Affordable Care Act and the Health Insurance Marketplace

Affordable Care Act and the Health Insurance Marketplace Nilsa Gutierrez, MD, MPH Chief Medical Officer Centers for Medicare & Medicaid Services, Region II

ACA Discussion Points Consumer Protections Consumer Protection Benefits to New Jerseyans The Uninsured: National and NJ Profile NJ Heath Insurance Marketplace

The Health Care Law On March 23, 2010, President Obama signed into law the Affordable Care Act, and ratified by Supreme Court on 2012 The three overarching goals of the ACA are: Make Healthcare more Affordable, Improve Access to Care and Protect Consumers from Insurance Company Abuses

Visit www.hhs.gov for a full list

SOME BENEFITS TO DATE 105 million Americans have been protected against lifetime insurance payment cap limits since 2010. (3.2M people in NJ, including more than 1.2M women and 877,000 Children) More than 3 million young people can stay on their parents' policies until they're age 26. (including 73,000 young adults in NJ) 129 million non-elderly Americans with pre-existing conditions beginning January the 1st can no longer be denied or discriminated against by health insurance companies. (affects 3.8M persons and almost 500,000 in NJ) 71 million people on private insurance have used no cost and no co-pay preventive services. (2,209,000 in NJ) 7 million seniors have saved $8 billion in discounts on prescription drugs. 9

The Uninsured National and New Jersey Profile

Who Are the Uninsured? 1 in 2 has an income below 138% FPL 1 in 5 has not finished high school 1 in 2 identifies as a racial or ethnic minority 1 in 5 has limited English proficiency 1 in 2 uninsured adults do not have a usual source of care 2 in 5 had no health care visit in the past year 1 in 2 likely to have been uninsured for more than 12 months 11

The Uninsured by Race/Ethnicity Source: U.S. Census Bureau Current Population Survey, Annual Social and Economic Supplement, 2012 **Other is defined as Asian, Pacific Islander, Alaskan Native, American Indian, and more than one race *All racial groups are non-hispanic

Uninsured Population in New Jersey Total State Population: 7,203,170 Eligible Uninsured Population: 901,290 individuals 12.5% of total population 13

Reaching the Uninsured in New Jersey www.enrollamerica.org/maps 14

Counties with more than 50,000 Uninsured County Number of Uninsured Essex 109,610 Hudson 94,173 Middlesex 90,782 Bergen 80,167 Passaic 69,105 Union 59,003 Camden 54,011 Monmouth 53,396 >50,000 Uninsured 15

Counties with less than 50,000 Uninsured County Number of Uninsured Ocean 42,585 Burlington 39,355 Atlantic 34,781 Morris 31,957 Gloucester/Salem 31,010 Mercer 28,526 Cumberland 27,193 Somerset 21,737 Cape May 10,925 Sussex 9,762 Hunterdon 7,101 Warren 6,110 16

Profile of Uninsured in NJ Age Race/Ethnicity Age 0-18 Age 19-25 Age 26-34 Age35-54 Age 55-64 Latino White (Non-Latino) Black (Non-Latino) Asian (Non-Latino) Multiracial or Other 106,684 157,959 187,611 336,112 112,919 276,921 363,316 160,740 77,930 21,981 < High School Education High School Diploma College Graduate 155,217 595,794 150,274 Primary Languages Spoken (Other than English) Spanish Chinese Korean Vietnamese Tagalog Russian Other Language 139,677 10,066 9,001 2,388 2,108 1,198 48,521 17

Passaic County 69,105 Uninsured Individuals Age Race/Ethnicity Age 0-18 Age 19-25 Age 26-34 Age35-54 Age 55-64 Latino White (Non-Latino) Black (Non-Latino) Asian (Non-Latino) Multiracial or Other 9,649 14,785 12,643 23,597 8,431 36,270 21,185 8,733 2,530 386 % of FPL < 138% FPL 139%-400% FPL >400% FPL 32,861 28,752 7,491 Primary Languages Spoken (Other than English) Spanish Chinese Korean Vietnamese Tagalog Russian Other Language 17,211 486-51 - 237 3,389

New Jersey Health Insurance Marketplace

Health Insurance Marketplace? Centerpiece of the Affordable Care Act (ACA) New way to buy health insurance Even working families can get help through the Marketplace Enrollment starts October 1, 2013 Coverage begins January 1, 2014 Everyone must obtain insurance through the Marketplace except for people who have private insurance, employer sponsored insurance, retirement insurance, Medicare, Medicaid, Tricare, or VA Health Benefits. o Excluded are undocumented individuals and the incarcerated. o Hardship exemption is available

States Health Insurance Marketplace Decisions, May 10, 2013 WA OR NV CA ID AZ UT* MT WY CO NM ND SD NE KS OK MN WI IA IL MO AR MS VT NY MI PA OH IN WV VA KY NC TN SC AL GA ME N MA H RI CT NJ DE MD DC AK HI TX LA FL State-based Marketplace (16 states and DC) Partnership Marketplace (7 states) Federally-facilitated Marketplace (27 states) * In Utah, the federal government will run the marketplace for individuals while the state will run the small business, or SHOP, marketplace.

Medicaid Expansion States have the option to expand Medicaid eligibility to adults ages 19 64 with incomes up to 133% of the Federal Poverty Level (FPL): $15,282/year for an individual, $31,322/yr. for family of 4 100% federal funding for newly Medicaid eligible States have no deadline to decide if they are going to expand One streamlined application for Medicaid or private health plans Shifts to simplified way of calculating income to determine Medicaid/CHIP eligibility Known as Modified Adjusted Gross Income (MAGI)

Medicaid/CHIP: Who is Currently Eligible? Source: kff.org

Introduction to the Marketplace The Marketplace (or Exchange) Is a place for individuals and small employers to directly compare private health insurance options - known as Qualified Health Plans (QHPs) Simplifies the search for health insurance All options in one place One application, one time, and an individual or family can explore every qualified insurance plan in the area. Can directly compare on the basis of price, benefits, quality, and other factors

Eligibility and Enrollment Marketplace initial open enrollment period starts October 1, 2013 and ends March 31, 2014 Marketplace eligibility requires consumers to 1) Live in its service area, and 2) Be a U.S. citizen or national, or 3) Be a non-citizen who is lawfully present in the U.S. for the entire period for which enrollment is sought 4) Not be incarcerated

Essential Health Benefits Qualified Health Plans cover Essential Health Benefits which include at least these 10 categories Ambulatory patient services Emergency services Hospitalization 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 Not required in benefits plan if stand-alone dental plan is in the Marketplace in which the plan operates

Catastrophic Plans Who is eligible? Young adults under 30 years of age Those who can not afford coverage and obtain a hardship waiver from the Marketplace What is catastrophic coverage? Plans with high-deductibles and lower premiums Includes coverage of 3 primary care visits and preventive services with no out-of-pocket costs Protects consumers from high out-of-pocket costs

Federal Poverty Level 2013 All States (Except Alaska and Hawaii) and D.C. Household Size 100% 133% 138% 150% 200% 250% 300% 400% 1 $11,490 $15,282 $15,856 $17,235 $22,980 28,725.00 $34,470 $45,960 2 15,510 20,628 $21,404 23,265 31,020 38,775.00 46,530 62,040 3 19,530 25,975 $26,951 29,295 39,060 48,825.00 58,590 78,120 4 23,550 31,322 $32,499 35,325 47,100 58,875.00 70,650 94,200 5 27,570 36,668 $38,047 41,355 55,140 68,925.00 82,710 110,280 6 31,590 42,015 $43,594 47,385 63,180 78,975.00 94,770 126,360 7 35,610 47,361 $49,142 53,415 71,220 89,025.00 106,830 142,440 8 39,630 52,708 $54,689 59,445 79,260 99,075.00 118,890 158,520

Who is eligible for Premium Tax Credit & Cost Sharing Reductions Premium Tax Credit is available to consumers with household incomes between 100% and 400% of the FPL and who don t qualify for other health insurance coverage o For an individual up to $45,960 in 2013 o For family of 4 up to $94,200 in 2013 Cost Sharing Reduction is generally available to those with income 250% FPL or below ($28,725 for an individual and $58,875 for a family of 4 in 2013)

Population (uninsured) State-Wide Uninsured by Income 400,000 350,000 300,000 250,000 Individual <$11,490 $11,491-$15,856 $15,857-$45,960 >$45,960 200,000 150,000 100,000 50,000 - < 100% 100% - 138% 139% - 400% > 400% Family of Four <$23,550 $23,551-$32,499 $32,500-94,200 >$94,200 33

How to Apply On Line Four Easy Ways to Enroll Convenient Streamlined By Mail By Phone In Person

Apply On Line www.healthcare.gov User friendly & easy to navigate Accessible for the visually impaired Available in Spanish: www.cuidadodesalud.gov

Apply by Phone 1-800-318-2596 From June to September 2013, the Call Center will respond to general inquiries about: o Health Insurance o Program o Preparation What s a premium? What s a deductible? I have insurance, will I be impacted? Where can I go to get additional information? When will I need to make a decision? Available for enrollment after October 1, 2013

Apply in Person In person assisters will be available to help prepare electronic and paper applications to establish eligibility and to enroll in coverage through the Marketplace o Navigators Federally Funded o Certified Application Counselor Local Community Health Centers Local Hospitals Libraries Faith-based institutions Other locations in local communities o Agents and brokers

You May Pay a Fee Starting in 2014, most people must enroll in a health insurance plan If you don t have a certain level of health coverage (employer coverage, Medicare, Medicaid, CHIP, TRICARE, certain VA coverage, an individual policy, or a plan in the Marketplace) you may have to pay a fee with your tax return Starting when you file your 2014 Federal tax return in 2015 Some people may qualify for an exemption

Navigator Program Navigators must Be certified Must take initial 20 hour web-based training Must take required on-going training Be recertified annually Not accept direct or indirect consideration from issuers Meet reporting requirements progress, financial, and performance Federally Facilitated and State-Partnership Marketplaces Find Navigators and other assisters by calling the Call Center or HealthCare.gov under Find Someone Local 05/09/2013 A New Way to Get Health Insurance 40

NEW JERSEY NAVIGATORS 1. Center For Family Services, Inc. : Seven southern counties 2. Orange ACA Navigator Project : Essex County* 3. Urban league of Hudson County: Primarily Hudson County, also cover Bergen, Morris & Union Counties 4. Public Health Solutions: Hudson & Essex Counties 5. FoodBank of Monmouth and Ocean Counties, Inc.

Certified Application Counselors The Federally-facilitated Marketplace will designate organizations to certify application counselors who perform many of the same functions as Navigators and non- Navigator assistance. Marketplace.cms.gov 05/09/2013 A New Way to Get Health Insurance 42

Ways your organization can be a Champion for Coverage Send your partners/members/customers to the official consumer sources to learn about the Marketplace and get coverage: HealthCare.gov CuidadoDeSalud.gov 24/7 Consumer Call Center: 1-800-318-2596 Send an email to your network about the Marketplace. Post the HealthCare.gov and/or CuidadoDeSalud.gov widget on your website. Hang posters and/or give out fact sheets and brochures about the Marketplace. Host a conference call, webinar, or another educational event about the Marketplace. Include a story about the Marketplace in your organizational newsletter or other publication. Record and send out a public service announcement about the Marketplace. Have your staff/members learn about the Marketplace in educational sessions. Connect with your partners/members/customers through official Marketplace social media channels to share their stories: Facebook.com/HealthCare.gov Facebook.com/CuidadoDeSalud.gov @HealthCareGov @CuidadoDeSalud Provide space for enrollment sessions or fairs (ideally, with computers so people can check out the Marketplace online).

More Marketplace Information www.healthcare.gov www.cuidadodesalud.gov (Spanish language) www.marketplace.cms.gov Twitter@HealthCareGov facebook.com/healthcare.gov Champions for Coverage: http://marketplace.cms.gov/helpus/champion.html Certified Application Counselors: http://marketplace.cms.gov/help-us/cacapply.html

Data Source www.data.cms.go v www.marketplace.cms.gov 46

Contact Information Nilsa Gutierrez MD, MPH, Chief Medical Officer, CMS Nilsa.Gutierrez@cms.hhs.gov 212-616-2212