Insurance Options under the Affordable Care Act

Brendan Riley NC 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

 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

 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

 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

 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

Step 1: Person can apply in person, by phone, or online Step 4: Compare plans and enroll Step 2: Marketplace verifies income, citizenship, and immigration status thru online data from federal and state agencies Step 3: Marketplace determines eligibility for public or private insurance coverage and subsidies 7

 ◦ ◦ 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

 ◦ ◦ 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.

 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

 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

 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 12

Eligibility for Premium Tax Credits

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

1 2 3 4 Each additional person $11,490 -$45,960 $15,510 - $62,040 $19,530 - $78,120 $23,550 - $94,200 $4,020 - $16,080

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

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 ◦ 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

 ◦ 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

 ACA provides full federal funding for expansion for first three years  Tapers down to 90% in 2020 and years beyond

 Marketplace Open Enrollment Period: October 1, 2013-March 31, 2014;  Full year enrollment period for Medicaid & CHIP www.HealthCare.gov

www.CuidadoDeSalud.gov

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

 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 19

Brendan Riley Outreach & Enrollment Coordinator North Carolina Community Health Care Association [email protected]

http://www.ncchca.org/