health care reform for small businesses and sole proprietors artists health insurance resource...
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HEALTH CARE REFORM FOR SMALL BUSINESSES AND SOLE PROPRIETORS
Artists Health Insurance Resource CenterA program of The Actors FundRenata Marinaro, Health Services Director, Eastern Region 917-281-5965 [email protected]
What is The Actors Fund?
The Actors Fund is a nationwide human services organization that helps all professionals in performing arts and entertainment. The Fund is a safety net, providing programs and services for those who are in need, crisis or transition.
www.actorsfund.org
Our services
Social Services Housing Employment and Training Services Health Services
Words to know
Co-payCo-insuranceDeductiblePremiumOut-of-pocket maximumHMO & POS/PPOFederal Poverty LevelMarketplaceAdvanced Premium Tax Credit (aka subsidy)
Children under age 19 with pre-existing conditions can’t be denied coverage.
Young adults up to age 26 (in NY, through age 29) can stay on or enroll in their parents’ coverage. Note: special rules apply for coverage from age 26-29.
Insurers can’t retroactively cancel the policies of people who get sick.
What has health care reform done for me so far?
All new plans must cover certain preventive services for free. These include: certain breast, colon and cervical cancer screenings; blood pressure, diabetes and cholesterol tests; vaccines, immunizations, and flu shots; and HIV & STD testing.
Insurers can’t impose annual or lifetime dollar limits on medical benefits.
Insurers must spend at least 80% of a consumer’s premium dollars on actual medical care.
What has health care reform done for me so far?
Insurers can’t refuse coverage
to anyone, or exclude pre-
existing conditions
Most people will be mandated to have coverage or pay a penalty. In 2014, the penalty is $95 or 1% of your income. It goes up to $695 or 2.5% of income in 2016.
Medicaid eligibility will be expanded to people with incomes up to 138% of FPL (approx $15,856/yr)
What happens in 2014?
New insurance marketplaces, called Marketplaces, will offer insurance to those who don’t get it through their employer or Medicaid.
Subsidies will be available to people who buy insurance through a Marketplace with income less than 400% of the Federal Poverty Level. ($45,960)
Enrollment in Marketplaces will begin Oct 1, 2013 and end March 31, 2014.
What happens in 2014?
Employers
2014: Employers do not have to offer coverage.
Starting in 2015, those with 50 or more employees will have to pay a penalty if they don’t.
• 2015: Mandate applies only for employers with 50 or more full time equivalent employees (FTEs)
- FTEs calculated on a 30 hour work week
Will employers be required to offer insurance?
If you choose to opt out of your employer’s coverage, you will still have to be insured or pay a penalty.
Employees who are offered coverage and choose not to take it will not be eligible for subsidies to pay for coverage through the Marketplace, unless the employer’s plan fails to meet certain benefit guidelines.
Guidelines: Policy must cover at least 60% of medical costs and cannot cost more than 9.5% of employee’s income
Does an employee have to accept an employer’s insurance?
You can continue to provide the same coverage you do now.
You can choose to buy: Directly from an insurer Through a broker or agent On the SHOP Marketplace (with or
without the help of a broker or navigator)
Where will an employer buy insurance?
What is the SHOP Marketplace?
• The SHOP Marketplace will sell and administer insurance plans for small businesses online
• You can select one or a variety of health plans for employees to choose from
• You can set a fixed contribution to employees’ coverage
• Administrative simplicity—one monthly invoice, one monthly bill, and help throughout the process!
Who can buy on the SHOP Marketplace?
To participate, employers must:• Have 50 or fewer employees
• Be a valid business
• Offer coverage to all full-time employees*
• Have a business address or a primary employee worksite in New York State
* Employer can define FT, but must be at least 20 hrs/wk
What do I need to enroll on the SHOP Marketplace?
Employer:
EIN or TIN
Gender, DOB, Social Security Number
Number of FT and FTE employees
Average annual wage (excl. owner and family)
Employee roster, incl. dates of birth of employees and dependents
When can I enroll?
• Initial open enrollment begins October 1, 2013, for coverage beginning January 1, 2014.
• If you apply between 1st-15th of the month, coverage begins the first of the following month
• If you apply between the 16th and last day of month, coverage begins the first of the second following month
• Annual Open enrollment occurs on the policy anniversary date.
In the SHOP, employers can….
• Choose whether to offer all, some or only one plan in the Marketplace to their employees
• Choose how much they want to contribute towards employees premiums. They can pay all, some or none of the employee’s premiums
• There is no minimum contribution, but in order to get a tax credit you have to pay at least 50% of the employee’s premium
Tax Credits for Non-Profit Small Businesses
Small businesses (2-49 employees) aren’t required to offer coverage; however…
Businesses can receive tax credits for doing so if they buy coverage on the SHOP Marketplace
The credit is refundable for a tax-exempt employer
Which employers are eligible?
• Fewer than 25 full-time (equivalent) employees• Two half-time employees count as one
full-time employee
• Average annual wages less than $50,000• Not counting wages of the owner or
her family
• Employer pays at least 50% of premium cost
How to claim the credit
• Claim credit using IRS Form 8941, available at www.irs.gov
• Non-profits also use Form 990T to claim credit
• Credit can be claimed for 2 consecutive taxable years
• Tax credit calculator http://www.smallbusinessmajority.org/tax-credit-calculator/ Talk to your
accountant!
Individuals
If you don’t get it through your job or a public program, you can buy it through the Marketplace.
Marketplace: a competitive, private insurance marketplace. Shop for plans and buy coverage on the Marketplace website. Marketplaces will also administer new subsidies.
For individuals and families, there will be 4 Tiers of benefits on the Marketplace – Bronze, Silver, Gold, and Platinum - and 1 catastrophic plan (for those under age 30).
Where will I buy insurance?
Name as it appears on your legal documents or identification card Social Security Number (if you have one) Date of birth (for all household members) Tax filing status The name and address of your current employer(s) Income information (It might be helpful to bring last’s year tax
returns for everyone in the household, paystubs, W2 forms, or if you are self-employed, a record of last three months earnings and expenses)
Information about any other health insurance you or other family member may have
If applicable, immigration (“Alien”) number for immigrant family members
Information about disability status
What do I need to bring with me to enroll?
Considerations when picking a plan
Cost of Care
• Premium• Deductible• Out of Pocket
Max• PCP• Specialist• Hospitalizatio
n
Access to Care
• Network• Doctors• Hospitals
• Benefits• Consider your
health status/needs!
Quality of Care
• Independent ratings
• Opinions from family and friends
• Feedback from doctors/providers
• Personal experience
Tier % of costs covered by insurer
Deductible Consumer’s max out of pockets costs
Bronze 60% $3,300 $6,350
Silver 70% $2,000 $5,500
Gold 80% $600 $4,000
Platinum 90% $0 $2,000
What will the plans look like in NY?
What benefits do plans on the Marketplace offer?
HospitalizationOffice visits (PCP &
Specialist)Emergency RoomAmbulanceMental Health
treatmentSubstance Abuse
treatment
MedicationsDiagnostic and lab
workPreventive Screenings
(free)Maternity careChiropraxisGym reimbursement!
Will there be dental coverage?
Only for children. For discounted dental services visit:
NYU & Columbia dental schools New York City Technical College
Dental hygiene clinic: Provides cleaning, fluoride treatment, and x-rays; 718.260.5074
Hospital-based low-cost dental care www.nyc.gov/html/hia/html/resources/servic
es_dental.shtml
Negotiate with your dentist!
If a company offers coverage to an employee, the company must also offer coverage to children (but not spouses).
The employer must make insurance affordable to the employee (less than 9.5% of the employee’s income) but does not have to offer affordable family coverage.
All children in New York are eligible for the Children's Health Insurance Program (CHIP).
What about family coverage?
Under age 30: high-deductible plan option. Deductible is $6,350. Prevention benefits and 3 primary care visits are exempt from deductible.
Under age 26: can stay on/enroll in parents’ plan, regardless of living situation, marital status, student status, or financial dependence.. In NY, adults age 26-29 can stay on their parents coverage, but special rules apply: you must be unmarried, live or work in NY, and have a policy that was issued in NY.
Are there special programs for people under 30?
You can buy insurance as an individual on the Marketplace. This increases your options and will reduce premiums for those with lower incomes. You may also qualify for the APTC (premium subsidy).
You can’t buy on the SHOP Marketplace.
You may qualify for Medicaid if your income is under $15,856 (single).
I’m self-employed. How will this affect me?
If your income is $11,490 - $45,960 (single), you will receive a subsidy to buy insurance through the Marketplace.
Subsidies will cap the amount you spend on premiums in relation to your total income.
Some people will also be eligible for subsidies that cap your deductible and annual out-of-pocket medical costs.
How Will I Afford Insurance?
Use your HOUSEHOLD modified adjusted gross income: Adjusted Gross Income (line 37 of Form 1040)
+Non-taxable social security benefitsTax Exempt InterestForeign Earned income
For Medicaid eligibility, you can exclude from your income: scholarships, awards and grants (for education only), and certain lump sum one-time payments
How do I calculate my income?
FPL 2013 Annual income range
Annual percent of income
Annual premium contribution
100-150% $11,490-17,235
2-4% $229-$689
150-200% $17,235-22,980
4-6.3% $ 689-$1,447
200-250% $22,980-28,725
6.3-8.05% $1447-$2312
250-300% $28,725-34,470
8.05-9.5% $2312-$3274
300-400% $34,470-45,960
9.5% $3274-$4366
Subsidy Chart
Example: Susan is single and makes $22,000/yr. She will have her premiums capped at 6.3% of her income (approx $130/mo) and her annual out-of-pocket medical costs will be limited to under $4000/yr (excluding premiums).
Calculate your potential subsidy here: http://www.healthbenefitexchange.ny.gov/Pre
miumEstimator
Example
More info: www.ahirc.org
Navigating the ACA for small businesses
First Tuesday of every month
5:30-7pm 729 7th Avenue, 11th floor
Rsvp: [email protected]
Navigating the ACA for individuals
Every Thursday 12:30-1:30pm 729 7th Avenue, 10th
floor Rsvp:[email protected]
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Individual seminar - weekly
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