Connecting People to Coverage Amy Rix Piedmont Health Services Special Projects Manager The Patient Protection and Affordable Care Act was signed March 2010 Open enrollment period runs from October 1, 2013 through March 31, 2014. 1
Under 50 employees Health Care Reform Small Business Individual Not subject to offering employees coverage Small Business Employer groups are eligible to obtain coverage from exchange Individuals must obtain coverage or pay penalty Individuals are eligible to obtain coverage from exchange Over 50 Employees Large Business Subject to offering employees coverage Large Business (over 100) not eligible for exchanges until 2017 People can meet this requirement with: Public health insurance coverage Medicaid Medicare NC Health Choice Employer sponsored insurance Purchasing coverage in the private insurance market 2
Those who would have to spend more than 8% of their income for the lowest premium Individuals who would have been eligible for Medicaid (in states that choose not to expand Medicaid). Businesses with less then 50 employees People with religious exemptions Prisoners, while incarcerated Shop for and Enroll in Health Plans Check eligibility for tax credit and subsidies Compare plans & prices up front before enrolling 34 3
The Four Medal Plans Assist with payment of premium Available only when you purchase through the Marketplace. Determined on an income-based sliding scale (Based on previous yr tax return) Based on the premium cost for the second lowest cost silver plan in the Marketplace servicing the individual. 4
You do not have to apply for a plan before finding out if you qualify 5
Full Time Equivalent (FTE) = 30+ (hrs wk) Part Time converted to FTES = Total PT hrs / 120 To Figure TOTAL FTES for your business (employees): Total # of Full Time Employees + Combination of Part Time Employees Example: Company A has 35 Full Time Employees (work 30+ hrs wk) And 20 Part Time Employees who work 24 hrs wk (96 hrs month) Formula: 20 x 96 = 1920 / 120 = 16 (takes PT converts to FT) 16 (PT) + 35 (FT) = 51 (FTE) (Company A= large company over 50) To Figure Eligibility: Annual employees wages alongside FTE determine if a company is eligible to receive tax credit. Annual Avg Wages determined by: Total wages / # of FTE s (round down to the nearest $1,000) To Claim tax credit (until SHOP opens 2016): Go to IRS.com and use form 8941 (calculate credit) 6
Small businesses can apply for tax breaks of up to 35% (25% for non profit) of their contributions to employees premiums if the company size is less then 25 employees To Qualify: Must pay at least 50% of employee premiums and the avg of workers annual wages can t be more then $50K a yr Example: Company A has 10 Employees Wages = $250K or $25K per employee Employer Contribution to premiums = $70K Tax Credit Amount = $35K (50% of employers contribution) www.healthcare.gov (Website) You can find in person help by calling Patricia Hickman at 919 724 5227 or Latisha Vincent at 919 619 5457 Piedmont Health Services Call the 24/7 marketplace helpline 1 800 318 2596 The North Carolina Department of Insurance (NCDOI) www.ncdoi.com/smart/ Contact Local Insurance Agent/Brokers 7
Piedmont Health has Certificated Application Counselors (CAC) at 6 of our Community Health Care Center locations to assist you. Contact a counselor today to schedule an appointment. Carrboro/Prospect Hill Outreach and Enrollment Coordinator (919) 724 5227 (bi lingual) Moncure/Siler City Outreach and Enrollment Coordinator (919) 357 8216 Scott (serving Alamance county) Outreach and Enrollment Coordinator (919) 357 7039 Charles Drew (serving Alamance county) Outreach and Enrollment Coordinator (336) 260 2720 (All counties) Outreach Enrollment Lead (919) 619 5457 Each household member, who is listed on the Marketplace application, needs to have the following information: Photo Identification for all adults Social Security numbers Birth dates Paystubs, W 2 forms or other info about your income Employer s company name, address, contact person, and phone number Policy/member numbers for any current health coverage. OR A completed Employer Coverage Tool (ECT) for every job based plan you or someone in your household is eligible for. (You will need to fill out this form even for coverage that you are eligible for but do not enroll in.) This form may be completed by the employer for the person in the household who has health insurance coverage. Document number (if you re an eligible immigrant who wants health coverage) 8
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You will be eligible for financial help if: You do not qualify for public coverage (eg, Medicaid, NC Health Choice, or Medicare) You do not have access to affordable employer based coverage. Your income is between 100 400% of the federal poverty level. If states did not expand Medicaid, most people (<100% FPL) will not be eligible for subsidies to purchase coverage in the Marketplace Protects lower-income individuals Available to those with a household income of up to 250% of the federal poverty level The subsidy amount is determined by a sliding scale based on: The federal poverty level The insured s benefits, including state mandated benefits Health and Human Services notifies the insurer if an enrollee is eligible for a subsidy 10
All insurance plans will have to cover Essential Benefits: Ambulatory Services Emergency and Hospitalization Maternity and Newborn Care Mental Health and Substance Abuse Prescriptions and Drugs Rehabilitative Services Laboratory services; Chronic Disease Management Pediatric Services, Including Oral and Vision Care * In North Carolina, the essential health plan will be based on BCBSNC s most commonly purchased small business health plan: Blue Options PPO. Will COVER prevention screenings/tests NO more exclusions for pre existing conditions NO more lifetime caps Insurance companies CANNOT cancel health plan because you get sick Children can be covered on parents plans until age 26 11
Does my business have to offer health insurance? What happens if I don t? Should I pay or play?... What is FTE? Do I (individual) qualify for any subsidies? When must I purchase insurance by? What happens if I don t? Where can I purchase Health Insurance? How much will it cost? Can I still use the Chamber/Piedmont Small Business Health Program? Employers with 50 or more full time employees required to offer insurance to the full time employee and his/her dependents or pay penalty (Sec. 1201, 1513, amended Sec. 1003 Reconciliation) Employers with less than 50 full time employees exempt from penalties. (Sec. 1513(d)(2)) Employers with 25 or fewer employees and average annual wages of less than $50,000 can receive a tax credit. (Sec. 1421, Sec. 10105) Note: the requirement that employers offer health insurance coverage to their employees was delayed until 2015. 24 12
HANDOUTS Persons in Family FPL (4) Annual (Monthly) L ($) 1 10,830 (903) 2 14,570 (1,214) 3 18,310 (1,526) 4 22,050 (1,838) Other Benchmarks 100% FPL ($) 10,830 (903) 14,570 (1,214) 18.310 (1,526) 22,050 (1,838) 133%FPL ($) 14,404 (1,200) 19,378 (1,615) 24,353 (2,029) 29,327 2,444) Annual income of minimum wage earner working 40 hours a week for 50 weeks is $7.25 per hour or annually, $14,500 200%FPL($ ) 21,660 (1,805) 29,140 (2,428) 36,620 (3,052) 44,100 (3,675) 300%FPL($ ) 32,490 (2,708) 43,710 (3,643) 54,930 (4,578) 66,150 (5,513) Starting salary of Iowa City School Teacher is about $28,000 400%FPL($ ) 43,336 (3,611) 58,280 (4,857) 73,240 (6,103) 88,200 (7,350) Average salary of UI Law graduate in first year is about $55,000 for in state and $91,000 outof state 13
27 1. Bronze plans split covered expenses 60 40. Bronze plans are the cheapest because insurers pay only 60 % of a your covered health expenses, and the policy holder must come up with the other 40 %. In other words a plan with 60% actuarial value covers 60% of your out of pocket costs. Bronze plans also have the most basic benefits and most limited networks of doctors and hospitals. This is a good choice for those who don't plan on using many medical services. Many low income Americans may qualify for free or very low cost Bronze plans, but out of pocket expenses should be considered as out of pocket cost assistance can be considerably higher for only a slightly higher monthly charge on "the marketplace standard" Sliver plan. 2. Silver plans split covered expenses 70 30. Silver plans are "the marketplace standard" meaning that premium caps are based on the cost of Sliver plans. A sliver plan on the marketplace can't cost more than 9.5% of your income if you make less than 400% of the Federal Poverty Level. The less you make, the lower your premium cap is. A sliver level plan is a good choice for individuals and families who use a few basic health services but don't have any serious health problems. 3. Gold plans split covered expenses 80 20. Gold plans cost a little more, but the lower deductibles and better out of pocket cost sharing coverage means that families won't have to worry about health care costs stopping them from their families getting the care they deserve. Even if your premium is capped you'll have to pay more to make up the difference if you want a gold plan. 4. Platinum plans split covered expenses 90 10. Platinum plans have the lowest out of pocket costs and the highest monthly premiums. This is the right choice for anyone who wants "the best coverage" for them and their family and is a smart buy for those who are sick or who have dependents who are likely to use costly health services. Even if your premium is capped you'll have to pay more to make up the difference if you want a Platinum plan. 5. Catastrophic Coverage Catastrophic coverage is available to some people under 30 and those with hardship exemptions. Catastrophic plans only cover the bare minimum health benefits and has a very limited network. You'll have high out of pocket costs and a high deductible but this type of plan will protect you in a worst case scenario and will ensure that you avoid paying the shared responsibly fee for not having health coverage. 14
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