Healthcare Financial Management Association

Stonewall ResortsMay 16, 2013

The ACA Signed into Law March 23, 2010

Four Goals of the ACAStrong emphasis on

prevention

New regulations of the insurance industry

Cost containment

Expand access to virtually every American

Expanding Coverage

Expand Medicaid up to 138 percent of the federal poverty level (FPL)

Establish the Health Insurance Marketplace where private insurance plans are offered

Current Eligibility Expansion Eligibility$0

$5,000

$10,000

$15,000

$20,000

$25,000

$30,000

$6,000

$27,000

Medicaid Expansion Income Eligibility for a Family of Three

Medicaid ExpansionNow that Governor Tomblin

has approved the Medicaid expansion, 120,000 low-income West Virginians become eligible

Enroll begins October 1, 2013 and coverage begins January 1, 2014

Medicaid ExpansionFederal 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

Examples of FPL for Medicaid

Family Size 138% of FPL 155% of FPL

1 $15,856 $17,810

2 $21,404 $24,040

3 $26,951 $30,272

4 $32,499 $36,502

Medicaid EligibilityMedicaid eligibility is

determined by:

◦Income◦Family size◦US citizenship◦State Residency◦Under age 65

Federal Poverty Level

Changes in CHIPWith the increase in Medicaid

eligibility, many children currently enrolled in CHIP will become Medicaid eligible and cannot remain on CHIP:

10,800 kids transfer to Medicaid

2,800 kids picked up under the new MAGI eligibility rules

Beyond MedicaidIf 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

Health Insurance Marketplace

Health Insurance MarketplaceOffers private insurance

policies: Blue Cross Blue Shield, The Health Plan, Carelink, etc.

Who is eligible? People who do not have access to employer sponsored plans or qualify for government plans (Medicaid, Medicare, Tricare, VA, etc.)

Qualified Health Plans (QHPs)Eligibility for a QHP include:

◦Be a US citizen or lawfully present in the US

◦State resident ◦Not being incarcerated

Premium SubsidiesIn order to qualify for

premium tax credits, 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 (there are two exceptions for ESI)

◦Are expected to file income tax at the end of the coverage year

Health Insurance Marketplace

An estimated 99,000 West Virginians will qualify for premium tax credits in the Marketplace by 2016.

An Example of the Subsidies

Family of four with annual income of $55,000. They pay $345 a month in premiums and the tax credits equal $840 a month.

Additional assist with deductibles and copayments plus out-of-pocket maximum protection.

Subsidies for Cost Sharing ExpensesIndividuals 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

FPL for Cost Sharing Subsidies and Premium Subsidies

Family Size 250% of the FPL 400% of the FPL

1 $28,725 $45,960

2 $38,775 $62,040

3 $48,825 $78,120

4 $58,875 $94,200

250% of the FPL level is the eligibility threshold for cost sharing reductions and 400% of the FPL is the threshold for premium assistance

Levels of Plan Options for QHPsFour “metal levels” of plans

may be offered in the Marketplace and vary based on their actuarial value

The actuarial value is what percentage of claims for essential health benefits the insurance company pays and what percentage on average consumers pay

Levels of Plan Options for QHPsIn a platinum plan, the insurance company pays 90% of claims and consumers on average pay 10% of the claims

Gold plans are split 80/20 between the insurance company and consumers

Siler is a 70/30 split, andBronze is a 60/40 split

Premiums in the Various Metal Levels

Premiums in a platinum plan would be higher, while deductibles and copayments would be lower

Conversely, the premiums in a bronze plan will be lower, while the cost sharing would be higher

Selecting a QHP

Unlike Medicaid, which is a two step process (eligibility and then enrollment), the Marketplace can determine eligibility and provide options for an individual or family to select an insurance plan and enroll in a plan.

Selecting a QHP

The Marketplace will have a calculator showing an individual or family their premium, deductibles, copayments or co-insurances for each insurance company

Summary of Benefits and Coverage

The Marketplace will allow have an 8-page summary of benefits and coverage:

◦What’s covered, what’s not ◦Costs for a typical Type II diabetic

◦Costs for a normal delivery

All written in plain English

Selecting a QHPThe Marketplace will also

have links to insurance company’s web site

Consumers can check to see if their doctor or hospital are in the company’s network

Consumers can check to see if the drug(s) they are taking are on the company’s formulary

Selecting a QHPIn future years, the

Marketplace will have the results of consumer satisfaction surveys for each insurance company

And a rating system for insurance companies

SHOP MarketplaceEligibility for the Small

Business Health Insurance Option Program (SHOP) is 50 or fewer employees, about 42,000 West Virginia businesses employing 280,000 people

Only 16,000 employees projected to be enroll in SHOP Marketplace by 2016

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

Personal Assistance Needed83% of people who will

qualify for assistance in the future know nothing about it

Skeptical and interest framed by past negative experience

75% want personal assistance

How Do We Enroll All These People?

Web site and call center operated by HHS

A number of entities will provide personal assistance

Personal AssistanceInsurance agents and brokers

Navigators

In-person Assisters

Certified Application Counselors

DHHR Employees

Community Assisters

The Enrollment ProcessSingle, Streamline

Application for Medicaid, CHIP and qualified health plans (QHPs) in the Health Insurance Marketplace

There is no asset test for any of theses three insurance policies

Take AwaysThe uninsured can enroll

where ever there is a lap top or iPad with internet connection. They can also use a toll-free call center or personal assistance.

Take AwaysFor the most part, the system

will be paperless and will rely on electronic databases or self-attestation to determine eligibility for Medicaid or the QHPs

Take AwaysThe numbers are staggering:

◦120,000 eligible for Medicaid

◦99,000 eligible for premium assistance

◦16,000 eligible for the SHOP Marketplace

OpportunityWe have a once-in-a-lifetime

opportunity to improve the lives of thousands of our friends and neighbors. I hope you will join WVAHC in this journey

We need…

Contact Information

Perry BryantWest Virginians for Affordable

Health Care1544 Lee Street, EastCharleston, West Virginia

25311304-344-1673perrybryant@suddenlink.netwww.wvahc.org