health coverage updates an affordable care act and badgercare primer for americorps members
TRANSCRIPT
Health Coverage Updates
An Affordable Care Act and BadgerCare primer for AmeriCorps
members
What do you know about the
Affordable Care Act?
Problems• 18 – 20%
uninsured rate– Affordability– Jobs– Already sick
• 70 million Americans in medical debt
What was the ACA intended to do?Solutions in the ACA• Mandatory health
insurance• Individual
Marketplace• Elimination of caps• MA Expansion• Guaranteed Issue
The Patient Protection and
Affordable Care Act
In Short…
Patient Protection…
• Allows young adults to stay on parents’ policies until they are 26
• Eliminates lifetime limits• Phases out annual limits (gone in 2014)• Many preventive care services must now also
be offered without co-pay or deductible • 80% of your premium most go to care (MLR)• No denials for pre-existing conditions!
AKA Health Insurance Reforms
Explain it to me like I’m 5 years old
What is COBRA?
TRIVIA QUESTION!!!
• Individual Marketplace – Subsidies for low-income individuals– Tiers of coverage
• New Funding for Community Health Center expansion– Hooray!
• Medicaid Expansion – State choice
…and Affordable Care Act!
ACA Creates New Marketplaces
TRICAREMilitary
VASome Veterans
MedicareSeniors and
SSDI
Individuals and Self-Employed
Small Groups1-50 FTEs
Large Groups50+ FTEs
Insured Products
HMOsPPOsFFSEtc.
ProvidersDoctors
SpecialistsHospitals
ClinicsRx Drugs
Etc.
Insured
Government Coverage
Private Coverage
Self-Insured
Employer
IndividualMarketplace
SHOPMarketplace
Medicaid< 100% of FPL,
EBD, SSI, Pregnant Women & Children
Uninsured
Exempt
Credit: Community Advocates Public Policy Institute
Avenues to Health Insurance
1. Create an account
The Marketplace will ask you a series of questions in order to determine your eligibility
2. Apply
OR
JOE’S SUPER AWESOME
HEALTH PLAN
Premium: $300WITH ATPC:
Now is $76
Co-Pay: $20 PCPWITH APTC:
Now is $0
Explain it to me like I’m 5 years old
What is a deductible?
TRIVIA QUESTION!!!
• Which Qualified Health Plan?• Which Metal Tier?• How much can I afford with or without APTCs
and CSRs?• Is my current doctor in network?• Are my specific medications covered?
3. Pick a Plan
The individual plans sold by health insurance companies on the Marketplace are known as
“Qualified Health Plans”
Qualified Health Plans in Wisconsin
1. Common Ground Healthcare 2. Compcare Health Services 3. Dean Health Plan, Inc.4. Group Health Cooperative of
South Central Wisconsin5. Gundersen Health Plan, Inc.6. Health Tradition Health Plan7. Medica Health Plans of
Wisconsin8. MercyCare HMO, Inc.
9. Molina Healthcare of
Wisconsin, Inc.10. Physicians Plus Insurance
Corporation11. Security Health Plan of
Wisconsin, Inc.12. Unity Health Plans Insurance
Corp.13. Arise (WPS Health Plan, Inc.)
Plans sold on the Health Insurance Marketplace are divided into four metal tiers, and some offer
catastrophic coverage.
Metal Tiers
Premium Tax CreditsIndividuals with lower incomes can receive
discounts on their health insurance premium. These are refundable or advance-able, but must
be reconciled at the end of the year.
Cost Sharing ReductionsIndividuals with lower incomes can also receive
discounts on their deductibles and co-pays. They further stretch the value of one’s health
insurance. These do not need to be reconciled.
Income Level Actuarial Value
100 - 150% FPL 94%
150 - 200% FPL 87%
200 - 250% FPL 73%
Explain it to me like I’m 5 years old
What is co-insurance?
TRIVIA QUESTION!!!
In order to start receiving benefits, you must enroll in that plan and begin making premium
payments.
3. Enroll!
Enrollment Numbers through April 19:• 81,274 determined/assessed eligible for Medicaid• 230,516 determined eligible for Marketplace
• 168,721 (73%) eligible for assistance• 139,815 selected a QHP*
*Selected does not = complete enrollment
Why Should I Enroll?Because it’s good for your health!
Also…
With some notable exceptions, the majority of Americans will be required to have health
coverage for at least 9 months of each year or risk paying a penalty.
Individual Mandate
2014Penalty is $95 per
adult and $47.50 per child (up to $385 for
a family) or 1% of family income,
whichever is greater
2015Penalty is $325 per adult and $162.50
per child (up to $975 for a family) or 2% of
family income, whichever is greater
2016 and beyondPenalty is $695 per
adult and $347.50 per child (up to $2,085 for
a family) or 2.5% of family income,
whichever is greater
When Can You Enroll?
• Open enrollment begins November 15th, 2014 and ends February 15th, 2015– Applies to all individual plans
• You can change plans from November 15th – December 15th, 2014
• Special enrollment periods are year round!
What is a Special Enrollment Period?• If a person or family experiences a qualifying life
event or in certain other circumstances related to the enrollment process, they may be eligible for a Special Enrollment Period (SEP)
• This SEP will allow them to enroll in health insurance coverage through the Health Insurance Marketplace outside of a open enrollment period. The individual or family will typically have 60 days from the qualifying life event or approval of their SEP request to enroll in new Marketplace coverage
Special Enrollment Periods • Marriage• Marriage with
Dependent Gained• Divorce (if loss of MEC)• Death (if loss of MEC)• Birth• Adoption• Placement for Adoption• Foster Care Placement• Permanent Move to New
Service Area• Becoming Lawfully
Present• Gaining AI status
• Income change resulting in change in APTC eligibility (if enrolled)
• Release from Prison • Involuntary loss of ESI• Loss of Dependent Status • Expiration of COBRA• Individual plan non-
renewal outside of open enrollment
• Errors, mis-representation or inaction by enrollment assister
• QHP misrepresentation
or contract violation• Technical problems• Immigration status error• Website display error• Unresolved casework• Medicaid/Marketplace
transfer issues• Natural Disaster• Serious Medical
Condition• Victims of Domestic
Violence• Loss of Hardship
exemption
What doesn’t trigger a SEP?
• Voluntarily dropping other coverage• Loss of eligibility for coverage when one was
not actually enrolled in it• Being determined newly eligible for subsidies if
you aren’t currently enrolled in a QHP• Income change• Being terminated from coverage• Divorce or death of a family member without it
resulting in a loss of MEC
The State and Federal Government train and certify individuals who can help you apply for health insurance through the Marketplace:
Who Can Help Me?
• Certified Application Counselors
• Navigators• Non-Navigator
Enrollment Assisters• Agents & Brokers
Find them here:www.e4healthwi.org
www.localhelp.healthcare.gov
Explain it to me like I’m 5 years old
What does actuarial value
mean?
TRIVIA QUESTION!!!
What do you know about BadgerCare?
BadgerCare BasicsBadgerCare is the name for Wisconsin’s
Medicaid program which offers health coverage to individuals with low-incomes.
Adults Children Pregnant Women
100%FPL
200%FPL
300%FPL
400%FPL
For context…BadgerCare today is different than it was as recently as April. Many people still may not
know they are eligible for it, and others may no longer be eligible for it.
Category Feb 2014 July 2014
Parents/Caretakers 214,358 168,270
Pregnant Women 19,089 19,474
Childless Adults 14,461 119,090
Children 423,028 433,044
When Can You Enroll?
Anytime!
Explain it to me like I’m 5 years old
What is the difference between an HMO and a PPO?
TRIVIA QUESTION!!!
Who Can Help Me?The Wisconsin Income
Maintenance Consortia are responsible for processing
BadgerCare, FoodShare and Medicaid Applications. Income Maintenance staff
are the only individuals who can make an eligibility
determination, however anyone can help an individual to apply.
Regional Enrollment Networks: Coalitions which came together to help individuals enroll in health coverageNavigator Awards: New Navigator awards will be made next month.Politics: The Affordable Care Act and related Medicaid decisions have been made highly political.General Confusion: Even with one year of open enrollment completed, people are still very confused about their coverage options.
Environmental Factors - FYI
