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Marketplace Overview

Marketplace Overview. November 5, 2013 Covering Kids & Families - Wisconsin. Topics to be Covered. What is the Affordable Care Act (ACA)? Individual Mandate What is the Marketplace? Essential Health Benefits Coverage Tiers Catastrophic Plans What is the Cost of Coverage?

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Marketplace Overview

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  1. Marketplace Overview November 5, 2013 Covering Kids & Families - Wisconsin Updated November 1, 2013

  2. Topics to be Covered • What is the Affordable Care Act (ACA)? • Individual Mandate • What is the Marketplace? • Essential Health Benefits • Coverage Tiers • Catastrophic Plans • What is the Cost of Coverage? • Financial Assistance • Premium Tax Credits • Cost-Sharing Subsidies • Out of Pocket Maximum • Household size/MAGI • Enrollment Periods • Application and Enrollment Process • Marketplace Practice Tips and Troubleshooting Updated November 1, 2013

  3. What is the ACA? • Also known as the Patient Protection and Affordable Care Act, ACA, ObamaCare and the Health Reform Law, it: • Provides new rules to improve the overall health care system • Improves coverage for those with health insurance • Provides coverage for people who are uninsured or looking for new coverage, beginning in 2014 Updated November 1, 2013

  4. ACA – Current Provisions • Free preventive care for those with insurance, including Medicare • Financial assistance for seniors for prescription drugs • No lifetime limits on coverage of essential benefits • Young adults on parent’s private insurance plans until age 26 • Children cannot be denied coverage for having pre-existing conditions • Tax breaks for small businesses to provide coverage • Increased funding to community health centers and programs through Prevention and Public Health Fund Updated November 1, 2013

  5. ACA – 2014 Provisions • Adults cannot be denied coverage for pre-existing conditions. • Annual limits on insurance coverage eliminated • Medicaid eligibility may change, based on each state’s decision • October/November – Opening of the Health Insurance Marketplace/Exchange/Small Health Options Program (SHOP) • Government will provide tax credits to purchase coverage for individuals within specific income ranges • Individual Mandate – most individuals required to have insurance or pay a fee Updated November 1, 2013

  6. Individual Mandate • Most individuals will be required to have insurance or pay a tax penalty/fee • 2014: $95 per adult or 1% of income • 2016: $695 per adult or 2.5% of income • Penalty also referred to as the “Shared Responsibility Payment” • Individuals may be uninsured for a period of up to three months before penalty would apply Updated November 1, 2013

  7. Individual Mandate Exemptions • Some individuals may be exempt including: • Religious conscience; • Membership in a health care sharing ministry; • Member of an Indian tribe; • Taxable income below the threshold to pay taxes ($9,750 for individual in 2013 tax year) • Hardship (based on personal circumstance or a lack of affordable coverage); and • Ineligible for Medicaid based on a state’s decision not to expand (In WI - income between 100-133% FPL - $958-$1,245 per month for an individual). Updated November 1, 2013

  8. Individual Mandate Exemptions • How do individuals apply for/claim exemptions? • Religious conscience and most hardship exemptions – apply for exemption certificate through the Marketplace • Member of an Indian tribe, members of health care sharing ministries and incarcerated individuals - apply for exemption certificate through the Marketplace certificate, or claim the exemption on federal income tax returns • Unaffordable coverage, short coverage gaps, certain hardships, and individuals who are not lawfully present can only claim the exemption on federal income tax returns • Individuals not required to file tax returns are automatically exempt, without further action Updated November 1, 2013

  9. What is the Marketplace? • A website people can go to compare insurance plans, purchase healthcare coverage and apply for discounts (tax credits) on their premiums- www.healthcare.gov • Active October 1, 2013 • Marketplaces are managed either by the state or the federal government - Wisconsin’s is managed by the federal government • Call center available at 1-800-318-2596 Updated November 1, 2013

  10. What is the Marketplace? • Citizens and people who are lawfully present who are not incarcerated can access the Marketplace • In the Marketplace, an individual or family can apply for: • Medicaid (BadgerCare+) • Private plans • Catastrophic plans • Those with income below 400% of the FPL can qualify for tax credits if they do not have access to affordable employer group insurance Updated November 1, 2013

  11. Insurance Plans in the Marketplace • Insurance plans available through the Marketplace must be qualified and cover 10 essential health benefits • People can choose which plan works for them based on its value and cost, based on a standard summary of benefits and coverage • Plans are categorized as Platinum, Gold, Silver, or Bronze • Plans may choose to include dental coverage for adults (dental coverage for children is required) or to offer a stand alone dental plan for adults Updated November 1, 2013

  12. Essential Health Benefits • Qualified Health Plans in the Marketplace must cover: Updated November 1, 2013

  13. Coverage Tiers in the Marketplace • 4 levels with different actuarial value for each metal tier (percentage of cost for health services covered by the insurance plan): • Bronze – 60%, Silver – 70%, Gold – 80%, and • Platinum – 90% • Bronze plans will have the lowest premiums (besides catastrophic), but the highest cost sharing (deductibles, copays and coinsurance) Updated November 1, 2013

  14. Coverage Tiers in the Marketplace • Platinum plans have the highest monthly premiums, but the lowest cost sharing (deductibles, co-pays and coinsurance) • Participating insurers must offer at least one plan at the “silver” level and one at the “gold” level of cost sharing Updated November 1, 2013

  15. Catastrophic Plans • A high-deductible-low-premium plan for young adults under age 30or qualify for a hardship exemption; includes free preventive care; available inside or outside the Marketplace • Advantage: Beneficial for people who cannot afford traditional plan premiums or who are healthy and do not need routine care • Disadvantage: Costs for routine care before the deductible is met can accumulate rapidly, no premium assistance available Updated November 1, 2013

  16. WI Insurers in the Marketplace Available Plans Vary by County Common Ground Healthcare CooperativeCompcare Health Services Insurance CorporationDean Health Plan, Inc.Group Health Cooperative of South Central WisconsinGundersen Health Plan, Inc.Health Tradition Health PlanMedica Health Plans of WisconsinMercyCare HMO, Inc.Molina Healthcare of Wisconsin, Inc.Physicians Plus Insurance CorporationSecurity Health Plan of Wisconsin, Inc.Unity Health Plans Insurance Corp.Arise (WPS Health Plan, Inc.) Updated November 1, 2013

  17. WI Insurers in the Marketplace • Most areas in Wisconsin have between 1-4 insurance companies offering plans • Insurers may offer more than one plan at each metal tier • The plans are structured as Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs) or Point of Service plans (POSs) • For a list of participating insurance companies in each county go to: http://oci.wi.gov/pressrel/0913serviceareas.htm Updated November 1, 2013

  18. What is the Cost of Coverage? • Premiums are influenced by: • geographic location • age • tobacco use (if the plan chooses to apply a tobacco surcharge) • The most an individual will pay for premiums is between 2-9.5% of their income • Go to the Kaiser Family Foundation Premium calculator for a cost estimate: http://kff.org/interactive/subsidy-calculator/ Updated November 1, 2013

  19. What is the Cost of Coverage? • Total costs (premiums, deductibles, co-pays and co-insurance) will vary based on the plan and tier of coverage • All plans are subject to a maximum out-of-pocket limit in 2014 of $6,350 for an individual and $12,700 for a family (out of pocket limits are lower for those who qualify for cost-sharing reductions) • Out-of-pocket limits do not include premiums • All plans are required to provide free preventative services such as an annual exam, blood pressure and cancer screenings, and immunizations Updated November 1, 2013

  20. Financial Assistance • Congressional Budget Office estimates that 7/8 people will qualify for financial assistance in the form of a premium tax credit or cost sharing subsidy • Premium Tax Credits (PTCs) are available for individuals with income between 100-400% FPL • $11,490-$45,960 for an individual • $23,550-$94,200 for a family of four • Cost-sharing assistance is available for individuals with income between 100-250% FPL (must purchase silver level plan!) • $28,725 for an individual • $58,875 for a family of four Updated November 1, 2013

  21. Annual Income Categories: Federal Poverty Level (FPL), 2013 Updated November 1, 2013

  22. Financial Assistance - Eligibility • Must not have access to “minimum essential coverage” from: • Medicare; • Medicaid; or • An offerof Employer-Sponsored Coverage that is “adequate” and “affordable” • What is “adequate and affordable” Employer-Sponsored Coverage? • Adequate – minimum value of at least 60% of total costs • Affordable – employee-only coverage costs less than 9.5% of household income Updated November 1, 2013

  23. Financial Assistance - Eligibility • ALL family members who are offered adequate and affordable coverage through an employer sponsored group plan are ineligible for financial assistance in the Marketplace • If employer offers individual coverage that meets the minimum essential coverage test but does not offer any family coverage, spouse and dependents are eligible for subsidies • If employer offers individual coverage that meets the minimum essential coverage test and offers employee and dependent coverage (not including spouse), employee and dependents are not eligible for subsidies but the spouse is Updated November 1, 2013

  24. Premium Tax Credit • Amount of the premium tax credit (PTC) is based on the cost of second lowest cost silver plan in the individual’s geographic area and the amount the individual is expected to pay (sliding scale of 2%-9.5% of family income) • Eligibility determination and amount of PTC is made through the Marketplace • Full amount of the PTC can be used to purchase any plan sold on the Marketplace – if you buy a bronze level plan, the PTC will cover more of the premium, if you buy a platinum level plan, the PTC will cover less of the premium cost Updated November 1, 2013

  25. Premium Tax Credit Source: Center on Budget and Policy Priorities http://www.cbpp.org/files/QA-on-Premium-Credits.pdf Updated November 1, 2013

  26. Premium Tax Credit Source: Center on Budget and Policy Priorities http://www.cbpp.org/files/QA-on-Premium-Credits.pdf Updated November 1, 2013

  27. Premium Tax Credit Example • John is 24 years old • His annual income is $22,980 = 200% FPL • Benchmark Silver plan for John = $5,000 annual premium • Expected contribution is 6.3% of income = $1,448 a year • John’s Premium Tax Credit = $3,552 ($5,000-$1,448) annually or $304 per month • John will pay $1,448 annually or $120.66 monthly for a silver plan • If John bought a Bronze plan that costs $3,000 a year, he would no premium because his annual credit is $3,552. Source: Center on Budget and Policy Prioritieshttp://www.cbpp.org/files/QA-on-Premium-Credits.pdf Updated November 1, 2013

  28. Receiving Premium Tax Credits • PTCs are refundable, so individuals with little or no income can still benefit (like the Earned Income Tax Credit), however, taxes must be filed • PTCs can be paid in advance, directly to the insurance company • Advanced PTCs allow individuals to only pay their portion of the premium to the insurer • Don’t have to take PTCs in advance, or take full amount • Advance PTCs are subject to reconciliation upon tax filing • Reporting changes in income throughout the year • is critical Updated November 1, 2013

  29. Cost-Sharing Assistance • The Cost-Sharing Reduction is designed to increase the actuarial value of the silver plans (70% without Cost-Sharing Assistance) • CAUTION: The consumer must purchase a silver level plan to receive the cost-sharing assistance Updated November 1, 2013

  30. Receiving Cost-Sharing Assistance • Cost-sharing reductions are automatically included for individuals with income between 100-250% FPL who are receiving PTCs and purchase a silver level plan • When shopping for coverage, eligible individuals will see the cost-sharing reductions reflected in prices • Their purchased plan will have a lower deductible, out-of-pocket maximum, or copayments • Unlike PTCs, cost-sharing reductions are not administered like a tax creditand do not need to be reconciled at tax time • Income changes should be reported to recalculate the PTC and cost-sharing reductions throughout the year Updated November 1, 2013

  31. Household Size • Determining household size is critical to assess eligibility for premium tax credits and cost-sharing assistance • Household = individuals for whom a taxpayer claims a deduction for a personal exemption • Self and spouse • Dependents, which includes children and other individuals • Household is based on expected tax filing status • NOTE: Married couples must file jointly in order to qualify for Premium Tax Credits or Cost-Sharing Assistance Updated November 1, 2013

  32. Household Size • Dependents include: • Children - child, step child, adopted child, foster child, brother, sister, niece, nephew or grandchild • Other Individuals: relative, in-law or full-time member of household • Household may include individuals even if they are ineligible for PTCs • Special rules apply for those not lawfully present Updated November 1, 2013

  33. Household Size – BadgerCare+ • Household Size rules for BadgerCare+ are not the same as the rules used in the Marketplace • BadgerCare household determination are based on each individual applicant • Based on expected tax filing status • If applicants are non-tax filers, Medicaid relationship-based rules may apply • CAUTION: Household determination for non traditional households may be complicated and will be determined by Income Maintenance staff Updated November 1, 2013

  34. Modified Adjusted Gross Income • Marketplace will Determine Modified Adjusted Gross Income (MAGI) for the Household: • Adjusted gross income (AGI, as defined by IRS) • + Excluded foreign income • + Tax exempt interest • + Non-taxable Social Security benefits • = MAGI • MAGI for Medicaid: • Exclude certain scholarships and fellowship income • Exclude certain Native American and Alaska Native income • Count lump sum income only in the month received Updated November 1, 2013

  35. Modified Adjusted Gross Income • Examples of Income that is included in MAGI: • Wages, salaries, tips • Taxable interest • Taxable pensions, annuities and IRAs • Unemployment Compensation • Examples of Income that is excluded for MAGI: • Certain self-employment expenses • Student loan interest deductions • University of California Berkeley Labor Center – MAGI Summary is available at http://laborcenter.berkeley.edu/healthcare/MAGI Updated November 1, 2013

  36. Enrollment Periods • October 1, 2013- March 31, 2014: Open Enrollment: Individuals can sign up for health insurance plans on the Marketplace • December 15: First premium payment due and deadline to enroll for January 1 coverage • After December 15: if enrolled between the 1st and 15th of the month, coverage will begin the 1st of the following month • Special Enrollment Periods: qualifying life events such as losing other insurance coverage, moving out of a plans service area, getting married or divorced, or having children may qualify someone for a special enrollment period Updated November 1, 2013

  37. Pay monthly premium for coverage Updated November 1, 2013

  38. Marketplace Application Process • Create an Account online with name, address, e-mail • Complete and Submit an individual or family application online, by phone or through the mail • Eligibility is determined for BadgerCare+ or Marketplace coverage • Enroll - applicants choose from available insurance plans and will know their costs of coverage right away • Pay monthly premium for coverage to begin Updated November 1, 2013

  39. Enrollment Assistance In person: • Navigators and Certified Application Counselor organizations • Inventory available - www.e4healthwi.org • Agents and brokers – list available at OCI By phone: • front page of healthcare.gov now includes phone option through the national call center 1-800-318-2596 Online: • chat with a Marketplace representative when filling out an application at www.healthcare.gov/chat Updated November 1, 2013

  40. Marketplace Practice Tips Online Applications: • Email account must be set up, Marketplace includes links to free email providers • Consumer must respond to email confirmation • CAUTION: technology policies at some application sites may make email confirmation problematic Direct Enrollment with QHPs: • The Marketplace has capacity for applicants to go directly to a QHP website to enroll • Applicant starts at the QHP website and then will be redirected to the Marketplace to complete the application • Unclear whether or not any QHPs in Wisconsin are set up for this yet Updated November 1, 2013

  41. Marketplace Practice Tips Mail Applications: • Paper applications can be downloaded at: http://marketplace.cms.gov/getofficialresources/publications-and-articles/publications-and-articles.html • Applications should be mailed to: Health Insurance Marketplace Dept. of Health and Human Services 465 Industrial Blvd. London, KY 40750-0001 • When returned, paper applications are entered into healthcare.gov • To complete the enrollment, applicant will need to call the 800 number or complete the enrollment online. • The Marketplace will call applicants if the information was incomplete and applications not processed Updated November 1, 2013

  42. Marketplace Practice Tips Marketplace Preview Tool: • New tool available on CMS website allows people to view available plans before creating an account or completing an application: https://www.healthcare.gov/find-premium-estimates • CAUTION: Listed prices do not take into account eligibility for premium tax credits or cost-sharing reductions • CAUTION: Listed prices do not account for exact age (tool limited to age categories of under 50 and over 50) QHP Websites: • Individual QHPs have plan information available on their websites including provider networks for each plan and prescription drug formularies Updated November 1, 2013

  43. Marketplace Practice Tips Information Needed: • Applicants should be prepared to provide information about each household member including age, social security number and estimated income for the coming year • CMS Marketplace Application Checklist - https://www.healthcare.gov/downloads/MarketplaceApp_Checklist_Generic.pdf • Employer Coverage Tool must be completed for every employer-based plan someone in the household is eligible for Updated November 1, 2013

  44. Marketplace Practice Tips Security Questions • Security questions are asked when setting up an account • Security levels will depend on correctly answered questions - use caution when entering full name and social security number – they must match • If answers to security questions are not accepted, the contracted agency (Experian) will follow-up with applicant Updated November 1, 2013

  45. Marketplace Practice Tips Are You Currently Enrolled in Health Coverage? • This questions is asked on page 3 of the individual application and page 6 of the family application • CAUTION: Individuals who are expected to be losing BadgerCare+ on January 1, 2013, should answer “NO” they are not covered by Medicaid even though they are currently on BadgerCare+ Updated November 1, 2013

  46. Marketplace Troubleshooting • What challenges have you encountered while using the Marketplace? • What strategies have been successful in overcoming these challenges? Updated November 1, 2013

  47. Marketplace Resources • CMS consumer website – ACA and marketplace information, set up account, apply and enroll: www.healthcare.gov • CMS partner website – brochures, videos, training information for Navigators, Certified Application Counselors and mobilizers: http://marketplace.cms.gov • Wisconsin Department of Health Services – BadgerCare+ updates, webcast links, Regional Enrollment Network information: http://www.dhs.wisconsin.gov/health-care/ Updated November 1, 2013

  48. Marketplace Resources • E4Health Wisconsin – Wisconsin resources and training information: www.e4healthwi.org • Covering Kids and Families - Training, fact sheets, blog, Wisconsin-specific resources, list serve: http://www.ckfwi.org/affordablecareacthome.html • Wisconsin Council on Children and Families – Frequently Asked Questions about the ACA and BadgerCare+: http://www.wccf.org/proj_health.php Updated November 1, 2013

  49. Marketplace Resources • University of California Berkeley Labor Center – MAGI Summary http://laborcenter.berkeley.edu/healthcare/MAGI • Kaiser Family Foundation – FAQs About ACA and Fact Sheets http://kff.org/health-reform/faq/health-reform-frequently-asked-questions/ Updated November 1, 2013

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