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Anticipating the Health Insurance Marketplace in Texas Pearland Chamber of Commerce August 29, 2013
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About Community Health Choice
• Non-profit Health Maintenance Organization licensed by the Texas Department of Insurance
• Affiliate of the Harris Health System • Serves over 230,000 Members with the following
programs: • Medicaid: State of Texas Access Reform (STAR) program for low-
income children and pregnant women • CHIP: Children’s Health Insurance Program for the children of low-
income parents—includes CHIP Perinatal benefits for unborn children of pregnant women who do not qualify for Medicaid STAR
• 3-Share Plan: TexHealth Harris County 3-Share Plan that subsidizes the premiums of a limited benefit plan for previously uninsured, low-income employees of small businesses
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CHC Service Area Map
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Membership and Revenue
$0
$100
$200
$300
$400
$500
$600
$700
-
50,000
100,000
150,000
200,000
250,000
2004 2005 2006 2007 2008 2009 2010 2011 2012
Rev
enue
(Mill
ions
)
Mem
bers
hip
(Tho
usan
ds)
Membership Total Revenue
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Our Mission
At Community Health Choice, our mission is to improve the health of underserved residents of Southeast Texas by facilitating access
to coordinated, high quality, affordable healthcare services. Our mission is achieved through:
Community Collaborating with community-based Providers and organizations to
improve access, quality, coordination and cost effectiveness of services
Health Developing programs to establish medical homes, manage health
conditions and promote wellness and preventive care
Choice Encouraging personal accountability and educated choices for individual
and family health
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Federal Reforms with Medicaid Expansion
$19,090
$76,360
$38,180
Family of 3:
$25,390
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Federal Reforms without Medicaid Expansion Federal Reforms without
Medicaid Expansion
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Potential Exchange Market Size
2% 19%
79%
72,917 Uninsured Children
Newborns Ages 1-5 Ages 6-18
25%
27% 23%
17%
8%
457,938 Uninsured Adults
Ages 19-26 Ages 27-34 Ages 35-44 Ages 45-54 Ages 55-64
Includes • all legal residents < 5 years between 0-400% FPL • child citizens and legal residents > 5 years between 200-400% FPL • adult citizens and legal residents > 5 years between 100-400% FPL
20 County SDA Eligible for Exchange Coverage
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Individual Mandate
• Effective January 1, 2014 most individuals will be required to purchase insurance or pay penalties
• Exceptions: • Individuals covered under an ER sponsored plan • Individuals already enrolled in an individual insurance plan meeting all ACA
requirements • Individuals who are eligible for Medicaid or CHIP • Individuals who would have to pay more than 9.5% of their income for health
insurance • Individuals below the threshold required to file an income tax return (2012 = $9,750 single) • Undocumented Immigrants • Individuals who are incarcerated • Members of Indian Tribes
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Penalties
• 2014: The greater of 1% of total family income or $95
adult and $47.50 per child up to $285 for a family
• 2015: The greater of 2% of total family income or $325 per adult and $162.50 per child up to $975 for family
• 2016: The greater of 2.5% of total family income or $695 per adult and $347.50 per child up to $2,085 for family
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Consumer Protections
• Guarantee issue • Guarantee renewable • No pre-existing limitation exclusions • No waiting periods • No cost sharing for covered preventive care/wellness • Dependent children can be covered up to age 26
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Products to be Offered
• Products offered in (or out) of the Exchange must include the ten categories of Essential Health Benefits specified in the ACA:
Ambulatory patient services Emergency services
Hospitalization Maternity and newborn care
Mental health and substance use disorder services
Prescription drugs
Rehabilitative and habilitative services and devices
Laboratory services
Preventive and wellness services* and chronic disease management
Pediatric services, including oral and vision care**
* At no cost to members ** Can be excluded in States with enough Stand Alone Dental Plans
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Plan Levels of Coverage
Level of
Coverage
Plan Pays
on Average (actuarial value)
Enrollees Pay on Average
(In addition to the monthly plan premium)
Bronze 60 percent 40 percent
Silver 70 percent 30 percent
Gold 80 percent 20 percent
Platinum 90 percent 10 percent
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Financial Assistance
Two forms of assistance available through the Exchanges
Eligibility
2013 Individual/Family of 4 Income Estimate Details
Advance Premium Tax Credits
Between 100% and 400% FPL
$11,490 to $45,960/ $23,550 to $94,200
Sliding scale basis to reduce the cost of the monthly member portion of premium
Cost-Sharing Reductions
Between 100% and 250% FPL
$11,490 to $28,725/ $23,550 to $58,875
Only available for silver plans; effectively raises the AV of the plan
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Premium Tax Credit Reconciliation
• Premium tax credits are applied to the monthly premium in advance
• Reconciliation of tax credits done on tax returns • If advance payments exceed the amount of credit
individuals are eligible, repayment is required • Advance credits provided in 2014 will be reconciled
on tax returns due on April 2015
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Sample Product Designs
Illustrative Bronze Benefit Plan
60% Actuarial Value
Illustrative Silver Benefit Plan
70% Actuarial Value
Illustrative Silver Benefit Plan with Cost Sharing
Reductions 94% Actuarial Value
Deductible $2,500 $0 $0
Coinsurance 0% 0% 0%
Out of Pocket Maximum (in network)
$6,350 $6,350 $1,000
Office Visits $35/$70 copays after deductible
$40/75 copays $10/$20 copays
Inpatient Hospitalization
$400 per day for first five days after deductible
$400 per day for first five days $200 per day for first five days
Prescription Drugs $25/$75/$100 copays $25/$75/$100 $5/$20/$40
Emergency Care $250 after deductible $250 $100
Premium $240 $290 $290
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• Determine eligibility for: • Enrollment in a
qualified health plan • Tax credits and cost-
sharing reductions • Medicaid or CHIP
Consumer Submits application to the
Marketplace
The Marketplace verifies and
determines (or assesses eligibility)
Eligible Consumer enrolls in a qualified
health plan or Medicaid/CHIP
Enrollment Overview
• Online • Phone • Mail • In Person
• Online plan comparison tool available to inform health plan choice
• Premium tax credit and cost-sharing reductions are sent to insurer (if eligible)
• Enrollment in a qualified health plan or Medicaid/CHIP
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Plan Comparison
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Certified
Navigators
Community Based Groups, Health Centers
Insurance Agents, Brokers
Medicaid eligibility workers
Consumer Assistance Programs
Certified Application Counselors
In-Person Assistance Programs
Who Can Help?
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Key Points to Remember
You have choices Employer-based coverage will continue Insurance will continue to be sold outside of the
Marketplace • Purchase from the Marketplace is not required
The Marketplace is the only place to get • New premium tax credits • Cost-sharing reductions
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Key Deadlines
October 1, 2013 2014 Open enrollment begins
January 1, 2014 Coverage begins
March 31, 2014 2014 Open enrollment ends
October 15th – December 7th
Annual open enrollment period for future years
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QUESTIONS? Karen Love, Senior VP [email protected] 713.295.5195 www.chcaffordablehealthcare.com
For more information on the Health Insurance Marketplace, sign up to get email and text alerts at signup.healthcare.gov