WHAT HEALTH PROFESSIONALS NEED TO KNOW THE HEALTH INSURANCE MARKETPLACE: CONTINUING EDUCATION TRAINING

WHAT THIS TRAINING WILL COVER The Affordable Care Act (ACA) Major Goals of the ACA Pathways to Affordable Quality Coverage Individual Shared Responsibility Medicaid State Option to Expand Medicaid Medicaid Coverage How to Access Medicaid Coverage Children’s Health Insurance Program (CHIP) CHIP Coverage How to Access CHIP Coverage The Health Insurance Marketplace State Options for Marketplace Structures How Individuals & Families Access the Health Insurance Marketplace AHEC Health Insurance Marketplace Continuing Education 2

WHAT THIS TRAINING WILL COVER Qualified Health Plans (QHPs) Sold in The Marketplace QHPs Subject to Insurance Reforms QHPs Cover Ten Categories of Essential Health Benefits (EHBs) QHPs Grouped into Metal Levels Catastrophic Coverage Plans Federal Subsidies for QHPs through Insurance Affordability Program QHP Summary of Benefits & Coverage (SBC) QHPs Maintain Provider Network Adequacy How to Access QHP Coverage Important Marketplace Enrollment Dates Small Businesses and the Marketplace Small Business Health Options Plan (SHOP) How Small Businesses Access SHOP Conclusions & Resources AHEC Health Insurance Marketplace Continuing Education 3

THE AFFORDABLE CARE ACT AHEC Health Insurance Marketplace Continuing Education 4

MAJOR GOALS OF THE AFFORDABLE CARE ACT (ACA) ACCESSIBLE COVERAGE QUALITY COVERAGE AFFORDABLE COVERAGE BETTER HEALTH CARE IMPROVED POPULATION HEALTH AHEC Health Insurance Marketplace Continuing Education 5

PATHWAYS TO AFFORDABLE QUALITY COVERAGE Medicaid Expansion States allowed, but not required, to expand Medicaid to cover low-income, uninsured adults between the ages of 18 and 64 Children’s Health Insurance Program (CHIP) Existing nationwide coverage for low-income children who cannot qualify for Medicaid is funded through 2015 Creation of the Health Insurance Marketplace Sells new Qualified Health Plans (QHPs) and provides Federal subsidies to help pay QHP premiums and out-of-pocket costs AHEC Health Insurance Marketplace Continuing Education 6 The Marketplace Provides Access to All Pathways of Coverage Complete One Enrollment Application for All Forms of Coverage

INDIVIDUAL SHARED RESPONSIBILITY INDIVIDUAL SHARED RESPONSIBILITY PAYMENT TRIGGERED AFTER THREE CONSECUTIVE MONTHS OF NON-COVERAGE 2014 FEE $95/adult & 47.50/child OR 1% household income 2015 FEE $325/adult OR 2% household income 2016 FEE $695/adult OR 2.5% household income FEE AFTER 2016 Adjusted for Inflation AHEC Health Insurance Marketplace Continuing Education 7 MOST EVERYONE IS REQUIRED TO CARRY MINIMUM ESSENTIAL COVERAGE (MEC) Some exemptions: Individuals who cannot afford coverage Taxpayers below the Federal income tax filing threshold Members of American Indian tribes Short coverage gaps (less than three consecutive months) Income between 100% and 133% of Federal Poverty Level (FPL) in states where Medicaid is not expanded Hardship

AHEC Health Insurance Marketplace Continuing Education 8 QUESTIONS ??????

MEDICAID AHEC Health Insurance Marketplace Continuing Education 9

10 STATE OPTION TO EXPAND MEDICAID

MEDICAID COVERAGE If Medicaid Expansion State: Previously required coverage of children, pregnant women, disabled and the elderly is still in place New coverage of all adults between the ages of 18 and 64 with incomes up to 133% of the Federal Poverty Level (FPL) If Non-Medicaid Expansion State: Previously required coverage of children, pregnant women, disabled and the elderly is still in place Any possible coverage of adults is subject to state law AHEC Health Insurance Marketplace Continuing Education 11 Coverage Gap in Non-Medicaid Expansion States Adults who cannot qualify for Medicaid and cannot qualify for Federal subsidies to buy QHPs.

HOW TO ACCESS MEDICAID COVERAGE MEDICAID COVERAGE GO TO THE MARKETPLACE SUBMIT APPLICATION INFO SENT DIRECTLY TO STATE MEDICAID OFFICE COMPLETE ENROLLMENT CONTACT STATE MEDICAID OFFICE SUBMIT APPLICATION COMPLETE ENROLLMENT AHEC Health Insurance Marketplace Continuing Education 12 One Enrollment Application for All Forms of Coverage Go to: or Call:

CHILDREN’S HEALTH INSURANCE PROGRAM (CHIP) AHEC Health Insurance Marketplace Continuing Education 13

CHILDREN’S HEALTH INSURANCE PROGRAM (CHIP) COVERAGE CHIP is for children in families that earn too much to qualify for Medicaid but not enough to afford private insurance coverage Offered in all states Not tied to state Medicaid program expansion Comprehensive CHIP coverage funded through 2017 Open enrollment and immediate coverage AHEC Health Insurance Marketplace Continuing Education 14 States may choose to: Integrate CHIP into Medicaid program Operate CHIP separately from Medicaid (with different income eligibility thresholds) Cover additional benefits Cover pregnant women and parents

HOW TO ACCESS CHIP COVERAGE AHEC Health Insurance Marketplace Continuing Education 15 CHIP COVERAGE GO TO MARKETPLACE & SUBMIT APPLICATION INFO TRANSMITTED TO STATE CHIP OFFICE COMPLETE ENROLLMENT CONTACT ”INSURE KIDS NOW” GO TO: OR CALL: CONTACT STATE CHIP AGENCY SUBMIT APPLICATION COMPLETE ENROLLMENT One Enrollment Application for All Forms of Coverage Go to: or Call:

AHEC Health Insurance Marketplace Continuing Education 16 QUESTIONS ??????

THE HEALTH INSURANCE MARKETPLACE AHEC Health Insurance Marketplace Continuing Education 17

IMPORTANT MARKETPLACE ENROLLMENT DATES OPEN ENROLLMENT DATES For coverage in 2015: Nov. 15, 2014 – Jan. 15, 2015 For coverage in 2016 and after: Oct. 15 – Dec. 7 each year COVERAGE START DATES Enroll between 1st and 15th of the month: Coverage starts first day of the next month Enroll between 16th and last day of the month: Coverage starts first day of the second following month SPECIAL ENROLLMENT PERIOD Any time a qualifying life event occurs (such as: moving to new state, loss of a job, change in family size) Triggers 60 days to enroll in coverage AHEC Health Insurance Marketplace Continuing Education 18

AHEC Health Insurance Marketplace Continuing Education 19 STATE OPTIONS FOR MARKETPLACE STRUCTURES

HOW INDIVIDUALS AND FAMILIES ACCESS THE HEALTH INSURANCE MARKETPLACE GO TO THE MARKETPLACE Find links to: State Marketplace State CHIP & Medicaid Offices Local Navigators and Assistors trained to help with enrollment APPLY Determine eligibility for: Medicaid CHIP Help with premiums & out-of- pocket costs PICK A PLAN Compare Qualified Health Plans (QHPs) Select a plan ENROLL Medicaid CHIP QHP AHEC Health Insurance Marketplace Continuing Education 20 The Marketplace Provides Access to All Pathways of Affordable Coverage Complete One Enrollment Application for All Forms of Coverage Go to: or Call:

QUALIFIED HEALTH PLANS (QHPs) SOLD IN THE MARKETPLACE AHEC Health Insurance Marketplace Continuing Education 21

QHPs SUBJECT TO INSURANCE REFORMS No exclusions due to pre-existing conditions Rates determined only by: age, family size, geography, tobacco use Rate increases must be filed with (but not approved by) HHS Required coverage of Essential Health Benefits (EHBs) No annual or lifetime limits or caps on coverage Annual out-of-pocket cost limit: $6,350 individual/$12,700 family Required coverage of preventive benefits with no out-of-pocket costs AHEC Health Insurance Marketplace Continuing Education 22

QHPs COVER TEN CATEGORIES OF ESSENTIAL HEALTH BENEFITS (EHBs) 1.Ambulatory Patient Services 2.Emergency Services 3.Hospitalization 4.Maternity & Newborn Care 5.Mental Health & Substance Use Disorder Services Including behavioral health treatment 6.Laboratory Services 7.Pediatric Services Including oral and vision care 8.Prescription drugs Special rules for prescription drug benefit including formulary exceptions 9.Preventive & Wellness Services and Chronic Disease Management No out-of-pocket costs 10.Rehabilitative & Habilitative Services and Devices AHEC Health Insurance Marketplace Continuing Education 23 EHB services must be balanced across all categories and cannot include: Adult routine dental and eye exams Cosmetic orthodontia Long-term/custodial nursing home care

QHPs GROUPED INTO METAL LEVELS AHEC Health Insurance Marketplace Continuing Education 24 BRONZE Plan pays 60% of costs of care Consumer pays 40% of cost of care Lowest premiums SILVER Plan pays 70% of costs of care Consumer pays 30% of cost of care Higher premiums GOLD Plan pays 80% of costs of care Consumer pays 20% of cost of care Higher premiums PLATINUM Plan pays 90% of costs of care Consumer pays 10% of cost of care Highest premiums METAL LEVELS CORRELATE TO ACTUARIAL VALUE (AV) (AV is the average percentage of costs a plan will cover for EHBs) Insurance carriers must offer: child-only plans, at least one silver and gold plan and a catastrophic plan. Stand-alone dental plans have different costs.

CATASTROPHIC COVERAGE PLANS AHEC Health Insurance Marketplace Continuing Education 25 Not a Metal Level plan Very low premium and very high deductible Available to individuals under 30 or those with hardship exemption from purchasing Metal Level coverage Covers three primary care visits per year (at no cost and before the deductible is met) Covers some free preventive care services (including screenings, vaccines and certain counseling services) EACH INSURANCE CARRIER IN THE MARKETPLACE MUST OFFER ONE CATASTROPHIC PLAN

FEDERAL SUBSIDIES FOR QHPs THROUGH INSURANCE AFFORDABILITY PROGRAM TO BE ELIGIBLE: Must be enrolled in a Silver Level plan through a Marketplace Must earn between 100% and 250% of the FPL: $11,490 to $28,725 for individuals $23,550 to $58,875 for a family of four IF QUALIFIED: Insurance carrier charges lower out-of-pocket costs (deductibles, copays, coinsurance) Total charges are less than the standard annual limit ($6,350/individual and $12,700/family) AHEC Health Insurance Marketplace Continuing Education 26 LOWER OUT-OF-POCKET COSTS WITH COST SHARING REDUCTION PLANS (CSR) To determine eligibility go to: Fill out an application Use the Cost and Savings Calculator Consult the Quick Check Chart

FEDERAL SUBSIDIES FOR QHPs THROUGH INSURANCE AFFORDABILITY PROGRAM TO BE ELIGIBLE: Must be enrolled in a Metal Level plan through a Marketplace Must earn between 100% and 400% of the FPL: $11,490 to $45,960 for individuals $23,550 to $94,200 for a family of four IF QUALIFIED: Premium assistance paid on a sliding scale Insurers receive premium assistance payments directly from Federal Government AHEC Health Insurance Marketplace Continuing Education 27 LOWER PREMIUMS WITH ADVANCE PAYMENT TAX CREDIT (APTC) To determine eligibility go to Fill out an application Use the Cost and Savings Calculator Consult the Quick Check Chart

QHP SUMMARY OF BENEFITS & COVERAGE (SBC) SBC is a summary of answers to general questions regarding: The QHP’s deductible, provider network, non-covered services Common medical events that the QHP covers and does not cover Copay and coinsurance costs for care from network providers and non-network providers AHEC Health Insurance Marketplace Continuing Education 28 EVERY QHP MUST HAVE A CORRESPONDING SUMMARY OF BENEFITS & COVERAGE (SBC) Insurance carriers required to provide standardized information to allow apples-to-apples comparison of plans

QHPs MAINTAIN PROVIDER NETWORK ADEQUACY AHEC Health Insurance Marketplace Continuing Education 29 QHPs MUST MAINTAIN AN ADEQUATE NETWORK OF PROVIDERS Such as: Hospitals, Community Health Centers, Rural Health Clinics, Health Professionals (including mental health & substance abuse) Considerations: Plans with lower premiums may have more restricted networks Plans have different costs for seeing non- network providers Patients should: Consult QHP’s provider directory or call insurance carrier SBCs provide link to directory and carrier contact info Providers should: Contact insurance carriers to confirm their participation in QHP networks

AHEC Health Insurance Marketplace Continuing Education 30 QUESTIONS ??????

HOW TO ACCESS QHP COVERAGE QHP COVERAGE SPM STATES GO TO FEDERAL MARKETPLACE & BE CONNECTED TO STATE IF NECESSARY COMPARE PLANS APPLY & ENROLL FFM STATES GO TO FEDERAL MARKETPLACE COMPARE PLANS APPLY & ENROLL SBM STATES GO TO FEDERAL MARKETPLACE & BE CONNECTED TO STATE OR GO DIRECTLY TO STATE MARKETPLACE COMPARE PLANS, APPLY & ENROLL AHEC Health Insurance Marketplace Continuing Education 31 TRAINED NAVIGATORS, ASSISTORS & OTHERS AVAILABLE TO HELP ENROLL Go to: or Call:

IMPORTANT MARKETPLACE ENROLLMENT DATES OPEN ENROLLMENT DATES For coverage in 2015: Nov. 15, 2014 – Jan. 15, 2015 For coverage in 2016 and after: Oct. 15 – Dec. 7 each year COVERAGE START DATES Enroll between 1st and 15th of the month: Coverage starts first day of the next month Enroll between 16th and last day of the month: Coverage starts first day of the second following month SPECIAL ENROLLMENT PERIOD Any time a qualifying life event occurs (such as: moving to new state, loss of a job, change in family size) Triggers 60 days to enroll in coverage AHEC Health Insurance Marketplace Continuing Education 32

BUSINESSES WITH 50 OR MORE FTE EMPLOYEES 33 Employer Shared Responsibility Provisions Number of FTE Employees 10 or fewer 11 to to and above

Employer Shared Responsibility Provisions 34 If employer meets 50 full-time/FTE employee threshold, two scenarios for potential shared responsibility payment Either an employer does not offer coverage to at least 95% of its full-time employees (and their dependents), OR The coverage offered to employer’s full-time employees is not “affordable” or does not provide “minimum value” AND At least one full-time employee receives a premium tax credit in the individual Marketplace

Employer Shared Responsibility: Insurance Coverage Standards Coverage Provides Minimum Value Plan must cover, on average, at least 60% of the plan’s total cost of incurred benefits HHS is developing a calculator employers can use to input their plan details and determine if it meets the 60% value threshold Coverage is Affordable Coverage is unaffordable if the full-time employee’s share of self-only coverage costs more than 9.5% of his/her annual household income Affordability safe harbor: If the cost to the employee of a self-only plan is not more than 9.5% of his/her wages as reported on Box 1 of the W-2, it’s deemed affordable 35

Employer Shared Responsibility Payments: Two Scenarios Coverage Not Offered to Substantially All Full- Time Employees Payment applies if any full- time employee receives a premium tax credit in the individual Marketplace Payment owed: $2K/year per full-time employee ABOVE 30 Payment calculated separately for each month for which coverage not offered ($166.67/month) Payment based on employer’s number of full- time employees for that month (minus the first 30) Coverage Offered to Full-Time Employees, But Either Not Affordable or Does Not Meet Minimum Value Payment owed : $3K/year per full-time employee who receives a premium tax credit in Marketplace Payment calculated on monthly basis = $250/month Payment based on number of full-time employees who receive premium tax credit for that month This payment can’t exceed payment in Scenario # 1 36

Employer Responsibility IF employer does not offer insurance and at least one employee receives a subsidy, employer must pay fee. – Does not apply to employers with fewer than 50 employees – FTE = individual employed on average at least 30 hours per week – 100 half-time employees = 50 full-time employees Penalties for large employers (over 50 employees): – If ER does not offer coverage and at least 1 FT EE gets subsidy, fee is $2000 per EE (all employees) BUT, the first 30 EEs are excluded Fee = $2000 x (all FTEs - 30), calculated monthly – If ER does offer coverage but at least 1 FT EE gets subsidy, fee is $3000 per EE who gets subsidy, up to max of $2000 x total number of EEs Fee = $3000 x (#FTEs receiving subsidies), up to max cap of $2000 x (#allFTEs - 30), calculated monthly

Employer Shared Responsibility Provisions 38 Additional Key Points There is no payment owed for non-coverage of part- time employees If employer offers affordable coverage that provides minimum value to a full-time employee and it’s declined, there is no liability for that employee No payment is owed if an employee obtains insurance through means other than the insurance Marketplace (e.g., spouse’s insurance) Beginning in 2015, employers that offer coverage to full-time employees must also offer coverage to the dependents of those full-time employees who are children under age 26 (coverage need not be offered to spouses)

AHEC Health Insurance Marketplace Continuing Education 39 QUESTIONS ??????

CONCLUSIONS Most everyone must enroll in some form of health coverage Several pathways to affordable health insurance coverage Federal assistance available for premiums &out-of-pocket costs Consumer choices affect their premiums & out-of-pocket costs Plans with lower premiums may have smaller networks State Fact Sheets are available with specifics for every state AHEC Health Insurance Marketplace Continuing Education 40

FEDERAL RESOURCES Health Insurance Marketplace Individual, family, small business coverage options/enrollment Medicaid Children’s Health Insurance Program (CHIP) AHEC Health Insurance Marketplace Continuing Education 41

MORE FEDERAL RESOURCES Internal Revenue Service Section on all ACA tax provisions The Center for Consumer Information and Insurance Oversight (CCIIO) Section on ACA rules for private insurance and marketplaces BusinessUSA Section on all health care changes of interest to businesses AHEC Health Insurance Marketplace Continuing Education 42