Transcript AHEC TRAINInG
AHEC Health Insurance Marketplace Continuing Education 1
WHAT THIS TRAINING WILL COVER
The Affordable Care Act
Major Goals of the Affordable Care Act
Pathways to Affordable Quality Coverage Individual Shared Responsibility
Medicaid
State Option to Expand Medicaid
Medicaid Coverage How to Access Medicaid Coverage
Children’s Health Insurance Program (CHIP)
CHIP Coverage
How to Access CHIP Coverage
The Health Insurance Marketplace
State Options for Marketplace Structures
How Individuals & Families Access the Health Insurance Marketplace
AHEC Health Insurance Marketplace Continuing Education 2
WHAT THIS TRAINING WILL COVER
Qualified Health Plans (QHPs) Sold in The Marketplace
QHPs Subject to Insurance Reforms
QHPs Cover Ten Categories of Essential Health Benefits (EHBs) QHPs Grouped into Metal Levels Catastrophic Coverage Plans Federal Subsidies for QHPs through Insurance Affordability Program QHP Summary of Benefits & Coverage (SBC) QHPs Maintain Provider Network Adequacy
How to Access QHP Coverage
Important Marketplace Enrollment Dates
Small Businesses and the Marketplace
Small Business Health Options Plan (SHOP)
How Small Businesses Access SHOP
Conclusions & Resources
AHEC Health Insurance Marketplace Continuing Education 3
THE AFFORDABLE CARE ACT
AHEC Health Insurance Marketplace Continuing Education 4
MAJOR GOALS OF THE AFFORDABLE CARE ACT
ACCESSIBLE COVERAGE QUALITY COVERAGE AFFORDABLE COVERAGE BETTER HEALTH CARE IMPROVED POPULATION HEALTH
AHEC Health Insurance Marketplace Continuing Education 5
PATHWAYS TO AFFORDABLE QUALITY COVERAGE
Medicaid Expansion States are given the option to expand Medicaid to cover low-income, uninsured adults between the ages of 18 and 64 Children’s Health Insurance Program (CHIP) Existing nationwide coverage for low-income children who cannot qualify for Medicaid is funded through 2015 Creation of the Health Insurance Marketplace Sells new Qualified Health Plans (QHPs) and provides Federal subsidies to help pay QHP premiums and out-of-pocket costs The Marketplace Provides Access to All Pathways of Coverage Complete One Enrollment Application for All Forms of Coverage
AHEC Health Insurance Marketplace Continuing Education 6
INDIVIDUAL SHARED RESPONSIBILITY
MOST EVERYONE IS REQUIRED TO CARRY MINIMUM ESSENTIAL COVERAGE (MEC) Some exemptions:
• • • • •
Individuals who cannot afford coverage Taxpayers below the Federal income tax filing threshold Members of American Indian tribes Short coverage gaps (less than three consecutive months) Hardship INDIVIDUAL SHARED RESPONSIBILITY PAYMENT TRIGGERED AFTER THREE CONSECUTIVE MONTHS OF NON-COVERAGE 2014 FEE 2015 FEE 2016 FEE FEE AFTER 2016 $95/adult & 47.50/child OR 1% household income $325/adult OR 2% household income $695/adult OR 2.5% household income Adjusted for Inflation
AHEC Health Insurance Marketplace Continuing Education 7
QUESTIONS
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AHEC Health Insurance Marketplace Continuing Education 8
MEDICAID
AHEC Health Insurance Marketplace Continuing Education 9
STATE OPTION TO EXPAND MEDICAID
AHEC Health Insurance Marketplace Continuing Education 10
MEDICAID COVERAGE
• • •
If Medicaid Expansion State:
Previously required coverage of children, pregnant women, disabled and the elderly is still in place • New coverage of all adults between the ages of 18 and 64 with incomes up to 133% of the Federal Poverty Level (FPL)
If Non-Medicaid Expansion State:
Previously required coverage of children, pregnant women, disabled and the elderly is still in place Any possible coverage of adults is subject to state law
Coverage Gap in Non-Medicaid Expansion States
Adults who cannot qualify for Medicaid and cannot qualify for Federal subsidies to buy QHPs.
AHEC Health Insurance Marketplace Continuing Education 11
HOW TO ACCESS MEDICAID COVERAGE
One Enrollment Application for All Forms of Coverage Go to: www.healthcare.gov or Call: 1-800-318-2596 GO TO THE MARKETPLACE SUBMIT APPLICATION INFO SENT DIRECTLY TO STATE MEDICAID OFFICE COMPLETE ENROLLMENT CONTACT STATE MEDICAID OFFICE SUBMIT APPLICATION COMPLETE ENROLLMENT MEDICAID COVERAGE
AHEC Health Insurance Marketplace Continuing Education 12
CHILDREN’S HEALTH INSURANCE PROGRAM (CHIP)
AHEC Health Insurance Marketplace Continuing Education 13
CHILDREN’S HEALTH INSURANCE PROGRAM (CHIP) COVERAGE
CHIP is for children in families that earn too much to qualify for Medicaid but not enough to afford private insurance coverage
• • • • Offered in all states Not tied to state Medicaid program expansion Comprehensive CHIP coverage funded through 2015 Open enrollment and immediate coverage • • • •
States may choose to:
Integrate CHIP into Medicaid program Operate CHIP separately from Medicaid (with different income eligibility thresholds) Cover additional benefits Cover pregnant women and parents AHEC Health Insurance Marketplace Continuing Education 14
HOW TO ACCESS CHIP COVERAGE
One Enrollment Application for All Forms of Coverage Go to: www.healthcare.gov or Call: 1-800-318-2596 CONTACT ”INSURE KIDS NOW” GO TO: WWW.INSUREKIDS.GOV OR CALL: 1-877-543-7669 GO TO MARKETPLACE & SUBMIT APPLICATION INFO TRANSMITTED TO STATE CHIP OFFICE COMPLETE ENROLLMENT CHIP COVERAGE CONTACT STATE CHIP AGENCY SUBMIT APPLICATION COMPLETE ENROLLMENT
AHEC Health Insurance Marketplace Continuing Education 15
QUESTIONS
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AHEC Health Insurance Marketplace Continuing Education 16
THE HEALTH INSURANCE MARKETPLACE
AHEC Health Insurance Marketplace Continuing Education 17
IMPORTANT MARKETPLACE ENROLLMENT DATES
• •
OPEN ENROLLMENT DATES For coverage in 2015: Nov. 15, 2014 – Feb. 15, 2015 For coverage in 2016 and after: Oct. 15 – Dec. 7 each year
•
COVERAGE START DATES Enroll between 1st and 15th of the month: Coverage starts first day of the next month
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Enroll between 16th and last day of the month: Coverage starts first day of the second following month
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SPECIAL ENROLLMENT PERIOD Any time a qualifying life event occurs (such as: moving to new state, loss of a job, change in family size) Triggers 60 days to enroll in coverage
AHEC Health Insurance Marketplace Continuing Education 18
STATE OPTIONS FOR MARKETPLACE STRUCTURES
AHEC Health Insurance Marketplace Continuing Education 19
HOW INDIVIDUALS AND FAMILIES ACCESS THE HEALTH INSURANCE MARKETPLACE
The Marketplace Provides Access to All Pathways of Affordable Coverage Complete One Enrollment Application for All Forms of Coverage Go to: www.healthcare.gov or Call: 1-800-318-2596 GO TO THE MARKETPLACE APPLY PICK A PLAN ENROLL
•Find links to: •State
Marketplace
•State CHIP &
Medicaid Offices
•Local
Navigators and Assistors trained to help with enrollment
•Determine
eligibility for:
•Medicaid •CHIP •Help with
premiums & out-of pocket costs
•Compare
Qualified Health Plans (QHPs)
•Select a plan •Medicaid •CHIP •QHP AHEC Health Insurance Marketplace Continuing Education 20
QUALIFIED HEALTH PLANS (QHPs) SOLD IN THE MARKETPLACE
AHEC Health Insurance Marketplace Continuing Education 21
QHPs SUBJECT TO INSURANCE REFORMS
No exclusions due to pre-existing conditions Rates determined only by: age, family size, geography, tobacco use Rate increases must be filed with (but not approved by) HHS Required coverage of Essential Health Benefits (EHBs) No annual or lifetime limits or caps on coverage Annual out-of-pocket cost limit: $6,350 individual/$12,700 family Required coverage of preventive benefits with no out-of-pocket costs
AHEC Health Insurance Marketplace Continuing Education 22
QHPs COVER TEN CATEGORIES OF ESSENTIAL HEALTH BENEFITS (EHBs)
1.
2.
3.
4.
5.
6.
7.
Ambulatory Patient Services Emergency Services Hospitalization Maternity & Newborn Care Mental Health & Substance Use Disorder Services
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Including behavioral health treatment Laboratory Services Pediatric Services
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Including oral and vision care 8.
9.
Prescription drugs
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Special rules for prescription drug benefit including formulary exceptions Preventive & Wellness Services and Chronic Disease Management
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No out-of-pocket costs 10. Rehabilitative & Habilitative Services and Devices
• • •
EHB services must be balanced across all categories. These services can be included but do not count as Essential Health Benefits: Adult routine dental and eye exams Cosmetic orthodontia Long-term/custodial nursing home care
AHEC Health Insurance Marketplace Continuing Education 23
QHPs GROUPED INTO METAL LEVELS
METAL LEVELS CORRELATE TO ACTUARIAL VALUE (AV) (AV is the average percentage of costs a plan will cover for EHBs)
BRONZE SILVER GOLD PLATINUM
Plan pays 60% of costs of care Consumer pays 40% of cost of care Plan pays 70% of costs of care Consumer pays 30% of cost of care Plan pays 80% of costs of care Consumer pays 20% of cost of care Plan pays 90% of costs of care Consumer pays 10% of cost of care Lowest premiums Higher premiums Higher premiums Highest premiums Insurance carriers must offer: child-only plans, at least one silver and gold plan and a catastrophic plan. Stand-alone dental plans have different costs.
AHEC Health Insurance Marketplace Continuing Education 24
CATASTROPHIC COVERAGE PLANS
EACH INSURANCE CARRIER IN THE MARKETPLACE MUST OFFER ONE CATASTROPHIC PLAN Not a Metal Level plan Very low premium and very high deductible Available to individuals under 30 or those with hardship exemption from purchasing Metal Level coverage Covers three primary care visits per year (at no cost and before the deductible is met) Covers some free preventive care services (including screenings, vaccines and certain counseling services)
AHEC Health Insurance Marketplace Continuing Education 25
FEDERAL SUBSIDIES FOR QHPs THROUGH INSURANCE AFFORDABILITY PROGRAM
LOWER OUT-OF-POCKET COSTS WITH COST SHARING REDUCTION PLANS (CSR)
• • •
To determine eligibility go to: www.healthcare.gov
Fill out an application Use the Cost and Savings Calculator Consult the Quick Check Chart
• •
TO BE ELIGIBLE: Must be enrolled in a Silver Level plan through a Marketplace Must earn between 100% and 250% of the FPL: $11,490 to $28,725 for individuals $23,550 to $58,875 for a family of four
• •
IF QUALIFIED: Insurance carrier charges lower out-of-pocket costs (deductibles, copays, coinsurance) Total charges are less than the standard annual limit ($6,350/individual and $12,700/family)
AHEC Health Insurance Marketplace Continuing Education 26
FEDERAL SUBSIDIES FOR QHPs THROUGH INSURANCE AFFORDABILITY PROGRAM
LOWER PREMIUMS WITH ADVANCE PAYMENT TAX CREDIT (APTC)
• • •
To determine eligibility go to www.healthcare.gov
Fill out an application Use the Cost and Savings Calculator Consult the Quick Check Chart
• •
TO BE ELIGIBLE: Must be enrolled in a Metal Level plan through a Marketplace Must earn between 100% and 400% of the FPL: $11,490 to $45,960 for individuals $23,550 to $94,200 for a family of four
• •
IF QUALIFIED: Premium assistance paid on a sliding scale Insurers receive premium assistance payments directly from Federal Government
AHEC Health Insurance Marketplace Continuing Education 27
QHP SUMMARY OF BENEFITS & COVERAGE (SBC)
•
EVERY QHP MUST HAVE A CORRESPONDING SUMMARY OF BENEFITS & COVERAGE (SBC) Insurance carriers required to provide standardized information to allow apples-to-apples comparison of plans
• • •
SBC is a summary of answers to general questions regarding:
The QHP’s deductible, provider network, non-covered services Common medical events that the QHP covers and does not cover Copay and coinsurance costs for care from network providers and non-network providers
AHEC Health Insurance Marketplace Continuing Education 28
QHPs MAINTAIN PROVIDER NETWORK ADEQUACY
QHPs MUST MAINTAIN AN ADEQUATE NETWORK OF PROVIDERS Such as: Hospitals, Community Health Centers, Rural Health Clinics, Health Professionals (including mental health & substance abuse) Considerations: Plans with lower premiums may have more restricted networks Plans have different costs for seeing non network providers Patients should: Consult QHP’s provider directory or call insurance carrier SBCs provide link to directory and carrier contact info Providers should: Contact insurance carriers to confirm their participation in QHP networks
AHEC Health Insurance Marketplace Continuing Education 29
QUESTIONS
??????
AHEC Health Insurance Marketplace Continuing Education 30
HOW TO ACCESS QHP COVERAGE
TRAINED NAVIGATORS, ASSISTORS & OTHERS AVAILABLE TO HELP ENROLL Go to: www.healthcare.gov or Call: 1-800-318-2596 FFM STATES GO TO FEDERAL MARKETPLACE COMPARE PLANS APPLY & ENROLL SPM STATES GO TO FEDERAL MARKETPLACE & BE CONNECTED TO STATE IF NECESSARY COMPARE PLANS APPLY & ENROLL QHP COVERAGE SBM STATES GO TO FEDERAL MARKETPLACE & BE CONNECTED TO STATE OR GO DIRECTLY TO STATE MARKETPLACE COMPARE PLANS, APPLY & ENROLL
AHEC Health Insurance Marketplace Continuing Education 31
IMPORTANT MARKETPLACE ENROLLMENT DATES
• •
OPEN ENROLLMENT DATES For coverage in 2015: Nov. 15, 2014 – Feb. 15, 2015 For coverage in 2016 and after: Oct. 15 – Dec. 7 each year
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COVERAGE START DATES Enroll between 1st and 15th of the month: Coverage starts first day of the next month
•
Enroll between 16th and last day of the month: Coverage starts first day of the second following month
• •
SPECIAL ENROLLMENT PERIOD Any time a qualifying life event occurs (such as: moving to new state, loss of a job, change in family size) Triggers 60 days to enroll in coverage
AHEC Health Insurance Marketplace Continuing Education 32
QUESTIONS
??????
AHEC Health Insurance Marketplace Continuing Education 33
SMALL BUSINESSES AND THE MARKETPLACE
AHEC Health Insurance Marketplace Continuing Education 34
SMALL BUSINESS HEALTH OPTIONS PLAN (SHOP)
SMALL BUSINESSES CAN ENROLL IN SMALL GROUP PLANS THROUGH SHOP
• • •
SHOP QHPs ARE METAL LEVEL PLANS: Subject to all insurance reforms and QHP requirements Options for level of employer contribution Options for level of employee out-of-pocket costs
• • • • •
TO ENROLL IN SHOP: Maximum allowable employees is 50 full-time equivalent employees (FTEs) (varies by state) Must offer coverage to all full-time employees Must meet employee participation rate (varies by state) Enroll between Nov. 15 th and Dec. 15 employee participation requirements th each year to be exempt from Must meet employer premium contribution requirement (varies by state)
AHEC Health Insurance Marketplace Continuing Education 35
SMALL BUSINESS HEALTH OPTIONS PLAN (SHOP)
SMALL BUSINESSES TAX CREDITS AVAILABLE FOR SHOP QHPs
• • •
TO BE ELIGIBLE: Fewer than 25 employees Average salary of $50,000 or less Employer pays 50% of full-time employees premium costs
• • •
IF QUALIFIED: Credit covers up to 50% of monthly employer premium contribution Allows the deduction of premium costs not covered by the credit Credit highest for businesses with fewer than 10 employees and average salaries of $25,000 or less
AHEC Health Insurance Marketplace Continuing Education 36
HOW SMALL BUSINESSES ACCESS SHOP
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SHOP HAS OPEN ENROLLMENT – HOWEVER: Enrollment through Federal Marketplace postponed until 2015 Not all State SHOP Marketplaces operational GO TO FEDERAL MARKETPLACE BE CONNECTED TO STATE MARKETPLACE IF NECESSARY COMPARE PLANS GET PRICE QUOTES GET INSURANCE CARRIER CONTACT INFO ENROLL THROUGH INSURANCE BROKER, AGENT OR CARRIER
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SHOP MARKETPLACE IN EVERY STATE Business enrolls in a state where it has an office or work site
AHEC Health Insurance Marketplace Continuing Education
SHOP SMALL GROUP PLAN
37
QUESTIONS
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AHEC Health Insurance Marketplace Continuing Education 38
CONCLUSIONS
Most everyone must enroll in some form of health coverage Several pathways to affordable health insurance coverage Federal assistance available for premiums &out-of-pocket costs Consumer choices affect their premiums & out-of-pocket costs Plans with lower premiums may have smaller networks State Fact Sheets are available with specifics for every state
AHEC Health Insurance Marketplace Continuing Education 39
FEDERAL RESOURCES
Health Insurance Marketplace Individual, family, small business coverage options/enrollment
• •
www.healthcare.gov
www.cuidadodesalud.gov
Medicaid
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www.medicaid.gov
Children’s Health Insurance Program (CHIP)
•
www.insurekidsnow.gov
AHEC Health Insurance Marketplace Continuing Education 40
MORE FEDERAL RESOURCES
Internal Revenue Service Section on all Affordable Care Act tax provisions
•
www.irs.gov
The Center for Consumer Information and Insurance Oversight (CCIIO) Section on Affordable Care Act rules for private insurance and marketplaces
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www.cms.gov/CCIIO BusinessUSA Section on all health care changes of interest to businesses
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www.business.usa.gov
AHEC Health Insurance Marketplace Continuing Education 41
STATE RESOURCES
AHEC Health Insurance Marketplace Continuing Education 42