Health Coverage Updates

1. Health Coverage Updates An Affordable Care Act and BadgerCare primer for AmeriCorps members

2. What do you know about the Affordable Care Act?

3. What was the ACA intended to do? Solutions in the ACA • Mandatory health insurance • Individual Marketplace • Elimination of caps • MA Expansion • Guaranteed Issue Problems • 18 – 20% uninsured rate • Affordability • Jobs • Already sick • 70 million Americans in medical debt

4. In Short… The Patient Protection and Affordable Care Act

5. Patient Protection… AKA Health Insurance Reforms • Allows young adults to stay on parents’ policies until they are 26 • Eliminates lifetime limits • Phases out annual limits (gone in 2014) • Many preventive care services must now also be offered without co-pay or deductible • 80% of your premium most go to care (MLR) • No denials for pre-existing conditions!

6. TRIVIA QUESTION!!! Explain it to me like I’m 5 years old What is COBRA?

7. …and Affordable Care Act! • Individual Marketplace • Subsidies for low-income individuals • Tiers of coverage • New Funding for Community Health Center expansion • Hooray! • Medicaid Expansion • State choice

8. ACA Creates New Marketplaces Avenues to Health Insurance TRICARE Military Providers Doctors Specialists Hospitals Clinics Rx Drugs Etc. Exempt Government Coverage VA Some Veterans Uninsured Medicare Seniors and SSDI Insured Products HMOs PPOs FFS Etc. Insured Medicaid < 100% of FPL, EBD, SSI, Pregnant Women & Children Individuals and Self-Employed Individual Marketplace Private Coverage SHOP Marketplace Small Groups 1-50 FTEs Self-Insured Employer Large Groups 50+ FTEs Credit: Community Advocates Public Policy Institute

10. 1. Create an account

11. 2. Apply The Marketplace will ask you a series of questions in order to determine your eligibility JOE’S SUPER AWESOME HEALTH PLAN Premium: $300 WITH ATPC: Now is $76 Co-Pay: $20 PCP WITH APTC: Now is $0 OR

12. TRIVIA QUESTION!!! Explain it to me like I’m 5 years old What is a deductible?

13. 3. Pick a Plan • Which Qualified Health Plan? • Which Metal Tier? • How much can I afford with or without APTCs and CSRs? • Is my current doctor in network? • Are my specific medications covered?

14. Qualified Health Plans in Wisconsin The individual plans sold by health insurance companies on the Marketplace are known as “Qualified Health Plans” Common Ground Healthcare Compcare Health Services Dean Health Plan, Inc. Group Health Cooperative of South Central Wisconsin Gundersen Health Plan, Inc. Health Tradition Health Plan MedicaHealth Plans of Wisconsin MercyCareHMO, Inc. Molina Healthcare of Wisconsin, Inc. Physicians Plus Insurance Corporation Security Health Plan of Wisconsin, Inc. Unity Health Plans Insurance Corp. Arise (WPS Health Plan, Inc.)

15. Metal Tiers Plans sold on the Health Insurance Marketplace are divided into four metal tiers, and some offer catastrophic coverage.

16. Premium Tax Credits Individuals with lower incomes can receive discounts on their health insurance premium. These are refundable or advance-able, but must be reconciled at the end of the year.

17. Cost Sharing Reductions Individuals with lower incomes can also receive discounts on their deductibles and co-pays. They further stretch the value of one’s health insurance. These do not need to be reconciled.

18. TRIVIA QUESTION!!! Explain it to me like I’m 5 years old What is co-insurance?

19. 3. Enroll! In order to start receiving benefits, you must enroll in that plan and begin making premium payments. Enrollment Numbers through April 19: • 81,274 determined/assessed eligible for Medicaid • 230,516 determined eligible for Marketplace • 168,721 (73%) eligible for assistance • 139,815 selected a QHP* *Selected does not = complete enrollment

20. Why Should I Enroll? Because it’s good for your health! Also…

21. Individual Mandate With some notable exceptions, the majority of Americans will be required to have health coverage for at least 9 months of each year or risk paying a penalty. 2014 Penalty is $95 per adult and $47.50 per child (up to $385 for a family) or 1% of family income, whichever is greater 2015 Penalty is $325 per adult and $162.50 per child (up to $975 for a family) or 2% of family income, whichever is greater 2016 and beyond Penalty is $695 per adult and $347.50 per child (up to $2,085 for a family) or 2.5% of family income, whichever is greater

22. When Can You Enroll? • Open enrollment begins November 15th, 2014 and ends February 15th, 2015 • Applies to all individual plans • You can change plans from November 15th – December 15th, 2014 • Special enrollment periods are year round!

23. What is a Special Enrollment Period? • If a person or family experiences a qualifying life event or in certain other circumstances related to the enrollment process, they may be eligible for a Special Enrollment Period (SEP) • This SEP will allow them to enroll in health insurance coverage through the Health Insurance Marketplace outside of a open enrollment period. The individual or family will typically have 60 days from the qualifying life event or approval of their SEP request to enroll in new Marketplace coverage

24. Special Enrollment Periods • Marriage • Marriage with Dependent Gained • Divorce (if loss of MEC) • Death (if loss of MEC) • Birth • Adoption • Placement for Adoption • Foster Care Placement • Permanent Move to New Service Area • Becoming Lawfully Present • Gaining AI status • Income change resulting in change in APTC eligibility (if enrolled) • Release from Prison • Involuntary loss of ESI • Loss of Dependent Status • Expiration of COBRA • Individual plan non-renewal outside of open enrollment • Errors, mis-representation or inaction by enrollment assister • QHP misrepresentation or contract violation • Technical problems • Immigration status error • Website display error • Unresolved casework • Medicaid/Marketplace transfer issues • Natural Disaster • Serious Medical Condition • Victims of Domestic Violence • Loss of Hardship exemption

25. What doesn’t trigger a SEP? • Voluntarily dropping other coverage • Loss of eligibility for coverage when one was not actually enrolled in it • Being determined newly eligible for subsidies if you aren’t currently enrolled in a QHP • Income change • Being terminated from coverage • Divorce or death of a family member without it resulting in a loss of MEC

26. Who Can Help Me? The State and Federal Government train and certify individuals who can help you apply for health insurance through the Marketplace: • Certified Application Counselors • Navigators • Non-Navigator Enrollment Assisters • Agents & Brokers Find them here: www.e4healthwi.org www.localhelp.healthcare.gov

27. TRIVIA QUESTION!!! Explain it to me like I’m 5 years old What does actuarial value mean?

28. What do you know about BadgerCare?

29. BadgerCare Basics BadgerCare is the name for Wisconsin’s Medicaid program which offers health coverage to individuals with low-incomes. 400%FPL 300%FPL 200%FPL 100%FPL

30. For context… BadgerCare today is different than it was as recently as April. Many people still may not know they are eligible for it, and others may no longer be eligible for it.

31. When Can You Enroll? Anytime!

32. TRIVIA QUESTION!!! Explain it to me like I’m 5 years old What is the difference between an HMO and a PPO?

33. Who Can Help Me? The Wisconsin Income Maintenance Consortia are responsible for processing BadgerCare, FoodShare and Medicaid Applications. Income Maintenance staff are the only individuals who can make an eligibility determination, however anyone can help an individual to apply.

34. Environmental Factors - FYI Regional Enrollment Networks: Coalitions which came together to help individuals enroll in health coverage Navigator Awards: New Navigator awards will be made next month. Politics: The Affordable Care Act and related Medicaid decisions have been made highly political. General Confusion: Even with one year of open enrollment completed, people are still very confused about their coverage options.

36. Thank you! Lisa Olson lolson@wphca.org 608-277-7477