Washington Health Benefit Exchange

Transcription

1 Washington Health Benefit Exchange HEALTHCARE REFORM SEMINAR November 25th, 2013 ACA INFORMATIONAL SESSION FOR SMALL BUSINESS OWNERS

2 The Affordable Care Act Exchange Basics Today s Agenda Exchange Functions and Service Washington Healthplanfinder SHOP Description of the Small Business Health Options Program (SHOP) Understand the requirements to participate within the SHOP Impact and Responsibilities of Employers and Employees within the SHOP Individual Understand the differences between SHOP and Individual market participation Understanding Free and Low Cost Healthcare Individual Mandate 2

3 The Affordable Care Act Changes to private insurance, e.g., Young adults on parent s policies to age 26 Prohibit lifetime monetary caps Minimum spending on medical care (medical loss ratio) Closing the prescription doughnut hole Expands coverage and imposes an individual mandate in 2014 Expands Medicaid to 138%* of FPL Exchanges for individuals/families and small businesses, with health insurance premium tax credits and cost sharing reductions 3

4 State based exchange The Exchange Basics Individuals >138% of FPL and SHOP (small groups 1-50) Health Insurance Premium Tax Credits available for individuals 138%- 400% of FPL Cost sharing reductions available for <250% of FPL Small Business Premium Tax Credit Qualified health plan (QHP) offerings Metallic tiers of actuarial value Apples-to-apples comparisons for consumers, one-stop shop 10 essential health benefits Agents/brokers, In-Person Assisters, Customer support center 4

5 Exchange Functions & Services Highlight Products, Oversee Navigators Develop, Host Website Customer Support, Quality Rating System Review & Certify Qualified Plans Aggregate Premiums Determine Eligibility, Tax Credits 5

6 What is the Washington Healthplanfinder? Creates a new online marketplace for employers and individuals Provides access to compare plans and costs Allows access to exclusive benefits Increase access to affordable Health Insurance Creates efficient, accurate and customer friendly eligibility determination system Enhance Health Insurance competition value, access, quality, service & innovation Connects customers to support including the Customer Support Center (toll-free), Agents/Brokers and Navigators/In-Person Assisters 7

7 Washington Health Benefit Exchange Structure Business Marketplace (SHOP) Individual Marketplace 8

8 How can I shop for Healthcare Coverage Using the Washington Healthplanfinder? Agent/ Broker Customer Support Center Website Navigator (In-person Assister) Partner Employer Self- Directed 9

9 Employer Requirements There are four general requirements: Employer of up to 50 employees Meet minimum participation requirements Up to 3 100% % Demonstrate an offer of coverage to full time employees Have a business located in Washington State or have employees whose primary worksite is within Washington State 10

10 What are the Benefits of Participating within SHOP? Ease of use for Employers and Employees Ease of access to broker assistance through Washington Healthplanfinder Expedites the plan selection process Apples to Apples/Side by Side plan comparison Access to exclusive additional benefits/tax credits Minimum 50% Employer contribution requirements 11

11 What are the Responsibilities of the Employer within the SHOP? Create an Account within the Washington Healthplanfinder ( Select a Broker, Navigator or In Person Assister (IPA) Input the employee roster Select a plan or plans Elect desired contribution amount Notify the employees via web link Track progress Ongoing administration Arrange payment preferences *Please visit the IRS Website to determine Tax Credit eligibility: 12

12 What are the Responsibilities of the Employee within the SHOP? Create Account via link sent from employer Compare plans (if applicable) Add dependents (if allowed by Employer) View Employee Final Summary E-sign Account administration 13

13 Small Business Premium Tax Credit Eligibility maximum credit is 35% for small employers and 25% for small tax-exempt employers such as charities. On Jan 1, 2014 the rate will increase to 50% and 35% respectively 50% contribution requirement Employers with 25 or fewer FTE s must have average wages of less than $50k per year 20 half time employees are equivalent to 10 full-workers* *Please visit the IRS Website to determine Tax Credit eligibility: 14

14 Washington Health Benefit Exchange Structure Business Marketplace (SHOP) Individual Marketplace 15

15 Individual vs. SHOP Exchange Individual Exchange SHOP Exchange Who: - Individuals who are not on public or employer sponsored plans - Small businesses with 1-50 employees What: - Access to QHPs, federal subsidies through APTC and / or CSR, and referral to alternative options (e.g., CHIP) - Employee access to employer sponsored plans with increased choice - Employer ability to define contributions and access to small business tax credits When: - Initial open enrollment is open to all with some special enrollment periods pending eligibility status - Initial open enrollment is open to all with some special enrollment periods pending eligibility status 16

16 Federal Poverty Guideline 2014 Persons in family/household* Poverty Guideline (100% FPL) 1 $11,490 2 $15,510 3 $19,530 4 $23,550 5 $27,570 6 $31,590 7 $35,610 8 $39,630 Federal Poverty Level Annual Income: Individual Annual Income: Family of 4 100% $11,490 $23, % $15,856 $32, % $28,725 $58, % $34,470 $70, % $45,960 $94,200 *For families/households with more than 8 persons, add $4020 for each additional person. 17

17 Individual Affordability <138% of Federal Poverty Level = Washington Apple Health For adults w/o children Children may qualify for Washington Apple Health <300% of FPL >138% but <250% = Cost Sharing Reduction Cost Sharing Reduction lowers the individuals out of pocket costs on the plan that they select >138% but <400% = Health Insurance Premium Tax Credit* *Health Insurance Premium Tax Credit can be taken immediately in the form of a Premium Reduction or at the end of the year in the form of a tax refund 18

18 Health Insurance Premium Tax Credits Individuals/Families below 400% of Federal Poverty Level qualify for Health Insurance Premium Tax Credits These credits can be taken immediately in the form of reduced premium or a Tax refund Income Level Premium as Percent of Income % FPL 3-4% of income % FPL 4-6.3% of income % FPL % of income % FPL % of income % 9.5% of income Tax credit calculator available at 19

19 Health Insurance Premium Tax Credit Calculation Income as % of FPL Max amount of income that can be contributed to a premium annually 138%-150% FPL 3-4% of income 150%-200% FPL 4-6.3% of income 200%-250% FPL % of income Current Household Income Maximum Annual Premium 250%-300% FPL % of income 300%-400% FPL 9.5% of income Maximum Annual Premium 12 months per year Maximum Monthly Premium Cost of Second Lowest Silver Plan in Area Maximum Monthly Premium Tax Credit 20

20 Cost Sharing Reductions Individuals making up to 250% of FPL are eligible for cost sharing reductions Cost Sharing Reductions reduce the out-of-pocket liability for an individual Income Level Reduction in Out-of-Pocket Liability % FPL 94% of the actuarial value* % FPL 87% of the actuarial value % FPL 73% of the actuarial value * Of the second lowest cost Silver Plan 21

21 Qualified Health Plans Qualified Health Plans (QHPs) will be available to individuals and small employers in the Exchange The Exchange will: Set standards for QHPs Certify participating plans, and Rank plans from bronze to platinum to indicate what level of coverage the plan offers QHPs must: Provide Essential Health Benefits (EHBs) Ensure sufficient choice of providers! Bronze covers 60% of actuarial value of benefits Silver covers 70% of actuarial value of benefits Gold covers 80% of actuarial value of benefits Platinum covers 90% of actuarial value of benefits Catastrophic high-deductible plan for individuals up to age 30 or individuals exempted from the mandate to purchase coverage Be accountable for performance on clinical quality measures and patient satisfaction Implement a quality improvement strategy Provide accurate and standardized consumer information Be a private health insurance plan 23

22 Ten Essential Health Benefit Categories 1. Ambulatory services 6. Prescription drugs 2. Emergency services 7. Rehabilitative and habilitative services and devices 3. Hospitalization 8. Laboratory services 4. Maternity and newborn care 9. Preventive and wellness services and chronic disease management 5. Mental health and substance use disorder services, including behavioral health treatment 10. Pediatric services, including oral and vision care 24

23 View of Individual QHP Market 40 Total plans approved including pediatric dental Gold, Silver, Bronze and Catastrophic plan choices 8 Carriers BridgeSpan King, Kitsap, Pierce, Skagit, Snohomish, Thurston, and Spokane Community Health Plan of Washington Adams, Benton, Chelan, Clark, Cowlitz, Douglas, Ferry, Franklin, Grant, Grays Harbor, King, Kitsap, Lewis, Okanogan, Pacific, Pend Oreille, Pierce, Skagit, Snohomish, Spokane, Stevens, Thurston, Wahkiakum, Walla Walla, Whatcom, Yakima Coordinated Care Adams, Benton, Chelan, Douglas, Franklin, Grant, Grays Harbor, King, Skagit, Snohomish, Spokane, Thurston, Walla Walla, Yakima Group Health Cooperative Benton, Columbia, Franklin, Island, King, Kitsap, Kittitas, Lewis, Mason, Pierce, San Juan, Skagit, Snohomish, Spokane, Thurston, Walla Walla, Whatcom, Whitman, and Yakima LifeWise All 39 counties Molina Healthcare of Washington, Inc. King, Pierce and Spokane Premera Blue Cross All counties except Clark Kaiser Foundation Health Plan of the Northwest Clark and Cowlitz (Small Business and Individual Market) Delta Dental of Washington, Kaiser Foundation Health Plan of the Northwest, LifeWise, Premera Blue Cross (Pediatric Dental Only) 25

24 Individual Mandate Doesn t Apply When any of the following apply: Religious objections Undocumented immigrant Incarcerated No penalty for being without health insurance. American Indians and Alaskan Natives Income below the tax filing threshold The lowest cost plan option exceeds 8% of an individual s income 26

25 Individual Mandate is Satisfied When: You were insured for the whole year through a combination of any of the following sources: Medicare TRICARE The veteran s health program A plan offered by an employer No Penalty. The requirement to have health insurance is satisfied. Medicaid or the Children s Health Insurance Program (CHIP) Insurance bought on your own that is at least at the Bronze level A grandfathered health plan in existence before the health reform law was enacted 27

26 What is the Penalty? 2014 $95 per adult $47.50 per child (up to $285 for a family) OR 1% of income, whichever is greater 2015 $325 per adult and $ per child (up to $975 for a family) OR 2%, whichever is greater 2016 $695 per adult and $ per child (up to $2,085 for a family) OR 2.5% of family income, whichever is greater Tied to inflation 28

27 Customer Support Center The Customer Support Center is provided for consumer support: Help during the enrollment process, including explaining the various health care coverage options that are available to consumers Provide ongoing support, including how to navigate the Washington Healthplanfinder, unlock or reset individual and employer/employee accounts Direct consumers to additional support You can contact the CSC at: WAFINDER ( ) 7:30am-8:00pm Monday-Friday Access to licensed translators 29

28 Washington Healthplanfinder Home Page QHP Logo 30

29 Washington Healthplanfinder Individual /Family Landing Page 31

30 Employer Landing Page 32

31 Find a Broker 33

32 Partner with a Broker 34

33 More on the Exchange Includes information about: Exchange Board Legislation and grants Policy discussion Technical Advisory Committees and stakeholder involvement IT systems development HHS guidance Listserv registration Healthplanfinder Calculator: Contact the Exchange at: 35

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