Affordable Care Act BasicsPlanned Parenthood

Advocates/Affiliates of Michigan (PPAM)

Creates new patient protections, new insurance company regulations, and a competitive Marketplace for purchasing health coverage. Also known as the ACA or Obamacare

What is the Affordable Care Act?

Enrollment Timeline2013 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

Why do we need the ACA?

Nationally: Significant lack of awareness of eligibility

72% don’t know they are eligible/how the ACA will benefit them

Nationally: Nearly 48 million uninsuredMichigan: 1.2 million uninsured

Changes to Insurance under ObamacareConsumer friendly insurance info (EOBs)No lifetime limits on coverageCertified health insurance plans (QHPs)Cannot deny coverage because of pre-existing conditions.No more gender ratingChildren can stay on their parents insurance until 26.

Essential Health Benefits (EHBs)Medicaid ExpansionThe Marketplace Tax Credits (APTCs)Cost-sharing Reductions (CSRs)Minimum Essential Coverage Requirements (MECs) Individual Responsibility Requirements

Major Provisions of the ACA

Essential Health BenefitsAmbulatory Services (doctors visits, check-ups, etc)Emergency Services (ER, ambulance, etc)HospitalizationMaternity & Newborn CareMental Health & Substance Abuse Screenings & ServicesRehabilitative & Habilitative ServicesLaboratory ServicesChronic Disease ManagementPediatrics (including pediatric dental & vision)Preventive & Wellness Screenings Prescription Drug Coverage

Medicaid Expansion

•All people with incomes up to 133% FPL - 2013: $15,586 (1) $32,499 (4) before taxes

•Michigan: 500,000 newly eligible for Medicaid

Current: -Pregnant Women-Children-Families-Elderly-Blind-Disabled

Expanded: -Pregnant Women-Children-Families-Elderly-Blind-Disabled-Childless Adults

The MarketplaceEasy, consumer friendly comparison toolsRequires eligibility to use Real-time Eligibility NoticesMedicaid & CHIP EligibilityCost Reduction OptionsLive Chat FeatureConsumer Assistance – Navigators, CACs Each State has a Marketplace3 Types:

* Federally Facilitated (FFM) - MI- State Facilitated (SFM)- State Partnership (SPM) www.healthcare.gov

Metal Level Plans

NOTE: As Premiums go up, Out of Pocket Costs go down

PLATINUM90% Premium/10% Premium

GOLD80/20

SILVER70/30

BRONZE60/40

PREM

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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.

An individual comes in to enroll for health

insurance

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 CURTAINInformation is entered into the HUB (IRS,

DHS, etc.) to determine eligibility. Eligibility may be determined in real time or

could take longer.*

Insufficient information. Applicant will need to submit

extra information before application can move forward.

If eligible for Medicaid, receives Medicaid coverage and starts Medicaid enrollment process

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)

Shop and compare health plans

Enroll in health plan and potentially pay premium

(individual won’t be covered until January 1, 2014)

The 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.

Cost Reduction: Tax CreditsLowers Monthly PremiumsProrated monthly and payment sent directly to insurance providerCan use with any planIncome Based: up to 400%FPL

- $45,960 (1)- $62,040 (2)- $94,200 (4)

Consumers can choose amount of APTC to useIf 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 taxAlso available for legal immigrants not eligible for Medicaid below 100%FPL

Cost Reduction: Cost Sharing ReductionsReduces out-of-pocket expenses (coinsurance)Must qualify for APTC to get CSRMust enroll in Silver Level Plan to use CSRIncome 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

Individual Responsibility RequirementFEE (paid when taxes are filed)Must have QHP with MEC all year2014: $95/adult or 1% of income (whichever is higher)

2015: $325/adult or 2% of incomeChildren: 2014 = $47.50 2015 = $162.50Exemptions are available

Fee ExemptionsAvailable through Marketplace and/or IRSExemption 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

ResourcesFor Enrollment Assistance•Call: 1-844-7ENROLL•Email: 8447ENROLL@ppmchoice.org

State Navigator: MI Consumers for Health Care http://consumersforhealthcare.orgThe Marketplacewww.healthcare.gov or 1.800.318.2596