2. After open enrollment period ends, what?
2
 Open Enrollment (Year 2)
 Report a Life Change
 File for an Exemption
 File for an Appeal
 Federal Poverty Level Guidelines for
2014
 Shared Responsibility Penalty Estimator
 Insurance 101

3. 3
Open Enrollment Period

4. NOVEMBER 01, 2015 -
JANUARY 31, 2016
 Sign up between:
Nov 1, 2015-Dec 15, 2015, your
plan will start on Jan 1, 2016
Dec 16, 2015 - Jan 15, 2016,
your plan will start Feb 1st
Jan 16, 2016-Jan 31, 2016, your
plan will start Mar 1st
4
 Next Open Enrollment Period

5. Report a Life Change
5

6. Type of Life Change/Change in Circumstance: Where to Report
 New person on the application (e.g., birth, marriage) Marketplace
 Relocation to a new zip code or county Marketplace
 Loss of access to other coverage (e.g., employer coverage) Marketplace
 Release from incarceration Marketplace
 Change in citizenship or immigration status Marketplace
 Removal of a person from the application (e.g., death, divorce) Marketplace
 Become incarcerated Marketplace
 New access to other coverage (e.g., employer coverage) Marketplace
 Pregnancy Marketplace
 Change in tax filing status/tax household composition Marketplace
 Change in status as an American Indian/Alaska Native or tribal Marketplace
 Change in disability status Marketplace
 Correction to name, DOB, or Social Security number Marketplace
 Increase or decrease in income Marketplace
Change in contact information, like:
 Relocation within the same zip code and county Marketplace AND
 Email address Insurance Company
 Phone number
 Add or remove phone text alert
 Mailing of paper notices
6
Reportable Changes

7. 7
Report your Change
on your account online

8. EXEMPTIONS
8

9. Exemptions from the Payment
Under certain circumstances, you won’t have to make the individual
shared responsibility payment (tax penalty). This is called an
“exemption.”
9
You may qualify for an exemption if:
 You’re uninsured for less than 3 months of the year
 The lowest-priced coverage available to you would cost
more than 8% of your household income
 You don’t have to file a tax return because your income is
too low
 You’re incarcerated, and not awaiting the disposition of
charges against you
 You’re not lawfully present in the U.S. and many more

10. 10
If you have any of the circumstances below that affect your ability to purchase
health insurance coverage, you may qualify for a “hardship” exemption:
 You were homeless.
 You were evicted in the past 6 months or were facing eviction or
foreclosure.
 You received a shut-off notice from a utility company.
 You recently experienced domestic violence.
 You recently experienced the death of a close family member.
 You experienced a fire, flood, or other natural or human-caused disaster
that caused substantial damage to your property.
 You filed for bankruptcy in the last 6 months.
 You had medical expenses you couldn’t pay in the last 24 months.
 You experienced unexpected increases in necessary expenses due to caring
for an ill, disabled, or aging family member.
 Many more…
Hardship Exemptions

11. 11
1. You can claim some exemptions
when you fill out your 2014 federal
tax return, which is due in April 2015.
How to Apply for Exemptions
2. You can apply for some exemptions,
by mailing in the right form.
You have 2 options, depending on which type of
exemption you’re asking for:
All exemption application forms can be found here:
https://www.healthcare.gov/exemptions/

12. 12
 APPEALS

13. 13
You may file a Marketplace eligibility appeal in two ways.
1st: Print the form that can be found on the eligibility appeals website:
https://www.healthcare.gov/can-i-appeal-a-marketplace-decision/
You should download the paper form, complete it and mail it in. While the form
looks complicated and has many pages, only two pages or so need to be completed
and it’s not hard to fill in or contact a local navigator or certified application counselor
for in-person assistance.
2nd: Write a letter. You should include the reason you’re appealing, and they
strongly urge you to attach a copy of your eligibility determination letter to the appeal.
Consumers should send the letter to:
Health Insurance Marketplace
Attn: Appeals Department
465 Industrial Blvd.
London, KY 40750-0061
How to submit an Eligibility Appeal

14.  Appeal Decisions
14
The government will let appellants know of their decision, including
whether you are eligible to obtain health insurance coverage through
the Marketplace, and whether you qualify for any subsidies. If you
receive a favorable eligibility appeal decision, you will be given a
special enrollment period to enroll in or to switch plans within the
Marketplace.
Retroactive enrollment - If the decision is favorable and retroactive
coverage is judged to be appropriate, you may choose to have your
insurance coverage and any subsidies retroactively. You may be able to
select a retroactive date based upon the date of your application to the
Marketplace.

15. 15
NEW FPL GUIDELINES FOR
SUBSIDY ELIGIBILITY
FOR 2014

16. 2014 Federal Income Level Guidelines
16
Household Size 100% 133% 150% 200% 250% 300% 400%
1 $11,670 $15,521 $17,505 $23,340 $29,175 $35,010 $46,680
2 15,730 20,921 23,595 31,460 39,325 47,190 62,920
3 19,790 26,321 29,685 39,580 49,475 59,370 79,160
4 23,850 31,721 35,775 47,700 59,625 71,550 95,400
5 27,910 37,120 41,865 55,820 69,775 83,730 111,640
6 31,970 42,520 47,955 63,940 79,925 95,910 127,880
7 36,030 47,920 54,045 72,060 90,075 108,090 144,120
8 40,090 53,320 60,135 80,180 100,225 120,270 160,360
AFFORDABLE CARE ACT
1) ADVANCE PREMIUM TAX CREDIT (APTC)
• APTC lowers the monthly premium owed by the consumer.
• Marketplace determines eligibility for APTC and the
amount allowed.
• Any APTC paid on an advance basis is reconciled at the end
of the year when you file your taxes.
• The amount of APTC is based on income and can be
adjusted by the consumer, at the time of plan selection.
• To receive APTC a consumer must file a tax return at the
end of the year.
2) COST SHARING REDUCTION (CSR)
• Cost Sharing Reductions limit consumers’ max out-of-
pocket cost (i.e. deductibles, coinsurance or
copayments).
• Marketplace determines eligibility for CSR.
• Consumers cannot adjust the amount of CSR assistance
received.
• In general, if a consumer is eligible for cost sharing
reductions, they must enroll in a silver plan.
Two Types of Government Financial Assistance Available:

17. Redetermination Process
 For individuals who are enrolled with advance
payments of the premium tax credit (APTC) or cost-
sharing reductions (CSR) and who have authorized the
Marketplace to request updated tax data, the
Marketplace will automatically request updated tax
return information from IRS.
 The Marketplace sends notices containing information
about the annual redetermination process to qualified
individuals and enrollees (paper or electronic,
depending on the consumer’s preference)
17

18. Standard Insurance Company Notices
 Individual insurance companies
must provide written notice of
renewals and any product
discontinuances.
 This notice should inform the individual if their plan
will be available, any changes to the plan, and if the
plan won’t be available, what plan the consumer will
be enrolled in. This notice will also be required to
contain additional information, including
information on premiums and APTC.
18

19. No Action taken by Consumer
 Scenario 1
 John applied through the Marketplace and has a household
income of $20,000. He was determined eligible for $100 of
APTC, and selected a plan on 12/10/13. On his application he
allowed the Marketplace to access tax return information for
redetermination.
 He will receive two notices: 1) Marketplace 2) Insurance Co.
telling him his plan will remain available and his premium
will be $200 (a total of $300 minus the $100 APTC he is
eligible for in 2014.)
 If he does not contact the Marketplace, he’s renewed in the
plan with $100 APTC (his 2014 eligibility) effective 1/1/15.
APTC for 2015 could be more!
19

20. 20
SHARED RESPONSIBILITY
PAYMENT (TAX PENALTY)

21. The fee in 2014 and beyond
The tax penalty in 2014 is calculated one of 2 ways.
If you or your dependents don’t have insurance that qualifies as
Minimal Essential Coverage (MEC) you'll pay whichever of
these amounts is higher:
 1% of your yearly household income. (Only the amount of
income above the tax filing threshold, $10,150 for an
individual, is used to calculate the penalty.) The maximum
penalty is the national average premium for a bronze plan.
 $95 per person for the year ($47.50 per child under 18).
The maximum penalty per family using this method is $285.
21

22. How is the penalty calculated
 The way the penalty is calculated, a
single adult with household income
below $19,650 would pay the $95 flat
rate. A single adult with household
income above $19,650 would pay an
amount based on the 1% rate. (If income
is below $10,150, no penalty is owed.)
 If you’re uninsured for just part of the
year, 1/12 of the yearly penalty applies to
each month you’re uninsured. If you’re
uninsured for less than 3 months, you
don’t have to make a payment.
 You’ll pay the fee on your 2014 federal
income tax return. Most people will file
this return in 2015.
22
The penalty
increases every
year.
In 2015 it’s 2%
of income or $325
per person.
In 2016 and later
years it’s 2.5%
of income or $695
per person.
After that it's
adjusted for
inflation.

23. 2014 IRS Federal Tax Filing Thresholds
Filing Status Age
Must File a Return If Gross
Income Exceeds
Single Under 65 $10,150
65 or older $11,700
Head of Household Under 65 $13,050
65 or older $14,600
Married Filing Jointly Under 65 (both spouses) $20,300
65 or older (one spouse) $21,500
65 or older (both spouses) $22,700
Married Filing Separately Any age $3,950
Qualifying Widow(er) with
Dependent Children
Under 65 $16,350
65 or older $17,550
23

24. Examples of the Tax Penalty
24
Example 1: Single individual with $40,000 income
Jim, an unmarried individual with no dependents, does not have
minimum essential coverage for any month during 2014 and does
not qualify for an exemption. For 2014, Jim’s household income is
$40,000 and his filing threshold is $10,150.

25.  To determine Jim’s payment using the income formula:
$40,000 Household Income
- $10,150 filing threshold
$29,850 Income left
x 1% Tax Penalty
$298.50 Jim’s Tax Penalty
 Jim’s flat dollar amount would be $95. Because $298.50 is greater
than $95 (and is less than the national average premium for bronze
level coverage for 2014), Jim’s shared responsibility payment for 2014
is $298.50, or $24.87 for each month he is uninsured (1/12 of $298.50
equals $24.87).
25
Jim will make his $298.50 shared responsibility payment when
he files his 2014 income tax return, which is due in April 2015.

26. Examples of Tax Penalty
26
Example 2: Married couple with 2 children, $70,000 income
Eduardo and Julia are married and have two children under 18.
They do not have minimum essential coverage for any family
member for any month during 2014 and no one in the family
qualifies for an exemption. For 2014, their household income is
$70,000 and their filing threshold is $20,300.

27.  To determine their payment using the income formula:
$70,000 Household Income
- $20,300 Filing threshold
$49,700 Income left
x 1% Tax Penalty
$497 Family’s Tax Penalty
 Eduardo and Julia’s flat dollar amount is $285, or $95 per adult
and $47.50 per child. The max total of $285 is the flat dollar amount
in 2014.
 Because $497 is greater than $285 (and is less than the national
average premium for bronze level coverage for 2014), Eduardo and
Julia’s shared responsibility payment is $497 for 2014, or $41.41 per
month for each month the family is uninsured (1/12 of $497 equals
$41.41).
27
Eduardo and Julia will make their $497 shared responsibility
payment when he files their 2014 income tax return, which is
due in April 2015.

28. IRS and Marketplace Forms
 IRS Form 1095-A is like the W-2 from your employer or the
statement from your bank.
 IRS Form 1095-A is completed and sent to enrolled consumers
by the Marketplace. If the consumer has not received it or
loses it, a duplicate can be downloaded from the consumer's
Marketplace account.
 Consumers must review the accuracy of the information on
IRS Form 1095-A and use it to complete IRS Form
8962 and/or IRS Form 8965 as part of their income tax
return.
 Use Form 8962 if you received tax credit (financial aid)
 Use Form 8965 if you have Exemption for not having health
coverage
28

29. 29
INSURANCE

30.  Insurance Card Details
30

31.  TERMS-TO-KNOW
 Co-insurance- amount you may be required to pay as your
share of cost for services after you pay any deductibles.
Coinsurance is usually a percentage (for example, 20%)
 Co-payment- amount required to pay for services, usually
a set amount; $10 or $20 for a doctor’s visit or prescription
 Deductible- amount you must pay for health care or
prescriptions before your prescription drug plan, or your
other insurance begins to pay.
 Excluded Services- services that your insurance plan
doesn’t pay for or cover.
31

32.  Terms-To-Know continued…
 Out-of-Network-provider who doesn’t have a contract
with your health insurer or plan to provide services to
you. You’ll pay more to use them.
 Out-of-pocket Maximum- limit you must reach
(using the deposit from the plan and/or your own
money) before your plan will cover your expenses. The
out-of-pocket maximum includes the yearly
deductible and may also include any cost sharing you
have after the deductible.
 Premium- A fixed monthly payment to an insurance
company.
32

33. 33
Open enrollment through the Marketplace
will begin again:
NOVEMBER 01, 2015 to
JANUARY 31, 2016
When is next open enrollment?

34. 34
• Marketplace:
www.Healthcare.gov
(800) 318-2596
• In person help with a Navigator:
(for outside West Volusia County)
(866) 295-5955
• In person help with a Certified
Application Counselor:
(for West Volusia County)
Deltona area:
(386) 532-1101
Deland area:
(386) 734-1026
HOW TO GET HELP