some retirement and pensions.
    14. 14. Individual responsibility  Beginning in 2014, individuals can choose to:  carry health insurance, or  pay a fee to offset the cost of treating the uninsured  Qualifying coverage: Medicare, Medicaid, Veterans’ coverage , Tricare, employer coverage, private insurance  The fee is the greater of:  $95 per person in the household or 1% of your income that exceeds the tax filing threshold in 2014  $325 per person or 2 percent of income in 2015  $695 per person or 2.5% of income in 2016 and thereafter  Maximum per household is the income percentage or 3 times the flat fee  The flat fee for each child is half the adult amount
    15. 15. Consumer assistance
    16. 16. No wrong door to enrollment
    17. 17. Healthcare.gov (aka “The Culprit”)  Links to key questions consumers have about health insurance, eligibility & enrollment  Offers Web chat capability to answer users’ questions  Directs users to appropriate destination based on geography  Footer contains links for nonconsumer users to find information  You can create an account*  You provide family and income information to qualify for discounts*  You peruse the health plan options*  You enroll in the plan best for you* *We’re working out the kinks
    18. 18. Marketplace Call Center Call Center launched in June 1-800-318-2596 TTY/TDD line for hearing-impaired callers:  Helps with wide range of questions, including:      Health insurance and how it works Premium assistance and health care affordability programs Steps to take now to get ready for open enrollment beginning Oct. 1 General inquiries, such as “I have insurance. How will I be affected?” After Oct. 1, the call center will help with:    1-855-889-4325 Filling out the application Plan selection Assistance is Available 24/7 in English and Spanish  Help in 150 other languages is available
    19. 19. Help for small employers Small Business Health Options Program – “The SHOP”  SHOP Call Center launched in August TTY/TDD line for hearing-impaired callers: 1-800-706-7893 1-800-706-7915 Hours: 8 a.m. to 4 p.m. (central time) Beginning Oct. 1: 8 a.m. to 6 p.m. (central)  Information on tax credits that cover up to 50 percent of the cost of employee health insurance for two years at eligible small employers  New, more competitive pricing for health insurance policies  Plans grouped by “metal level” to let employers compare plans with truly similar benefits  Metal levels – bronze, silver, gold, platinum – reflect the generosity of the plan’s coverage  SBA Fact Sheets, Training Materials and insurance finder tool:  http://www.sba.gov/content/affordable-care-act-training-materials  Information based on your business location, size, and whether you now offer insurance  SHOP enrollment expected to begin in November
    20. 20. Finding the right health plan  Once an account is created, the website offers:  A comparison tool to evaluate policies  A calculator to estimate each plan’s:  premiums  co-payments  deductibles  maximum out-of-pocket costs  Filtering options to let the user narrow the choices based on specific criteria  The most relevant plans are presented first, based on the applicant’s answers  Key data listed with links to plan details
    21. 21. In-person assistance
    22. 22. Sources of enrollment help  Navigators  Navigators received grants from Marketplace funds  They must provide community outreach and education programs  They are agencies or individuals trained to work with the uninsured and the underinsured and with employers buying health benefits for employees  Key groups that Navigators will work with include:  Young people who may never have had health insurance  The self-employed, many of whom previously could never afford insurance  Vulnerable populations, including     Low-income groups Non-English-speaking populations People with disabilities Workers between jobs  To ensure that their advice is impartial, Navigators cannot accept compensation directly or indirectly from any health insurer  Navigators will be listed on the Marketplace website under “Find Local Help”
    23. 23. Missouri Navigators Navigator funding was announced Aug. 15: Missouri received $1.8 million for navigator organizations  Primaris Healthcare Business Solutions $1,045,624  Primaris will lead a coalition of 11 community partners to provide free and unbiased information about insurance plans offered on the Marketplace  Primaris already works with health care providers to improve quality of care  Primaris also operates the Medicare CLAIM program, which provides counseling to help people choose the most appropriate Medicare Advantage plan  Missouri Alliance of Area Agencies on Aging  These agencies have an extensive $ 750,000 network of contacts and experience dealing with vulnerable populations  They will provide navigators in most of Missouri, outside Kansas City
    24. 24. Sources of enrollment help  Application Counselors  They receive similar, but less extensive, training than Navigators. They must pass a similar, though less comprehensive test  Training is available online at http://marketplace.cms.gov/training/get-training.html  Counselors are certified by the organization they work or volunteer for  Individuals can take the training and provide assistance, but they will not be listed on the Marketplace website as certified application counselors  No funding is attached to becoming an application counselor  Most counselors are likely to be staff and volunteers of organizations with a business interest or a social mission to get people insured  Clinics, hospitals, health care providers, social agencies are encouraged to become designated to certify their staff members as application counselors  Counselors must show applicants all insurance options available  To ensure unbiased advice, counselors cannot accept compensation in connection with enrollment and must disclose any potential conflict
    25. 25. Becoming a CAC agency  To apply to be designated as a certified application counselor agency, go to:  http://marketplace.cms.gov/help-us/cac.html  Agencies designated as certified application counselors will be listed on the www.healthcare.gov website under “Find local help”  Questions about becoming a certified application counselor or agency can be sent to CACQuestions@cms.hhs.gov
    26. 26. Sources of enrollment help  Licensed health Insurance agents and brokers  To enroll individuals, must undergo training on:     website enrollment Marketplace affordability programs Medicaid options security of personal information  Paid by insurers  Brokers and agents represent certain insurance companies and are not required to show applicants all insurance options  Broker training in the federally run Marketplaces is available at:  http://www.cms.gov/CCIIO/programs-and-initiatives/health-insurancemarketplaces/a-b-resources.html
    27. 27. Security of personal information  Navigators and application counselors must:  comply with the Marketplace privacy policies  follow Marketplace rules on security of personal information  Information entered on paper applications should not be retained  Information in electronic applications is secure within applicant’s online account  Designated application counselor organizations must:  screen staff and volunteers to ensure they protect personal information  confirm in writing that its workers will comply with privacy and security rules  All certified application counselors must:  obtain authorization from each consumer before obtaining personal information  maintain a record of the authorization  The consumer can revoke the authorization at any time  Organizations or individuals who violate privacy and security standards are subject to monetary penalties  Fraudulent activity will be investigated and addressed under federal law
    28. 28. Steps to take now  Learn about different types of health coverage  The Marketplace lets you choose a health plan with the right balance of costs and coverage. You’ll be better prepared if you understand different types of coverage  Make sure you understand how coverage works, including things such as premiums, deductibles, out-of-pocket maximums, copayments, and coinsurance. You'll want to consider these details while you're looking for health insurance  Gather basic information about your household income  Most people using the Marketplace will qualify for discounts on monthly premiums or out-of-pocket costs. To find out your savings, you'll need income information from documents such as your W-2 form, current pay stubs, or your tax return.  Set your budget Different types of health plans meet different needs and budgets. You'll need to figure out how much you want to spend on premiums each month.
    29. 29. A final thought “Opportunity is missed by most people because it is dressed in overalls and looks like work.“ ----Thomas Edison
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