ahec health insurance marketplace continuing education1 produced for the u.s. department of health...

1AHEC Health Insurance Marketplace Continuing Education

Produced for the U.S. Department of Health and Human Services, Health Resources and Services Administration by the National AHEC Organization under Contract # HHSH250200900063C.

The views expressed in this presentation are solely the opinions of the author(s) and do not necessarily reflect the official policies of the U.S. Department of Health and Human Services or the Health Resources and Services Administration, nor does mention of the department or agency names imply endorsement

by the U.S. Government.

AHEC Health Insurance Marketplace Continuing Education

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WHAT THIS TRAINING WILL COVER

The Affordable Care Act Major Goals of the Affordable Care Act Pathways to Affordable Quality Coverage Individual Shared Responsibility

Medicaid State Option to Expand Medicaid Medicaid Coverage How to Access Medicaid Coverage

Children’s Health Insurance Program (CHIP) CHIP Coverage How to Access CHIP Coverage

The Health Insurance Marketplace State Options for Marketplace Structures How Individuals & Families Access the Health Insurance

Marketplace


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WHAT THIS TRAINING WILL COVER

Qualified Health Plans (QHPs) Sold in The Marketplace QHPs Subject to Insurance Reforms QHPs Cover Ten Categories of Essential Health Benefits (EHBs) QHPs Grouped into Metal Levels Catastrophic Coverage Plans Federal Subsidies for QHPs through Insurance Affordability Program QHP Summary of Benefits & Coverage (SBC) QHPs Maintain Provider Network Adequacy

How to Access QHP Coverage

Important Marketplace Enrollment Dates

Small Businesses and the Marketplace Small Business Health Options Plan (SHOP) How Small Businesses Access SHOP

Conclusions & Resources


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THE AFFORDABLE CARE ACT


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MAJOR GOALS OF THE AFFORDABLE CARE ACT

ACCESSIBLE

COVERAGE

QUALITY COVERAGE

AFFORDABLE

COVERAGE

BETTER HEALTH CARE

IMPROVED POPULATION HEALTH


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PATHWAYS TO AFFORDABLEQUALITY COVERAGE

Medicaid Expansion

States are given the option to expand Medicaid to cover low-income, uninsured adults between the ages of 18 and 64

Children’s Health Insurance Program (CHIP)

Existing nationwide coverage for low-income children who cannot qualify for Medicaid is funded through 2015

Creation of the Health Insurance Marketplace

Sells new Qualified Health Plans (QHPs) and provides Federal subsidies to help pay QHP premiums and out-of-pocket costs

The Marketplace Provides Access to All Pathways of Coverage Complete One Enrollment Application for All Forms of

Coverage


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INDIVIDUAL SHARED RESPONSIBILITY

INDIVIDUAL SHARED RESPONSIBILITY PAYMENT TRIGGERED AFTER THREE CONSECUTIVE MONTHS OF NON-COVERAGE

2014 FEE

$95/adult & 47.50/child

OR1% household

income

2015 FEE

$325/adultOR

2% household income

2016 FEE

$695/adultOR

2.5% household income

FEE AFTER 2016

Adjusted for Inflation

MOST EVERYONE IS REQUIRED TO CARRY MINIMUM ESSENTIAL COVERAGE (MEC)

Some exemptions:

• Individuals who cannot afford coverage• Taxpayers below the Federal income tax filing threshold• Members of American Indian tribes• Short coverage gaps (less than three consecutive months)• Hardship


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QUESTIONS

??????


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MEDICAID


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STATE OPTION TO EXPAND MEDICAID


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MEDICAID COVERAGE

If Medicaid Expansion State: • Previously required coverage of children, pregnant

women, disabled and the elderly is still in place• New coverage of all adults between the ages of 18 and

64 with incomes up to 133% of the Federal Poverty Level (FPL)

If Non-Medicaid Expansion State: • Previously required coverage of children, pregnant

women, disabled and the elderly is still in place• Any possible coverage of adults is subject to state law

Coverage Gap in Non-Medicaid Expansion States

Adults who cannot qualify for Medicaid and cannot qualify for Federal subsidies to buy QHPs.


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HOW TO ACCESS MEDICAID COVERAGE

MEDICAID COVERAGE

GO TO THE MARKETPLACE

SUBMIT APPLICATION

INFO SENT DIRECTLY TO STATE MEDICAID OFFICE

COMPLETE ENROLLMENT

CONTACT STATE MEDICAID OFFICE

SUBMIT APPLICATION

COMPLETE ENROLLMENT

One Enrollment Application for All Forms of Coverage Go to: www.healthcare.gov or Call: 1-800-318-2596


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CHILDREN’S HEALTH INSURANCE PROGRAM (CHIP)


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CHILDREN’S HEALTH INSURANCE PROGRAM (CHIP) COVERAGE

CHIP is for children in families that earn too much to qualify for Medicaid but not enough to afford private insurance coverage

• Offered in all states • Not tied to state Medicaid program expansion• Comprehensive CHIP coverage funded through 2015• Open enrollment and immediate coverage

States may choose to:• Integrate CHIP into Medicaid program• Operate CHIP separately from Medicaid (with different income eligibility thresholds) • Cover additional benefits• Cover pregnant women and parents


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HOW TO ACCESS CHIP COVERAGE

CHIP COVERAGE

GO TO MARKETPLACE &SUBMIT APPLICATION

INFO TRANSMITTED TO STATE

CHIP OFFICE

COMPLETE ENROLLMENT

CONTACT ”INSURE KIDS NOW”

GO TO: WWW.INSUREKIDS.GOV

ORCALL: 1-877-543-7669

CONTACT STATE CHIP AGENCY

SUBMIT APPLICATION

COMPLETE ENROLLMENT

One Enrollment Application for All Forms of Coverage Go to: www.healthcare.gov or Call: 1-800-318-2596


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QUESTIONS

??????


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THE HEALTH INSURANCE MARKETPLACE


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IMPORTANT MARKETPLACE ENROLLMENT DATES

OPEN ENROLLMENT DATES• For coverage in 2015: Nov. 15, 2014 – Feb. 15, 2015• For coverage in 2016 and after: Oct. 15 – Dec. 7 each year

COVERAGE START DATES• Enroll between 1st and 15th of the month: Coverage starts first day of the next month

• Enroll between 16th and last day of the month: Coverage starts first day of the second following month

SPECIAL ENROLLMENT PERIOD• Any time a qualifying life event occurs (such as: moving to new state, loss of a job, change in family size)• Triggers 60 days to enroll in coverage


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STATE OPTIONS FOR MARKETPLACE STRUCTURES


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HOW INDIVIDUALS AND FAMILIES ACCESS THE HEALTH INSURANCE MARKETPLACE

GO TO THE MARKETPLACE • Find

links to:• State

Marketplace

• State CHIP & Medicaid Offices

• Local Navigators and Assistors trained to help with enrollment

APPLY

• Determine eligibility for:

• Medicaid

• CHIP• Help

with premiums & out-of-pocket costs

PICK A PLAN

• Compare Qualified Health Plans (QHPs)

• Select a plan

The Marketplace Provides Access to All Pathways of Affordable Coverage Complete One Enrollment Application for All Forms of

CoverageGo to: www.healthcare.gov or Call: 1-800-318-2596


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QUALIFIED HEALTH PLANS (QHPs) SOLD IN THE

MARKETPLACE


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QHPs SUBJECT TO INSURANCE REFORMS

No exclusions due to pre-existing conditions

Rates determined only by: age, family size, geography, tobacco use

Rate increases must be filed with (but not approved by) HHS

Required coverage of Essential Health Benefits (EHBs)

No annual or lifetime limits or caps on coverage

Required coverage of preventive benefits with no out-of-pocket costs


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QHPs COVER TEN CATEGORIES OF ESSENTIAL HEALTH BENEFITS (EHBs)

1. Ambulatory Patient Services

2. Emergency Services3. Hospitalization4. Maternity & Newborn

Care5. Mental Health &

Substance Use Disorder Services • Including behavioral

health treatment6. Laboratory Services7. Pediatric Services

• Including oral and vision care

8. Prescription drugs• Special rules for

prescription drug benefit including formulary exceptions

9. Preventive & Wellness Services and Chronic Disease Management • No out-of-pocket costs

10.Rehabilitative & Habilitative Services and Devices

EHB services must be balanced across all categories. These services can be included but do not count as Essential Health Benefits:• Adult routine dental and eye exams• Cosmetic orthodontia • Long-term/custodial nursing home care


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QHPs GROUPED INTO METAL LEVELS

BRONZEPlan pays

60% of costs of care

Consumer pays 40% of cost of care

Lowest premiums

METAL LEVELS CORRELATE TO ACTUARIAL VALUE (AV)(AV is the average percentage of costs a plan will cover for

EHBs)

Insurance carriers must offer: child-only plans, at least one silver and gold plan and a catastrophic plan. Stand-alone dental plans have different costs.

CATASTROPHIC COVERAGE PLANS


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Not a Metal Level plan

Very low premium and very high deductible

Available to individuals under 30 or those with hardship exemption from purchasing Metal Level coverage

Covers three primary care visits per year (at no cost and before the deductible is met)

Covers some free preventive care services (including screenings, vaccines and certain counseling services)

EACH INSURANCE CARRIER IN THE MARKETPLACEMUST OFFER ONE CATASTROPHIC PLAN


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FEDERAL SUBSIDIES FOR QHPs THROUGH INSURANCE AFFORDABILITY PROGRAM

TO BE ELIGIBLE:• Must be enrolled in a Silver Level plan through a Marketplace• Must earn between 100% and 250% of the FPL: $11,490 to $28,725 for individuals $23,550 to $58,875 for a family of four

IF QUALIFIED:• Insurance carrier charges lower out-of-pocket costs (deductibles, copays, coinsurance)• Total charges are less than the standard annual limit ($6,350/individual and $12,700/family)

LOWER OUT-OF-POCKET COSTS WITH COST SHARING REDUCTION PLANS (CSR)

To determine eligibility go to: www.healthcare.gov• Fill out an application• Use the Cost and Savings Calculator• Consult the Quick Check Chart


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FEDERAL SUBSIDIES FOR QHPs THROUGH INSURANCE AFFORDABILITY PROGRAM

TO BE ELIGIBLE:• Must be enrolled in a Metal Level plan through a Marketplace• Must earn between 100% and 400% of the FPL: $11,490 to $45,960 for individuals $23,550 to $94,200 for a family of four

IF QUALIFIED:• Premium assistance paid on a sliding scale• Insurers receive premium assistance payments directly from Federal

Government

LOWER PREMIUMS WITH ADVANCE PAYMENT TAX CREDIT (APTC)

To determine eligibility go to www.healthcare.gov• Fill out an application• Use the Cost and Savings Calculator• Consult the Quick Check Chart


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QHP SUMMARY OF BENEFITS & COVERAGE (SBC)

SBC is a summary of answers to general questions regarding:• The QHP’s deductible, provider network, non-covered

services• Common medical events that the QHP covers and does

not cover• Copay and coinsurance costs for care from network

providers and non-network providers

EVERY QHP MUST HAVE A CORRESPONDINGSUMMARY OF BENEFITS & COVERAGE (SBC) • Insurance carriers required to

provide standardized information to allow

apples-to-apples comparison of plans


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QHPs MAINTAIN PROVIDERNETWORK ADEQUACY

QHPs MUST MAINTAIN AN ADEQUATE NETWORK OF PROVIDERS

Such as: Hospitals, Community Health Centers, Rural Health Clinics, Health Professionals (including mental

health & substance abuse) Considerations:Plans with lower premiums may

have more restricted networks

Plans have different costs for

seeing non-network

providers

Patients should: Consult QHP’s

provider directory or call insurance

carrier SBCs provide link to directory and carrier contact

info

Providers should:Contact insurance

carriers to confirm their

participation in QHP networks


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QUESTIONS

??????


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HOW TO ACCESS QHP COVERAGE

QHP COVERAGE

SPM STATES

GO TO FEDERAL MARKETPLACE &BE CONNECTED

TO STATE IF NECESSARY

COMPARE PLANS

APPLY & ENROLL

FFM STATES

GO TO FEDERAL MARKETPLACE

COMPARE PLANS

APPLY & ENROLL

TRAINED NAVIGATORS, ASSISTORS & OTHERS AVAILABLE TO HELP ENROLL

Go to: www.healthcare.gov or Call: 1-800-318-2596


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IMPORTANT MARKETPLACE ENROLLMENT DATES

OPEN ENROLLMENT DATES• For coverage in 2015: Nov. 15, 2014 – Feb. 15, 2015• For coverage in 2016 and after: Oct. 15 – Dec. 7 each year

COVERAGE START DATES• Enroll between 1st and 15th of the month: Coverage starts first day of the next month

• Enroll between 16th and last day of the month: Coverage starts first day of the second following month

SPECIAL ENROLLMENT PERIOD• Any time a qualifying life event occurs (such as: moving to new state, loss of a job, change in family size)• Triggers 60 days to enroll in coverage


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QUESTIONS

??????


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SMALL BUSINESSES ANDTHE MARKETPLACE


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SMALL BUSINESS HEALTH OPTIONS PLAN (SHOP)

SHOP QHPs ARE METAL LEVEL PLANS:• Subject to all insurance reforms and QHP requirements• Options for level of employer contribution• Options for level of employee out-of-pocket costs

TO ENROLL IN SHOP: • Maximum allowable employees is 50 full-time equivalent employees

(FTEs) (varies by state)• Must offer coverage to all full-time employees• Must meet employee participation rate (varies by state)• Enroll between Nov. 15th and Dec. 15th each year to be exempt from

employee participation requirements• Must meet employer premium contribution requirement (varies by

state)

SMALL BUSINESSES CAN ENROLL IN SMALL GROUP PLANS THROUGH SHOP


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SMALL BUSINESS HEALTH OPTIONS PLAN (SHOP)

TO BE ELIGIBLE:• Fewer than 25 employees• Average salary of $50,000 or less• Employer pays 50% of full-time employees premium costs

IF QUALIFIED: • Credit covers up to 50% of monthly employer premium

contribution• Allows the deduction of premium costs not covered by the

credit• Credit highest for businesses with fewer than 10 employees

and average salaries of $25,000 or less

SMALL BUSINESSES TAX CREDITS AVAILABLE FOR SHOP QHPs


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HOW SMALL BUSINESSES ACCESS SHOP

GO TO FEDERAL MARKETPLACE BE CONNECTED

TO STATE MARKETPLACE IF NECESSARY

COMPARE PLANS

GET PRICE QUOTES

GET INSURANCE

CARRIER CONTACT INFO

ENROLL THROUGH INSURANCE BROKER, AGENT OR CARRIER

SHOPSMALL GROUP PLAN

SHOP HAS OPEN ENROLLMENT – HOWEVER:• Enrollment through Federal

Marketplace postponed until 2015• Not all State SHOP Marketplaces

operational

SHOP MARKETPLACE IN EVERY STATE• Business enrolls in a state where it

has an office or work site


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QUESTIONS

??????


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CONCLUSIONS

Most everyone must enroll in some form of health coverage

Several pathways to affordable health insurance coverage

Federal assistance available for premiums &out-of-pocket costs

Consumer choices affect their premiums & out-of-pocket costs

Plans with lower premiums may have smaller networks

State Fact Sheets are available with specifics for every state


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FEDERAL RESOURCES

Health Insurance MarketplaceIndividual, family, small business coverage options/enrollment• www.healthcare.gov• www.cuidadodesalud.gov

Medicaid• www.medicaid.gov

Children’s Health Insurance Program (CHIP)• www.insurekidsnow.gov


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MORE FEDERAL RESOURCES

Internal Revenue ServiceSection on all Affordable Care Act tax provisions• www.irs.gov

The Center for Consumer Information and Insurance Oversight (CCIIO) Section on Affordable Care Act rules for private insurance and marketplaces• www.cms.gov/CCIIO

BusinessUSA Section on all health care changes of interest to businesses• www.business.usa.gov


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STATE RESOURCES

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