Health Insurance,

©

Health Care Reform

www.ahirc.org

Dancers’ Health Insurance Resource Center A program of The Actors Fund A program of The Actors Fund with www.actorsfund.org

support from The Doris Duke Foundation

Presenter:

Renata Marinaro, LMSW, Director of Eastern Region Health Services,

Presenter:

Jim Brown, Director of Health Services, [email protected]

.

[email protected]

Introduction

• Throughout this tutorial you will see questions.

Click on the question to find the answer

. • To navigate the presentation, use the buttons in the green area below. They are just like the buttons on your DVD player. To advance to the next slide, click the play button. You can also advance to the next slide by clicking the forward button. To pause, click the pause button. To go back, click the rewind button. • You can also click on any of the slide titles in the outline on the left to advance to that slide.

Timeline • Since its inception, the Artists Health Insurance Resource Center (AHIRC) has had a single mission: to help all entertainers and artists in this country get quality affordable insurance for themselves and their families. • The Patient Protection and Affordable Care Act has brought us within reach of that goal. Because so many of its provisions are directed at the individual and small group market, where the majority of artists and entertainment professionals find themselves, it is critical that we understand how we can benefit from them. • This tutorial is a clear explanation in a simple question and answer format of the most significant programs and reforms within the law, with special emphasis on those that directly impact the lives of artists. Please click on the timeline below to see the major provisions of the law.

Timeline – March and July, 2010 • March 23, 2010: The Patient Protection and Affordable Care Act, also known as The Affordable Care Act (ACA), is signed into law by President Barack Obama. • July 2010: Those with pre-existing conditions who've been uninsured for 6 months or more can get subsidized coverage through the Pre-Existing Condition Insurance Program (PCIP). • The Small Business Health Insurance Tax Credit, which allows certain employers to claim a credit for providing insurance for their workers, takes effect for tax year 2010.

Timeline – September 2010 • Children under the age of 19 with pre-existing conditions can’t be denied coverage.

• Young adults up to age 26 can stay on or enroll in their parents’ coverage.

• Insurers can’t retroactively cancel the policies of people who get sick.

• Lifetime dollar limits on medical benefits are banned.

• All new plans must cover certain preventive services without charging a deductible, co-pay or co-insurance.

• All new plans will provide consumers with a way to appeal coverage or claims determinations.

Timeline – 2011 • Medicare recipients in the Part D “doughnut hole” receive 50% off brand-name drugs; by 2019, the discount will be 75%.

• Annual wellness visits and certain preventive services are free for Medicare recipients.

• Insurers must spend at least 80-85% of premium dollars on medical benefits and quality improvement. If they fall short, they must offer customers a rebate.

• The law provides new funding for the expansion of community health centers.

Timeline – 2012 and 2013 • The law institutes a series of changes to standardize billing and requires health plans to begin adopting and implementing rules for the secure, confidential, electronic exchange of health information.

• Medicaid payments to primary care physicians are increased to no less than 100% of Medicare payment rates.

Timeline – 2014 • Insurers cannot refuse coverage to anyone.

• Most people are mandated to have coverage, and penalties will apply if you don’t.

• New insurance marketplaces, called Exchanges, offer insurance to those who don’t get coverage through their employer or a government program like Medicare or Medicaid.

• Subsidies and sliding-scale limits on out-of-pocket costs are available to people who buy insurance through an Exchange and have incomes up to 400% of the Federal Poverty Level.

Timeline – 2014 • All new plans must offer an essential benefits package with limits on out-of-pocket costs.

• Medicaid eligibility is expanded in some states to include people with incomes up to 138% of the Federal Poverty Level.

• Annual dollar limits on medical benefits are banned.

Do I have to have insurance?

Yes! If you don't have insurance, you'll pay a penalty. The penalty increases from $95 or 1% of your income (whichever is higher) in 2014 to $695 or 2.5% of your income in 2016.

There are some exemptions. These include: • people who’ve been uninsured for less than 3 months • Native Americans • those with religious objections • undocumented immigrants • those for whom the least expensive option would cost more than 8% of their income • those who don’t meet the tax filing threshold

How will the government know whether I have insurance?

You will submit documentation that proves you have insurance when you file your taxes. If you don’t have insurance, the IRS will notify you and explain your options.

Can an insurance company refuse to sell me insurance?

No. Beginning in 2014, insurance companies will no longer be able to deny you coverage or exclude pre-existing conditions.

Is my employer required to offer me insurance, and if so, do I have to take it?

• Employers do not have to offer coverage, but starting in 2015, those with 50 or more employees will have to pay a penalty if they don’t. • If you choose to opt out of your employer’s coverage, you will still have to be insured or pay a penalty. • Employees who are offered coverage and choose not to take it will not be eligible for subsidies to pay for coverage through an Exchange, unless the employer’s plan fails to meet certain benefit guidelines.

Can I keep my current coverage?

• Yes. There is nothing in the new law that forces you to change your plan.

I’m an employer. Do I have to cover my employees?

If you are a small employer (fewer than 50 full-time equivalent employees) you do not have to offer coverage, and there is no penalty. Beginning in 2015, if you have 50 or more full-time equivalent employees, you must offer coverage or pay a penalty. Penalties also apply if you offer “unaffordable” coverage, or don’t offer “minimum value” coverage.

For more information on full-time equivalency, mandates, and coverage, as well as the Small Business Health Options Program, see our tutorial on Health Care Reform for Employers and Sole Proprietors.

What is the small business tax credit and how do I know if I’m eligible?

• Businesses with fewer than 25 full-time equivalent employees with average yearly wages of less than $50,000 may qualify for the Small Business Tax Credit. • To receive the credit, the employer must offer a group health plan and pay at least 50% of the premium. • The credit is equal to a percentage of what the employer pays. For 2013, the maximum credit is 35% of the employer’s contribution (25% for non-profits). Beginning in 2014, the maximum credit is 50% (35% for non-profits).

Where will I buy insurance?

 If you don’t get it through your job or a public program, you can buy it directly through an insurer, a broker, or through what’s called the Exchange. • The Exchange is a competitive, private insurance marketplace. You can shop for plans and buy coverage on the Exchange website, or apply by mail. • Only plans that meet certain quality and affordability guidelines will be allowed to sell on the Exchange. • Exchanges will also administer the new subsidies and help enroll people in Medicaid and the Child Health Insurance Program (CHIP).

When can I enroll?

The initial open enrollment period for plans on the Exchange is October 1, 2013 March 31, 2014. In an open enrollment period, you’re free to sign up for a plan or switch plans. Only in limited circumstances will you be able to enroll in or switch plans outside of this period.

Circumstances that would trigger a “special enrollment period” include: losing job-based insurance, losing Medicaid coverage because of an increase in income, marriage, divorce, and the birth or adoption of a child.

What do I need to fill out the application?

• The application is fairly short if you're a single adult. You'll need your social security number, employer information, and income information (for example, pay stubs, W2 forms, or wage and tax statements). • If you're self-employed, you'll need to declare your net income from self-employment for the month in which you apply. • On the next slide, we'll show you what the paper application looks like. Applications online will ask the same questions but be in a different format .

Step 1

Step 2

Steps 3 & 4

What will the individual Exchange plans look like in most states?

Tier % of costs covered by insurer Deductible Consumer’s max out of pockets costs

Bronze Silver Gold Platinum 60% 70% 80% 90% N/A N/A N/A N/A $6,350 $6,350 $6,350 $6,350 Catastrophic 100% after deductible $6,400 $6,400

Note that the catastrophic plan is only available to: 1) those who are under age 30; 2) those who are exempt from the mandate to have health insurance.

What are the federally mandated essential benefits?

• Outpatient services (such as office visits) • emergency services • hospitalization • maternity and newborn care • mental health and substance abuse services • prescription drugs • rehabilitative services and devices • laboratory services • preventive and wellness services • chronic disease management • pediatric services, including oral and vision care

What will the Individual Exchange plans look like in NY?

Tier Deductible

Bronze

% of costs covered by insurer

60% $3,300

Consumer’s max out of pockets costs

$6,350 Silver Gold 70% 80% $2,000 $600 $5,000 $4,000 Platinum 90% $0 $3,000 Catastrophic 100% after deductible $6,350 $6,350

Note that the catastrophic plan is only available to: 1) those who are under age 30; 2) those who are exempt from the mandate to have health insurance.

What benefits do plans on the NY Exchange offer?

• • • • • • • • • • • • • • • • Outpatient services (such as office visits) emergency services ambulance hospitalization maternity and newborn care mental health and substance abuse services prescription drugs rehabilitative services and devices laboratory services preventive and wellness services chronic disease management pediatric services, including oral and vision care chiropraxis hearing aids home care gym reimbursement!

What will the Individual Exchange plans look like in CA?

Tier

Bronze Silver Gold Platinum

% of costs covered by insurer

60% 68% 78% 88%

Deductible

$5,000* $2,000** $0 $0

Consumer’s max out of pockets costs

$6,400 $6,400 $6,400 $4,000 Catastrophic 100% after deductible $6,400 $6,400

* for medical services and drugs ** for medical services only; a separate drug deductible applies

Note that the catastrophic plan is only available to: 1) those who are under age 30; 2) those who are exempt from the mandate to have health insurance.

What will HSA plans look like on the California Exchange?

Tier

Bronze w/HSA Silver w/HSA

% of costs covered by insurer

60% 68%

Deductible

$4,500* $1,500*

Consumer’s max out of pockets costs

$6,400 $6,400

You can also buy the Silver and Bronze plans with a Health Savings Account (HSA) if you wish. An HSA is like a savings account, but the money is used solely to pay for health care expenses. The deductibles are different than for the Bronze and Silver plans without an HSA. * for medical services and drugs

What benefits do plans on the California Exchange offer?

• Outpatient services (such as office visits) • emergency services • ambulance • hospitalization • maternity and newborn care • mental health and substance abuse services • prescription drugs • rehabilitative services and devices • laboratory services • preventive and wellness services • chronic disease management • pediatric services, including oral and vision care • home health care

Are there special programs for people under 30? • For those under age 30, there is a high-deductible plan option. In New York the deductible is $6350. In most other states it's $6400. However, the deductible is waived for preventive screenings and 3 primary care visits. The maximum amount you will pay out of your own pocket for medical services in 1 year is equal to the deductible. • Also, if you are under age 26, you can stay on or enroll in your parents’ plan, regardless of living situation, marital status, student status, or financial dependence. Exclusion: if you have access to insurance through an employer.

I’m self-employed. How will this affect me?

• You can buy insurance as an individual on the Exchange, without having to worry about being turned down for pre-existing conditions, or paying more because of your medical history or gender. This increases your options and will reduce premiums for those with lower to middle incomes. • You may qualify for Medicaid if your income is under $15,400 (single).

How Will I Afford Insurance? If your income is $15,856 (single), you will be eligible for

Medicaid

.

• Medicaid is a joint federal-state program that provides comprehensive health insurance at no (or very low) cost to patients. There are no premiums or deductibles. • Some states, including New York and California, will expand their Medicaid income eligibility guidelines in 2014. If your income is below 138% of the Federal Poverty Level - which is $15,856 annually (or $1,322 per month) for 1 person - you will be eligible for Medicaid in those states.

• If you have a child, your child may be eligible for the Children's Health Insurance Program (CHIP). To find out what the Medicaid and CHIP guidelines are in your state, visit http://www.healthcare.gov/using insurance/low-cost-care/medicaid/

What will it cost to buy coverage on the Exchange? • People who have low to moderate incomes will receive subsidies which will lower the cost of premiums and out-of-pocket medical expenses. • The amount of the subsidy will depend on your household size and income. If your household income is below 400% of the Federal Poverty Level you will receive a subsidy to buy insurance through an Exchange. 400% of the Federal Poverty level is equal to an annual income of $45,960 for a single person and $62,040 for a couple. • On the next slide we'll show you how subsidies will cap the amount you spend on premiums in relation to your total income.

• Calculate your potential subsidy and max out of pocket costs here: http://healthreform.kff.org/subsidycalculator.aspx

Income as % of Federal Poverty Level

Up to 133% 133-150%

Income range for 1 person at this level

$15,282

Max % of your income you will spend on premiums

2% $15,282-$17,235 3-4% 150-200% 200-250% 250-300% 300-400% $17,235-$22,980 4-6.3% $22,980-$28,725 6.3-8.05% $28,725-$34,470 8.05-9.5% $34,470-$45,960 9.5%

http://healthreform.kff.org/subsidycalculator.aspx

I’m on Medicare. How will this affect me? • Your Medicare benefits will not be cut. • If you're in the Part D coverage gap known as the "doughnut hole", you will receive a 50% discount on brand name drugs. By 2020, the "doughnut hole" will be phased out. • You do not have to change your Medigap or Medicare Advantage plans. • Certain preventive screenings are now free. These include: blood pressure, cholesterol and diabetes tests, certain cancer screenings (including colorectal, breast and cervical cancers), osteoporosis screenings, vaccines and immunizations, flu and pneumonia shots, HIV and STD testing, and counseling on healthy lifestyle changes.

Additional Resources

For more information on the Affordable Care Act, visit the following websites: Federal health care reform website: www.healthcare.gov

Kaiser Family Foundation: http://kff.org/health-reform/ Families USA: www.familiesusa.org

Consumer Reports: http://www.consumerreports.org/cro/2012/06/update-on-health-care reform/index.htm