Qualified health plans
Download
1 / 58

Qualified Health Plans - PowerPoint PPT Presentation


  • 108 Views
  • Uploaded on

Qualified Health Plans. Summer 2013 Navigator/In-person Assister Program. Purpose. Purpose: This presentation will provide a high level overview of Qualified Health Plans (QHPs) available through the Washington Healthplanfinder .

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about ' Qualified Health Plans' - flavia-pittman


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
Qualified health plans

Qualified Health Plans

Summer 2013

Navigator/In-person Assister Program


Purpose
Purpose

Purpose:

This presentation will provide a high level overview of Qualified Health Plans (QHPs) available through the Washington Healthplanfinder.

More in-depth information and procedures will be included in the Healthplanfinder system training module.


Course summary
Course Summary

  • Program rules and guidelines related to Individual Eligibility and Enrollment for Qualified Health Plan (QHP) programs.

  • Application, eligibility results, QHP enrollment and payment for individuals and households applying for coverage.

  • Pediatric dental plans


Learning objectives
Learning Objectives

Upon completing this module, you will

  • Understand the different types of health care coverage available through the Healthplanfinder

  • Know program rules and guidelines related to Qualified Health Plans for either an individual or for an entire household

  • Understand basis for eligibility results

  • Know the steps to facilitate plan selection and enrollment


Learning objectives continued
Learning Objectives (Continued)

Upon completing this module, you will also understand:

  • The functions performed through the Federal Hub in verifying applicant information

  • Reasons for non-eligibility (incarceration, citizenship, non-WA resident, etc.).


Exchange a single doorway
Exchange – A Single Doorway

Public Insurance

Private (commercial) Insurance

Unsubsidized

Medicaid (Apple Health)

Subsidized (tax credits)

<138% FPL

139-400% FPL

>400% FPL

Exchange


What is a qualified health plan
What is a Qualified Health Plan?

  • A health insurance plan that has been certified by The Office of Insurance Commissioner as meeting all state rules and requirements.

  • Approved by the HBE as meeting the requirements of a Qualified Health Plan to be offered through the Washington Healthplanfinder.

  • A plan that provides comprehensive coverage by meeting the standard of “10 Essential Benefits”


Qualified health plans1
Qualified Health Plans

Key Point

  • Commercial insurance plans offered through the Healthplanfinder

  • The same insurance carriers as outside the Exchange (Group Health, Regence, Lifewise, etc.)

  • Subject to open enrollment periods

  • Regulated/certified by the Office of the Insurance Commissioner

  • Approved by the Health Benefit Exchange Board


In general
In General…

  • Plans with higher PREMIUMS have lower cost sharing and/or richer coverage


Key considerations for selecting a plan
Key Considerations for Selecting a Plan

  • Premium – monthly payment to be insured

  • Cost sharing – you pay some, insurance pays some

    • Deductible

    • Co-insurance – a percentage

    • Co-pay – a predetermined amount per visit

  • Coverage – what services are part of the “package”?

  • Providers – which ones participate in the plan?


  • 10 essential benefits
    10 Essential Benefits

    Key Point

    Laboratory Services

    Prescription Drug

    Rehabilitative/Habilitative

    Preventive/Wellness

    Pediatric (including vision and dental)

    Ambulatory Services

    Emergency Services

    Hospitalization

    Maternity/Newborn Care

    Mental Health and Substance Abuse


    Metal tiers
    Metal Tiers

    Key Point

    * Silver plan or higher required to get tax credits.

    Actuarial Value: The amount (%) of the bill that the insurer pays


    Health insurance premium tax credits hiptc
    Health Insurance Premium Tax Credits (HIPTC)

    Key Point

    • Designed to make premiums affordable for individuals and families with lower incomes

    • Only available to individuals and families with income up to 400% Federal Poverty Level (FPL)

      • Can be used to reduce monthly premiums

      • Can be claimed as a credit on annual tax return

    • Applications must be completed through Washington Healthplanfinder


    Premium tax credit and cost sharing reductions
    Premium Tax Credit and Cost Sharing Reductions

    Key Point

    Premium Tax Credits

    Cost Sharing Reductions

    *Of the second lowest cost Silver plan

    14


    Insurance carriers in exchange as of september 4 2013
    Insurance Carriers in Exchangeas of September 4, 2013

    • Community Health Plan of Washington

    • Molina Health Care of Washington – King Pierce & Spokane

    • Group Health Cooperative – Benton, Columbia, Franklin, Island, King, Kitsap, Kittitas, Lewis, Mason, Pierce, San Juan, Skagit, Snohomish, Spokane, Thurston, Walla Walla, Whatcom, Whitman, and Yakima

    • Lifewise – All 39 counties

    • Premera Blue Cross – All counties except Clark

    • Bridgespan – King, Kitsap, Pierce, Skagit, Snohomish, Thurston, and Spokane

    • Kaiser Foundation Health Plan – Clark and Cowlitz


    Pediatric dental plan insurance carriers in the exchange as of september 4 2013
    Pediatric Dental Plan Insurance Carriers in the Exchangeas of September 4, 2013

    • Delta Dental of Washington

    • Kaiser Foundation Health Plan

    • LifeWise

    • Premera Blue Cross


    Health insurance programs and benefits
    Health Insurance Programs and Benefits

    Competitively Priced Qualified Health Plans (QHP)

    • Individuals or families with income above 400% of the Federal Poverty Level (FPL) can purchase a QHP at the insurance carrier’s published premium cost

    • QHPs are offered through commercial carriers such as Blue Cross Blue Shield, Aetna, etc.

    • Consumers choose a plan that best meets their health and financial needs

    • Families with children under 19 must enroll the children in a pediatric dental plan

    • Parents can cover children up to age 26 under a family plan


    Health insurance programs and benefits1
    Health Insurance Programs and Benefits

    Free and Low-Cost Opportunities

    • Individuals or households with income below 400 % of the Federal Poverty Level (FPL) are eligible for free or low-cost options.

    • Based on household size and income, applicants can qualify for either:

      • Washington Apple Health (Medicaid) – no cost

      • Health Insurance Premium Tax Credit (HIPTC) – reduced premium rates (must get a Silver Plan to qualify)

  • Additional reductions are available to those with the lowest incomes (< 250% FPL) to reduce out of pocket expenses such as deductibles and co-pays


  • Eligibility enrollment flow qhp
    Eligibility & Enrollment Flow - QHP

    Eligibility Determination

    QHP Enrollment & Pediatric Dental Enrollment

    Application Data Collection

    Payment

    Account Creation

    Post Application Shopping


    Primary applicant
    Primary Applicant

    The primary applicant is an individual who creates an account on Washington Healthplanfinder and initiates one of three types of applications types.

    Individuals:

    1. Myself

    Household:

    2. Myself and others

    3. Other household members



    Lesson 1
    Lesson 1

    Application Type ‒ Individual


    Account creation
    Account Creation

    Eligibility Determination

    QHP Enrollment & Pediatric Dental Enrollment

    Application Data Collection

    Payment

    Account Creation

    Post Application Shopping


    Account creation1
    Account Creation

    From the homepage there are two paths to creating an account:

    Projected Plan Options

    Anonymous Browsing

    Create Account

    Qualified Health Plan (QHP)

    Free and Low-Cost Health Insurance

    Qualified Health Plan (QHP)

    Free and Low-Cost Health Insurance

    Required to Create and Account

    Not Required to Create Account

    Required to Create and Account

    Not Required to Create Account


    Application data collection
    Application Data Collection

    Once an account is created – the first step in applying for coverage is Application Data Collection.

    The following data pages need to be completed:

    • About You

    • Contact Information

    • Additional Questions

    • Tribal Membership

    • Application Review

    • eSignature


    Application options
    Application Options

    For Qualified Health Plan (QHP) Programs, the Applicant would select “No.”

    For Free and Low Cost Health Insurance programs, the Applicant would select “Yes.”


    Confidential information
    Confidential Information

    • Personal information must be disclosed throughout the application process

    • The primary applicant and all household members who reside in the applicant’s household

    • Income information and tax filing status

    • Family composition and relationships, including custody


    Federal hub verification
    Federal Hub Verification

    The primary applicant’s social security number will be verified by the Federal Hub.

    Application Data Collected:

    Social Security Number

    Federal Hub Response:

    Verified

    Unverified

    Federal Hub Data Verifications are stored in the Healthplanfinder and are not visible to the consumer.


    Conditional eligibility
    Conditional Eligibility

    If any member of the household is deemed conditionally eligible, additional documentation will be required as shown in these screens. The primary applicant will have 90 days to submit required documentation.


    American indians alaska natives
    American Indians/Alaska Natives

    • Special provisions

    • Tribal members can be served by a non-tribal In-Person Assister or a Tribal Assister

    • Training Module for serving AI/AN


    Eligibility enrollment flow qualified health plan qhp
    Eligibility & Enrollment Flow (Qualified Health Plan (QHP))

    Eligibility Determination

    QHP Enrollment & Pediatric Dental Enrollment

    Application Data Collection

    Payment

    Account Creation

    Post Application Shopping


    Eligibility determination federal hub
    Eligibility Determination – Federal Hub

    In order for an individual to be eligible for a Qualified Health Plan (QHP) on Washington Healthplanfinder, he or she must be:

    • A U.S. citizen or lawfully present

    • Not incarcerated

    • A resident of the State of Washington

    When the Federal Hub verifies the individual’s SSN, it also looks for Citizenship and Incarceration status associated with that SSN.


    Eligibility results
    Eligibility Results

    • Eligibility determined for each family member

    • Coverage options displayed based on eligibility

    • If eligible for Qualified Health Plan, the consumer will use tools to compare and select a Plan

    • Plan details can be viewed side by side

    • Payment entry finalizes the transaction


    Eligibility rules what the system uses to decide eligibility
    Eligibility Rules(what the system uses to “decide” eligibility)


    Knowledge check
    Knowledge Check

    What are the three different application types for eligibility on Washington Healthplanfinder?

    • Myself

    • _______________

    • __________________________

    Myself and Others

    Other Members of My Household


    Knowledge check1
    Knowledge Check

    Who creates an account on Washington Healthplanfinder and initiates one of three types of applications types?

    • Exchange Administrator (EA)

    • Primary Applicant

    • Household

    • Myself and Others


    Knowledge check2
    Knowledge Check

    What organization verifies the social security number of the primary applicant?

    • Federal Hub

    • eHealth

    • Eligibility Services

    • Washington Healthplanfinder


    Knowledge check3
    Knowledge Check

    Which of the following it not true about Qualified Health Plan (QHP) programs?

    • Households can claim children up to age 26 under the parents' plan.

    • Consumer choice offered through plan selection and metal levels.

    • Applicants eligible for QHPs only.

    • Applicants automatically enrolled in plans.



    Lesson 2
    Lesson 2

    Application Type – Household (All Eligible Members)


    Application types
    Application Types

    The primary applicant is an individual who creates an account on Washington Healthplanfinder and initiates one of three types of applications types.

    Individuals:

    1. Myself

    Household:

    2. Myself and others

    3. Other household members


    Qhp eligibility enrollment flow
    QHP Eligibility & Enrollment Flow

    Eligibility Determination

    QHP Enrollment & Pediatric Dental Enrollment

    Application Data Collection

    Payment

    Account Creation

    Post Application Shopping


    Application data collection1
    Application Data Collection

    When the primary applicant enters data for themselves and their household, the data collected will be the same as for an individual.

    The sections bolded below will be completed for both the primary applicant and the other household members.

    • About You

    • Contact Information

    • About Your Household*

    • Additional Questions*

    • Tribal Membership*

    • Application Review

    • eSignature


    Household composition rules
    Household Composition Rules

    To be considered part of the same household, the household member must have one of the following relationships to the primary applicant:

    • Legal Guardian

    • Child (up to age 26)

    • Spouse (including same sex marriage)

    • Spouse (including domestic partners)

      Other family members living in the same home, such as nieces/nephews, aunts/uncles, cousins, and grandmothers/ grandfathers would not be considered part of the household application for eligibility determination.


    Children up to age 26
    Children Up to Age 26

    • Children up to age 26 are eligible to be covered under their parent’s plans.

    • Common Examples:

      • College Students

      • Young Professionals

  • Children do not need to live in the same household or location as the parents to qualify.

  • For instance, a child away at college would still be covered under his or her parent’s plan.


  • Eligibility determination
    Eligibility Determination

    SSN Verification

    Primary Applicant Completes Additional Questions

    Primary Applicant Completes eSignature

    Primary Applicant Completes “About You”

    Primary Applicant Enters Contact Information

    Eligibility Results Displayed

    IRS

    Primary Applicant Completes Application Review

    Primary Applicant Completes “About Your Household”

    SSN Verification


    Eligibility enrollment flow qhp1
    Eligibility & Enrollment Flow (QHP)

    Eligibility Determination

    QHP Enrollment & Pediatric Dental Enrollment

    Application Data Collection

    Payment

    Account Creation

    Post Application Shopping


    Qhp pediatric dental plan enrollment
    QHP & Pediatric Dental Plan Enrollment

    • For household members over the age of 19:

    • The primary applicant will enroll each eligible household member in a QHP.

    • For household members under the age of 19:

    • The primary applicant will enroll each child in a QHP and is required to also enroll each child in a pediatric dental plan.


    Knowledge check4
    Knowledge Check

    In order for an individual to be eligible for a Qualified Health Plan (QHP) on Washington Healthplanfinder, he or she must:

    • Live with the individual.

    • Not live with the individual.

    • Not be incarcerated.

    • Be employed.


    Knowledge check5
    Knowledge Check

    To be considered part of the same household, the household member must have one of the following relationships to the primary applicant:

    • Niece

    • Aunt

    • Grandparent

    • Legal Guardian


    Knowledge check6
    Knowledge Check

    The primary applicant will be required to select and enroll their qualifying children (up to age 19) in…

    • A health insurance policy of their own.

    • A pediatric dental plan

    • Pediatric health care coverage

    • Summer school


    Knowledge check7
    Knowledge Check

    • In a Qualified Health Plan (QHP) scenario, which of the following family members qualify as members of the primary applicant’s household?

    • Spouse (including same-sex marriage)

    • Grandfather

    • Child (up to age 26)

    • Answers a and c


    Knowledge check8
    Knowledge Check

    • The primary applicant is required to enroll any children under 19 in a pediatric dental plan.

    • True

    • False


    Knowledge check9
    Knowledge Check

    • To be eligible for insurance coverage through Washington Healthplanfinder, you must be:

    • U.S. Citizen or Lawfully Present

    • Not Incarcerated

    • Washington Resident

    • All of the Above


    Agents brokers
    Agents-Brokers

    • Key partners with IPAs

    • Must complete Exchange training

    • Must be registered with Exchange

    • Listed on Exchange website

    • Receive commission for QHP enrollments (paid by carrier)

    • No charge to consumers



    Thank you
    Thank you!

    Congratulations! You have completed the

    QHP Rules and Guidelines course!


    ad