Transcript ConnectorCare: The New Commonwealth Care

ConnectorCare:
The New Commonwealth Care
Suzanne Curry
[email protected]
MLRI Basic Benefit Training
December 10, 2014
Commonwealth Care
o Comprehensive health coverage for adults at or below
300% FPL not eligible for MassHealth
o Created through 2006 Massachusetts health reform law
o Run by the Health Connector
o Sliding scale premiums based on income, copays also
based on income: Plan Type 1, 2, 3
o Cannot be offered health insurance from job
o As of December 31, 2013, about 220,000 enrollees
Commonwealth Care
As of January 1, 2014:
o About 130,000 of Commonwealth Care enrollees
transitioned to MassHealth
o Due to systems issues, Commonwealth Care coverage
for the remaining 90,000 members was extended
multiple times and will end on January 31, 2015
o About 13,000 former Medical Security Program
members also given the option of maintaining MSP
coverage under the Commonwealth Care program –
coverage is also extended to January 31, 2015
ACA Subsidized Insurance
How does subsidized health insurance
work under the Affordable Care Act?
Qualified Health Plans
o Qualified Health Plan (QHP): insurance plan
certified by health insurance marketplaces
o In Massachusetts, the health insurance
marketplace is the Health Connector
Types of QHPs
o QHPS are categorized into different types or
metallic tiers, based on how much cost-sharing the
plan covers
o Platinum (least cost-sharing, highest premiums)
o Gold
o Silver
o Bronze (most cost-sharing, lowest premiums)
Federal Subsidies
o ACA offers two types of help paying for health
insurance to purchase a QHP through the health
insurance marketplace:
 Advanced premium tax credits (APTCs)
 Cost-sharing reductions
o Paid directly to the health plan, consumer pays the
rest
Advanced Premium Tax Credits (APTCs)
o Size of credit is based on a percentage of
income and cost of 2nd lowest cost “Silver”
plan available through the marketplace
o If you buy a more expensive plan (e.g.
Gold, Platinum), pay the difference
o If you buy a cheaper plan (e.g. Bronze),
save the difference
Cost-Sharing Reductions
o Lowers out-of-pocket costs, such as
deductibles, co-pays or co-insurance
o Must purchase “Silver” plan to get costsharing reductions
Federal Eligibility Requirements
o Income at or below 400% FPL
o At or below 250% FPL for cost-sharing
reductions
o US Citizen, national or lawfully present immigrant
o Resident
o Not incarcerated
o Not eligible for or enrolled in:
o Other “minimum essential coverage” (e.g.
Medicaid, Medicare)
o Affordable Employer Sponsored Insurance
Employer Sponsored Insurance
o May be eligible for APTCs if ESI available to you:
 Costs more than 9.5% of household income for
lowest-cost self-only plan
 Does not meet “minimum value” (i.e. does not
cover 60% of average cost-sharing)
More on ESI
o Application asks questions about premium cost of
ESI & minimum value to see if uninsured person
offered ESI may be eligible for APTCs
o “Family glitch” – whether ESI is affordable for family
members is also based on cost of self-only plan NOT
cost of family plan
o If “self-only” ESI is considered affordable, family
members also cannot receive APTCs
ACA vs. MA Subsidies
ConnectorCare
o Plans designed to look more like
Commonwealth Care in terms of premiums &
cost-sharing
Federal APTCs + Federal Cost-Sharing
Reductions + State Funds =
ConnectorCare Subsidies
ACA Subsidized Coverage in Mass.
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Eligibility for ConnectorCare
o Income at or below 300% FPL
o Meet eligibility standards for federal APTCs
o Must choose from subset of plans offered
through the Health Connector
Selecting a Plan
o No automatic assignment, applicant must select
plan
o ConnectorCare-eligibles can choose any plan
offered through the Health Connector BUT:
o Added state subsidies lowering premiums and
cost-sharing to Commonwealth Care levels are
only available if choose ConnectorCare plan
ConnectorCare Plans
Carriers offering ConnectorCare plans in 2015:
o BMC HealthNet Plan
o CeltiCare
o Fallon Health Plan
o Health New England
o Minuteman Health
o Neighborhood Health Plan
o Tufts Health Plan - Network Health
ConnectorCare Plans
ConnectorCare plan names do not display correctly on
the Health Connector website.
ConnectorCare Health Insurance Carriers
ConnectorCare plan name as it is
displayed in the system
Boston Medical Center HealthNet Plan
CeltiCare Health Plan
Fallon Health
Health New England
Minuteman Health
Tufts Health Plan-Network Health
Neighborhood Health Plan
BMC HealthNet Plan - Silver A
Ambetter Balanced Care
Community Care Silver Connector A
HNE Silver A
MyDoc HMO Silver Basic
Tufts Health Direct Silver
NHP Prime HMO 2000/4000 30/50
Although the names are wrong, the premiums, co-pays and
benefits are displayed correctly.
ConnectorCare Premiums
o Base enrollee premiums for members selecting the lowestcost ConnectorCare plan in their region equals that in
Commonwealth Care today
o Plan Type I members will not be charged a premium,
regardless of which plan they choose
Premium Payment
o Must pay premium by the 23rd of the month
for coverage to be effective for the 1st of the
next month
o If payment is received after the 23rd,
coverage will not be effective until the 1st of
the 2nd month
o Premiums must be received by the 23rd of
each month to maintain coverage.
Premium Non-Payment
o After 30 days of non-payment, APTCs to the
plan are suspended and plan suspends
payment to providers
o If all premiums owed are not paid after 90
days, coverage is terminated retroactively
back to the end of the first 30 days of nonpayment
o Health Connector has process to apply for
premium hardship waivers
 Same as Commonwealth Care process
ConnectorCare Cost-Sharing
o Co-pays only; no deductibles or co-insurance
o Plan Type 1 (at or below 100% FPL): MassHealthlevel co-pays for prescription drugs only
o Plan Type 2 (100-200% FPL): Low to moderate
co-pays
o Plan Type 3 (200-300% FPL): Moderate co-pays
Open Enrollment Period
o Under federal rules, there is a set open enrollment
period (e.g. for this year, it is November 15, 2014February 15, 2015) – only time a consumer can
enroll in plan through marketplace
o Exception – experiencing a “triggering event”
o In Massachusetts, being determined eligible for
ConnectorCare is considered “triggering event”
o Can enroll in ConnectorCare any time during the
year
What about people over 300% FPL?
o People with incomes between 300-400% FPL
may be eligible to receive help paying for
health insurance
 Must meet federal eligibility guidelines
 May be eligible for APTCs
 Choice of all plans offered through the
Health Connector
Reconciliation
o APTCs are based on annual income and
“reconciled” at tax time
o IRS compares amount of premium tax credits you
qualify for at end of year with those you received in
advance
o Final premium tax credit is calculated based on
actual income reported on federal taxes
o If APTC is less than amount of final premium tax
credit, you will receive the difference as a credit
o If APTC is more than amount of final premium
tax credit, you must repay the difference
through your tax return
Reconciliation
o Reconciliation amounts are capped for individuals
and families at or below 400% FPL
o Additional subsidies provided by the state are not
subject to reconciliation
Thank you!
Questions?