Affordable Care Act 101


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Join us as we learn about the benefits of the Affordable Care Act, the ways you can get help paying for insurance, and where you can get help enrolling. (Hint: We can help!)

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  • This slide shows the process for enrolling in the Marketplace and purchasing an insurance plan. An individual goes online or to Consumer Assistor – a Navigator or CAC. They create a login and password and complete a profile with identifying information such as income, age, address, social security numbers, etc. That information is checked against the Hub, which is a collection of government agencies that can verify information about you such as the IRS. If the information given does not match the Hub, then the consumer will need to provide additional documentation such as a paycheck stub. IF the information does match, then the Marketplace confirms your identity and provides an Eligibility Notice. This notice provides information on tax credits, cost reduction programs and Medicaid eligibility. If a person qualifies for Medicaid, then the consumer’s information is transferred to the appropriate government agency to complete Medicaid enrollment. In Michigan, this process has not yet been finalized. If a consumer does not qualify for Medicaid, they will proceed to shopping for insurance plans. They will browse the website and select a plan that works for them. Once a plan is selected, it is recommended that consumer proceed directly to the plan website and make their first premium payment online.
  • Affordable Care Act 101

    1. 1. Affordable Care Act Basics Planned Parenthood Advocates/Affiliates of Michigan (PPAM)
    2. 2. What is the Affordable Care Act? Creates new patient protections, new insurance company regulations, and a competitive Marketplace for purchasing health coverage. Also known as the ACA or Obamacare
    3. 3. Enrollment Timeline 2013 Open Enrollment: October 1, 2013 – March 31, 2014 > 1st Phase: October 1 – December 23: Insurance coverage will begin on January 1st, 2014 > 2nd Phase: December 23, 2013 – March 31st, 2014: Insurance will begin on a rolling basis based on premium payment > Open enrollment will begin again November 15th, 2014 – December 31st, 2014 Note: People can only enroll during open enrollment periods unless they have a qualifying event
    4. 4. Why do we need the ACA? Nationally: Nearly 48 million uninsured Michigan: 1.2 million uninsured Nationally: Significant lack of awareness of eligibility 72% don’t know they are eligible/how the ACA will benefit them
    5. 5. Changes to Insurance under Obamacare Consumer friendly insurance info (EOBs) No lifetime limits on coverage Certified health insurance plans (QHPs) Cannot deny coverage because of pre-existing conditions. No more gender rating Children can stay on their parents insurance until 26.
    6. 6. Major Provisions of the ACA Essential Health Benefits (EHBs) Medicaid Expansion The Marketplace Tax Credits (APTCs) Cost-sharing Reductions (CSRs) Minimum Essential Coverage Requirements (MECs) Individual Responsibility Requirements
    7. 7. Essential Health Benefits Ambulatory Services (doctors visits, check-ups, etc) Emergency Services (ER, ambulance, etc) Hospitalization Maternity & Newborn Care Mental Health & Substance Abuse Screenings & Services Rehabilitative & Habilitative Services Laboratory Services Chronic Disease Management Pediatrics (including pediatric dental & vision) Preventive & Wellness Screenings Prescription Drug Coverage
    8. 8. Medicaid Expansion Current: -Pregnant Women -Children -Families -Elderly -Blind -Disabled Expanded: -Pregnant Women -Children -Families -Elderly -Blind -Disabled -Childless Adults •All people with incomes up to 133% FPL 2013: $15,586 (1) $32,499 (4) before taxes •Michigan: 500,000 newly eligible for Medicaid
    9. 9. The Marketplace Easy, consumer friendly comparison tools Requires eligibility to use  Real-time Eligibility Notices Medicaid & CHIP Eligibility Cost Reduction Options Live Chat Feature Consumer Assistance – Navigators, CACs  Each State has a Marketplace 3 Types: * Federally Facilitated (FFM) - MI - State Facilitated (SFM) - State Partnership (SPM)
    10. 10. Metal Level Plans SILVER 70/30 BRONZE 60/40 OUT OF POCKET COSTS GOLD 80/20 PREMIUMS PLATINUM 90% Premium/10% Premium NOTE: As Premiums go up, Out of Pocket Costs go down Premiums: monthly costs you pay to have insurance. Out-of-pocket cost (co-insurance): medical care you pay for after insurance pays covered costs. Co-pays: fee for service costs you pay for appointments and prescriptions.
    11. 11. The Enrollment Process Insufficient information. Applicant will need to submit extra information before application can move forward. The individual can apply for coverage online, in person, by mail, and by phone. An online application for a single person can take up to 30-60 MINUTES MAGIC CURTAIN Information is entered into the HUB (IRS, DHS, etc.) to determine eligibility. Eligibility may be determined in real time or could take longer.* An individual comes in to enroll for health insurance Shop and compare health plans Enroll in health plan and potentially pay premium (individual won’t be covered until January 1, 2014) If eligible for federal premium tax credit, will start enrollment process for private plan in the Marketplace. (May or may not happen in real time) If eligible for Medicaid, receives Medicaid coverage and starts Medicaid enrollment process *The time needed to assess and determine eligibility will depend on a number of factors, such as the applicant’s information, type of Exchange, administration of the HUB.
    12. 12. Cost Reduction: Tax Credits Lowers Monthly Premiums Prorated monthly and payment sent directly to insurance provider Can use with any plan Income Based: up to 400%FPL - $45,960 (1) - $62,040 (2) - $94,200 (4) Consumers can choose amount of APTC to use If income changes, differences will be reconciled in tax filing (Income goes up, you will owe money back to the IRS. If income goes down, the IRS will reimburse the amount you are owed.) MUST file income tax Also available for legal immigrants not eligible for Medicaid below 100%FPL
    13. 13. Cost Reduction: Cost Sharing Reductions Reduces out-of-pocket expenses (coinsurance) Must qualify for APTC to get CSR Must enroll in Silver Level Plan to use CSR Income Based & Sliding Scale: below 250%FPL ($58,875 (4)) Example: 100%FPL without CSR = 70/30 coinsurance split 100%FPL with CSR = 94/6 split
    14. 14. Individual Responsibility Requirement FEE (paid when taxes are filed) Must have QHP with MEC all year 2014: $95/adult or 1% of income (whichever is higher) 2015: $325/adult or 2% of income Children: 2014 = $47.50 2015 = $162.50 Exemptions are available
    15. 15. Fee Exemptions Available through Marketplace and/or IRS Exemption Categories: - financial hardship - lack of coverage for less then 3 months - 8% Rule (no coverage available for less than 8% of income) - income does not meet federal filing threshold ($10,000 for 1 person or $20,000 for family) - illegal immigration status - membership in a recognized tribe - membership in a recognized religious sect that refuses coverage - incarceration
    16. 16. Resources For Enrollment Assistance •Call: 1-844-7ENROLL •Email: State Navigator: MI Consumers for Health Care The Marketplace or 1.800.318.2596