Qualified Health Plans

1. Qualified Health Plans Summer 2013 Navigator/In-person Assister Program

2. 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.

3. 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

4. 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

5. 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.).

6. Exchange – A Single Doorway Public Insurance Private (commercial) Insurance Unsubsidized Medicaid (Apple Health) Subsidized (tax credits) <138% FPL 139-400% FPL >400% FPL Exchange

7. 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”

8. 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

9. In General… • Plans with higher PREMIUMS have lower cost sharing and/or richer coverage

10. 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?

11. 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

12. Metal Tiers Key Point * Silver plan or higher required to get tax credits. Actuarial Value: The amount (%) of the bill that the insurer pays

13. 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

14. Premium Tax Credit and Cost Sharing Reductions Key Point Premium Tax Credits Cost Sharing Reductions *Of the second lowest cost Silver plan 14

15. 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

16. Pediatric Dental Plan Insurance Carriers in the Exchangeas of September 4, 2013 • Delta Dental of Washington • Kaiser Foundation Health Plan • LifeWise • Premera Blue Cross

17. 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

18. 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

19. Eligibility & Enrollment Flow - QHP Eligibility Determination QHP Enrollment & Pediatric Dental Enrollment Application Data Collection Payment Account Creation Post Application Shopping

20. 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

21. Questions

22. Lesson 1 Application Type ‒ Individual

23. Account Creation Eligibility Determination QHP Enrollment & Pediatric Dental Enrollment Application Data Collection Payment Account Creation Post Application Shopping

24. 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

25. 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

26. 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.”

27. 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

28. 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.

29. 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.

30. 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

31. Eligibility & Enrollment Flow (Qualified Health Plan (QHP)) Eligibility Determination QHP Enrollment & Pediatric Dental Enrollment Application Data Collection Payment Account Creation Post Application Shopping

32. 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.

33. 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

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

35. Knowledge Check What are the three different application types for eligibility on Washington Healthplanfinder? • Myself • _______________ • __________________________ Myself and Others Other Members of My Household

36. 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

37. Knowledge Check What organization verifies the social security number of the primary applicant? • Federal Hub • eHealth • Eligibility Services • Washington Healthplanfinder

38. 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.

39. Questions

40. Lesson 2 Application Type – Household (All Eligible Members)

41. 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

42. QHP Eligibility & Enrollment Flow Eligibility Determination QHP Enrollment & Pediatric Dental Enrollment Application Data Collection Payment Account Creation Post Application Shopping

43. 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

44. 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.

45. 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.

46. 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

47. Eligibility & Enrollment Flow (QHP) Eligibility Determination QHP Enrollment & Pediatric Dental Enrollment Application Data Collection Payment Account Creation Post Application Shopping

48. 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.

49. 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.

50. 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