Enrolling in the Health Insurance Marketplace MAINE LOBSTERMEN S ASSOCIATION APRIL GILMORE, NAVIGATOR

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1 Enrolling in the Health Insurance Marketplace MAINE LOBSTERMEN S ASSOCIATION APRIL GILMORE, NAVIGATOR

2 Overview Provide information to help you understand the Health Insurance Marketplace MLA s focus is working with Maine lobstermen and their families WMCA and Qualified Health Centers also providing assistance MLA s Navigator can help you through the enrollment process

3 Some Health Insurance Statistics It is estimated that there are 145,000 uninsured Mainers Lack of health insurance is responsible for ~1,400 bankruptcies in Maine each year There is a hidden tax with each family paying $1,017 each year in health care premiums due to the uninsured population

4 Why is the MLA involved? Lobster industry comprised of a unique group of small businesses with highly variable annual income working in one our nation s most dangerous professions No HR department to help these small businesses Up to 50% of lobstermen in some areas do not have health insurance Many carry only catastrophic plans If you are a lobsterman, you risk losing your business assets if you can not pay your medical expenses Partnering with Fishing Partnership Support Services

5 Uninsured Maine Lobstermen and Families % of Lobstermen without health insurance / % Lobstermen s families without health insurance Source, GMRI 2006 Zone F 35% / 18% Zone D 46% / 28% Zone C 45% / 26% Zone B 33% / 23% Zone A 52% / 32% Zone G 23% / 10%

6 Changes Under Affordable Care Act ACA passed in March 2010 Children can stay on parent s health insurance until age 26 Limit of 20% for insurance overhead-80/20 rule No denial for pre-existing condition Coverage can t be dropped without fraud Established health insurance CO-OPS Small business tax credits for people who provide health insurance to their employees 2013 Health Insurance Marketplace launched 2014 Individual mandate begins

7 What s changed under ACA Play or pay -- you must have a qualified health insurance plan in 2014 or pay a penalty Plans must cover 10 essential health benefits No denial for pre-existing conditions (during open enrollment) Plans must cover certain % of claims cost Plans must be affordable (not exceed 9.5% of income) Catastrophic plans offered for people under age 30 Out of pocket max is $6,350/individual or $12,700/family, no lifetime limits

8 What s changed under ACA Play or pay -- you must have a qualified health insurance plan in 2014 or pay a penalty Plans must cover 10 essential health benefits No denial for pre-existing conditions (during open enrollment) Plans must cover certain % of claims cost Plans must be affordable (not exceed 9.5% of income) Catastrophic plans offered for people under age 30 Out of pocket max is $6,350/individual or $12,700/family, no lifetime limits

9 Individual Mandate Play or Pay If you don t have a qualified health insurance plan in 2014, you will pay a penalty Several Ways to get health insurance 1. Health Insurance Marketplace 2. Private Insurance 3. Employer 4. Government 5. SHOP for small businesses- for employers

10 Several Ways to Obtain Insurance Health Insurance Marketplace Two companies offering individual plans outside the marketplace Anthem, MCHO Enroll by March 31, 2014 to avoid penalty Tax credits and cost sharing based on income Several ways to enroll CMS call center Private Insurance Still Available Not eligible for a subsidy Four companies offering individual plans outside the marketplace Anthem, MCHO, Harvard Group, Mega Life Plans in place before March 23, 2010 are grandfathered ( qualified ) Only if they have not been changed check with your broker! Insurance through Employer If a spouse has affordable coverage through an employer that is available to the family, family members do not qualify for subsidy in the Marketplace. They can still purchase insurance through the Marketplace, but they cannot receive a subsidy If the company does not extend this coverage to the family, family members could qualify for subsidies in the Marketplace. Paper application Government Programs available Medicare Medicaid CHIP Veterans plans, etc REMEMBER You qualify for Medicare at age 65 SHOP Marketplace for businesses with < 50 employees

11 Private insurance is still available Four companies offering individual plans outside the marketplace Anthem, MCHO, Harvard Group, Mega Life Plans in place before March 23, 2010 are grandfathered ( qualified ) Only if they have not been changed check with your broker! No subsidy if you purchase a plan outside the Marketplace REMEMBER You qualify for Medicare at age 65

12 What is the penalty for no insurance? Individual Responsibility Penalty for not having qualified health coverage is the greater of: % of income or $95 ($500 penalty of you earn $50,000) % of income or $325 ($1,000 penalty of you earn $50,000) % of income or $695 ($1,500 penalty of you earn $50,000) 2017 Adjusted up in future years Plus 50% for each child under 19; up to 3x the individual penalty Up to $285 per family OR 1% of family income, whichever is greater Penalty will be paid when taxes are filed; pro-rated for months without insurance IRS will have notification if you have insurance

13 Who doesn t have to pay the penalty? Already have qualified health coverage MaineCare, Medicare, CHIP, Job coverage, COBRA, veteran s health program Cannot afford health insurance because: Insurance would cost more than 8% of your income You do not have to file a tax return (<$10,000 individual; <$20,000 married couples) Income is below 138% of federal poverty level and you cannot get MaineCare Have a gap in coverage for less than 3 months Qualify for a hardship exemption Other categories: Are a member of a federally recognized Indian tribe, Belong to a recognized religion that objects to buying health insurance, Are a member of a health care sharing ministry, Are in jail or prison, Are an undocumented immigrant or guest worker in U.S for < 3 months, Are not lawfully present in the U.S. Courtesy of Consumers for Affordable Health Care, CMS

14 What s changed under ACA Play or pay -- you must have a qualified health insurance plan in 2014 or pay a penalty Plans must cover 10 essential health benefits No denial for pre-existing conditions (during open enrollment) Plans must cover certain % of claims cost Plans must be affordable (not exceed 9.5% of income) Catastrophic plans offered for people under age 30 Out of pocket max is $6,350/individual or $12,700/family, no lifetime limits

15 Essential Health Benefits These benefits must be included in qualified health plan: 1. Outpatient care without being admitted to a hospital 2. Emergency services 3. Hospitalization (such as surgery) 4. Maternity and newborn care 5. Mental health and substance use disorder services, including behavioral health treatment 6. Prescription drugs 7. Rehabilitative and habilitative services and devices 8. Laboratory services 9. Preventive and wellness services and chronic disease management 10.Pediatric services

16 What s changed under ACA Play or pay -- you must have a qualified health insurance plan in 2014 or pay a penalty Plans must cover 10 essential health benefits No denial for pre-existing conditions Plans must cover certain % of claims cost Plans must be affordable (not exceed 9.5% of income) Catastrophic plans offered for people under age 30 Out of pocket max is $6,350/individual or $12,700/family, no lifetime limits

17 Open Enrollment Open enrollment Oct 1-March 31,2014 Applications must be completed by December 15, 2013 for coverage to start Jan 1, 2014 Several ways to apply: Maine s Health Insurance Marketplace: Mail paper application (available online or through Navigators) Over the phone through CMS Call Center ( ) Assistance through Navigators and Assistors Maine Lobstermen s Association (focus on lobstermen) Western Maine Community Action Federally Qualified Health Centers Bucksport Regional Health Penobscot Community Health

18 Enrolling after deadline You may also apply for insurance, or change your insurance, anytime if: You lose minimum essential coverage (could be due to job loss, divorce, or a change in family status) You gain (or become) a dependent (for example, you have a child) You need new insurance because you move to another state You gain or lose eligibility for premium tax credits or cost sharing subsidies The Marketplace makes a mistake enrolling you in an insurance plan You gain lawful presence Your insurance plan materially violates your insurance contract

19 What s changed under ACA Play or pay -- you must have a qualified health insurance plan in 2014 or pay a penalty Plans must cover 10 essential health benefits No denial for pre-existing conditions (during open enrollment) Plans must cover certain % of claims cost Plans must be affordable (not exceed 9.5% of income) Catastrophic plans offered for people under age 30 Out of pocket max is $6,350/individual or $12,700/family, no lifetime limits

20 Plans are put into 5 Categories Plan Categories Catastrophic <60% Bronze 60% Silver 70% Gold 80% Platinum 90% Of the total average costs of care Categories are based on how you and the plan share the costs of healthcare The category you choose affects how much the premium costs each month and what portion of the bill you pay to cover the cost of care It also affects your total out of pocket costs for care

21 Premium Ratings Premiums are based on several factors including: Geography Maine is split into rating areas for each company Age (in one year age bands) Tobacco Use Premiums are also higher where the cost of health care is higher

22 What s changed under ACA Play or pay -- you must have a qualified health insurance plan in 2014 or pay a penalty Plans must cover 10 essential health benefits No denial for pre-existing conditions (during open enrollment) Plans must cover certain % of claims cost Plans must be affordable (not exceed 9.5% of income) Catastrophic plans offered for people under age 30 Out of pocket max is $6,350/individual or $12,700/family, no lifetime limits

23 Two Ways to Reduce Premium Cost 1. Advanced Tax Credit Reduces the monthly premium Referred to as a subsidy Eligibility based on income levels ranging from 100% to 400% of federal poverty level 2. Cost-Sharing Reductions Provides savings that help pay the cost of care Eligibility based on incomes between 100% and 250% of the federal poverty level Enroll in a SILVER LEVEL Qualified Health Plan on the Marketplace

24 Advanced Premium Tax Credits Advanced Premium Tax Credits are reductions or subsidies handled with a tax credit Can be applied directly to your monthly premiums, so you get the lower costs immediately The amount you save depends on your family size and how much money your family earns In general, if your income is below 400% of FPL, you'll qualify to save money on your premiums; the lower your income, the more you'll save Income changes will be reconciled when you pay your taxes If your projected income goes up, you should update your account to reduce the tax credit, otherwise you will pay it back at tax time

25 Who Qualifies for Advanced Tax Credits? Income to qualify for tax credit on health insurance premium Persons in Family 100% FPL 133% FPL 250% FPL 400% FPL 1 $11,735 $15,608 $29,338 $46,940 2 $15,896 $21,142 $39,740 $63,584 3 $20,056 $26,674 $50,140 $80,224 4 $24,217 $32,209 $60,543 $96,868 5 $28,377 $37,741 $70,943 $113,508 6 $32,538 $43,276 $81,345 $130,152 7 $36,698 $48,808 $91,745 $146,792 8 $40,859 $54,342 $102,148 $163,436. * 2014 estimate based on 2012 levels increased by 2.5% per year.

26 Who Qualifies for Advanced Tax Credits? For those with health insurance through employer If affordable coverage through an employer is available to the family; family members do not qualify for subsidy in the Marketplace. They can still purchase insurance through the Marketplace, but they cannot receive a subsidy If the company does not extend coverage to the family; family members could qualify for subsidies in the Marketplace.

27 Cost-Sharing Reduction Additional cost savings to help pay the cost of care Helps with out-of-pocket costs like deductibles, coinsurance and copayments Have incomes between 100% and 250% of the FPL [Up to $60,543 for a family of four in 2013] Must qualify for Advanced Tax Credit Must enroll in a SILVER LEVEL Qualified Health Plan on the Marketplace

28 What s changed under ACA Play or pay -- you must have a qualified health insurance plan in 2014 or pay a penalty Plans must cover 10 essential health benefits No denial for pre-existing conditions (during open enrollment) Plans must cover certain % of claims cost Plans must be affordable (not exceed 9.5% of income) Catastrophic plans offered for people under age 30 Out of pocket max is $6,350/individual or $12,700/family, no lifetime limits

29 Catastrophic Plan Who is eligible? Young adults under 30 years of age Those who obtain a hardship waiver from the Marketplace What is catastrophic coverage? Includes coverage of 3 primary care visits and preventive services with no out-of-pocket costs Plans with high deductibles and lower premiums Protects consumers from higher out-of-pocket costs Maximum out of pocket cap applies ($6,350/individual) Source: CMS Training

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31 Maine s Health Insurance Marketplace The Marketplace is designed for those who don t have affordable health insurance Designed as an easier way to shop for health coverage with clear comparison of options Maine is one of 36 states with a federally managed Health Insurance Marketplace Must meet with same criteria established under ACA whether state or federally operated Maine s Health Insurance Marketplace is located at Two companies offering plans in Maine s Marketplace

32 Maine s Health Insurance Marketplace 4 Rating areas by county Wide spread network Tobacco cessation program Prescription coverage Chronic Illness Program 2 rating areas Reduced network to follow new requirements for affordable coverage Prescription coverage No cost preventative care

33 Maine Community Health Options Coops formed under the Affordable Care Act Maine based, member led, shared decision making through board of directors 4 Rating areas in Maine, all Preferred Provider Organization Chronic Illness Support Program Hypertension, Diabetes, Asthma, Emphysema, COPD (chronic obstructive pulmonary disease) Provider Services covered with $0 cost share when performed by plan Specific medication are covered and at 0$ cost for generics, 50% reduction in cost sharing for preferred brands Do not rate for tobacco use Cover tobacco Cessation program, emphasize treatment over penalty Member Services : / Source: Beth O Hara-Miklavic, MCHO

34 Anthem Anthem splits state into 2 rating areas: Northern service area (Aroostook, Hancock, Penobscot, Piscataquis, Somerset, Washington counties): Point of Service management (POS) Southern service area (Cumberland, Franklin, Androscoggin, Knox, Kennebec, Lincoln, Oxford, Sagadahoc, Waldo, York): Health Maintenance Organization (HMO) Several providers are not included in Anthem s network Mercy, Parkview, York, Inland, Central Maine Medical Center, Bridgton, Rumford Anthem plans include No- cost preventative care, like checkups and flu shots 24/7 Nurse Line Online support to manage your plan Pathway X Enhanced network includes Doctors and hospitals Lab, durable medical equipment and behavioral health providers Urgent and emergency providers

35 First consider what you need for coverage Who do you need to insure? yourself, your family, your children only? What level of coverage do you need? Are there chronic conditions and prescription coverage needed? What hospitals are within my network? If I pick a plan out of network, am I willing to change doctors? Do I qualify for government insurance such as Medicare, Medicaid; or do my kids qualify for CHIP? Can I qualify for a subsidy (Tax credit, cost sharing) due to my income level?

36 Ready to Enroll!

37 Getting Ready to Enroll You ll need some key information in order to get started in the Health Insurance Marketplace Birth dates, Social security numbers For yourself and any family members who need coverage Need document numbers for legal immigrants Employer and income information for every member of your household who needs coverage Pay stubs, W-2 forms, or Wage and Tax Statements Information about employer-sponsored coverage options Policy numbers for any current health insurance

38 NOTE: you need to have your own account!

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44 Do you need help with enrollment? You MUST sign a consent form to get assistance with enrollment The Consent Form explains the process of working with a Navigator and that the proper privacy training has been completed to work with you and your personal information.

45 SHOP: Small Business Health Options Program A new, streamlined way for small employers to offer coverage to employees, enroll directly through the Marketplace Small businesses with <50 full time employees (FTE) May be Eligible Small Business Tax Credit: - Up to 25 (FTE) -Wages average less than $50K -Contribute to at least 50% of employees premium costs * See me for more information on SHOP

46 Beware of Health Insurance Fraud HealthCare.gov insurance plans are exclusively government-approved, comprehensive insurance programs. Millions of Americans have unknowingly signed up for junk insurance scams and mini-med programs that seem attractive because they have low premiums, but often don t even cover basic medical expenses. If you are suspicious of Fraud contact: State Department of Insurance or Federal Trade Commission or HHS-TIPS

47 Helpful resources Washington/Hancock County CAP: (207) Bucksport Regional Health Penobscot Community Health Consumers for Affordable Health: Maine Health Access Foundation: Subsidy Calculators: -Kaiser Foundation: -Turbo Tax: Questions to ask your provider: Bureau of Insurance at Maine Medicaid: Maine Care:

48 Thank you! Questions? April Gilmore Maine Lobstermen s Association april@mainelobstermen.org