Health Reform and You

Insurance Options under the Affordable Care Act

Brendan RileyNC Community Health Center Association

January 23, 2014

As of October 1, 2013, you can enroll in new health coverage options

Insurance options based on eligibility:◦ Employer-sponsored coverage ◦ Medicaid & CHIP◦ Medicare◦ Individual/non-group coverage you buy yourself

Enrolling in Health Coverage

Medical bills leading cause of bankruptcy

Premium costs rising faster than wages

No protections for people with pre-existing conditions

Insurance companies can deny coverage to sick people, even children

Before Health Reform

Can’t be denied coverage because of a pre-existing condition

No lifetime limits or annual caps on coverage

Limits on out-of-pocket costs for consumers

Companies can’t charge women more money for same coverage

Companies can’t cancel your policy because of an illness

Higher Quality Coverage: Consumer Protections

Plans must cover “essential health benefits”

Plans must provide easy-to-read summaries of benefits and covered services

Children can stay on parents’ plan ‘til age 26

Preventive services with no cost-sharing

Tax credits for small businesses that provide coverage

Higher Quality Coverage: Consumer Benefits

Single, streamlined application

Determine eligibility for and enroll in nearly all types of coverage

Application and enrollment assistance◦ Certified in-person assisters ◦ 24-hour call center◦ Online chat helpers

Applying for Health Coverage

Applying for Health Coverage

Step 2: Marketplace verifies income, citizenship, and immigration status thru online data from federal and state agencies

Step 1: Person can apply in person, by phone, or online

Step 3: Marketplace determines eligibility for public or private insurance coverage and subsidies

Step 4: Compare plans and enroll

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Medicare◦ No eligibility changes◦ Strengthens program with new benefits

Free preventive services Closes doughnut hole on Rx drug costs

Medicare Advantage◦ Premium dollars must go toward improving care

per 80/20 rule Keeps seniors’ costs down & makes plans more

efficient

What’s in it for You: Medicare & Medicare Advantage

Job-based coverage◦ >50% of non-elderly North Carolinians◦ Most will continue on this coverage in 2014

Don’t have to apply, but can shop around to see if better coverage or better costs

Benefit from consumer protections, such as caps on lifetime limits, protections for pre-existing conditions, etc.

What’s in it for You: Job-Based Coverage

Pre-ACA, very difficult and costly to purchase health insurance on individual market

ACA creates Health Insurance Marketplace◦ Like Expedia or Priceline — consumers can shop

for and compare insurance plans and levels of coverage in online Marketplace www.HealthCare.Gov

◦ Plans must provide essential health benefits

What’s in it for You: Buying Individual/Non-Group Coverage

Financial help for many to purchase health insurance through Health Insurance Marketplace

Eligible for Premium Tax Credits if:◦ Between 100% and 400% of Federal Poverty Level◦ No access to affordable employer-based coverage◦ Ineligible for Medicaid, CHIP, or Medicare

Amount of tax credit depends varies on sliding scale ◦ Tax credit at 200% FPL will be larger than 300% FPL

credit

What’s in it for You: More Affordable Coverage

What’s in it for You: More Affordable Coverage How do premium tax credits work?

◦ Used to purchase qualified health plan on Marketplace

◦ Eligibility determined by household size and income

◦ Can be claimed fully in advance, in part in advance, or at end of year

◦ Paid directly by the Marketplace to the insurer◦ Consumer is responsible for the difference each

month

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More Affordable Coverage: Premium Tax Credits

Family Size Eligible for Subsidies in Marketplace (100-400% FPL)

1 $11,490 -$45,9602 $15,510 - $62,0403 $19,530 - $78,1204 $23,550 - $94,200

Each additional person $4,020 - $16,080

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Note: This example is based on the 2013 Federal Poverty Levels (FPL). These income limits will be increased by 2014.

Eligibility for Premium Tax Credits

Caps on out-of-pocket expenses◦ Deductible, co-pays, coinsurance

Eligible if household at or below 250% FPL (~$28,750/household of one)

Must select silver tier plan

More Affordable Coverage: Cost-Sharing Reductions

CHIP ◦ Public program that covers children in families up to

200% FPL (~$47k for family of four)

Medicaid◦ Public program that covers some individuals & families◦ Provides funding to states to expand eligibility for all

individuals up to 138% FPL Supreme Court rendered expansion voluntary for states

12 month eligibility period — can enroll anytime in the year

What’s in it for You: Medicaid & CHIP

ACA provides full federal funding for expansion for first three years

Tapers down to 90% in 2020 and years beyond

Medicaid Expansion

Medicaid Expansion

Marketplace Open Enrollment Period: October 1, 2013-March 31, 2014;

Full year enrollment period for Medicaid & CHIP

www.HealthCare.govwww.CuidadoDeSalud.gov

1-800-318-2596 (TTY 1-855-889-4325)

Get Ready for Coverage

Get Ready for Coverage The North Carolina Department of

Insurance (NCDOI) consumer information office can help you with questions about your insurance coverage◦ Health Insurance Smart NC◦ 1-877-885-0231◦ www.ncdoi.com/Smart/

NCDOI can also help you file complaints or appeals with your insurance company

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Brendan RileyOutreach & Enrollment Coordinator

North Carolina Community Health Care Associationrileyb@ncchca.org

http://www.ncchca.org/

Questions?