affordable care act insurance counseling and navigation

Affordable Care ActInsurance Counseling and Navigation

Table of Contents

Affordable Care Act 2014

State & Federal Marketplace

Uninsured Population

Medicare & Medicaid

Private Commercial Market

Small Business State & Federal Marketplace

Patient Service Opportunities

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Affordable Care Act 2014

Current Insurance Channels

Commercial Insurance

*Employer Sponsored

*Individual Purchase

Government Funded

Insurance

*Medicare

*Medicaid

*Publicly Funded Insurance

Uninsured*Self Employed

*Commonly 26-35 Years Old

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2011 US Insurance Coverage

2010 US Census Population: 308,747,508

www.census.govProperty of Pharma Dynamics, Inc.

Affordable Care Act 2014- Insurance Channels

Medicare &

Medicaid


Private Commercial

Market

Small Business State

& Federal Marketp

lacePostponed to

2015Health & Pharmaceutical

Insurance


Affordable Care Act 2014-State & Federal Marketplace


*Most states who are participatingg in the Partner Marketplace are using the Federal Marketplace technology but will offer state specific plans.

www.hhs.gov/healthcareProperty of Pharma Dynamics, Inc.


The Health Insurance Marketplace was created to assist individuals with

purchasing a personal health insurance plan that meets the requirements

established by the Affordable Care Act.

All State & Federal Marketplace approved plans are required to include the following essential health benefits:

• Ambulatory patient services• Emergency services• Hospitalizations• Maternity and newborn care• Mental health care• Substance abuse care• Prescription drugs• Rehabilitative service

• Laboratory service• Preventative Wellness

service• Chronic Disease

Management• Pediatric service

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http://www.hhs.gov/healthcare/insurance/index.html


www.healthcare.gov

The Affordable Care Act requires that most individuals obtain an insurance plan that meets the Minimal Essential Coverage Standards. This excludes plans which

have been grandfathered. Individuals will be able to utilize the State & Federal

Marketplace to purchase their personal or family insurance plan.

Individuals who meet defined income guidelines will be eligible for the Advance Premium Tax Credit:

Income Eligibility Levels for Advance Premium Tax Credit

Up to $45,960 for individualsUp to $62,040 for a family of 2Up to $78,120 for a family of 3Up to $94,200 for a family of 4Up to $110,280 for a family of 5

Up to $126,360 for a family of 6Up to $142,440 for a family of 7Up to $158,520 for a family of 8


State & Federal Marketplace- Plan Levels

ACA Patient Out-of-Pocket Limit: $6350

*Individuals under 30 years old, and some individuals with limited income, are eligible to purchase a “catastrophic” plan which covers 3 primary care visits annually and free preventative benefits but requires the individual to pay all of their up-front health costs (upwards of several thousands dollars) before the insurance will pay for medical costs.


State & Federal Marketplace- Kaiser Plan Level Examples

ACA Patient Out-of-Pocket Limit: $6350

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Affordable Care Act 2014- Uninsured Population

Medicare & Medicaid



Small Business State & Federal Marketplace

Health & Pharmaceutical

Insurance

Uninsured



Individuals who do not have required insurance coverage will be obligated to pay a

penalty tax for each adult is the greater of 2.5% of their annual income or $695. The penalty tax for children is half of the adult

rate. This penalty tax is expected to increase substantially over the next several years.

Total Uninsured Population: 49,720,668

Exemptions from the Federal Healthcare Mandate include individuals who have an income low enough that they are not required to file an income tax return, members of Indian Tribes, individuals whose premium requirement would exceed 8% of their income, unauthorized immigrants, hardships, or conflicts related to religious beliefs.

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State ID Population Uninsured %

Alabama AL 4,779,736 669,163 14%

Alaska AK 710,231 127,842 18%

Arizona AZ 6,392,017 1,150,563 18%

Arkansas AR 2,915,918 524,865 18%

California CA 37,253,956 7,450,791 20%

Colorado CO 5,029,196 704,087 14%

Connecticut CT 3,574,097 357,410 10%

Delaware DE 897,934 98,773 11%

District of Columbia DC 601,723 66,190

11%

Florida FL 18,801,310 3,760,262 20%

Georgia GA 9,687,653 1,937,531 20%

Hawaii HI 1,360,301 108,824 8%

Idaho ID 1,567,852 282,213 18%

Illinois IL 12,830,632 1,924,595 15%

Indiana IN 6,483,802 842,894 13%

Iowa IA 3,046,355 335,099 11%

Kansas KS 2,853,118 370,905 13%


Kentucky KY 4,339,337 650,901 15%

Louisiana LA 4,533,372 906,674 20%

Maine ME 1,328,361 132,836 10%

Maryland MD 5,773,552 750,562 13%

Massachusetts MA 6,547,629 261,905 4%

Michigan MI 9,883,640 1,284,873 13%

Minnesota MN 5,303,925 477,353 9%

Mississippi MS 2,967,297 563,786 19%

Montana MT 5,988,927 838,450 14%

Missouri MO 989,415 178,095 18%

Nebraska NE 1,826,341 237,424 13%

Nevada NV 2,700,551 594,121 22%

New Hampshire NH 1,316,470 144,812 11%

New Jersey NJ 8,791,894 1,406,703 16%

New Mexico NM 2,059,179 432,428 21%

New York NY 19,378,102 2,712,934 14%

North Carolina NC 9,535,483 1,621,032 17%




North Dakota ND 672,591 73,985 11%

Ohio OH 11,536,504 1,615,111 14%

Oklahoma OK 3,751,351 637,730 17%

Oregon OR 3,831,074 574,661 15%

Pennsylvania PA 12,702,379 1,397,262 11%

Rhode Island RI 1,052,567 126,308 12%

South Carolina SC 4,625,364 925,073 20%

South Dakota SD 814,180 105,843 13%

Tennessee TN 6,346,105 888,455 14%

Texas TX 25,145,561 6,034,935 24%

Utah UT 2,763,885 386,944 14%

Vermont VT 625,741 56,317 9%

Virginia VA 8,001,024 1,120,143 14%

Washington WA 6,724,540 941,436 14%

West Virginia WV 1,852,994 259,419 14%

Wisconsin WI 5,686,986 568,699 10%

Wyoming WY 563,626 101,453 18%

United StatesTotal Population: 308,745,778

Uninsured Population: 49,720,668


Affordable Care Act 2014-Medicare & Medicaid

Medicare & Medicaid

The 2013 Federal Minimum Requirement for State Medicaid Coverage indicates that states must provide

health care to all children, pregnant women, former foster care children (up to age 26) and individuals

diagnosed with specific disease states who have an individual or family income level of 100% FPL or lower.

States who choose to participate in the Affordable Care Act will be required to provide health coverage for all individuals, regardless of health status, with an income level of 138% FPL or lower.

In June 2012, the US Supreme Court ruled that states may choose to opt out of the ACA Medicaid requirement which would allow them to remain at the 2013 standard. These states will not receive Federal Funding Assistance.

As of January 2014, a new Medicare-Medicaid Coordination Office will open to assist individuals who are dually eligible.

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Medicare & Medicaid

2013 Medicaid FPL Requirement

State E D C P

Alabama 225% 75% 100% 133%

Alaska 185% 250% 175% 175%

Arizona 100% 100% 200% 200%

Arkansas NO NO 200% 200%

California 200% 100% 133% 200%

Colorado 10% 10% 250% 185%

Connecticut 185% 185% 185% 185%

Delaware 75% 75% 133% 185%

District of Columbia

100% 200% 185% 300%

Florida 88% 88% 200% 185%

Georgia NO 22% 185% 200%

Hawaii NO 100% 133% 185%

State E D C P

Idaho 78% 78% 133% 133%

Illinois 100% 100% 185% 200%

Indiana 233% 233% 133% 200%

Iowa 75% 75% 133% 300%

Kansas 75% 75% 133% 150%

Kentucky 75% 250% 200% 185%

Louisiana 75% 75% 133% 200%

Maine 100% 100% 133% 200%

Maryland 75% 75% 185% 250%

Massachusetts 300% 300% 300% 300%

Michigan 100% 100% 150% 185%

Minnesota 100% 100% 280% 175%

Mississippi 80% 80% 133% 185%

E- Individuals 65+D- Individuals with qualified disabilityC- ChildrenP- Pregnant Women

*Individuals who qualify for SSI or SSDI receive required Medicaid coverage as long as their assets do not exceed $2,000

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Medicare & Medicaid

2013 Medicaid FPL Requirement

State E D C P

Missouri 85% 85% 133% 185%

Montana 75% 75% 133% 150%

Nebraska 74% 74% 133% 185%

Nevada 86% 75% 133% 185%

New Hampshire 79% 79% 185% 185%

New Jersey 100% 100% 133% 185%

New Mexico 75% 75% 185% 235%

New York 85% 85% 133% 200%

North Carolina 100% 200% 200% NO

North Dakota 75% 83% 133% 133%

Ohio 65% 250% 150% 200%

Oklahoma 185% 75% 185% 185%

State E D C P

Rhode Island 100% 100% 250% 250%

South Carolina 100% 250% 150% 185%

South Dakota 75% 75% 133% 133%

Tennessee 75% 75% 133% 185%

Texas 75% 75% 133% 185%

Utah 100% 150% 100% 133%

Vermont 185% 185% 225% 200%

Virginia 80% 80% 133% 133%

Washington 75% 75% 200% 185%

West Virginia 75% 75% 133% 150%

Wisconsin 84% 84% 185% 300%

Wyoming 75% 75% 133% 133%

E- Individuals 65+D- Individuals with qualified disabilityC- ChildrenP- Pregnant Women

*Individuals who qualify for SSI or SSDI receive required Medicaid coverage as long as their assets do not exceed $2,000

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Medicare & Medicaid

2014 Medicaid ACA State Participation

*2014 State Medicaid FPL Guidelines have not been published.


Medicare & Medicaid

According to the 2010 US Census, 13% of the uninsured population

within the United States are earning an income of 100%-138% Federal

Poverty Level.

Potential New Medicaid Recipients: 6.9 Million

www.hhs.gov/healthcareProperty of Pharma Dynamics, Inc.

Medicare Population

State ID Population Medicare %

Alabama AL 4,779,736 716,960 15%

Alaska AK 710,231 49,716 7%

Arizona AZ 6,392,017 830,962 13%

Arkansas AR 2,915,918 466,547 16%

California CA 37,253,956 3,725,396 10%

Colorado CO 5,029,196 553,212 11%

Connecticut CT 3,574,097 464,633 13%

Delaware DE 897,934 134,690 15%


10%

Florida FL 18,801,310 3,196,223 17%

Georgia GA 9,687,653 968,765 10%

Hawaii HI 1,360,301 190,442 14%

Idaho ID 1,567,852 203,821 13%

Illinois IL 12,830,632 1,667,982 13%

Indiana IN 6,483,802 907,732 14%

Iowa IA 3,046,355 396,026 13%

Kansas KS 2,853,118 399,437 14%


Kentucky KY 4,339,337 2,082,882 48%

Louisiana LA 4,533,372 589,338 13%

Maine ME 1,328,361 185,971 14%

Maryland MD 5,773,552 692,826 12%


Michigan MI 9,883,640 1,482,546 15%

Minnesota MN 5,303,925 689,510 13%

Mississippi MS 2,967,297 356,076 12%

Montana MT 5,988,927 838,450 14%

Missouri MO 989,415 168,201 17%

Nebraska NE 1,826,341 219,161 12%

Nevada NV 2,700,551 351,072 13%

New Hampshire NH 1,316,470 197,471 15%

New Jersey NJ 8,791,894 1,142,946 13%

New Mexico NM 2,059,179 288,285 14%

New York NY 19,378,102 2,325,372 12%



Medicare Population


North Dakota ND 672,591 94,163 14%

Ohio OH 11,536,504 1,615,111 14%

Oklahoma OK 3,751,351 525,189 14%

Oregon OR 3,831,074 536,350 14%

Pennsylvania PA 12,702,379 2,032,381 16%

Rhode Island RI 1,052,567 157,885 15%


South Dakota SD 814,180 113,985 14%

Tennessee TN 6,346,105 888,455 14%

Texas TX 25,145,561 2,514,556 10%

Utah UT 2,763,885 276,389 10%

Vermont VT 625,741 81,346 13%

Virginia VA 8,001,024 960,123 12%

Washington WA 6,724,540 874,190 13%

West Virginia WV 1,852,994 315,009 17%

Wisconsin WI 5,686,986 853,048 15%

Wyoming WY 563,626 61,999 11%


Medicare Population: 41,162,133


Medicaid Population

State ID Population Medicaid %

Alabama AL 4,779,736 716,960 15%

Alaska AK 710,231 99,432 14%

Arizona AZ 6,392,017 1,150,563 18%

Arkansas AR 2,915,918 524,865 18%

California CA 37,253,956 7,078,252 19%

Colorado CO 5,029,196 653,795 13%

Connecticut CT 3,574,097 464,633 13%

Delaware DE 897,934 143,669 16%


24%

Florida FL 18,801,310 2,632,183 14%

Georgia GA 9,687,653 1,356,271 14%

Hawaii HI 1,360,301 244,854 18%

Idaho ID 1,567,852 219,499 14%

Illinois IL 12,830,632 2,181,207 17%

Indiana IN 6,483,802 1,102,246 17%

Iowa IA 3,046,355 426,490 14%

Kansas KS 2,853,118 370,905 13%


Kentucky KY 4,339,337 173,573 4%

Louisiana LA 4,533,372 906,674 20%

Maine ME 1,328,361 292,239 22%

Maryland MD 5,773,552 692,826 12%

Massachusetts MA 6,547,629 1,309,526 20%

Michigan MI 9,883,640 1,680,219 17%

Minnesota MN 5,303,925 742,550 14%

Mississippi MS 2,967,297 593,459 20%

Montana MT 5,988,927 838,450 14%

Missouri MO 989,415 128,624 13%

Nebraska NE 1,826,341 200,898 11%

Nevada NV 2,700,551 270,055 10%

New Hampshire NH 1,316,470 92,153 7%

New Jersey NJ 8,791,894 1,055,027 12%

New Mexico NM 2,059,179 453,019 22%

New York NY 19,378,102 4,263,182 22%



Medicaid Population


North Dakota ND 672,591 60,533 9%

Ohio OH 11,536,504 1,730,476 15%

Oklahoma OK 3,751,351 600,216 16%

Oregon OR 3,831,074 574,661 15%

Pennsylvania PA 12,702,379 1,905,357 15%

Rhode Island RI 1,052,567 178,936 17%


South Dakota SD 814,180 122,127 15%

Tennessee TN 6,346,105 1,142,299 18%

Texas TX 25,145,561 4,023,290 16%

Utah UT 2,763,885 248,750 9%

Vermont VT 625,741 150,178 24%

Virginia VA 8,001,024 720,092 9%

Washington WA 6,724,540 1,008,681 15%

West Virginia WV 1,852,994 315,009 17%

Wisconsin WI 5,686,986 909,918 16%

Wyoming WY 563,626 67,635 12%


Medicaid Population: 49,321,964


Other Public Insurance Population

State ID Population Public %

Alabama AL 4,779,736 95,595 2%

Alaska AK 710,231 35,512 5%

Arizona AZ 6,392,017 63,920 1%

Arkansas AR 2,915,918 58,318 2%

California CA 37,253,956 372,540 1%

Colorado CO 5,029,196 100,584 2%

Connecticut CT 3,574,097 NSD NSD

Delaware DE 897,934 8,979 1%

District of Columbia DC 601,723 NSD

NSD

Florida FL 18,801,310 376,026 2%

Georgia GA 9,687,653 290,630 3%

Hawaii HI 1,360,301 40,809 3%

Idaho ID 1,567,852 15,679 1%

Illinois IL 12,830,632 128,306 1%

Indiana IN 6,483,802 64,838 1%

Iowa IA 3,046,355 30,464 1%

Kansas KS 2,853,118 57,062 2%


Kentucky KY 4,339,337 781,081 18%

Louisiana LA 4,533,372 NSD NSD

Maine ME 1,328,361 26,567 2%

Maryland MD 5,773,552 57,736 1%

Massachusetts MA 6,547,629 NSD NSD

Michigan MI 9,883,640 NSD NSD

Minnesota MN 5,303,925 53,039 1%

Mississippi MS 2,967,297 59,346 2%

Montana MT 5,988,927 59,889 1%

Missouri MO 989,415 19,788 2%

Nebraska NE 1,826,341 36,527 2%

Nevada NV 2,700,551 54,011 2%

New Hampshire NH 1,316,470 13,165 1%

New Jersey NJ 8,791,894 NSD NSD

New Mexico NM 2,059,179 41,184 2%

New York NY 19,378,102 0 0%

North Carolina NC 9,535,483 190,710 2%


Other Public Insurance Population


North Dakota ND 672,591 6,726 1%

Ohio OH 11,536,504 115,365 1%

Oklahoma OK 3,751,351 75,027 2%

Oregon OR 3,831,074 NSD NSD

Pennsylvania PA 12,702,379 NSD NSD

Rhode Island RI 1,052,567 10,526 1%


South Dakota SD 814,180 16,284 2%

Tennessee TN 6,346,105 126,922 2%

Texas TX 25,145,561 251,456 1%

Utah UT 2,763,885 NSD NSD

Vermont VT 625,741 NSD NSD

Virginia VA 8,001,024 320,041 4%

Washington WA 6,724,540 201,736 3%

West Virginia WV 1,852,994 37,060 2%

Wisconsin WI 5,686,986 NSD NSD

Wyoming WY 563,626 11,273 2%

United StatesTotal Population: 308,745,778Public Insurance Population:


Affordable Care Act 2014-Private Commercial Market


The Affordable Care Act was established in part as a motivator for the Private Commercial

Insurance Market to be competitive in the services they offer and the premiums and

out-of-pocket costs they charge to their customers.

5% of the US Population, or 15.4 million individuals, purchase individual and family

insurance policies through the Private Commercial Market as opposed to

Employer Sponsored Plans.


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Commercial Population- Employer Sponsored

State ID Population Employer %

Alabama AL 4,779,736 2,342,071 49%

Alaska AK 710,231 369,320 52%

Arizona AZ 6,392,017 2,940,328 46%

Arkansas AR 2,915,918 1,224,686 42%

California CA 37,253,956 16,764,280 45%

Colorado CO 5,029,196 2,615,182 52%

Connecticut CT 3,574,097 2,108,717 59%

Delaware DE 897,934 475,905 53%


48%

Florida FL 18,801,310 7,896,550 42%

Georgia GA 9,687,653 4,650,073 48%

Hawaii HI 1,360,301 734,563 54%

Idaho ID 1,567,852 721,212 46%

Illinois IL 12,830,632 6,415,316 50%

Indiana IN 6,483,802 3,371,577 52%

Iowa IA 3,046,355 1,675,495 55%

Kansas KS 2,853,118 1,483,621 52%


Kentucky KY 4,339,337 607,507 14%

Louisiana LA 4,533,372 1,904,016 42%

Maine ME 1,328,361 637,613 48%

Maryland MD 5,773,552 3,290,925 57%

Massachusetts MA 6,547,629 3,797,625 58%

Michigan MI 9,883,640 4,941,820 50%

Minnesota MN 5,303,925 3,023,237 57%

Mississippi MS 2,967,297 1,275,938 43%

Montana MT 5,988,927 2,994,464 50%

Missouri MO 989,415 405,660 41%

Nebraska NE 1,826,341 986,224 54%

Nevada NV 2,700,551 1,296,264 48%

New Hampshire NH 1,316,470 803,047 61%

New Jersey NJ 8,791,894 4,747,623 54%

New Mexico NM 2,059,179 782,488 38%

New York NY 19,378,102 9,301,489 48%



Commercial Population- Employer Sponsored


North Dakota ND 672,591 369,925 55%

Ohio OH 11,536,504 5,883,617 51%

Oklahoma OK 3,751,351 1,725,621 46%

Oregon OR 3,831,074 1,877,226 49%

Pennsylvania PA 12,702,379 6,732,261 53%

Rhode Island RI 1,052,567 536,809 51%

South Carolina SC 4,625,364 2,035,160 44%

South Dakota SD 814,180 398,948 49%

Tennessee TN 6,346,105 2,982,669 47%

Texas TX 25,145,561 11,315,502 45%

Utah UT 2,763,885 1,630,692 59%

Vermont VT 625,741 306,613 49%

Virginia VA 8,001,024 4,400,563 55%

Washington WA 6,724,540 3,362,270 50%

West Virginia WV 1,852,994 889,437 48%

Wisconsin WI 5,686,986 3,070,972 54%

Wyoming WY 563,626 293,086 52%


Employer Spons. Population: 149,166,714


Commercial Population- Individually Funded

State ID Population Individual %

Alabama AL 4,779,736 238,987 5%

Alaska AK 710,231 21,307 3%

Arizona AZ 6,392,017 255,681 4%

Arkansas AR 2,915,918 116,637 4%

California CA 37,253,956 2,235,237 6%

Colorado CO 5,029,196 402,336 8%

Connecticut CT 3,574,097 178,705 5%

Delaware DE 897,934 35,917 4%


7%

Florida FL 18,801,310 940,066 5%

Georgia GA 9,687,653 484,383 5%

Hawaii HI 1,360,301 54,412 4%

Idaho ID 1,567,852 125,428 8%

Illinois IL 12,830,632 641,532 5%

Indiana IN 6,483,802 194,514 3%

Iowa IA 3,046,355 182,781 6%

Kansas KS 2,853,118 142,656 5%


Kentucky KY 4,339,337 43,393 1%

Louisiana LA 4,533,372 181,335 4%

Maine ME 1,328,361 53,134 4%

Maryland MD 5,773,552 288,678 5%


Michigan MI 9,883,640 494,182 5%

Minnesota MN 5,303,925 265,196 5%

Mississippi MS 2,967,297 148,365 5%

Montana MT 5,988,927 359,336 6%

Missouri MO 989,415 89,047 9%

Nebraska NE 1,826,341 146,107 8%

Nevada NV 2,700,551 135,028 5%

New Hampshire NH 1,316,470 65,824 5%

New Jersey NJ 8,791,894 351,676 4%

New Mexico NM 2,059,179 82,367 4%

New York NY 19,378,102 775,124 4%

North Carolina NC 9,535,483 381,419 4%


Commercial Population- Individually Funded


North Dakota ND 672,591 60,533 9%

Ohio OH 11,536,504 576,825 5%

Oklahoma OK 3,751,351 150,054 4%

Oregon OR 3,831,074 229,864 6%

Pennsylvania PA 12,702,379 635,119 5%

Rhode Island RI 1,052,567 42,103 4%


South Dakota SD 814,180 65,134 8%

Tennessee TN 6,346,105 317,305 5%

Texas TX 25,145,561 1,005,822 4%

Utah UT 2,763,885 165,833 6%

Vermont VT 625,741 31,287 5%

Virginia VA 8,001,024 400,051 5%

Washington WA 6,724,540 336,227 5%

West Virginia WV 1,852,994 37,060 2%

Wisconsin WI 5,686,986 341,219 6%

Wyoming WY 563,626 28,181 5%


Individually Funded Population: 15,087,925


Affordable Care Act 2014-Small Business Marketplace

Small Business Marketplace

By 2016, all small businesses must provide health insurance coverage for their employees. A small business has the choice of providing a private commercial plan or utilizing the SHOP Marketplace.

The Small Business Health Options Program (SHOP) was established to assist small businesses in purchasing health insurance for their employees. It allows the small business to control the level of coverage and determine the amount they will pay towards the employee premiums.

For Small Businesses with fewer than 25 full-time employees making an average of $50,000 a year or less, a Business Health Care Tax Credit has been established. The small business must pay a minimum of 50% of the employee premiums or more to qualify for the tax credit. In order to obtain this tax credit, the insurance plan must be purchased through the SHOP Marketplace.


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Insurance Counseling- Navigating the Insurance Marketplace can be a difficult task. Healthcare.gov will provide resources to determine the best insurance options. In addition, each state will employ Navigators and Insurance Counselors to provide additional one-on-one guidance.

Medicaid Application Assistance: It is anticipated that the Medicaid/Medicare application process will be streamlined, however, a significant population will require assistance applying for Medicaid under the new requirements.

Appeal Assistance- Each insurance plan within the Insurance Marketplace and the Medicaid programs are required to have an established appeals process for patients to appeal any coverage decision. Patients will be able to utilize a representative to assist them.

Financial Assistance Prescreening- Financial Assistance Programs are expected to have several changes over the next two years in response to the ACA changes. Patients will need extended assistance in determining their eligibility.

Affordable Care ActInsurance Counseling and Navigation

affordable care act insurance counseling and navigation

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