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A new age in health care: Insurance that works,
Navigators to show the way
Kit WagarAffordable Care Act SpecialistU.S. Department of Health and Human Services
Region 7 – Missouri, Kansas, Iowa, Nebraska
The Affordable Care Act
1
Enrollment schedule: The first enrollment period began Oct. 1, and ends on March 31,
2014 We are in only the fourth week of a six-month enrollment period
Coverage through the Marketplaces begins as early as Jan. 1, 2014
Must be enrolled by Dec. 15, 2013, for coverage to begin in January
In subsequent years, enrollment runs from October 15 to December 7
Enrollment is a marathon, not a sprintEnrollment is a marathon, not a sprint
Moving ahead
Two benchmarks from the first three weeks: Nearly 20 million unique visitors have checked out Healthcare.gov Nearly 700,000 people have completed online applications nationwide
But the health reform law is not just a website: It’s a new approach that makes health insurance more affordable and
health care more accessible to everyone
Marketplaces – A fairer system In 2014, private insurers will no longer deny coverage or charge a
higher price based on a person’s medical history
Prices for individuals will vary based only on four criteria: Age – a maximum of 3 times the price of younger applicants Tobacco use – a maximum of 50 percent higher than non-smokers
Location – states can establish rating areas
Family size
Ending gender discrimination Women will no longer be charged more than
men the same age
Currently, 22-year-old women are often charged 50 percent more than men their age simply because women bear children
A fairer market – Essential Health Benefits
Ambulatory patient services Emergency Services Hospitalization Maternity and newborn care Mental health and substance abuse
services, including behavioral health treatment
In 2014, all health insurance plans must cover the following 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
Currently, many plans offered in the individual market leave out major categories of coverage
Consumers often don’t realize the omission until they need the coverage 62 percent don’t have maternity benefits 34 percent don’t cover substance abuse 18 percent don’t provide mental health coverage 9 percent don’t cover prescription medication
Key requirements of a Marketplace Marketing of policies
These functions include: Toll-free phone number Website Presenting benefits in a standardized format Single application for Medicaid/CHIP/private insurance Providing electronic calculator to determine actual cost of policy
Includes premium subsidies for less than 400% of poverty level Cost-sharing reductions for households at less than 250% of poverty
Determining eligibility for Medicaid and CHIP Certifying people too poor to make personal responsibility payments
Review insurance plans for eligibility in the marketplace In Kansas & Missouri, insurers had to file their proposed plans and rates by May 3 They were reviewed last summer and approved in September
Making insurance affordable
Help for the middle class
Beginning in 2014: Workers without health benefits receive tax credits to help buy
insurance through the marketplaces Credits will be available up to 400 percent of the poverty level
Maximum income of: $45,960 for 1 person $94,200 for family of 4
The IRS estimates the average credit will be more than $5,000
These credits: allow family farmers and the self-employed to obtain health insurance as if
they had an employer helping them buy it help small business owners that can’t afford health insurance to compete
for employees with large companies that provide generous benefits
Affordable Health Plans
Expected contribution to insurance premiums, silver-level plan
For an individual: Reduction in Consumer’s Expected Maximum Out-of-Pocket Portion of
Annual Income % of FPL Contribution Monthly Premium Maximum Total costs
$13,788 120* 2% of income $23 2/3 6% $16,200 141 3.5% $47 2/3 6% $20,107 175 5.15% $86 2/3 13% $25,852 225 7.18% $155 1/2 27% $31,597 275 8.78% $231 0 30% $40,215 350 9.5% $318 0 30%
Incomes below 250% of the poverty level qualify for lower co-pays and deductibles
* This level of income would be eligible for Medicaid in states that expand their programs in accordance with the Affordable Care Act
Affordable Health Plans
Expected contribution to insurance premiums, silver-level plan
For a family of 4: Reduction in Consumer’s Expected Maximum Out-of-Pocket Portion of
Annual Income % of FPL Contribution Monthly Premium Maximum Total costs
$28,260 120* 2% of income $47 2/3 6% $33,205 141 3.5% $97 2/3 6% $41,212 175 5.15% $177 2/3 13% $52,987 225 7.18% $317 1/2 27% $64,762 275 8.78% $474 0 30% $82,425 350 9.5% $653 0 30%
Incomes below 250% of the poverty level qualify for lower co-pays and deductibles
* This level of income would be eligible for Medicaid in states that expand their programs in accordance with the Affordable Care Act
Individual policies, lowest-priced plan in each category:
Annual Plan Monthly Actual Size ofAge County income level premium payment Discount27 Boone $20,107 Silver $242 $76 $16627 Boone $20,107 Bronze $195 $29 $16627 Boone $25,852 Silver $242 $145 $9727 Boone $25,852 Bronze $195 $98 $97
27 St. Louis $20,107 Silver $196 $66 $13027 St. Louis $20,107 Bronze $147 $17 $13027 St. Louis $25,852 Silver $196 $135 $6127 St. Louis $25,852 Bronze $147 $86 $61
Many rural areas, which traditionally have higher insurance prices than urban areas, get bigger discounts to even out the costs
Actual prices in the Missouri MarketplaceActual prices in the Missouri Marketplace
Family of 4, lowest-priced plan in each category:
Annual Plan Monthly Actual Size ofCounty Income level premium payment DiscountBoone $41,212 Silver $816 $141 $675Boone $41,212 Bronze $659 $0 $675*Boone $52,987 Silver $816 $281 $535Boone $52,987 Bronze $659 $124 $535
St. Louis $41,212 Silver $663 $110 $553St. Louis $41,212 Bronze $496 $0 $553**St. Louis $52,987 Silver $663 $250 $413St. Louis $52,987 Bronze $496 $83 $413
* In Boone County, 1 plan would produce a $0 monthly premium; 1 plan would produce a monthly premium of $5.
**In St. Louis County, 2 bronze plans would produce a $0 monthly premium
Actual prices in the Missouri MarketplaceActual prices in the Missouri Marketplace
When you apply for lower costs in the Marketplace, you’ll need to estimate your household income for 2014 Most people can use their household’s adjusted gross income for this estimate
If you know your 2013 adjusted gross income, use that and take into account any changes you expect in 2014
You could also add up the following items for everyone in your household, based on what you think they’ll receive in 2014:
Wages Salaries Tips Net income from any self-employment or business Unemployment compensation Social Security payments Other kinds of income to include when estimating your 2014 income are:
rental income, interest, dividends, capital gains, annuities, alimony, and some retirement and pensions.
Calculating your income Calculating your income
Individual responsibility Beginning in 2014, individuals can choose to:
carry health insurance, or pay a fee to offset the cost of treating the uninsured
Qualifying coverage: Medicare, Medicaid, Veterans’ coverage , Tricare, employer coverage, private insurance
The fee is the greater of: $95 per person in the household or 1% of your income that exceeds
the tax filing threshold in 2014 $325 per person or 2 percent of income in 2015 $695 per person or 2.5% of income in 2016 and thereafter
Maximum per household is the income percentage or 3 times the flat fee
The flat fee for each child is half the adult amount
Consumer assistance
Enrollment Assistance
NavigatorsConsumer Assistance Programs
Public Eligibility Workers
Insurance Agents and
Brokers
Unions
Community-Based
Organizations
Health Care
Providers
Community Health Centers
Chambers of Commerce
County MH and SA Depts.
No wrong door to enrollment
Links to key questions consumers have about health insurance, eligibility & enrollment
Offers Web chat capability to answer users’ questions
Directs users to appropriate destination based on geography
Footer contains links for non-consumer users to find information
You can create an account* You provide family and income
information to qualify for discounts* You peruse the health plan options* You enroll in the plan best for you**We’re working out the kinks
Healthcare.gov (aka “The Culprit”)
Call Center launched in June 1-800-318-2596TTY/TDD line for hearing-impaired callers: 1-855-889-4325
Helps with wide range of questions, including: Health insurance and how it works Premium assistance and health care affordability programs Steps to take now to get ready for open enrollment beginning Oct. 1 General inquiries, such as “I have insurance. How will I be affected?”
After Oct. 1, the call center will help with: Filling out the application Plan selection
Assistance is Available 24/7 in English and Spanish Help in 150 other languages is available
Marketplace Call Center Marketplace Call Center
Small Business Health Options Program – “The SHOP” SHOP Call Center launched in August 1-800-706-7893
TTY/TDD line for hearing-impaired callers: 1-800-706-7915 Hours: 8 a.m. to 4 p.m. (central time) Beginning Oct. 1: 8 a.m. to 6 p.m. (central)
Information on tax credits that cover up to 50 percent of the cost of employee health insurance for two years at eligible small employers
New, more competitive pricing for health insurance policies Plans grouped by “metal level” to let employers compare plans with truly similar benefits Metal levels – bronze, silver, gold, platinum – reflect the generosity of the plan’s coverage
SBA Fact Sheets, Training Materials and insurance finder tool: http://www.sba.gov/content/affordable-care-act-training-materials Information based on your business location, size, and whether you now offer insurance
SHOP enrollment expected to begin in November
Help for small employers Help for small employers
Finding the right health plan Once an account is created, the
website offers: A comparison tool to evaluate policies
A calculator to estimate each plan’s: premiums co-payments deductibles maximum out-of-pocket costs
Filtering options to let the user narrow the choices based on specific criteria
The most relevant plans are presented first, based on the applicant’s answers
Key data listed with links to plan details
In-person assistance
Sources of enrollment help Navigators
Navigators received grants from Marketplace funds
They must provide community outreach and education programs
They are agencies or individuals trained to work with the uninsured and the underinsured and with employers buying health benefits for employees
Key groups that Navigators will work with include: Young people who may never have had health insurance The self-employed, many of whom previously could never afford insurance Vulnerable populations, including
Low-income groups Non-English-speaking populations People with disabilities Workers between jobs
To ensure that their advice is impartial, Navigators cannot accept compensation directly or indirectly from any health insurer
Navigators will be listed on the Marketplace website under “Find Local Help”
Navigator funding was announced Aug. 15:Missouri received $1.8 million for navigator organizations
Primaris Healthcare Business Solutions $1,045,624 Primaris will lead a coalition of 11 community partners to provide free and unbiased information about insurance plans offered on the Marketplace
Primaris already works with health care providers to improve quality of care Primaris also operates the Medicare CLAIM program, which provides counseling to help people choose the most appropriate Medicare Advantage plan
Missouri Alliance of Area Agencies on Aging $ 750,000
These agencies have an extensive network of contacts and experience dealing with vulnerable populations They will provide navigators in most of Missouri, outside Kansas City
Missouri Navigators Missouri Navigators
Sources of enrollment help Application Counselors
They receive similar, but less extensive, training than Navigators. They must pass a similar, though less comprehensive test
Training is available online at http://marketplace.cms.gov/training/get-training.html
Counselors are certified by the organization they work or volunteer for Individuals can take the training and provide assistance, but they will not be listed on the
Marketplace website as certified application counselors No funding is attached to becoming an application counselor
Most counselors are likely to be staff and volunteers of organizations with a business interest or a social mission to get people insured
Clinics, hospitals, health care providers, social agencies are encouraged to become designated to certify their staff members as application counselors
Counselors must show applicants all insurance options available
To ensure unbiased advice, counselors cannot accept compensation in connection with enrollment and must disclose any potential conflict
Agencies designated as certified application counselors will be listed on the www.healthcare.gov website under “Find local help”
Questions about becoming a certified application counselor or agency can be sent to [email protected]
Becoming a CAC agency Becoming a CAC agency
To apply to be designated as a certified application counselor agency, go to:
http://marketplace.cms.gov/help-us/cac.html
Licensed health Insurance agents and brokersTo enroll individuals, must undergo training on:
website enrollment Marketplace affordability programs Medicaid options security of personal information
Paid by insurers
Brokers and agents represent certain insurance companies and are not required to show applicants all insurance options
Broker training in the federally run Marketplaces is available at: http://www.cms.gov/CCIIO/programs-and-initiatives/health-insurance-marketpl
aces/a-b-resources.html
Sources of enrollment help Sources of enrollment help
Navigators and application counselors must: comply with the Marketplace privacy policies follow Marketplace rules on security of personal information
Information entered on paper applications should not be retained Information in electronic applications is secure within applicant’s online account
Designated application counselor organizations must: screen staff and volunteers to ensure they protect personal information confirm in writing that its workers will comply with privacy and security rules
All certified application counselors must: obtain authorization from each consumer before obtaining personal information maintain a record of the authorization
The consumer can revoke the authorization at any time
Organizations or individuals who violate privacy and security standards are subject to monetary penalties Fraudulent activity will be investigated and addressed under federal law
Security of personal informationSecurity of personal information
Learn about different types of health coverage The Marketplace lets you choose a health plan with the right balance of costs and
coverage. You’ll be better prepared if you understand different types of coverage
Make sure you understand how coverage works, including things such as premiums, deductibles, out-of-pocket maximums, copayments, and coinsurance. You'll want to consider these details while you're looking for health insurance
Gather basic information about your household income Most people using the Marketplace will qualify for discounts on monthly premiums or
out-of-pocket costs. To find out your savings, you'll need income information from documents such as your W-2 form, current pay stubs, or your tax return.
Steps to take now Steps to take now
Set your budget Different types of health plans meet different
needs and budgets. You'll need to figure out how much you want to spend on premiums each month.
“Opportunity is missed by most people because it is dressed in overalls and looks like work.“
----Thomas Edison
A final thought