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Navigating the Affordable Care Act

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Navigating the Affordable Care Act

  1. 1. VIRGINIA’S HEALTH INSURANCE MARKETPLACE --THE BASICS--  
  2. 2. Where Americans Get Health Coverage
  3. 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. 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. 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. 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. 7. Insurance Marketplace How to Apply   Multiple “doors” for applications ◦ Online – www.healthcare.gov ◦ Phone –  ◦ Federal - 1-800-318-2596 ◦ Virginia call center – 1-888-392-5132 ◦ Website: www.enroll-Virginia.com  ◦ Virginia Local Departments of Social Services ◦ DSS  - “CommonHelp” - Online applications ◦ https://commonhelp.virginia.gov/access/   Federal Paper Application - http://www.cms.gov/CCIIO/Resources/FormsReports-and-Other-Resources/Downloads/marketplace-app-standard.pdf
  8. 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. 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. 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. 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. 12. Plans Offered in Northern Virginia
  13. 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 https://www.healthcare.gov/find-premium-estimates/ and the Kaiser Family Foundation subsidy calculator
  14. 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. 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. 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. 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. 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. 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 - http://kff.org/interactive/subsidycalculator/
  20. 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. 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. 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. 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. 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. 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. 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. 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 cocel@lsnv.org jkilleen@lsnv.org cocel@enroll-virginia.com Jessica@enroll-virginia.com Group Phone #: (703) 647-4748
  28. 28. QUESTIONS? Thank you!

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