2016 Regional Conferences FOR ENROLLMENT ASSISTERS

Transcription

1 Regional Conferences FOR ENROLLMENT ASSISTERS

2 Eligibility 2 All lawfully present individuals living in the US are eligible to purchase Marketplace health insurance. EXCEPT those who have job-based (affordable & MV) or other subsidized MEC health insurance (ex. Medicaid, Medicare, Tricare, etc.) Young adults under age 26 can remain on parent s health plan. Taxpayers with incomes between % Federal Poverty Level (FPL) are eligible for Advanced Premium Tax Credits (APTC). Lawfully present immigrants denied Medicaid due to the 5 year bar can be <100% FPL Consumers whose household MAGI is less than 250% FPL are eligible for cost sharing reductions (CSR) if they enroll in Silver-level plans. Individual Responsibility payment ( penalty ) Exemptions are available to eligible consumers. Special Enrollment Periods are available to eligible consumers. Must have a Qualifying Life Event (QLE).

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4 Job-based coverage 4 Employer pays a portion of premium Employer may not discriminate Employer may limit coverage (ex. dependents, FT/PT, generic meds) Employee is not eligible for APTC or cost-sharing if the plan is: Affordable - Employee share of the annual self-only premium must not exceed 9.66% of the household income Minimum Value Standard - Plan must cover no less than 60% of total allowed benefit costs for a standard population. COBRA allows employees to keep job-based coverage temporarily but employees pay employer-share & administrative costs. It may be wise to purchase a QHP with APTC and/or CSR instead.

5 Affordability & Hardship Exemption 5 The 9.66% affordability test is for determining whether an individual is eligible for the premium tax credit. Job-based coverage is considered affordable if the employee's share of the annual premium for the lowest cost self-only coverage is less than 9.66% of the household's income. This same rule applies for any family members even if the cost of family coverage is higher. The 8.13% test is for determining whether an individual is eligible for a hardship exemption from the individual shared responsibility fee. If the cost of employee-only coverage in a job-based plan exceeds 8.13% of the employee s household income, they can be exempt from the fee. Family members can also qualify for the hardship exemption if the contribution for family coverage exceeds 8.13% of household income.

6 What does the Marketplace do? 6 Marketplace determines eligibility for Qualified Health Plans (QHP) Advanced Premium Tax Credits (APTC) Cost-sharing reductions (CSR) Marketplace assess v. determine eligibility Medicaid Children s Health Insurance Program (CHIP)

7 Ways to Apply 7 On-line with or without in-person assistance Valid address (user name) and password Log-in may be deactivated if not used By Phone Call Center at (TTY: ) By mail Health Insurance Marketplace Dept. of Health & Human Services 465 Industrial Blvd London KY

8 Before you begin 8 Organization s Privacy Policy Authorization for Assistance All PII must be stored securely for 6 years, per HIPAA. Storage may be electronic. Authorization for Representation For anyone over age 18 who is not present to make decisions. Listen to consumer Do they have an address? Do they have & use a computer? Who needs insurance in their tax household? What is important to them? Do they have a doctor they want to keep? Do they have any special/chronic health concerns? Do they need a national provider network for travel or college age children?

9 Who is in the household? 9 If no financial assistance (APTC and/or CSR) is requested, application should reflect only the names of those seeking insurance. If financial assistance (APTC and/or CSR) is requested, application should reflect the complete tax household including tax payers and dependents, regardless of their actual address. Do not include your unmarried partner, their children or their dependents or anyone who files their own tax returns.

10 Create Marketplace account log-in. Enter personal identity data. Consumers may view and compare complete health plan details (ie., detailed cost-sharing requirements) only after account creation and eligibility determination. You can indicate the consumer s preferred language and/or regular mail, instead of . 10

11 Give Yourself Credit! 11 But don t be an authorized representative!

12 Eligibility & Enrollment Process 12 Marketplace account user name & password depends on valid address. Don t give consumers written passwords or answers to their security questions. Data matching inconsistencies (DMI) can easily occur.

13 Verification 13 Marketplace uses the Federal Data Services Hub to verify: Name (Identity) Social Security number (SSN), if applicable Citizenship or lawful presence Incarceration status Membership in federally recognized tribe, if applicable For consumers who apply for financial assistance (ie., APTC and/or CSR), the Marketplace also verifies: Eligibility or enrollment in non-marketplace minimum essential coverage (ex., job-based coverage, Medicare, Medicaid, the CHIP, TRICARE, Veteran's Health Program, or the Peace Corps Monthly household income and family for Medicaid/CHIP eligibility. Annual household income and family size for APTC & CSR eligibility.

14 Lawfully Present Immigrants (LPI) 14 Alien Registration Numbers (USCIS #) are critical. You may need to provide more than 1 document.

15 Native American Eligibility 15 Year-round enrollment. Income eligibility for CSR is 300% FPL. Cost-sharing may be applied to any QHP metal-level.

16 Data Matching Inconsistencies (DMI) 16 After 2 attempts to verify identity, the Marketplace will: Refer to Experian Help Desk at Notify consumer of DMI. Request upload or mailing of supporting documentation. The Marketplace will provide consumers with a temporary eligibility determination if there is a DMI. Accepting APTC and/or CSR = agree to reconcile at tax time! Consumers get notices explaining how long they have to resolve a DMI (usually max. 90 days) before changing the eligibility determination. If consumers do not submit sufficient documentation, they could lose their APTC and/or CSR, or their health coverage. Doesn t excuse reconciliation at tax time! Consumers are notified in writing when DMI is resolved.

17 Estimating Household Income 17 Calendar year = Plan Year, prospective v. retrospective Annual income v. monthly income Application/Tax filing status (5) Married, filing jointly v. Married, filing separately Victims of domestic abuse and/or abandonment can apply as Single (2 years maximum, per IRS) Head of Household can apply as Single Qualified Widow/er depends on date of event AGI (line 37 of IRS Form 1040) v. MAGI Do not include Supplemental Security Income (SSI) Child support Gifts Veterans' disability payments Workers' compensation Proceeds from student, home equity or bank loans

18 Additional application questions 18 Race & Ethnicity (optional) Physical/mental disability, chronic health condition Pregnancy Smoking Foster Care Job-based health insurance (Employer Coverage Tool) Life Events (SEP Screener) Allow access to tax returns Designated Authorized Representative Communication Preferences Review & Sign Penalty of Perjury (Consumer) Civil Money Penalties (CMPs)