ACA Jill Hanken Virginia Poverty Law Center

New Insurance Marketplace Virginia is served by “Federally Facilitated Marketplace” (FFM) To compare / purchase private health insurance Qualified Health Plans (QHPs) Premium Tax Credits only available with FFM plans Also available to small employers in November Fewer than 50 “full time equivalent” employees Small Business Health Options Program “SHOP”

Qualified Health Plans QHP/4 TIERS of COVERAGE Essential Health Benefits (Standardize Coverage) Bronze = 60% Ambulatory Patient Services Emergency Services Silver = 70% Hospitalization Maternity & Newborn Care Gold = 80% Mental Health & Substance Disorders Prescription Drugs Platinum = 90% Rehabilitative & Habilitative Services Laboratory Services Catastrophic (available for <30 years old) Preventive & Wellness Services Pediatric Services includes Oral & Vision

Basic Eligibility U.S. citizen or national, or non-citizen who is lawfully present in the U.S. for the entire time coverage is sought Live in service area Not incarcerated No access to “affordable and adequate” insurance Income between 100% FPL and 400% FPL to receive financial assistance

2015 Federal Poverty Guidelines Family Size Family’s Annual Income Levels 100% FPL 133% FPL 150% FPL 200% FPL 250% FPL 400% FPL 1$11,770$15,654$17,655$23,540$29,425$47,080 2$15,930$21,187$23,995$31,860$39,825$63,720 3$20,090$26,720$30,135$40,180$50,225$80,360 4$24,250$32,253$36,375$48,500$60,625$97,000 5$28,410$37,785$42,615$56,820$77,025$113,640

“Affordable and Adequate” Coverage People who have “Minimum essential coverage” are not eligible for tax credits: Medicaid, FAMIS, Medicare, Tricare Job-based coverage Job-based coverage is not affordable/adequate if employee-only plan: costs ↑9.5% family income; or covers ↓ 60% costs

Eligibility For Financial Assistance Premium tax credits reduce the amount you pay for your premium. Cost sharing reductions lower your deductibles, co- pays and out of pocket costs.

Advanced Premium Tax Credits Income between 100% and 400% FPL Maximum contribution towards premium Based on cost of 2 nd least expensive Sliver Plan Income Level (FPL) Contribution From Income Up to 133%2% %3 – 4% %4 – 6.3% %6.3 – 8.05% %8.05 – 9.5% %9.5%

Premium Tax Credit Example Elina is a 34-year old single female Annual Income of$17,200/year (150% FPL) Maximum Contribution 4% Income = $688/ yr Cost of 2 nd lowest Silver Plan$4,000 ($333.33/mo.) Subtract Max. Contribution- $688 Premium Tax Credit $3,312 ($276/mo) Full cost of plan /mo Subtract Tax Credit /mo Elina pays $57.33/mo

Using the Tax Credit Can be used for all plans except catastrophic Can be received as a credit on tax return Can be paid in advance directly to the insurance plan to help pay monthly premiums Must report changes in income/family size during the year to ensure an accurate tax credit amount “Reconciliation” will occur when taxes are filed

Cost-Sharing Reductions: The Importance of Silver Plans Special out-of-pocket protections for those with income under 250% FPL Only applies if Silver Plan is purchased! Increases Actuarial Value of Silver Plans to: 94% AV (income 100%-150% FPL) 87% AV (income 150%-200% FPL) 73% AV (income 200%-250% FPL)

Open Enrollment for Coverage Beginning as Early as January 1, 2016 November 1, 2015-January 31, 2016 Must enroll by the 15 th of a month for coverage to begin the 1 st of the following month Note: Medicaid/FAMIS applications accepted & processed all year You can enroll outside of Open Enrollment under a Special Enrollment Period

Special Enrollment Periods Losing coverage family member died turning 26 Changing/losing job COBRA ends Medicaid terminated Employer coverage is no longer affordable or adequate Life Change marriage moved to a new state new baby, child immigration status changed Released from jail Other situations Error by call-center, navigator, insurance company Native Americans & Alaska Natives Person in Medicaid Gap earns over 100% FPL

How to Apply: Multiple “doors” Online Marketplace Medicaid/FAMIS Phone Marketplace – Cover VA – In Person – local DSS Local assistance Enroll Virginia –

Information Needed to Apply Availability of Employer-based Coverage Identity of applicants Names and contact info Social Security Numbers Immigration Status and Documents Household Size Using tax code principles to determine household size Tax dependents are in the tax filers household Countable Income (MAGI) Using tax code principles & expected 2015 income Databases will verify most information Paper documents used for discrepancies

Renewing Coverage for 2016 Most consumer’s plans will be automatically renewed Insurers will inform consumers of Continuation of previously selected plan Changes to previously selected plan Premium increases Financial assistance the consumer will receive in 2015 The Marketplace will also contact consumers enrolled in the Marketplace informing them of the automatic renewal process

What Action Should You Take? Consumers should still review their Marketplace account before December 15 to: Determine whether they are enrolled in the best plan Determine if they are eligible for additional assistance Update application to reflect changes in income or household expected in 2016

Virginia Health Insurance Marketplace

Choosing Your Plan Monthly Premium is only one factor Also Consider Deductible Cost sharing – Co-insurance – Co-payments Provider Network - Specialists Drug Formulary Review service descriptions and limits on coverage

Assistance for those with income under 100% FPL ACA Medicaid expansion ruled optional by U.S. Supreme Court Virginia legislature has rejected – forfeited $ billions Up to 400,000 low income Virginians could be served Without Medicaid they must find health services: Community Health Centers Free Clinics Prescription Assistance Medicaid “Plan First” program for family planning only Hospital emergency rooms

WHO FALLS INTO THE MEDICAID GAP? Individuals with disabilities from 80% FPL to 100% FPL Childless adults below 100% FPL Parents with income from between 30% FPL and 51% FPL to 100% FPL—Medicaid eligibility depends on location Without Medicaid Expansion under the Affordable Care Act, approximately 200,000 Virginians will not be able to get health coverage.

Ex: Working single parent with 2 children who makes $9.00/hr ($18,720/yr)

QUESTIONS? Phone Number Facebook-

Thank you! ENROLL Virginia! is a nonprofit, nonpartisan entity that assists individuals and small businesses to obtain health insurance including commercial health coverage through the federally facilitated health insurance marketplace, to qualify for applicable tax subsidies, and to comply with the U.S. Patient Protection and Affordable Care Act and avoid penalties for failure to do so. The program is paid for by a federal grant (Funding Opportunity Number CA-NAV from the U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services) and administered by the Virginia Poverty Law Center. The contents provided here are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.