Enroll West Virginia Regional Training

1. Enroll West Virginia Regional Training

2. What we’ll cover today • Overview of the ACA and expanded coverage • New coverage Options: Medicaid expansion and the Health Insurance Marketplace • Subsidies and the uninsured • Enrollment: who will enroll everyone who qualifies? • Qualified Health Plans (QHP) • Examples of individual and family situations • Take Aways • Resources

3. The ACA Is Signed into Law March 23, 2010It is the law of the land

4. The ACA Builds on Our Existing System

5. Four Goals of the ACA • Strong emphasis on prevention • New regulations of the insurance industry • Cost containment • Expand access to virtually every American

6. Prevention • No financial barriers for clinically appropriate preventive services • No co-pays; no deductibles • Most private plans and Medicare

7. Preventive Services • Examples • Mammography • Cervical cancer screening • Childhood immunizations • Obesity screening/counseling • All FDA-approved contraceptives • Domestic violence screening • Breastfeeding support • Vision screening for children • Many more

8. Insurance Regulations • Young adults can stay on their parents’ policy to age 26 • No pre-existing condition exclusions • No lifetime or annual limits on benefits • No gender rating • Limit profits/admin to 80/85%

9. Cost Containment • USA health costs highest in world • Goal: Increase quality and lower rate of increase • Reduce Medicare Advantage Costs • Change payment/delivery system

10. Expanding Health Insurance Coverage: An Overview

11. The ACA Expands Coverage in Two Primary Ways • Expand Medicaid up to 138 percent of the federal poverty level (FPL) • Establish the Health Insurance Marketplace thatoffers subsidized private insurance plans • Subsidies for people earning between 100-400% of FPL

12. New Coverage Options

13. Medicaid Expansion: Income Eligibility for a Family of Three

14. Medicaid Expansion • Governor Tomblin approved the Medicaid expansion in May • 133,500 low-income West Virginians become eligible for Medicaid • Enrollment begins October 1, 2013 and coverage begins January 1, 2014

15. Medicaid Expansion • Federal government pays 100% of the expansion costs the first three years • The federal share gradually reduces but never drops below 90% • Medicaid is exempt from sequestration

16. Health Insurance Marketplace

17. Health Insurance Marketplace • Offers private insurance policies: Highmark Blue Cross Blue Shield will be the only insurance company in WV’s Marketplace in 2014 • Who is eligible? • People without access to employer sponsored plans • Don’t have government plans (Medicaid, Medicare, Tricare, VA, etc.)

18. Health Insurance Marketplace • Subsidies for individuals and families on a sliding scale earning between 100% and 400% of the FPL • 400% of FPL is $46,000 for a single person and $78,000 for a family of three

19. Subsidy for family of 4 earning $55,000 Policy Cost = $961 Family Pays = $337 Govt. Subsidy = $624 (65%) Additional assist with copayments And out-of-pocket maximum Family of four with annual income of $55,000. They pay $337 a month in premiums and the tax credits equal $624 a month, 65% of the total premium. Additional assist with deductibles and copayments plus out-of-pocket maximum protection.

20. Health Insurance Marketplace • Estimated 99,000 West Virginians will qualify for subsidies(2016)

21. Small Business Health Insurance Marketplace(SHOP) • Eligibility for SHOP is 50 or fewer employees, • About 42,000 West Virginia businesses employing 280,000 people • 16,000 employees projected to be enrolled by 2016

22. Who are the uninsured? • 48% Healthy and Young • Take health for granted • Tech savvy • Low motivation to enroll • 29% Sick, Active and Worried • Generation X and Baby Boomers • 15% Passive and Unengaged • 49 and older • Live for today • Don’t understand health insurance Source: HHS Marketing Survey, March 2013

23. Uninsured in West Virginia,Ages 0-64 A majority of uninsured West Virginians are under age 39 with more than a quarter of the uninsured between ages 19 and 29 63% Live in Families with at least One Full Time Worker 52% 48% Sources: Kaiser Commission on Medicaid and the Uninsured, October 2012

24. Enrollment Opportunities in West Virginia by 2016

25. Enrollment: Personal Assistance Needed • 78% of people who will qualify for assistance know nothing about it • Skeptical and interest framed by past negative experience • 75% want personal assistance

26. How Will the Enrollment Process Work?

28. How Do We Enroll All These People? • On the web: • By phone: 800-318-2596 • By mail: • Personal assistance www.healthcare.gov

29. Personal Assistance • Insurance agents and brokers • Navigators • Advanced Patient Advocacy/Hospitals • WV Parent Training and Information Center • In-person assisters – 270 • Maximus • Placement in CAP agencies, free clinics, etc. • Community health center employees • Certified Application Counselors • DHHR Employees

30. Community Assisters • Enroll simple cases in Medicaid • Connect the uninsured to web site, 800 number, in-person assisters, community health centers, etc. • WVAHC is providing small grants to nonprofit organizations to fund community assisters

31. BREAK BREAK

32. The Enrollment Process • Single, streamlined application for Medicaid, CHIP and qualified health plans (QHPs) • No asset test for Medicaid & QHPs

33. Medicaid Eligibility • Income • Household size • US citizenship • State Residency • Under age 65 <138% of FPL

34. What’s Income? • Modified adjusted gross income (MAGI) as reported to IRS • For Medicaid and CHIP during the month that an application is made to determine income • For QHP income is for year in which person is enrolled • MAGI income is verified electronically with the IRS database

35. Who is a family (household) for Medicaid? • Household for tax filer = all persons the taxpayer expects to claim as a tax dependent • Except: Custodial parent counts child in household even if other spouse claims child as tax dependent • Household for non-tax filers = individual plus spouse and children living with individual.

36. Example: Married Couple with Children • Reyes family: married couple with 2 children • Mom and dad file a joint return and claim both children as dependents • HH = 4 • If Mrs. Reyes is Pregnant, HH = 5

37. Example: Three generation household • Rose lives with and supports her 60-year old mother and 7-year old daughter • Rose is the tax filer and claims her daughter and mother as dependents • HH = 3

38. Example: Child Claimed by Non-Custodial Parent • Lisa lives with her son and files taxes as a single individual • Non-custodial dad claims son • Household for Medicaid = 2

39. Why Household Size Matters 138% applies to children over age one and adults. 155% applies to pregnant women and children under age one.

40. Note: Changes in CHIP • With the increase in Medicaid eligibility, many children currently enrolled in CHIP will become Medicaid eligible and cannot remain on CHIP: • 10,800 CHIP kids transfer to Medicaid • 2,800 kids gain CHIP coverage under the new MAGI eligibility rules

41. More Medicaid Enrollment • Income/household by self-attestation but checked electronically by IRS data • Citizenship is verified electronically with the Social Security Administration • Documented (legal) immigrants only qualify for Medicaid under limited circumstances • Undocumented immigrants do not qualify at all

42. Medicaid’s Two Step Process: • If an applicant is determined eligible for Medicaid, the information is transferred to the Bureau for Medical Services, and enrolled “promptly and without undue delay” • An enrollment broker (Automated Health) will ask Medicaid eligible to choose a managed care organization (MCO)

43. Beyond Medicaid Expansion • An applicant ineligible for MAGI Medicaid: • Will be reviewed, if appropriate, for traditional Medicaid • Examples : Persons with disabilities, over age 65, long term care and support, etc.

44. Qualified Health Plans(QHP) • If an applicant earns too much to qualify for MAGI Medicaid, and does not qualify for traditional Medicaid, they will be screened for eligibility for a qualified health plan • Enrollment in a qualified health plan is more complex than Medicaid and requires consumers to make additional decisions

45. Eligibility for (QHPs) • US citizen or lawfully present in the US • State resident • Under age 65 • Not incarcerated

46. Verification of Eligibility for QHPs • US citizenship is verified electronically with the Social Security Administration • Legal immigrant status is verified electronically with Homeland Security

47. QHPs come with premium subsidies • In order to qualify for premium subsidy, an applicant must meet the qualifications for QHPs plus: • Have projected income between 100% and 400% of the FPL in 2014 • Not have access to other insurance coverage (with two exceptions) • Is expected to file income tax at the end of the coverage year

48. QHPs also have subsidies for cost sharing expenses • Individuals and families earning less than 250% of the FPL, and • Select a silver plan (to be discussed later), then • They receive subsidies to reduce the costs of deductibles, copayments and co-insurances

49. FPL for Cost Sharing Subsidies and Premium Subsidies 250% of the FPL level is the eligibility threshold for cost sharing reductions and 400% of the FPL is the threshold for premium assistance

50. QHP Choices: 4 Levels • Four “metal levels” of plans are offered in the Marketplace and vary based on their actuarial value • The actuarial value is what percentage of legitimate claims the insurance company pays and what percentage on average consumers pay