Transcript Document

How the ACA impacts your current
individual and family plan customers
Update for Covered California
Certified Insurance Agents
November 2013
v5
Helping your customers gain the
most from the Affordable Care Act
• Quick course on the impact of the ACA on the current
Individual and Family Plan (IFP) market
• Helping your IFP customers with three big questions –
1. What’s in the ACA for me?
2. What do I need to consider in making a decision?
3. What do I need to do to become enrolled?
• Your next steps to be sure your current IFP customers
are all set for January 1, 2014
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2
What is Covered California?
• A marketplace of private insurance products
• People + technology to learn, shop, compare, and enroll
• Enrollment gateway for almost 5 million Californians
who can benefit from financial assistance with health
insurance
• Part of the overall transformation of the individual
health insurance market
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3
Changes to the
Individual Health
Insurance
Market
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4
2014 Changes to IFP Market
• Reward for managing risk well
• 1 risk pool with annual risk adjustment
• Transitional risk programs for reinsurance and risk corridors
• Pricing/underwriting reform
• Only age, zip code and plan can be used to drive rates
• Guarantee issue during open enrollment or with qualifying
event
• Age rate factor limited to 1:3 ratio with 1 year increments
• Family rate calculation change
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5
2014 Changes to IFP Market
• Coverage reform
• Establishment of actuarial values and metal plans
• Essential benefits must be covered
• Maximum annual out-of-pocket set at $6,350/$12,700
• Grandfathered plans
• Choice to keep or change
• Non-grandfathered plans
• Must comply with market rules at renewal
• Most transitioning 1/1/14
• Blue Shield’s CDI book has up to 3/31/14
7:21and
PM
• 7/16/2015
Aetna
United exiting the IFP market
6
2014 Changes to Market
• Individual mandate driving a culture of coverage
• Most people don’t have to change
• 5+ million uninsured in California must comply
• Affordability for millions
• Expansion of Medi-Cal (1.4 million)
• Tax credits for working poor and middle class (2.6 million)
• Affordability tests for exemption or access to Minimum
Coverage Plan (aka catastrophic plan – 800,000)
• Penalty for non-compliance phased in over three years
• 2014 - $95 per person or 1% of income, whichever is greater
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7
IFP Market – 700,000 grandfathered
out of 1.6 million total covered lives
Most with12/31/13
Discontinued Plan
700,000
GRANDFATHERED
900,000
NOT GRANDFATHERED
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8
IFP Market – 600,000 eligible for
$3 billion in 2014 tax credits
$3 billion in 2014
Tax Credits
600,000
both Grandfathered and
Non-Grandfathered
TAX CREDIT
ELIGIBLE
1,000,000
NOT TAX CREDIT
ELIGIBLE
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Transferring current customer to
an ACA compliant plan
2013 NonCompliant
Plan
$150
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Pick ACA
compliant
plan with all
Essential
Benefits
Meet
Required
Financial
Protection
Apply New
Underwriting
and Pricing
Rules
Adjust for
Trend and
Utilization
Changes
2014 ACA
Compliant
Plan
$215
10
New world of choice and support
2013 NonCompliant
Plan
$150
2013
Take it or???
2014 ACA
Compliant
Plan
$215
OLD WORLD: Your client was stuck
with renewal. Could not move due to
medical underwriting. No source of
premium assistance. Buy down was
only strategy to address rate increase.
2014
2014
Customer
with Tax
Credit
$95
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Real Choice
2014
Customer
buys Min
Benefit Plan
$155
2014
Customer
keeps plan as
is
$215
NEW WORLD: 35% of your
customers are eligible for Premium
Assistance via the Tax Credit. 100%
of your customers can purchase any
plan from any insurer due to
Guaranteed Issue. A sizeable
portion will be able to buy the
Minimum Coverage Plan due to the
8% affordability test.
11
New Family Rate Structure
FAMILY RATE = Every adult
rate plus rate for first 3
children 18 or under
INPUT
Tax Household/Family of 11
Income = $160,000
Zip = 94105 (San Francisco)
OUTPUT
Chinese Community
Bronze60
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Cost Details
Adult #1 (age 40):
Adult #2 (age 40):
Adult #3 (age 25):
Adult #4 (age 23):
Adult #5 (age 23):
Adult #6 (age 21):
Dependent #1 (age 0-18):
Dependent #2 (age 0-18):
Dependent #3 (age 0-18):
Dependent #4 (age 0-18):
Dependent #5 (age 0-18):
Total dependent (age 0-18) cost:
Total monthly premium:
Premium assistance:
You pay:
$
$
$
$
$
$
328
328
184
183
183
183
$116
$116
$116
$ 0
$ 0
$ 349
$ 1,739
$ -1,527
$ 212
12
Why are my rates going up?
• All essential benefits including drugs, maternity, and preventive health
• No “gotchas” with inside limits or coverage gaps
• Maximum Out-of-Pocket of $6,350
individual/$12,700 family
• No lifetime maximums on covered service
• Choice of all products in your rating area
• Choice of health insurers at each renewal
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Joint communication campaign
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Joint communication campaign
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The Covered
California
Marketplace
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Who is eligible for tax credits?
Eligible If:
Not Eligible If:
• Legal California residents
• New Citizens, Nationals, or
Lawfully Present Individuals
• American Indians
• Some Students
• Not a California Resident
• Undocumented Immigrants
• Currently Incarcerated Individuals
• Don’t have access to
affordable employer based
coverage
• Insured or uninsured
• Have a pre-existing condition
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17
Affordability = Premium + Out-ofPocket Expenses
For those purchasing health insurance through the exchange -
• Gross Premium rate is driven by
• Age of each adult being covered
• Household’s zip code (tied to pricing region)
• Benefit plan selected
• For families, a separate rate is charged for the first three
children under the age of 18. Adult children are counted
separately
• Net Premium rate is driven by
• Eligibility for premium assistance in the form of an Advance
Tax Credit
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18
Premium rates influenced by age
of adults
$600
$500
Affordable Care Act
limits age factor to
a 3:1 ratio
$400
$300
$200
$100
21 years old
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64 years old
19
2.5 million Subsidy Eligible
Pricing Region
Northern California
100,000
Sacramento
130,000
San Joaquin Valley
185,000
Fresno
65,000
Bay Area
390,000
Central Coast
140,000
Los Angeles County
780,000
Orange County
200,000
Riverside
180,000
San Bernardino
160,000
San Diego
190,000
Total
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Subsidy Eligible
2,520,000
20
Pricing Regions with Average
Silver-level Plan Cost
2nd Lowest Silver-Level Plan Rates for a 40-year-old,
by Rating Region
Sacramento
San Francisco
Los Angeles
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San Diego
1
$318
10
$322
2
$343
11
$288
3
$333
12
$326
4
$373
13
$396
5
$347
14
$281
6
$357
15
$252
7
$340
16
$259
8
$383
17
$259
9
$382
18
$286
19
$30821
Premium rates influenced by
benefit plan
Plan pays an average percent of health care
costs – ranging from 60% to 90%
100%
80%
60%
40%
20%
0%
Bronze60
Silver70
Gold80
Platinum90
Actuarial Value or AV is the expected percent coverage. Gold has an AV of 80%
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22
Modified Adjusted Gross Income
(MAGI) is a driver of eligibility
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Quick summary of FPL ranges
Income as % of Federal Poverty Level
Family Size
138%
150%
200%
250%
400%
1
$15,971
$17,235
$22,980
$28,725
$45,960
2
$21,559
$23,265
$31,020
$38,775
$62,040
3
$27,147
$29,295
$39,060
$48,825
$78,120
4
$32,582
$35,160
$46,880
$58,600
$93,760
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Medi-Cal expansion for 1.4
million Californians
Medi-Cal – adding adults,
increasing income limits
for adults and kids
Medi-Cal – Adult
and Kids
(138%)
Medi-Cal – Kids (266%)
Up to
Number
138%
150%
200%
250%
400%
1
$15,971
$17,235
$22,980
$28,725
$45,960
2
$21,559
$23,265
$31,020
$38,775
$62,040
3
$27,147
$29,295
$39,060
$48,825
$78,120
4
$32,582
$35,160
$46,880
$58,600
$93,760
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Covered California brings tax
credits to 2.6 million Californians
Covered California adding
premium assistance and
enhanced benefits
Covered California – Premium
Assistance + Enhanced Silver
Covered California –
Premium Assistance
Only
Number
138%
150%
200%
250%
400%
1
$15,971
$17,235
$22,980
$28,725
$45,960
2
$21,559
$23,265
$31,020
$38,775
$62,040
3
$27,147
$29,295
$39,060
$48,825
$78,120
4
$32,582
$35,160
$46,880
$58,600
$93,760
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Total of 4 million Californians with
new affordable coverage options
Medi-Cal – Adult
and Kids
Covered California – Premium
Assistance + Enhanced Silver
Medi-Cal – Kids (266%)
Covered California –
Premium Assistance
Only
Number
138%
150%
200%
250%
400%
1
$15,971
$17,235
$22,980
$28,725
$45,960
2
$21,559
$23,265
$31,020
$38,775
$62,040
3
$27,147
$29,295
$39,060
$48,825
$78,120
4
$32,582
$35,160
$46,880
$58,600
$93,760
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Covered California Marketplace
Your MAGI drives three possible
paths to enrolling
Under
138% FPL
Low or No Cost
Medi-Cal
138% FPL to
250% FPL
138% FPL to
400% FPL
251% FPL to
400% FPL
Over
400% FPL
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Covered California
Premium Assistance
+ Enhanced Benefits
Medi-Cal
Kids
266%
Covered California
Premium Assistance with
Standard Benefits
Covered California with
Standard Benefits & Prices
(Minimum Coverage Plan w/ waiver)
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Consumers need to pay their
“fair share” of premium
“Fair Share” payment under ACA
3.5% of income growing to a maximum of 9.5% of income
Covered California – Premium
Assistance + Enhanced Silver
Covered California –
Premium Assistance
Only
Free or Nearly Free
Medi-Cal – Adult
and Kids
% of FPL
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$13 per child, maximum $39 per family
138%
Medi-Cal - Kids
150%
200%
Income Rises
250%
400%
29
Consumers eligible for the tax
credit pay their “fair share”
“Fair Share Payment” is defined by ACA as
a sliding scale percent of income.
$600
Monthly Payment
$500
$400
$300
$200
$100
$15,971 for a single at 139% of FPL.
Fair Share = 3.5% of income or $45
21 years old
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64 years old
30
Consumers eligible for the tax
credit pay their “fair share”
“Fair Share Payment” is defined by ACA as
a sliding scale percent of income.
$600
Monthly Payment
$500
$400
$45,960 for a single at 400% of FPL.
Fair Share = 9.5% of income or $364
$300
$200
$100
$15,971 for a single at 139% of FPL.
Fair Share = 3.5% of income or $45
21 years old
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64 years old
31
Tax credit eligible consumers pay “fair
share” amounts regardless of age; tax
credit makes up the difference
$600
Fairs Share payment + Tax Credit =
Premium for 2nd Lowest Silver70 plan
Monthly Payment
$500
$400
$639
$300
$200
$100
$183
$45
$228 total premium
21 years old
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Tax Credit payment
from IRS
$45
Fair Share payment
$684 total premium
64 years old
NOTE: Example reflects 2014 rates for Fresno using 2nd lowest priced Silver70 plan
32
The tax credit is sensitive to age
$600
$500
Tax credit is the
difference between
the actual premium
and the consumer’s
“fair share” payment
$400
$300
Tax Credit Zone
$200
$100
Fair Share Payment = 3.5% of Household Income
21 years old
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64 years old
33
Prices for young adults can be
below “fair share” amount
$600
$500
Consumer pays
“Fair Share” level or
Premium, which
ever is less
$300
Tax Credit
Zone
$200
Fair Share Payment =
9.5% of Household Income
$400
$100
Credit Not
Needed
21 years old
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Tax Credit covers above
“Fair Share” level
64 years old
34
Reduced cost sharing improves
affordability for many
In addition to the tax credit that helps pay for the monthly
premium, many consumers are eligible for Enhanced Silver
plans with very generous benefits
100%
Silver94
80%
60%
Silver87
“Platinum” Level
Coverage at Silver
Level Price
Silver73
40%
Silver70
20%
0%
94 150%
87
73
70
138%
- 150%
- 200%
200%
- 250%
250%
- 400%
Silver
Silver
Silver
Silver
Income as Percent of Federal Poverty Level (FPL)
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35
Enduring value proposition
Access to
Care
In a system of care with
broad choice of physicians
and hospitals
Pay Fair
Share
If eligible for tax credit, you
pay a percent of income for
health insurance
Low Outof-Pocket
Enhanced Silver brings
additional subsidy, as much
as $1,000 per year
Broad use of copays mean
predictable costs when
receiving care
Pay negotiated rate under
high deductible plans
$6,350 annual out-ofpocket maximum means
reduction in bankruptcy
exposure
Financial
Security
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Get necessary preventive
care provided at no cost in all
benefit plans
You won’t pay more unless
your income increases (rate
increase paid by increased
tax credit)
36
Technology enables accurate
personalized information
1
Robust .com “one stop” platform
2 Robust mobile environment
Your destination for
affordable, quality
health care,
including Medi-Cal
Enroll
Get Covered
3 Support consumer journey and pace
4 Proactively manage each touch
Enroll
Hi!
CRM Platform
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What you need
to do for your
customers
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What do you need to do?
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What do you need to do?
all of your IFP customers, grandfathered
and non-grandfathered alike
on the Affordable Care Act, the renewal
packet if they have received one, the options they
have and the timeline
to see if they are eligible for the tax credit
or the 8% affordability exemption – check everyone
– your client must be enrolled by
December 15th and premium must be paid by
December 26th to be covered for January 2014.
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Technology enables accurate
personalized information
1
Robust .com “one stop” platform
2 Robust mobile environment
Your destination for
affordable, quality
health care,
including Medi-Cal
Enroll
Get Covered
3 Support consumer journey and pace
4 Proactively manage each touch
Enroll
Hi!
CRM Platform
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41
Enroll Now through CalHEERS
Hi!
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42
The art of simplicity is the study of
complexity.
Hey Droid, you gotta get
- Douglas Horton
this app! It calculates
your tax credit, your
premium, and soon you
can order a proposal!
Yes!
Am I eligible for
the ACA tax
credits?
Get Covered
.com
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43
Covered California - Two Shop
and Compare environments
Quick View
Calculator
Shop, Compare,
and Enroll
On CoveredCA.com
Yes
Yes
On iOS and Android
phones and tablets
Yes
No
Premium and tax credit
calculation
Yes
Yes
Yes – shows “healthy”
assumption only
Yes – can be customized
by family member
By Metal Tier
By Total Cost
Is my doctor in the
network?
No
Yes
Ties to proposal?
Yes
No
No – standalone sales tool
Yes – can be anonymous
or with account 44
Out-of-pocket costs
Preliminary sort
Part
of enrollment process
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Covered California Shop and
Compare Quick View
1
For a quote, you need
household size and
income, zip code,
adult ages, and
number of children.
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45
Covered California Shop and
Compare Quick View
2
Tax Credit of $589 can
be used to buy up or
down within metal tier
or across metal tiers
More
Plans
$1
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46
Covered California Shop and
Compare Quick View
3
Get up to speed on
“Enhanced Silver Plans” –
Platinum coverage at
Silver prices
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47
Covered California Shop and
Covered California
Compare Quick View
focuses on TOTAL
monthly cost, not just
premium cost
4
Your Health Status
VERY HEALTHY
Description of health care services used each 1 illness or injury per year (office
year
visit, lab test, plus medication)
HEALTHY
MANAGING CHRONIC MANAGING COMPLEX
CONDITIONS
HEALTH CONDITIONS
Regular check-ups with lab tests Monthly doctor visits, periodic lab
2+ doctor visits per month, 4+
or x-rays, 1 illness or injury each and diagnostic tests and 3 routine medications, outpatient services
year and 1 routine medication
medications
and 1 or more hospitalizaitons
STANDARD PLANS
Platinum90
Gold80
Silver70
Bronze60
Minimum Coverage Plan
$8
$17
$25
$50
$50
$33
$50
$67
$150
$150
$83
$117
$150
$375
$375
$333
$529
$529
$529
$529
ENHANCED SILVER
PLANS
Silver94
Silver87
Silver73
Silver70
$2
$8
$17
$25
$5
$25
$58
$67
$17
$58
$125
$150
$188
$188
$433
$529
NOTE: These are only an estimate of the out-of-pocket expense you could see with these plans. Your actual utilization of services,
7/16/2015
PMnon-participating providers, could dramatically increase your cost. Remember, the out-of-pocket maximum
including
the use7:22
of any
in your plan is for participating providers and for covered services.
48
Covered California Shop and
Compare Quick View
5
Bronze60
Silver87
$1
$108
“Healthy” level
expected
OOP
$150
$25
TOTAL COST
$151
$133
Premium
Best Deal
Best Deal requires monthly
premium but consumer
has lower OOP costs
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Helping Consumers Select the Right Covered California Benefit Plan
Single
Income Table
<138%
1 family member
$15,856
138% - 250%
$15,857 to
$28,724
250% - 400%
400+%
$28,725 to $45,959
$45,960
1. Key Value Points of what we offer California consumers
• No or nearly no cost for Medi-Cal comprehensive coverage
• Premium assistance so your cost is tied to a percent of income
94
87
• Get "nearly Platinum" coverage Silver or Silver at no additional cost
• No cost for preventive care including prescription contraception, mammograms,
colonoscopies
• Excellent financial OOP protection
Yes
-
-
-
-
Yes
Yes
-
-
Yes
-
Yes
Yes
Yes
Yes
Yes
-
Yes
94
87
• No deductibles -- know exactly what you pay for every in network service
-
Silver or Silver
• Copays for typical services -- know exactly what you pay for most services in
network
-
Silver94 or Silver87
Silver
• Higher deductibles means lower premium cost up front but still great protection
-
Bronze
Silver and Bronze
Silver, Bronze
and Minimum
Coverage Plan*
Gold or Platinum
• Stop paying retail for health care -- pay a negotiated rate while satisfying your
deductible
-
Bronze
Silver and Bronze
Silver, Bronze
and Minimum
Coverage Plan
• Your plan choice is for 2014 -- you can try a different plan next year if you would
like to
-
Yes
Yes
Yes
Bronze with
premium
assistance
Bronze with
premium
assistance
Bronze with
premium
assistance
Bronze with
premium
assistance
Bronze or
Minium
Coverage Plan*
Bronze or
Minium
Coverage Plan*
Silver94 or Silver87
Gold or Silver
Gold or Silver
2. Matching what is important to your customer to the "best fit"
products
• Just can't afford to add another item to my budget -- minimum cost is essential
Medi-Cal
• Wants value but largely healthy and can afford costs under a deductible
Medi-Cal
• Adults use many services and low out-of-pocket is important
Medi-Cal
* Minimum Coverage Plan -- Only for under 30 and not eligible for premium assistance or for individual
with affordability waiver (lowest cost Bronze is more than 8% of income)
Critical Dates for 2013/2014
Open Enrollment Period
Coverage
Effective Data
Enrollment Deadline
Premium Deadline
Penalty
Exposure?
January 1, 2014
December 15, 2013
December 26, 2013
No
February 1, 2014
January 15, 2014
January 28, 2014
No
March 1, 2014
February 15, 2014
February 25, 2014
No
April 1, 2014
March 15, 2014
March 26, 2014
No by rule
May 1 2014
March 31, 2014*
April 25, 2014
No by rule
Missed Open
Enrollment
n/a
n/a
12 Months
*Open enrollment closes on March 31, 2014. NOTE: 2015 Open Enrollment will run
from October 15, 2014 to December 7, 2014.
**Medi-Cal applications are accepted all year
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51
How to enroll in
a Covered
California
health plan
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52
We are working to clear obstacles
7/16/2015 7:22 PM
53
7/16/2015 7:22 PM
54
Thank you for supporting
Covered California and remember . . .
KEEP CALM
AND
GET THEM
COVERED