The Patient Protection and Affordable Care Act (PPACA) Updated as of March 17, 2014 www.hcpaths.com 856.671.6000 Corporate Office: 9 Executive Campus, Cherry Hill, New Jersey 08002
www.hcpaths.com 856.671.6000 Corporate Office: 9 Executive Campus, Cherry Hill, New Jersey 08002 2
Note: Pennsylvania is not expanding Medicaid so the threshold for subsides will be 100-399% www.hcpaths.com 856.671.6000 Corporate Office: 9 Executive Campus, Cherry Hill, New Jersey 08002 3
Initial Open Enrollment Period October 1, 2013 March 31, 2014 Enroll during the Initial Open Enrollment Period Between the 16 th and the last day of December March Your coverage is effective* First day of second following month 2015 Enrollment Period November 15, 2014 to February 15, 2015 Between the 1 st and the 15 th of the month November February Between the 16 th and the last day of November February First day of following month First day of second following month www.hcpaths.com 856.671.6000 Corporate Office: 9 Executive Campus, Cherry Hill, New Jersey 08002 4
Special Enrollment Period Consumers may enroll or change QHP: Within 60 days in individual market and 30 days in small group market from qualifying event Special Enrollment Period Qualifying Events Loss of minimum essential coverage Material contract violations by Qualified Health Plans Gaining or becoming a dependent Gaining lawful presence Enrollment errors of the Marketplace Gaining or losing eligibility for premium tax credits or cost sharing reductions Relocation resulting in new or different Qualified Health Plan selection Exceptional circumstances Change in Circumstances: If you're receiving advance payments of the premium tax credit to help pay for your insurance coverage, you should report life changes, such as income, marital status or family size changes, to your marketplace. Reporting changes will help to make sure you are getting the proper amount of advance payments. www.hcpaths.com 856.671.6000 Corporate Office: 9 Executive Campus, Cherry Hill, New Jersey 08002 5
Exemptions from the Payment (Penalty) Under certain circumstances, you won t have to make the individual responsibility payment. This is called an exemption. You may qualify for an exemption if: You re uninsured for less than 3 months of the year The lowest-priced coverage available to you would cost more than 8% of your household income You don t have to file a tax return because your income is too low You re a member of a federally recognized tribe or eligible for services through an Indian Health Services provider You re a member of a recognized health care sharing ministry You re a member of a recognized religious sect with religious objections to insurance, including Social Security and Medicare You re incarcerated, and not awaiting the disposition of charges against you You re not lawfully present in the U.S. www.hcpaths.com 856.671.6000 Corporate Office: 9 Executive Campus, Cherry Hill, New Jersey 08002 6
Hardship Exemptions If you have any of the circumstances below that affect your ability to purchase health insurance coverage, you may qualify for a hardship exemption: You were homeless. You were evicted in the past 6 months or were facing eviction or foreclosure. You received a shut-off notice from a utility company. You recently experienced domestic violence. You recently experienced the death of a close family member. You experienced a fire, flood, or other natural or human-caused disaster that caused substantial damage to your property. You filed for bankruptcy in the last 6 months. You had medical expenses you couldn t pay in the last 24 months. You experienced unexpected increases in necessary expenses due to caring for an ill, disabled, or aging family member. You expect to claim a child as a tax dependent who s been denied coverage in Medicaid and CHIP, and another person is required by court order to give medical support to the child. In this case, you do not have the pay the penalty for the child. As a result of an eligibility appeals decision, you re eligible for enrollment in a qualified health plan (QHP) through the Marketplace, lower costs on your monthly premiums, or cost-sharing reductions for a time period when you weren t enrolled in a QHP through the Marketplace. You were determined ineligible for Medicaid because your state didn t expand eligibility for Medicaid under the Affordable Care Act. Your plan was cancelled since it did not meet QHP eligibility standards extension possible to 2016 www.hcpaths.com 856.671.6000 Corporate Office: 9 Executive Campus, Cherry Hill, New Jersey 08002 7
Tax Penalty: Who Will Pay & How Much If you can afford health insurance and don't buy it, you'll pay a fine when you file your 2013 income taxes in April 2014. For the first year of the new law, 2014, the fine for not having insurance is the lowest it will be. After that, it goes up steeply in 2015 and again in 2016. In 2014: There are two ways the government calculates what you owe. You have to pay whichever amount is higher. One way is to charge you $95 for each adult and $47.50 for each child, but not more than $285 total per family. The other way is to fine you 1% of your family income. If your family makes $50,000 a year, the fine will be $500. In 2015: There will still be two ways to calculate what you owe. You have to pay whichever amount is higher. One way is to charge you $325 for each adult and $162.50 for each child, but no more than $975 total per family. The other way is 2% of your family income. If your family makes $50,000 a year, the fine will be $1,000. In 2016 and beyond: There will still be two ways to calculate what you owe. You have to pay whichever amount is higher. One way is to charge you $695 for each adult and $347.50 for each child, but no more than $2,085 per family. The other calculation is 2.5% of your family income. If your family makes $50,000 a year, the fine will be $1,250. www.hcpaths.com 856.671.6000 Corporate Office: 9 Executive Campus, Cherry Hill, New Jersey 08002 8
Federal Poverty Guidelines - 2013 The law is intended to make private insurance affordable by subsidizing premium costs so that no one earning between 100 percent and 400 percent of the poverty level pays more than a specified percentage of annual income (equal to $6,350 for individuals and $12,700 for families) in out-of-pocket costs for the benchmark plan. Family size Poverty level 138% of FPL 150% of FPL 200% of FPL 250% of FPL 300% of FPL 400% of FPL 1 $11,490 $15,856 $17,235 $22,980 $28,725 $34,470 $45,960 2 15,510 21,404 23,265 31,020 38,775 46,530 62,040 3 19,530 26,951 29,295 29,060 48,825 58,590 78,120 4 23,550 32,499 35,325 47,100 58,875 70,650 94,200 www.hcpaths.com 856.671.6000 Corporate Office: 9 Executive Campus, Cherry Hill, New Jersey 08002 9
Premium Tax Credits Who is Eligible? How much will people get? The premium tax credit is generally available to individuals and families with incomes between 100% and 400% of the Federal Poverty Level ($23,550 $94,200 for a family of four in 2013) who do not have access to certain other types of minimum essential coverage, which will make coverage much more affordable for the middle class. With most tax credits, you have to wait until you file your taxes to get the credit. However,the new Advanced Premium Tax Credit (APTC), available through the Marketplace lets you reduce your premiums right away or let s you wait to receive the Premium Tax Credit (PTC) until tax time. www.hcpaths.com 856.671.6000 Corporate Office: 9 Executive Campus, Cherry Hill, New Jersey 08002 10
Cost-sharing Reductions (CSR) A program that limits the out-of-pocket costs for health benefits (like deductibles and copayments) associated with a QHP through the Marketplace. There are several categories of cost-sharing reductions based on annual household income and family size. Each insurance company applies these differently, based on their specific health plan design. Consumers who are eligible for cost-sharing reductions can review the reduced costs when they compare their available health plans. In general, CSRs are only available for consumers who select a plan at the Silver level of coverage. www.hcpaths.com 856.671.6000 Corporate Office: 9 Executive Campus, Cherry Hill, New Jersey 08002 11
Qualified Health Plan Payment for Services during Grace Period for Nonpayment of Premiums Per recently published Final Rule: QHPs are required to allow a three month grace period of non-payment of premiums before discontinuing coverage. First Month: QHPs to pay all appropriate claims for services provided during the first month of the grace period. Second Month: Allows QHPs to pend claims Third Month: Allows QHPs to pend claims If the consumer does not pay his/her outstanding premiums by the end of the three month grace period, the QHP may retroactively terminate coverage and deny all pending claims for services rendered during the second and third months. www.hcpaths.com 856.671.6000 Corporate Office: 9 Executive Campus, Cherry Hill, New Jersey 08002 12
www.hcpaths.com 856.671.6000 Corporate Office: 9 Executive Campus, Cherry Hill, New Jersey 08002 13
Pennsylvania Backlog of Medicaid Applications A bit of progress is being made in Pennsylvania, when it comes to dealing with a backlog of Medicaid applications submitted through the federal website, HealthCare.gov. To date, the state has successfully processed 400 out of an estimated 50,000 As a result, in November, officials with the Centers for Medicare and Medicaid Services, offered up applicant information to states through so-called 'flat files,' or excel spreadsheets, so states could in turn follow up with applicants directly while technical problems were being sorted out. Pennsylvania declined, says Gillis, believing the issues would be resolved shortly. The files CMS offered also didn't provide "sufficient information to accurately process these accounts." By December, CMS started notifying about 20,000 Pennsylvanians, deemed potentially eligible for Medicaid through HealthCare.gov, to reapply for Medicaid directly through the state. DPW issued a consumer alert. DPW has obtained a lot more of them 22,000, to date, of those 50,000 but many are missing essential information like social security numbers and income details, according to Gillis, by no fault of the applicants. So for applications to be complete, county workers are now charged with following up with applicants directly to confirm and fill in details. Of those 22,000 transferred accounts, 14,000 have gone through the electronic acceptance system, says Gillis, and have in turn gone to those county assistance offices to be checked. Of those 14,000 applications, 400 have been fully processed and accepted into the state Medicaid system. Another 800 accounts were identified as already existing in DPW's system. www.hcpaths.com 856.671.6000 Corporate Office: 9 Executive Campus, Cherry Hill, New Jersey 08002 14
Changes to Healthy PA Proposal Corbett and secretary of the Pennsylvania Department of Public Welfare Beverly D. Mackereth have insisted that enrollees will have to prove they are looking for full-time work to obtain benefits. The original draft of Healthy PA, published back in December, proposed that most enrollees between the ages of 21 and 65 working less than 20 hours a week demonstrate that they were fulfilling 12 job-searching activities a month in order to keep coverage. No state has ever tethered Medicaid eligibility to searching for employment. Last week, the administration signaled they are backing off. In a letter sent to Health and Human Services Secretary Kathleen Sebelius, Corbett proposed a potential modification to the waiver. From the letter, dated March 5: This proposal will be a voluntary, one-year pilot program to positively encourage those who are able to work, to participate in job training and work opportunities. This pilot program will not be a condition of eligibility, but rather those individuals who participate will lower their premiums and cost sharing as incentives Comment period is still open. www.hcpaths.com 856.671.6000 Corporate Office: 9 Executive Campus, Cherry Hill, New Jersey 08002 15
Policy Changes 2015 open enrollment extended by one month: The 2015 open enrollment period will last from November 15, 2014 through February 15, 2015 Consumers can keep their pre-affordable Care Act (ACA) coverage through 2016: To accommodate consumers who wanted to keep these plans, the Administration previously decided to allow insurers to offer consumers the option to renew their 2013 health plans through 2014. This policy has now been extended until 2016. Out-of-pocket maximums set for 2015: The out-of-pocket maximum in the small group market also will change to $2,050 for individuals and $4,100 for families (up narrowly from $2,000 for individuals and $4,000 for families). 2014 2015 $6,350 Individuals $6,600 Individuals $12,700 Families $13,200 Families Insurers applying for QHP certification in the FFM will submit complete and accurate QHP Applications into HIOS by approximately June 27, 2014. New deadline for becoming a SBM: States now have until June 15, 2014 (moved from January 1, 2014) to get approval from HHS if they want to become a state-based marketplace (SBM). Steps taken to avoid premium increases: HHS made adjustments to the reinsurance program to protect consumers from spikes in premium prices for the 2015 plan year. www.hcpaths.com 856.671.6000 Corporate Office: 9 Executive Campus, Cherry Hill, New Jersey 08002 16
www.hcpaths.com 856.671.6000 Corporate Office: 9 Executive Campus, Cherry Hill, New Jersey 08002 17
A Spin on Numbers With the first annual open enrollment period for the Affordable Care Act down to its final few weeks; this is what we know now or can reasonably expect: Enrollment may fall modestly short of meeting the administration s revised enrollment goals although still "large enough for the market to function. Starting in 2017, between 24 million and 25 million people are expected to obtain coverage each year through exchanges, and roughly 80 percent of those enrollees are expected to receive subsidies for purchasing that insurance. The enrollment numbers will be a complicated mix of people who previously didn t have coverage (the uninsured), people who had to switch plans because their old plans didn t meet ACA standards (some of whom will like their new plans, others who won t), people newly eligible for Medicaid, people who already were eligible for Medicaid but didn t know it, and people who left employer-coverage to buy a marketplace plan, either on their own volition or because they had no choice. Enrollment will vary greatly by state. Reports of success stories in some states with better than expected enrollment are likely to be counterbalanced by reports of failures in other states with lower than expected enrollment. For example, as of March 1st, Pennsylvania was way ahead of many other states in ACA marketplace penetration: out of 286,926 eligible to enroll in a marketplace plan, 159,821 just over 55.7%--had signed up. www.hcpaths.com 856.671.6000 Corporate Office: 9 Executive Campus, Cherry Hill, New Jersey 08002 18
These data are based on more than 28,000 interviews with Americans from Jan. 2-Feb. 28, 2014, as part of the Gallup-Healthways Well- Being Index. With only a few weeks remaining in the first quarter, the uninsured rate is on track to be the lowest quarterly level that Gallup and Healthways have measured since 2008. The uninsured rate has been declining since the fourth quarter of 2013, after hitting an all-time high of 18.0% in the third quarter. The uninsured rate for the first quarter of 2014 so far includes a 16.2% reading for January and 15.6% for February. www.hcpaths.com 856.671.6000 Corporate Office: 9 Executive Campus, Cherry Hill, New Jersey 08002 19
Enrollment Numbers Are In as of 02.28.2014 Key findings from February s report include: More than 4.2 million (4,242,300) people selected Marketplace plans from Oct. 1, 2013, through Mar. 1, 2014, including 1.6 million in the State Based Marketplaces and 2.6 million in the Federally-facilitated Marketplace. About 943,000 people enrolled in the Health Insurance Marketplace plans in the February reporting period, which concluded March 1, 2014. Of the more than 4.2 million: 55 percent are female and 45 percent are male; 31 percent are age 34 and under; 25 percent are between the ages of 18 and 34; 63 percent selected a Silver plan (up one percentage point over the prior reporting period), while 18 percent selected a Bronze plan (down one point); and 83 percent selected a plan and are eligible to receive Financial Assistance (up one point). www.hcpaths.com 856.671.6000 Corporate Office: 9 Executive Campus, Cherry Hill, New Jersey 08002 20
HEALTH INSURANCE MARKETPLACE: DECEMBER ENROLLMENT REPORT For the period: October 1 February 28 Published by HHS on March 11, 2014 www.hcpaths.com 856.671.6000 Corporate Office: 9 Executive Campus, Cherry Hill, New Jersey 08002 21
Obama says enrollment is high enough to ensure his health law's survival. "President Obama said Friday, March 14 th that he was confident enough Americans had enrolled under the Affordable Care Act to make the program 'stable.' In an interview with WebMD, Obama said the fact that 4.2 million people have already signed up for plans under federal and state marketplaces mean enough companies will be invested to stay in the system... Obama noted, however, that the larger question is whether the risk pool is diverse enough to ensure premiums don't skyrocket, since "the more you can spread the risk with more people, the better deal you're going to get"...even as he touted the virtues of the law, Obama acknowledged that some previously-uninsured Americans may not be able to see the providers they want if they were focused on keeping costs down." Juliet Eilperin in The Washington Post. www.hcpaths.com 856.671.6000 Corporate Office: 9 Executive Campus, Cherry Hill, New Jersey 08002 22
The latest report by the Department of Health and Human Services says only 27 percent of enrollees as of Feb. 28th were aged 18 to 34, short of the 40 percent goal among a demographic considered vital to making the law work. www.hcpaths.com 856.671.6000 Corporate Office: 9 Executive Campus, Cherry Hill, New Jersey 08002 23
National Age < 18 6% Age 18 25 10% Age 55 64 29% Age 26 34 16% With Assistance No Assistance 17% Platinum 5% Gold 11% Bronze 16% Catastrop hic 1% Age 45 54 23% Age 35 44 16% 83% Silver 67% Pennsylvania Age < 18 3% Age 55 64 34% Age 45 54 22% Age 26 34 17% Age 35 44 15% Age 18 25 9% 20% 80% Platinum 9% With Assistance No Assistance Gold 15% Silver 68% Catastrop hic 1% Bronze 7% www.hcpaths.com 856.671.6000 Corporate Office: 9 Executive Campus, Cherry Hill, New Jersey 08002 24
Total Marketplace Eligibility Determinations, and Marketplace Plan Selection By Marketplace Type and State 10 1 2013 to 3 1 2014 State Name Number of Individuals Determined Eligible to Enroll in a Marketplace Plan Total Eligible to Enroll in a Marketplace Plan Eligible to Enroll in a Marketplace Plan with Financial Assistance Determined or Assessed Number of Individuals Who Eligible for Medicaid / CHIP Have Selected a Marketplace by the Marketplace Plan States Implementing Their Own Marketplaces (SBMs) Number Number Number Number Maryland 50,900 42,786 103,670 38,070 New York 533,948 258,556 310,645 244,618 States With marketplaces that are Supported by or fully Run by HHS (FFM) Delaware 15,085 9,023 7,663 6,538 New Jersey 187,231 110,509 123,092 73,370 Pennsylvania 349,151 195,218 32,793 159,821 www.hcpaths.com 856.671.6000 Corporate Office: 9 Executive Campus, Cherry Hill, New Jersey 08002 25
www.hcpaths.com 856.671.6000 Corporate Office: 9 Executive Campus, Cherry Hill, New Jersey 08002 26
Health Insurance Marketplace Patient Navigator Organizations and Contacts for Pennsylvania Resources for Human Development Philadelphia, PA 19144 4248 1 855 668 9536 healthinsurance@rhd Pennsylvania Association of Community Health Centers Wormleysburg, PA 17043 717 761 6443 1 866 944 CARE Pennsylvania Mental Health Consumers Association Pennsylvania Mental Health Consumers Association Harrisburg, PA 17111 Ellen@PMHCA.org Mental Health America Alexandria, VA 22311 1 267 507 3894 www.hcpaths.com 856.671.6000 Corporate Office: 9 Executive Campus, Cherry Hill, New Jersey 08002 27
Revenue Cycle Impact Problems identifying the patient as an exchange/marketplace consumer Patients unaware of very high co-pays and deductibles Patients unfamiliar with HMO regulations Exchange plans have slower payment time frames Unclear EOB's in regards to Cost Sharing Reductions Verifying eligibility through normal channels Long wait times for calls to insurers Possible increase in turn around time for Medicaid Applications Charity Care Policies Self Pay procedures and follow up www.hcpaths.com 856.671.6000 Corporate Office: 9 Executive Campus, Cherry Hill, New Jersey 08002 28
Resources http://marketplace.cms.gov/ Heath Insurance Marketplace If you re a professional learning about the Marketplace and helping people apply, get the latest resources here. https://www.healthcare.gov/ Marketplace website for individuals and small businesses. http://cms.hhs.gov/ Centers for Medicare and Medicaid Services http://cciio.cms.gov/ The Center for Consumer Information and Insurance Oversight (CCIIO) is charged with helping implement many provisions of the Affordable Care Act, the historic health reform bill that was signed into law March 23, 2010. CCIIO oversees the implementation of the provisions related to private health insurance. http://www.dpw.state.pa.us/affordablecareact/index.htm The Affordable Care Act will dramatically change the health care landscape in Pennsylvania and primarily affect people who do not have health care or who have limited health care coverage. Individuals and families using this page will be directed to the resources they need to get their health insurance questions answered. www.hcpaths.com 856.671.6000 Corporate Office: 9 Executive Campus, Cherry Hill, New Jersey 08002 29
Contact Information Tony DiLuca 856.671.6000 tdiluca@hcpaths.com Anne DelPizzo 856.671.6000 adelpizzo@hcpaths.com www.hcpaths.com 856.671.6000 Corporate Office: 9 Executive Campus, Cherry Hill, New Jersey 08002 30