Navigating the Federal Marketplace AFFORDABLE CARE Open Enrollment is here!
Reminders On November 20 at 9:30 AM ET, IPHCA is hosting a call with Matt Cesnik from FSSA again. CMS has released guidance on PII. https://marketplace.cms.gov/technical-assistanceresources/obtain-consumer-authorization.pdf
Help Paying for Health Insurance Premium Tax Credit (PTC) Lowers the monthly premium amount Available to consumers 100-400% of the Federal Poverty Level (FPL) Cost-Sharing Reduction Program (CSR) Reduces out-of-pocket costs for consumers Available for consumers up to 250% FPL Consumer must select at least a Silver plan
Who is eligible for the PTC and CSR? Individual must be a citizen, national or legal resident of U.S. Not currently incarcerated Meet income requirements Meet tax-based requirements Lack access to Minimum Essential Coverage (MEC) OR Have MEC available, but the premium amount is 9.5% of household income or does not provide minimum value (at least 60% actuarial value)
Premium Tax Credit (PTC) Full Advanced Payment Reduces monthly premium cost Paid in full to insurance carrier Potential to owe at tax filing if income increases Partial Advanced Payment Reduces premium costs & likelihood of PTC overpayment Consumer bears more of the premium cost immediately Claim Later Ensures that PTC is not overpaid and that consumer will not owe at tax filing Consumer bears the full cost of the premium immediately
Cost-Sharing Reductions (CSR) Eligibility Requirements Meet all requirements for the PTC Have household income between 100% to 250% of the Federal Poverty Level (FPL) Enroll in a Silver plan (70% Actuarial Value) on the federal Marketplace
Cost-Sharing Reductions (CSR) Benefits Increases the Actuarial Value (AV) of health coverage plans for low-income consumers Reduce out-of-pocket costs for consumers Offered in addition to PTC Qualifying individuals do not have to apply for CSR separately
HEALTH INSURANCE PLANS
What s Offered on the Marketplace? The Marketplace offers four categories of Qualified Health Plans (QHPs), known as Metal Levels Distinguished by the share of health care costs the QHPs are expected to cover (Actuarial Value) Catastrophic plans Stand-alone plans such as dental Small Business Options Health Program (SHOP)
Actuarial Value and Metal Tiers
The Individual Mandate Also called the Individual Shared Responsibility Requirement Affordable Care Act (ACA) condition requiring individuals to maintain health coverage for themselves and their dependents, receive an exemption, or pay a penalty o Health coverage must be considered Minimum Essential Coverage (MEC) o All Qualified Health Plans (QHPs) on the Marketplace must cover 10 Essential Health Benefits (EHBs)
Shared-Responsibility Payment
Minimum Essential Coverage (MEC) TYPES OF MINIMUM ESSENTIAL COVERAGE Coverage under a government sponsored program including: The Medicare Program The Medicaid Program The Children s Health Insurance Program (CHIP) Veteran s Administration programs including TriCare and CHAMP VA Coverage for Peace Corps Volunteers Coverage under an employer-sponsored health plan Coverage under a health plan offered in the individual market within a State Coverage under a grandfathered health plan Additional coverage as specified such as Refugee medical assistance and Medicare advantage plans
Minimum Essential Coverage (MEC) NOT CONSIDERED MINIMUM ESSENTIAL COVERAGE Policies that cover only a specified disease or illness Medi-gap policies Accidental death and dismemberment coverage Disability insurance Workers compensation Coverage for employer-provided on-site medical clinics Limited-scope dental or vision benefits Long-term care benefits
Essential Health Benefits (EHBs) What are Essential Health Benefits (EHBs)? Comprehensive package of items and services within at least these 10 categories.
Qualified Health Plans (QHPs) Plans sold on the Marketplace must be certified as QHPs which: o Provide Minimum Essential Coverage (MEC) o Cover Essential Health Benefits (EHBs) o Meet Actuarial Value (AV) o Meet provider network standards QHPs are the only plans that an individual can purchase that are eligible for the Premium Tax Credit (PTC) or Cost-Sharing Reductions (CSRs)
Catastrophic Coverage What is it? Plans with high deductibles and lower premiums Includes 3 primary care visits per year and preventive services with no out-of-pocket costs Who is eligible? Young adults under 30 Those who qualify for a hardship exemption Those whose plan was cancelled and believe Marketplace plans are unaffordable People who enroll in catastrophic health plans are not eligible for PTC.
Excepted Benefit Plans Plans that cover a specific service or condition and do not provide comprehensive health coverage Stand-alone dental plans are the only excepted benefit plans offered on the Marketplace Not offered in the metal tier levels of QHP Subject to a $700 maximum out of pocket amount for a single individual and $1,400 for family May be purchased using the APTC Not eligible for cost-sharing reductions
Screening Consumers To purchase coverage on the Marketplace, individuals must: Be a United States citizen or legal resident Reside in the state they are applying in Not be incarcerated Screen for: Household size Household income Plan to file taxes Doctor preferences Knowledge of ACA and Marketplace
Preparing to Apply Before and during the application process, you ll want to explain certain key things to each consumer like: What to expect during the application process How the Marketplace verifies provided information and how it remains private Who determines the consumers eligibility The Department of Health & Human Services (HHS) and the Department of the Treasury
Application Basics: Reporting Household Size Include Consumer Consumer s spouse Children who live with the consumer, even if they make enough money to file a tax return themselves Unmarried partner needing health coverage Anyone claimed as a dependent on tax return, even if they don t live with the consumer Anyone else under 21 who consumer lives with and takes care of Do NOT Include Unmarried partner who does not need health coverage Unmarried partner s children, if they are not consumer s dependents Parents living with the consumer, but file their own tax return and are not consumer s dependents Other relatives who file their own tax return and are not the consumer s dependents
Application Basics: Estimating Income Include Consumer s and their spouse s gross income, if they are married and will file a joint tax return Any dependent s gross income who is required to file a tax return Wages Salaries Tips Net income from any self-employment or business Unemployment compensation Social security payments, including disability payments but not SSI Alimony Do NOT Include Child support Gifts Supplemental Security Income (SSI) Veterans disability payments Workers compensation Proceeds from loans (like student loans, home equity loans or bank loans)
Modified Adjusted Gross Income (MAGI) APTC and CSR (as well as Medicaid) rely on the measure of income known as MAGI Adjusted Gross Income (AGI) Any social security benefits (not included in AGI) Tax Exempt Interest or Foreign Earned Income MAGI Add up the income of all household members who must file taxes
Modified Adjusted Gross Income (MAGI) Adults Parents and Caretaker relatives Children IMPACTS Pregnant Women DOES NOT IMPACT Aged Blind Disabled Those needing longterm care Former foster children under age 26 Deemed newborns
Completing the Application: Disability Questions The consumer should answer yes to the Marketplace disability question if he or she and/or other household members: Is blind, deaf, or hard of hearing Receives SSDI or SSI Has physical, intellectual or mental health condition causing: Serious difficulty completing activities of daily living Difficulty doing errands Activities of daily living Bending Hearing Thinking Sleeping Seeing Eating Lifting Breathing Standing Walking Serious difficulty concentrating, remembering or making decisions Difficulty walking or climbing stairs
Completing the Application: Employer-Sponsored Coverage The Marketplace may require consumers who are currently employed with access to employer-sponsored coverage to enter additional information about: Who (with employer) to contact about employee health coverage (usually HR) Amount employee pays for premium cost Any known changes in future employer coverage Whether employer-sponsored coverage meets minimum value
Assisting Immigrants There are two categories of immigrants for federal benefits eligibility purposes: Qualified Not Qualified Lawfully Permanent Residents Undocumented Refugees, Asylees,Conditional entrants immigrants Cuban and Haitian entrants Parolees (in U.S. for more than 1 year) Certain American Indians Persons granted withholding of deportation/removal Lawfully present individuals (e.g. nonimmigrant visa holders; i.e. students or temporary workers) For Medicaid: Individuals who have met the 5 year waiting period (post-august 22, 1996 with some exceptions)
Assisting Immigrants Eligibility Rules - Undocumented immigrants are ineligible to purchase QHPs and are exempt from the penalty - May be eligible for Medicaid payment of package E Emergency Services or services through FQHCs or other health centers - Immigrants must be in a status recognized by HHS as lawfully present
Assisting Immigrants: Unique Challenges The Marketplace can t require applicants to provide information about citizenship or immigration status of any household members who are not applying for coverage Information obtained on the Marketplace application cannot be used by the Immigration and Customs Enforcement (ICE) or Department of Homeland Security (DHS) for immigration enforcement purposes The Call Center can connect language lines for immediate interpretation into 150 languages
Coverage Start Dates The start date for federal Marketplace coverage: o Based on the date a consumer completes enrollment in a QHP In general: o Coverage purchased before the 15 th of the month is effective the 1 st of the next month o Coverage purchased after the 15 th is effective the 1 st of the following month 2014/2015 Enrollment Date Effective Coverage Date November 15 th - December 15 th January 1, 2015 December 16 th - January 15 th February 1, 2015 January 16 th - February 15 th March 1, 2015
What Happens After Enrollment? The consumer must pay the first month s premium by the insurer s deadline to the insurer to initiate the coverage Issuers must accept at lease these payment methods: Paper check Cashier s check Money order Electronic fund transfer (EFT) Pre-paid debit card Some issuers may also accept online credit card or debit card payments
What Happens After Enrollment? The consumer should check with their insurance company to make sure they have enrolled and paid their first premium Educate the consumer on: Reviewing their member card and plan information Reporting life changes and income changes to the Marketplace Annual renewal process Supply the consumer with: Links to other community resources Information about using health insurance (Like the Coverage 2 Care platform)
Best Practices Offer services for extended hours, including nights and weekends Monitor wait times Coordinate consumers appointments so they align with other appointments consumers may have with your organization Establish a follow-up process to ensure that consumers receive health insurance Ensure that staff and volunteers are familiar with your organization s policies regarding outreach, in-reach and using personally identifiable information (PII) Set up an organizational reminder system that notifies people about their appointments by texting, emailing, or calling them the day before
Best Practices Build trust with consumer by greeting them warmly, smiling and listening carefully throughout the appointment Be patient, detail-oriented and take your time Ensure appropriate accommodations are available for consumers with disabilities Have the appointment in a space that is private and free from distractions Assist consumers in a culturally sensitive manner Check with the consumer frequently to make sure that he or she understands the information
Reporting Life Changes Once a consumer has Marketplace coverage, they are responsible for reporting certain life changes which may change the coverage or savings they re eligible for.
Reporting Life Changes Consumers should report changes as soon as possible, which may activate a special enrollment period (SEP) SEPs generally last 60 days from the life event Reporting a change: Online Log-in to account. Select the application, then select Report a life change A new eligibility notice will be generated that will explain eligibility for a SEP, lower costs, and other options (Medicaid) By phone Contact the Marketplace Call Center and a representative will authorize the SEP
Special Enrollment Periods SEP Event Loss of coverage Marriage Denial of Medicaid or CHIP Birth, Adoption, Foster Care Gaining lawfully present status Newly eligible or ineligible for APTC, change in CSRs Moving & Incarceration Release Native American status QHP Effective Date If loss of coverage is in the past, 1 st of the month following QHP selection. If loss is in the future, 1 st of the month following loss of coverage 1 st of the next month following plan selection Date of birth, adoption, placement of adoption or placement in foster care Within 1 st 15 days of the month: 1 st of the month On or after 16 th of the month: 1 st of the month after next
The Annual Enrollment Period Annual Redeterminations Insurer will send information prior to November 15 th about updated premiums and benefits If consumer is happy with current plan and income or household size HAVE NOT changed s/he doesn t need to do anything. o The Marketplace will auto-enroll the consumer in the same plan for 2015 If income or household size HAVE changed, the consumer will need to report it to the Marketplace to get the correct PTC amount o If information is not updated, the PTC from 2014 will be used 2014-2015 OPEN ENROLLMENT PERIOD: NOVEMBER 15 FEBRUARY 15
Exemptions Individuals seeking an exemption from the individual shared responsibility requirement may apply for one or more of the exemption types To be eligible for an exemption in any month, the individual must meet the criteria for the exemption for at least one day in that month.
Exemptions Uninsured for < 3 months of the year Lowest-priced coverage available costs more than 8% of household income Income below tax filing limit Member of a federal recognized tribe or eligible for services through an Indian Health Services Provider Member of a recognized religious sect with religious objections to insurance Incarcerated and not awaiting disposition of charges Not lawfully present Suffer a hardship http://familiesusa.org/sites/default/files/product_doc uments/exemptionschart_0.pdf
Exemptions Tips for helping consumers with an exemption application 1.Read each type of exemption to find best fit for consumer 2.Submit supporting documents with application 3.Do not leave questions blank this may cause delays 4.Make a copy of the Step 2 page for each adult in the household, even if the adult doesn t want an exemption Include tax-filing information for every adult 5.Consumer should keep a copy of their completed application
Terminating Plans Individuals may terminate their enrollment in a Qualified Health Plan (QHP) at any time To terminate enrollment in a QHP the individual should contact their qualified health plan directly. QHPs may terminate enrollees for non-payment of premiums, enrollment in another QHP, or fraud. Coverage under the QHP does not initiate until the first premium payment is received. Grace periods exist
Where does Indiana stand? During the first open enrollment period, 132,423 Hoosiers selected a plan on the Marketplace 56% female and 44% male 33% under age 35 26% between ages of 18 and 34 67% selected a Silver plan 89% selected a plan with financial assistance An estimated 880,000 to 909,636 individuals are still uninsured, and 181,930 are in the coverage gap. Source: HHS and KFF
Helpful Resources and Tools for Assisters CMS Assister Resources Page Families USA Enrollment Assister Resource Center In The Loop: Connecting the Enrollment Community Indiana Family and Social Services Administration (FSSA) Indiana Department of Insurance: Navigator Certification Enroll America Easy Premium Calculator Cover Indiana Get Covered America InsureKidsNow.gov ACA Tax Penalty Calculator Enroll America In-Person Assistance Page Kaiser Family Foundation Families USA Exemption Chart