Understanding the Health Insurance Marketplace August 14, 2013 Catherine Leonis Health Insurance Marketplace To provide qualified individuals and employers Access to affordable coverage options Ability to buy certain private health insurance Access to health insurance information Allows apples-to-apples comparison of Qualified Health Plans 2 How the Marketplace Works Coverage to fit individual needs Marketplace affordability May be able to get lower costs on premiums and outof-pocket costs Unbiased help and customer support provided Quality health coverage Easy to use 3 1
How the Marketplace Works (Continued) One process to determine eligibility for Qualified Health Plans through the Marketplace New tax credits to lower premiums Reduced cost sharing Medicaid Children s Health Insurance Program (CHIP) Offers choice of plans and levels of coverage Insurance companies compete for business 4 Essential Health Benefits Ambulatory patient services Emergency services Hospitalization Qualified Health Plans cover Essential Health Benefits which include at least these 10 categories Maternity and newborn care Mental health and substance use disorder services, including behavioral health treatment Prescription drugs Rehabilitative and habilitative services and devices Laboratory services Preventive and wellness services and chronic disease management Pediatric services, including oral and vision care (pediatric oral services may be providedby stand-alone plan) 5 How the Marketplace Works hi 6 2
Application and Eligibility Submit streamlined application to the Marketplace Verify and determine eligibility Premium Tax Credit Cost-sharing Reduction Eligible for Qualified Health Plan, Medicaid or CHIP Enroll in Marketplace Qualified Health Plan Online By Phone By Mail In Person Supported by Data Services Hub Enroll Medicaid/CHIP 7 A New Way to Lower Premium Costs A new refundable or Advanced Premium Tax Credit (APTC) that lowers the cost of Qualified Health Plans Eligibility is based on Household income, and family size (at end of year) Income between 100% to 400% of the Federal Poverty Level (FPL) ($23,550 $94,200 for a family of four in 2013) Obtaining qualified health insurance through the Marketplace Ineligibility for government-sponsored coverage, affordable employer-sponsored insurance, or certain other minimum essential coverage 8 Marketplace Assistance Assisters Navigators In-person Assisters SBM (optional) Consumer SPM (required) Certified Application Counselors (CACs) Agents/Brokers Call Center Representatives Listed on www.healthcare.gov in Local Help & Customer Service Referrals 3
Enrollment Assistance Help available in Marketplaces The Marketplace Toll-Free Call Center Certified Assisters Navigators program Non-Navigator in-person assisters Agents and brokers HealthCare.gov and state Marketplace websites 10 Navigator Responsibilities Navigators must Maintain expertise in eligibility, enrollment, and program specifications and conduct public education activities Distribute fair, accurate, and impartial information about enrollment in Qualified Health Plans (QHPs) and other health programs such as Medicaid and CHIP Facilitate selection of a QHP Refer consumers to Consumer Assistance Programs (CAPs) and other ombudsmen programs Provide information in a manner that is culturally and linguistically appropriate and accessible for people with disabilities Navigator Requirements Navigators must Provide fair, accurate, impartial information about full range of QHP and coverage options Meet conflict of interest standards May not accept direct or indirect compensation from issuers related to enrollment in QHPs or non-qhps Must disclose certain other potential conflicts of interest Comply with privacy and security requirements May not retain any personally identifiable information about consumers 4
Navigator Requirements Navigators in FFM/SPM states must Be trained and certified Must take initial web-based training and pass exam Up to 30 hours Must take required on-going training Must be recertified annually States may add additional training requirements Meet grant reporting requirements Submit progress, financial, and performance reports SBMs develop own requirements/standards Certified Application Counselors (CAC) Provide assistance in every Marketplace Educate consumers about insurance affordability programs and coverage options Help consumers apply for coverage through the Marketplace Marketplace designates organizations that may serve as CACs For example, community health centers, hospitals, other health care providers, social service agencies CAC Responsibilities Have more limited role than other assisters Only help with eligibility and enrollment Certified application counselors aren t required to Conduct outreach activities Make referrals to CAPs, ombudsmen Help with complaints, grievances, or appeals Provide assistance to SHOP employers 5
CAC Responsibilities Have different conflict of interest standards Must act in best interest of consumers Don t have same fair and impartial standard Must provide information about full range of QHP options and insurance affordability programs May have potential conflicts of interest as long they re disclosed to consumers and Marketplace For example, financial or business relationships with QHPs or non-qhps CAC Requirements Training and certification is shorter Must take abbreviated initial training and pass exam On-going training and/or recertification may be required Funding for CACs and designated organizations No new funding through Marketplace May receive other private, state, or federal funding Counselors may be paid by employers for their labor CAC Designation Process FFM will designate certain types of organizations Must have processes to screen staff/volunteers to ensure they protect personally identifiable information Must engage in services that position them to help those they serve with health coverage issues Must have experience providing social services State-based Marketplace may follow FFM guidance for designating organizations or establish own processes 6
Examples of Qualified Organizations Community health centers, including FQHCs Hospitals Health care providers Mental or behavioral health providers Ryan White HIV/AIDS providers Agencies with experience providing social services Other local governmental agencies that have similar processes and protections in place Such as other health care providers, health departments and libraries How Organizations Can Apply May apply to be a designated organization for FFM or SPM http://marketplace.cms.gov/help-us/cac-apply.html How Organizations Can Apply CAC application information Organization name, contact information, and nature of business Whether organization is designated as a Medicaid or CHIP application assistance program Whether organization is a governmental entity or 501(c) Whether organization screens employees/volunteers it will certify as CACs Whether organization or its employees/volunteers already handle personally identifiable information Organization s experience, if any, assisting individuals applying for health coverage 7
Post-Designation Process Organization enters into written agreement with FFM Organizations have certified application counselors sign an agreement promising to keep personal consumer information private and secure FFM will provide sample agreement Once organization has entered into the agreement, it will be listed on the FFM website as having certified application counselors available to help consumers apply for and enroll in coverage Updates 23 HealthCare.gov Cuidadodesalud.gov for Spanish The consumer site for info now, application and plan comparison in Oct Social media connections Responsive design Accessible for those with visual disabilities 24 8
National Marketplace Toll-Free Call Center for Federally Facilitated and State-Partnership Marketplaces 1-800-318-2596 (TTY 1-855-889-4325) Customer service representatives - 24/7 English and Spanish Language line for 150 additional languages June September Provide general information to individuals in the Marketplace and employees of SHOP employers SHOP call center for Employers opens in August Starting October Eligibility, enrollment and referral assistance 25 Champion for Coverage Send partners, members or customers to the official Marketplace website Post www.healthcare.gov on your website Host a webinar of other educational event Provide enrollment sessions Promote the Marketplace through widgets, badges and social media sites such as Twitter and Facebook 26 A Look Ahead August 2013 October 1, 2013 Expect training to begin for consumer assisters like Navigators as well as for agents and brokers SHOP (Employer) Call Center live January 1, 2014 Open enrollment in the Health Insurance Marketplace begins Coverage through Health Insurance Marketplace begins (as early as) Discrimination due to pre-existing conditions or gender is prohibited Annual Limits on Insurance Coverage will be eliminated Advanced Premium Tax Credits will be available The Small Business Tax Credit will increase More people will be eligible for Medicaid (in some states) 27 9
5 Ways to Connect With the Marketplace 1. Sign up for email or text updates: HealthCare.gov/subscribe 2. Twitter.com/HealthCareGov - Follow @HealthCareGov 3. Facebook.com/HealthCareGov 4. Youtube.com/HealthCareGov 5. The Health Insurance Blog: http://www.healthcare.gov/blog/ 28 10