UNDERSTANDING HEALTH PLANS in the Health Insurance Marketplace

Transcription

1 UNDERSTANDING HEALTH PLANS in the Health Insurance Marketplace

2 Consumers Mutual Insurance of Michigan Jayson Welter, Legal and Chief Compliance Officer Holly Wilson, Regional Outreach Manager

3 Consumers Mutual Insurance of Michigan Newly developed CO OP Mutual non profit insurance company 51%+ Board membership will be consumers Excess revenue must be used for enhanced or increased benefits, reduction in premium costs Community oriented

4 What Insurance Companies Will Be On the Marketplace? In Michigan 14 insurance companies have applied to offer health insurance on the Marketplace including Consumers Mutual Consumers Mutual will offer health plans on and off the Marketplace including individual and group plans Some Medicaid plans are on the Marketplace to address churn for those individuals who may fall in and out of Medicaid eligibility

5 What Will Be Covered? On January 1, 2014 every policy must cover: Doctor visits Services to keep you healthy like vaccines, mammograms, etc. Emergency and Hospital care Prenatal, maternity and newborn care Prescription drugs and lab tests Mental health and substance abuse treatment Physical, speech and occupational therapy Children s dental and vision care

6 Health Insurance Marketplace All plans offered will include standard benefits so it will be easy to compare And amount of coverage and premium prices are arranged in four levels: Bronze Silver Gold Platinum

7 Policies Available Through the Marketplace Bronze Silver Gold Platinum Lowest monthly premium Medium monthly premium Higher monthly premium Highest monthly premium Higher costs for services Low costs for services Lowest cost for services A good option if you expect to use a low amount of health services Medium costs for services Majority of large employer plans are closest to Gold plan designs A good option if you expect to use a lot of health services

8 Metal Levels and Actuarial Value Platinum Gold Silver Bronze 88 92% 78 82% 68 72% 58 62% Catastrophic plan for under 30 has a mandated coverage and value 8

9 How We Get to Actuarial Value 9

10 How We Get to Actuarial Value Emergency Room Inpatient Hospital Primary Care Visit Specialist Visit Mental/Behavioral Health and Substance Abuse Disorder Imaging Labs Speech Therapy, PT, OT Preventive Care/Screening/Immuni zation Skilled Nursing Facility Outpatient Facility Fee Outpatient Surgery Physician Services Medications 10

11 How We Get to Actuarial Value Network vs out of network coverage Services subject to deductible and amounts Services subject to coinsurance and amounts Services subject to copays and amounts Out of pocket maximums 11

12 How Does the Tax Credit Work? Health premium tax credits reduce the amount of income tax you owe the IRS. To use the tax credit you must buy health insurance from the Marketplace. You can take the credit in advance to reduce monthly insurance premiums or pay full premiums now and subtract the tax credit from income taxes you might owe in April 2015.

13 How Does the Tax Credit Work? Tax credits are paid directly to the health plan by the Marketplace. Tax credits will be adjusted at the end of the year based upon your actual income.

14 Will Health Insurance Be Affordable? Federal tax credits available for many people to help pay the cost of insurance premiums. You may be eligible for a tax credit if your annual income is below $45,960 if you are a family of one and under $94,200 for a family of 4. Go to calculator to see how much you might be eligible for.

15 Will Health Insurance Be Affordable? In addition to subsidies, there will be cost sharing reductions to help many people pay their portion of health care services such as hospital stays, tests, and doctor visits. Consumers may be eligible for cost sharing reductions if they make less than $28,725 annually for a family of 1, or $58,875 for a family of 4.

16 Cost Sharing Reductions Table *Not final, just concept

17 Will Health Insurance Be Affordable? Examples: Household Size Annual Income Estimated Amount of Health Insurance (without subsidy) Annual Subsidy Actual Cost of Health Insurance 4 $31,900 $12,300 $11,100 $1,200 ($100 per month) 4 $88,800 $12,300 $3,900 $8,400 ($700 per month) 1 $27,000 $4,548 $2,460 $2,100 ($175 per month)

18 What Determines Rates for Small Group? Pre ACA Coverage for individual or family blended rates Health Status (pre existing conditions) Gender Age (5:1 ratio) Age curve set by insurer Type of business (SIC code) Tobacco Use Area was undefined Post ACA Coverage for individual or family per member rating Age (3:1 ratio for adults, age 0 20 is one age band) Mandated Age Curve Rating Area (16 rating areas set by state) Tobacco use (1.5:1 ratio) 18

19 Michigan Rating Areas 19

20 Annual and Lifetime Maximums Health plans can no longer restrict annual and lifetime dollar expenditures for essential health benefits. Members will have difficulty knowing what services qualify as essential health and should consult their health plan directly.

21 Cost Sharing Small group health plan deductibles cannot exceed $2000 Individual $4000 Family No limitation on individual market deductibles HSA Minimum Deductible $1250 Individual $2500 Family Maximum Out of Pocket Limit $6350 Individual $12,700 Family 21

22 High Deductible Plans and Health Savings Accounts Health Savings Account (HSA) compliant plans will be available on the exchange The same out of pocket maximums apply, however, in contrast to a normal plan, HSA plans require the deductible be met before any costs are paid by the plan. Example: It is common for office visits or emergency room to be a flat copay and not subject to the deductible. This is not allowed on an HSA plan. 22

23 Schedule of Benefits Examples

24 When Can I Sign Up? Open enrollment will begin October 1, 2013 and last until March 31, If consumers want coverage to start January 1, 2014, they should sign up October or November, 2013

25 How Do I Sign Up for Coverage? Go to to create your account now! On October 1, compare plans, make a selection and apply for tax credits and help with costs of health care services. Enrollment by calling available as well.

26 Marketplace Website

27 Who Can Help Me Figure This Out? To help people understand their options and sign up for insurance, Navigators and Community Health Center representatives will be available. Other organizations will also be available this fall to help people fill out applications.

28 How Do Members Pay Their Premiums? A full enrollment file containing subsidy information is sent from the government to the health insurance company Billing and payment will occur directly with the health insurance company The expectation is that the enrollees will pay within 30 days (effective date or enrollment date in question)

29 Grace Periods QHPs are required to pay for services provided up to 30 days after non payment occurs. Services provided in the 31st 90th day could be held and marked as pending. If the insured fails to bring the account to full status by the 90th day of the grace period the policy may be terminated and all pending claims can be denied.