Transcript Document

Countdown to Coverage: the Health
Insurance Marketplace
International Society of Certified Employee
Benefits Specialists
Trey Daly, Ohio State Director, Enroll America
[email protected] 513-659-0187
172 days
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WHAT IS ENROLL AMERICA
•IDENTIFY THE UNINSURED
•INFORM THE UNINSURED ABOUT ACA
•INSPIRE THE UNINSURED TO ENROLL
Lucas County’s Uninsured
• Lucas County Uninsured (under 65)
57,994
o 18 – 64
51,981
89.6%
o Under 19
6,742
11.6%
o Male
o Female
32,128
25,866
o White
o Black
o Hispanic
n/a
n/a
n/a
o <= 138% fpl
o <= 400% fpl
25,745
52,228
55.4%
44.6%
44.4%
90.1%
http://www.census.gov/did/www/sahie/data/interactive/
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Cuyahoga County’s Uninsured
• Cuyahoga County Uninsured (under 65) 160,828
o 18 – 64
146,816
91.3%
o Under 19
15,977
9.9%
o Male
o Female
89,810
71,019
o White
o Black
o Hispanic
n/a
n/a
n/a
o <= 138% fpl
o <= 400% fpl
72,196
143,915
55.8%
44.2%
44.9%
89.5%
http://www.census.gov/did/www/sahie/data/interactive/
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New Health Coverage Options in
2014
3 different options are available to the uninsured
based on income.
- Medicaid
- The Marketplace (with financial assistance)
- The Marketplace or private plan (without financial
assistance)
Medicaid
• The federal government sets requirements
minimum requirements
• States have the option to expand coverage
• Historically – Low-income parents, children,
and pregnant women, low-income elderly,
and disabled individuals
• Medicaid doesn’t cover: Undocumented
immigrants
• The ACA allows states to expand their
Medicaid programs to cover all individuals
who have incomes less than 138% of
poverty
Coverage levels dependent upon
Medicaid expansion…
STATES WITH MEDICAID EXPANSION:
0%
138%
400% +
Marketplace
(“Exchange") with Tax
Credits
Medicaid
Marketplace
or Private
Plan
STATES WITHOUT MEDICAID EXPANSION:
0%
100% 138%
Potential Gap in
Eligibility for
Assistance
Marketplace (“Exchange")
with Tax Credits
400% +
Marketplace
or Private Plan
Ohio Medicaid Expansion
•Governor Kasich included in Budget
•Republican Leadership Removed from Budget
•Speaker Bill Batchelder says House will take up
Medicaid Reform language in October
•Controlling Board
•Executive Order
More Will Qualify for Medicaid Without
Expansion
•MAGI Income Guidelines
•5% Income Disregard
• Children / Pregnant Women up to 205% fpl
• Parents up to 95% fpl
•New Income Exemptions
• Child Support / Social Security Income
•New Household Formation Rules
• Stepparents and their income included
Most Uninsured Kids Eligible
111,511 out of 177,870
(62.7%) uninsured Ohio
children are currently
income eligible for Medicaid
Connecting to Coverage
•
•
•
Can enroll online, by phone, in person, or using paper application
– Data-driven system that integrates eligibility across programs
Give basic info about self and household
– Contact information and who’s applying for coverage
– Income/types of income
– Number of people in household
– Citizenship/immigration status
– If have affordable coverage now
Process will vary from state to state
If applying
online…
Enter
essential
information
System
pulls
existing
data about
applicant(s)
Supplement
or correct
info, if
needed
System
determines
eligibility
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Or, enroll in
Medicaid
or CHIP
Pick a plan,
amount of
tax credit to
receive in
advance,
enroll!
Who Is Eligible for Financial Assistance?
•Income <400% of poverty
• 400% of poverty = $44,680 for a single adult, $92,200 for a family of
four
•Must not have a offer of job-based coverage
•Are immigrants eligible?
• Legal immigrants, yes
• Undocumented immigrants, no
•Refundable, advance-payment federal tax credit (“APTC”)
• Do not have to wait until file taxes to get the tax credit – it can be
applied to the cost the coverage when they enroll
• If taken in advance, tax credit goes directly to health plan consumer
chooses
• Pays a portion of consumer’s monthly premium
How much will coverage cost
(for those with financial assistance)?
• Cost is based on sliding-fee scale for people with income
<400% FPL:
Income
Percent of income required to pay
toward premiums
Up to 133% of poverty
2%
133-150% of poverty
3-4%
150-200% of poverty
4-6.3%
200-250% of poverty
6.3-8.05%
250-300% of poverty
8.05-9.5%
300-400% of poverty
9.5%
• Tax credit picks up difference between required contribution
and premium for second lowest cost silver plan.
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How Much Will Coverage Cost
•27 year old single male making $17,235 a year
•150% federal poverty guidelines
•C = S – (M x P)
•C = Tax Credit
•S = $2,798
•M = $17,235
•P = 4.0%
•$2,798 - ($17,235 x .04)
•$2,798 – ($689) = $2,109 yr / $175.75 mos Tax Credit
How Much Will Coverage Cost
•40 year old man with wife and two children
•$50,000 annual income
•212% federal poverty guidelines
• C = S – (M x P)
•C = Tax Credit
•S = $9,453
•M = $50,000
•P = 6.72%
•$9,453 - ($50,000 x .0672)
•$9,453 – ($3,360) = $6,093 yr / 507.75 mos Tax Credit
Average Cuyahoga County Premiums
•Without subsidies
Premium Adult
Individual Age
27
Bronze
$207.00
Silver
$252.16
Gold
$293.07
Platinum
N/a
Catastrophic
$147.81
Premium Adult Individual
Age 50
$352.57
$429.74
$499.46
n/a
$251.90
Average Cuyahoga County Premiums
•Without subsidies
Premium
Family
Bronze
$699.23
Silver
$851.78
Gold
$989.97
Platinum
n/a
Premium
Single
Parent
Family
$474.04
$578.68
$672.56
n/a
Premium
Premium
Couple
Child
$504.87
$125.43
$615.01
$152.79
$714.79
$177.58
n/a
n/a
Maximum Out-of-Pocket Limit (OOP)
•Puts a cap on what the enrollee pays in cost-sharing
charges each year
• Set on a yearly basis
• Applies to in-network services
•2014 amounts: $6,350 individual/$12,700 family
•OOP limit is not the amount that an enrollee must
spend each year
Cost Sharing Reduction
•People with income up to 250% FPL
•Must enroll in a silver plan through the Health
Insurance Marketplace (also called the exchange)
•Cost Sharing Reduction pegged to Actuarial Value (AV)
• Income > 150% fpl = 94% AV
• Income 151% >200% fpl = 87%
• Income 201% > 250% fpl = 73%
Essential Benefits
•Ambulatory patient services
•Emergency services.
•Hospitalization.
•Maternity and newborn care.
•Mental health and substance use disorder services, including
behavioral health treatment.
•Prescription drugs.
•Rehabilitative and habilitative services and devices.
•Laboratory services.
•Preventive and wellness services and chronic disease
management.
•Pediatric services, including oral and vision care.
Different Types of Plans
•Plan that covers 100% of actuarial value would have no
cost-sharing other than premium
•Platinum 90% actuarial – 10% cost sharing
•Gold
80% actuarial – 20% cost sharing
•Silver
70% actuarial – 30% cost sharing
•Bronze
60% actuarial – 40% cost sharing
•Catastrophic
• Under 30 yo
• Coverage kicks in after deductible = cost sharing limits
Enrollment – The Players
Consumer
Assistance
Programs
Certified
Application
Counselors
In-Person
Assistance
Programs*
Medicaid
eligibility
workers
Navigators
Community
Based
Groups
Insurance
Agents,
Brokers
Navigators
•Maintain expertise in eligibility, enrollment, and program
specifications;
•Conduct public education activities to raise awareness
about the Exchange;
•Provide fair, accurate, impartial Facilitate selection of a
Qualified Health Plan;
•Provide referrals regarding health plan, coverage, or a
determination under such plan or coverage; and
•Provide culturally and linguistically appropriate
information
Ohio Navigators
•Ohio Association of Foodbanks
• Anticipated grant amount: $1,958,961
• Access Health Mahoning Valley
• Asian Services in Action, Inc.
• Carmella Rose Health Foundation
• Cuyahoga Health Access Partnership
• Community Action Committee of Pike County
• Disability Rights Ohio
Ohio Navigators
•Ohio Association of Foodbanks cont’
• Health Care Access Now
• Heart of Ohio Family Health Center
• Hospital Council of Northwest Ohio
• Ohio Association of Free Clinics
• Ohio Department of Health
• United Way of Greater Cleveland 2-1-1
• Community Action of Washington Morgan Counties
• Western Reserve Area Agency on Aging
Ohio Navigators
•Children's Hospital Medical Center
• Anticipated grant amount: $124,419
•Clermont Recovery Center, Inc.
• Anticipated grant amount: $44,938
•Helping Hands Community Outreach Center
• Anticipated grant amount: $230,920
•Neighborhood Health Association
• Anticipated grant amount: $684,630
FQHC Outreach and Enrollment
Health Centers
•Hire and train O/E assistance workers as certified
application counselors
•Conduct in-reach and outreach and assist with the
enrollment process
•Share barriers and successes
•Report metrics, successes, and barriers to HRSA
quarterly
Cuyahoga County FQHCs
•CARE ALLIANCE
$137,280
•NEIGHBORHOOD HEALTH CARE INCORPORATED
$89,969
•NORTHEAST OHIO NEIGHBORHOOD HLTH. SVCS.
$246,411
•THE FREE MEDICAL CLINIC OF GREATER CLEVELAND
$107,701
Which Organizations May Be Certified
Application Counselors
•(1) Processes in place to screen staff and volunteers to ensure that they
protect personally identifiable information,
•(2) Engage in services that position them to help those they serve with
health coverage issues, and
•(3) Have experience providing social services to the community.
• Community health centers such as FQHCs;
• Hospitals;
• Health care providers;
• Behavioral health or mental health providers;
• Agencies that have experience providing social services to the community such as
Supplemental Nutrition Assistance Program (SNAP) outreach, energy assistance,
or tax assistance; and
• Other local governmental agencies that have similar processes and protections in
place such as other health care providers, health departments and libraries.
Process for Becoming Certified
Application Counselor
•Must submit an application
http://www.cms.gov/CCIIO/Programs-andInitiatives/Health-Insurance-Marketplaces/assistance.html
•Must enter into written agreement with FFM
•Must disclose potential conflicts of interest
•Successfully complete training
Ohio State Law Issues
•Sec. 3905.01(D) "In-person assister" means any person,
other than a navigator, who receives any funding from, or
who is selected or designated by, an exchange, the state, or
the federal government to perform any of the activities and
duties identified in . . . the Affordable Care Act.
•Sec. 3905.474. No person shall act as, perform the duties
of, or hold one's self out to be an in-person assister unless
that person is either a licensed insurance agent certified to
sell insurance through an exchange . . . or an insurance
navigator certified under . . . the Revised Code.
Ohio State Law Issues
•Sec. 3905.471. (A) No individual or entity shall act as
or hold itself out to be an insurance navigator unless
that individual or entity is certified as an insurance
navigator under this section and is receiving funding
under division (i) of section 1311 of the Affordable
Care Act.
O.A.C. 3901-5-13(F) Exemptions
•Licensed health care provider or a hospital
•FQHC or look a like
•Non profit organization whose primary purpose is the
distribution of food stuffs, groceries, donated goods or
purchased goods
•A state agency
ODI Assistant Director Farley
•"We're not exempting them per se;
we're giving an example of safe
harbor, . . . If you do not hold yourself
out (as a navigator), you will not
trigger the statute.”
• JCARR August 12, 2103