ACA 101Matt JewettAssociate Director of GrantsMountain Park Health Center

What is health insurance to you?

The ACA

(The Affordable Care Act or Obamacare)

Coverage Expansion Where were Arizonans getting health insurance?2011-12 US Census American Community Survey through statehealthfacts.orgUninsured 20.1%Employer 52.2%AHCCCS (Medicaid) 20.1%Direct from Insurer 4.9%Other Public 2.8%

No more denials because of pre-existing conditionsYoung adults can stay on their parents health insurance plan until they are 26 years of ageFree preventative servicesEnds lifetime and yearly dollar limits on coverage of essential health benefits

What changes have happened as a result of the ACA?

Medicaid/AHCCCSIndividual plans in the Marketplace with financial assistance and without financial assistanceEmployer-based coverageWhat are coverage options under the ACA?

AHCCCSArizona Health Care Cost Containment System

What is AHCCCS?

Who could qualify for AHCCCS?AHCCCS Income limits

Number In HouseholdIncome133% of Federal Poverty Level1$15,6602$21,1923$26,7244$32,2565$37,788Each additional person, add$5,532

AHCCCS- Health-e-Arizona Plus www.healthearizonaplus.gov

AHCCCS = health insurance

SNAP = Food Stamps

TANF = Cash Assistance

Clinic SFS = Sliding Fee Scale care

The Marketplace

Coverage Expansion The Health Insurance Marketplace

What is the Marketplace?

Must live in the United StatesMust be a U.S. citizen/national or a lawfully present residentCan't be currently incarceratedDetails at: healthcare.gov

Who is eligible for the Marketplace?

What will a Marketplace health plan provide?

The buyer can choose from four levels of coverage

What levels of coverage can I choose from?Bronze Silver Gold PlatinumCost of policy (premium)Percentage of a medical cost covered by insurancePercentage of a medical cost the insured must pay (co-pay)$$$$$40%30%20%10%90%80%70%60%Under a Silver level plan, the insured may be eligible for cost-sharing or help paying their share of medical costs $$$$$

Are my doctor and specialist on the health plan network?Are my medications covered?Can I get dental coverage?Which plan fits my budget but still meets my needs?There are people available to help!What will guide a person in choosing a Qualified Health Plan (QHP)?

Financial Assistance for Insurance from the Marketplace

Premium Tax Credits (PTC)

Cost Sharing Reduction (CSR)What financial assistance is available in the Marketplace?

Who could qualify for financial assistance?Marketplace Income limits

Number In Household250% Federal Poverty Level1$29,1752$39,3253$49,4754$59,6255$69,775Each additional person, add*$10,150

Depends on projected household income and household sizeCannot be eligible for public insurance or affordable employer-based insurance Must be a citizen or legal resident

Who qualifies for financial help paying monthly premiums?

When a person qualifies for a Premium Tax CreditWhen should I take my PTC?

Is there more financial assistance available?

Eligibility for cost sharing is based on:

Household income and family sizeEligibility for the Premium Tax Credit Enrollment in a Marketplace silver-level plan

Cost Sharing Reduction (CSR)

To calculate the Premium Tax Credit and Cost Sharing Reduction go to:

How to find out how much assistance a person might qualify for

Catastrophic Coverage: A Limited Marketplace Option

Catastrophic Coverage

Workplace-based Insurance Coverage

What if I get insurance through my workplace?

Is the Marketplace available to employees with affordable workplace insurance?If the employees personal insurance premium is 9.5% or less of their income or affordable The family can elect coverage through the employees workplace OR apply for insurance through the Marketplace but will not qualify for the Premium Tax Credit.

When is the Marketplace available to employees with workplace insurance?If the employees personal insurance premium is over 9.5% of income or unaffordableThe employee and family may qualify for insurance and financial assistance through the Marketplace

Enrolling in Coverage through the Marketplace

Where to Apply or Renew:www.HealthCare.gov

There are many ways to apply

When can people enroll in Marketplace coverage or make changes to coverage?Important dates for 2016 enrollment:

November 1, 2015:Start of 2016 Open Enrollment period first day you can enroll in a 2016 Marketplace plan

January 1, 2016:First date 2016 coverage can start

January 31, 2016:2016 Open Enrollment endsAHCCCS (Medicaid): 365 days a year

What if someone needs to apply for coverage outside the Open Enrollment Period?

Health Insurance Expansion

2015: 11.7 million MP Nov 15 2014 March 31 2015Plus 12.2 million Medicaid

2014: 8 million MP ACA Results NationallyResults

Plan Enrollment

QUESTIONS?

Engage the audience with this question. Solicit answers from the audience but also provide the definition belowHealth insurance is a contract between an individual and an entity that provides health insurance. The health insurer agrees to cover some or all of the healthcare costs of the individual in exchange for payment (premium).

5/9/2014Value of Health InsuranceNOTE: This slide illustrates coverage before the Marketplace and is for the population under the age of 65 years.

Most Arizonans were and still are covered under employer-based health plans. Nearly one-in-five Arizonans was uninsured before the ACA. Almost 5% Arizonans purchased coverage directly from an insurer. These plans could discriminate based on pre-existing condition, and were often unaffordable. Both of these groups have options they didnt have before under the Affordable Care Act. AHCCCS eligibility has been restored to childless adults and expanded to 133% FPL.

Other refers to public insurance such as Tri Care.ACA = Affordable Care Act, also sometimes called Obamacare Prior to the implementation of the ACA, insurance companies could deny you coverage is you had a condition prior to enrolling (know as a pre-existing condition). Say your child has asthma plans could refuse to cover your child. No more. Prior to the ACA your children could stay on your insurance only until 21 years of age they can now stay on until age 26 years. If your on a tight budget what do you do when its time to have your mamogram? You forgo it because it costs too much. Now it is free. And no longer can health plans say, sorry were not covering anything else for you this year because youve reached our payout limit There are multiple options available to Arizonans. Medicaid/AHCCCS in Arizona is public health insurance coverage based on income and household size. The Marketplace (created under the ACA) has Health insurance plans available to individuals who previously did not have access to employer based and/or could not afford to buy an individual plan on the open market. Plans in the Marketplace are available with financial assistance (based on income and household size) and without financial assistance. Many people continue to get coverage through their employer and employers

Lets take a look at AHCCCS first...5/9/2014Value of Health InsuranceArizona Health Care Cost Containment SystemPublic Health insurance with little or no cost to the family.AHCCCS eligibility is based on household income and size.Its possible that some members of the family could qualify for AHCCCS while others may not.AHCCCS requires each member to select a health plan. Plans are county specific. For example, Maricopa County has six health plans to choose from. One is not necessarily better than the other. They simply have different providers.

As I said in the previous slide, eligibility for AHCCCS is based on household income (gross income before taxes) and size.

Households with incomes up to 133% of the federal poverty level may qualify for AHCCCS.

NOTE: the web address is animated (bounces around)

The HEA Plus application allows people to apply for other programs as well as AHCCCS

SNAP = Supplemental Nutrition Assistance Program (Nutrition Assistance)TANF = Temporary Assistance for Needy Families (Cash Assistance)Clinic SFS = Clinic-based Sliding Fee Scale programs. Federally qualified health centers provide discounted visits and other services to patients depending on income.

People can use the Health-e- Arizona website to apply and renew on their own or they can get assistance.For people who need assistance applying there is local help available - we will talk about that later.

5/9/2014Value of Health InsuranceSo now its on to the Health Insurance Marketplace The health insurance marketplace is an entirely new entity, created as a result of the Affordable Care Act. Many health insurance companies sell plans on the Marketplace. Insurance coverage through the Marketplace is available with financial assistance and without financial assistance. To receive Marketplace financial assistance you must qualify based on income and household sizeAsk this question of the audience- How many of you have ever shopped at Amazon.com? The Marketplace is similar - its an online shopping venue where, instead of buying toilet paper, you can buy health insurance. At healthcare.gov you can see if you qualify for financial assistance and see all your options to help you make a decision. And yes you can enroll at healthcare.gov as well.

Many are eligible for the Marketplace but there are some eligibility requirements. Many people have questions about immigration status and eligibility in the Marketplace. Here is a handout that will help explain. Provide handout on various immigration statusesPictures on this slide are animated and will appear with a click of a mouse of hit of the enter key. They are roughly in order of the list below but not every benefit has a corresponding picture.

All plans are must offer these 10 essential benefits (name them). Ambulatory patient services, Emergency services, Hospitalization, Maternity and newborn care, Mental health and substance use disorder services, incl. behavioral health treatment, Prescription drugs, Rehabilitative and habilitative services and devices, Laboratory services, Preventative and wellness services and chronic disease management, Pediatric services, incl. oral and vision care

Most health plans offered in the Marketplace have several levels of coverage. You will need to choose a level of coverage. With health insurance coverage both the consumer and the health plan share costs. The higher the level of coverage, the higher the percentage of medical cost is paid by insurance

While the higher the level, the more expensive it typically is, it is possible that one insurance companys Silver plan could be less expensive than another companys Bronze plan Individual insurance companies are not required to offer all four plans. And remember this: Cost-sharing is only available under a Silver level planThe pills in the corner of the slide are animated. It might be tempting to choose a plan simply because it has the lowest monthly premium. There are a number of considerations outside of cost you should take into account when selecting a health plan.

The list of doctors that can be seen through a specific plan is called the network of providers. If you want to see a specific doctor or specialist, it is important to find out if he or she is in the network of providers for that plan. Call the health plan to make sure your medical provider is part of that plans network because network providers change oftenWhich plan fits my budget but still meets my needs? If you use a lot of health care (make a lot of visits to doctors and/or specialists), it might not make sense to choose a low monthly premium plan with a high deductible, because you may end up paying a lot up front until you reach your deductible. Are my medications covered? Every health plan has a list of prescription drugs that are covered, called a formulary. There are often several tiers of medications. The lowest tier, which costs the least, is generic (not brand name) drugs. Brand name drugs may also be available on a plan but may cost more so the person may have to pay more out of pocket. Can I get dental coverage? Dental coverage is available in the Marketplace for both adults and children. Dental coverage must be offered by Marketplace plans for children, either embedded in the health insurance or as a stand alone product. Neither adults nor children are required to purchase dental insurance - i.e. - you will not be penalized if you dont have dental coverage. Nonetheless, it makes sense to have dental coverage if you can. There are people available to help! There are several types of trained, certified people available locally to answer your questions and assist you with your decision-making.

5/9/2014Value of Health InsuranceThe graphic is animated. There are two ways to get help paying for health insurance in the Marketplace PTC and CSR. The Premium Tax Credit or PTC is a contribution from the government which is applied to your monthly premium cost and can reduce your monthly payment. The Cost Sharing Reduction or CSR is applied to your personal costs (your out of pocket costs such as co-pays and co insurance. Your eligibility for this financial assistance depends on your income and family size.You will want to know if you qualify for financial assistance. The amount of financial assistance you qualify for will determine your premium (monthly payment) and your out - of - pocket costs such as co-pays, deductibles, etc.

Stress that the income levels on this slide are guidelines they are not hard and fast levels and that they will change yearlyPremium Tax Credits or PTC are available to eligible individuals and families. The government expects that you can contribute between 2% and 9.5% of you income towards a premium. Eligibility is based on: Projected (estimated over the coming year) household income and family sizeCant be eligible for public insurance such as Medicare, Medicaid, Veterans Affairs, Tricare, Indian Health ServicesEmployer-sponsored coverage that meets certain requirements - well talk about this a little bit laterMust be Citizens or legal residents of US

Must file a tax return for the year in which credit is claimedMarketplace is the only place to get the tax credit and the tax credit can be used on any level of coverage

If you qualify for the PTC you have a few options on how you would like to apply the tax credit. The PTC is sent directly to the insurer and is available to the consumer only during the months they are enrolled in QHPClaim all in advance will lower your monthly premium cost immediatelyClaim some in advance will lower your premium cost some, Claim none in advance will not lower your monthly premium cost, you could receive a refund at the end of the yearSince the PTC is a tax credit there is a reconciliation when taxes are done. If actual income exceeds expected income, a portion of the Premium Tax Credit may need to be repaid. Report any major changes in income to the MarketplaceYes. In addition to help with premiums, help is available for to pay for healthcare costs such as deductibles, co-payments, and co-insurance. This is known as Cost Sharing Reductions or CSR. In order to take advantage of CSR consumers must be enrolled in a Silver level plan

You must be eligible in order to receive CSRLike with the PTC, you must meet certain criteria to be eligible for CSRTo be eligible for cost-sharing reductions, you must:have a household income less than or equal to 250% of the Federal Poverty Level (FPL) ($58,875 annually for a family of four presently); meet the requirements to enroll in a health plan through the Marketplace and receive the premium discount; and enroll in a silver-level plan through the Marketplace. OPTIONAL:there is limited cost sharing reduction for members of American Indian and Alaska native tribes who purchase health insurance through the Marketplace do not have to pay co-pays or other cost sharing if their income is under 300 percent of the Federal poverty level, which is roughly $70,650 for a family of four in 2013 ($88,320 in Alaska).Health Insurance Marketplace 10105/15/2013Web address is not live If you want to do an example with the audience you will need internet access. Suggest having the web site up but minimized so that you can switch to it easier. Invite one participant to navigate to the website valuepenguin.com and enter the information below. Read the information aloud from the example below and input into the calculator:

Single mother, age 27 with 2 children making $28,000 a year with no option for insurance through work.

143% of FPL, estimated cost for insurance is $6,996, they pay $1,011 (14% of total premium and 3.61% of income) and the tax credit covers 86% of the premium $5,9855/9/2014Value of Health InsuranceCatastrophic coverage is designed to cover catastrophe the unexpected things that happen to our health. This coverage has a high deductible and usually doesnt cover much in the way of prevention.

What do you get with Catastrophic Coverage?Premiums are lower than other Quality Healthcare Plans, but costs to the consumer for deductibles, copayments, and coinsurance are generally higher.Covers three primary care visits per year at no cost and free preventative benefits.BOTTOM LINE: COVERAGE IS CHEAPER BUT IS SKIMPY!!!!*No financial assistance is available for catastrophic coverageTo qualify for Catastrophic Coverage:Must qualify for extreme Hardship ExemptionMust be under the age of 30 Nothing available in your area costs less than 8% of your income

5/9/2014Value of Health InsuranceMany people have coverage through their place of employment and will continue with that coverage.

The Marketplace was designed to extend coverage to people who were unable to get coverage from the workplace - i.e. employees of small businesses who couldnt afford to offer coverage, (other examples). It wasnt designed to offer people who have access to employer based insurance to jump the wall or drop their employer based coverage for a better deal through the Marketplace.

The ACA sets forth guidelines to keep coverage affordable for employees but the government does expect employees to contribute up to 9.5% of their income towards their own insurance premiums.

If the employees required contribution forinsurance coveragefor themselves is 9.5% or less of the their (the employees) income, it is considered affordable, by the government. In this case, the employees family members can apply for insurance through the Marketplace if they meet other requirements but they will not qualify for the premium tax credit.

Right now, in deciding if the premium cost is unaffordable, the Marketplace only takes into account the cost of employer-based coverage for the employee . Currently the Marketplace does not take into account the cost of covering the rest of the family through employer-based insurance. Changes to this policy are being considered.

Required premium contribution by an employee that is greater than 9.5% of the employees income is considered unaffordable.The employee may qualify for insurance and financial assistance through the Marketplace as long as they meet other requirements (e.g., legally in the U.S., income requirements).

5/9/2014Value of Health Insurancewww.healthcare.gov is the place to go to learn about health insurance coverage or to apply for coverage during the open enrollment period. Health Insurance Marketplace 10105/15/2013Handout available (With Nuestra Salud on top) with important web addresses on it There are various ways to apply Spanish language Marketplace is available at www.cuidadodesalud.govYou can also apply by mail, telephone or in-person with the help of a Navigator or other qualified helper.Telephone support offers 150 languages (See which languages at Healthcare.gov)Downloadable and paper applications are availableTelephone help and online chat are available 24/7 to help you complete your application.1-800-318-2596 or TTY: 1-855-889-4325

Health Insurance Marketplace 10105/15/2013The next Marketplace open enrollment period will start on 11/1/15 and end on 1/31/2016.

During open enrollment, people can enroll OR make changes to their current policy. For those who are already enrolled and do not want to change anything it looks like they will be automatically renewed in the same plan. For those already enrolled who want to make changes will need to do so between Nov. 15 - Dec. 31. to avoid a lapse in coverage. This applies to people who enrolled during the last OPEN enrollment period AND people who enrolled during the SPECIAL enrollment period

For people who are enrolled in the Marketplace we advise them to get into their account, reset/update passwords to be ready. For people who havent enrolled in the Marketplace but plan to, they should obtain an email address (required if they will be enrolling online) and set up an account in healthcare.gov before OE.

The 1st and 15th days of the month are key (as they were before) as to when coveage starts.

During open enrollment, if one enrolls between the 1st and 15th day of the month and pays their premium, their coverage begins the first day of the next month. If one enrolls between the 16th and the last day of the month and pays their premium, their effective date of coverage will be the first day of thesecond following month.

Can I get financial assistance through the Marketplace outside of the open enrollment period? Yes but it depends on the reason: Examples :Loss of health coverage (i.e. you lose your job)Changes in family marriage, divorce, birth, adoption, deathBecoming a citizen or gaining lawful presenceReleased from prison Enrollment errors of the Marketplace (the Marketplace makes a mistake)Material contract violations by the Qualified Health PlanMoved Expanded Medicaid (known as AHCCCS in AZ) eligibility is a provision of the ACA. Before the ACA, only families at or below the Federal Poverty Level were eligible. Now families up to 133% of the FPL are eligible. Adults without dependent children up to 133% of the FPL are also now eligible.

As of May 2014 over 145,000 Arizonans have enrolled in AHCCCS. This number is increasing every day because:Eligibility determinations and enrollment available year round; there is no open enrollment period for AHCCCS like there is for the Marketplace