Washington Health Benefit Exchange Qualified Health Plans SUMMER 2013 NAVIGATOR/IN-PERSON ASSISTER PROGRAM

Purpose Purpose: This presentation will provide a high level overview of Qualified Health Plans (QHPs) available through the Washington Healthplanfinder. More in-depth information and procedures will be included in the Healthplanfinder system training module.

Course Summary Program rules and guidelines related to Individual Eligibility and Enrollment for Qualified Health Plan (QHP) programs. Application, eligibility results, QHP enrollment and payment for individuals and households applying for coverage. Pediatric dental plans 3

Learning Objectives Upon completing this module, you will Understand the different types of health care coverage available through the Healthplanfinder Know program rules and guidelines related to Qualified Health Plans for either an individual or for an entire household Understand basis for eligibility results Know the steps to facilitate plan selection and enrollment

Learning Objectives (Continued) Upon completing this module, you will also understand: The functions performed through the Federal Hub in verifying applicant information Reasons for non-eligibility (incarceration, citizenship, non-WA resident, etc.). 5

Exchange – A Single Doorway 6 <138% FPL Medicaid (Apple Health) >400% FPL Unsubsidized % FPL Subsidized (tax credits) Exchange Public InsurancePrivate (commercial) Insurance

What is a Qualified Health Plan? ▪ A health insurance plan that has been certified by The Office of Insurance Commissioner as meeting all state rules and requirements. ▪ Approved by the HBE as meeting the requirements of a Qualified Health Plan to be offered through the Washington Healthplanfinder. ▪ A plan that provides comprehensive coverage by meeting the standard of “10 Essential Benefits” 7

Qualified Health Plans ▪ Commercial insurance plans offered through the Healthplanfinder ▪ The same insurance carriers as outside the Exchange (Group Health, Regence, Lifewise, etc.) ▪ Subject to open enrollment periods ▪ Regulated/certified by the Office of the Insurance Commissioner ▪ Approved by the Health Benefit Exchange Board 8 Key Point

In General… ▪ Plans with higher PREMIUMS have lower cost sharing and/or richer coverage

Key Considerations for Selecting a Plan ▪ Premium – monthly payment to be insured ▪ Cost sharing – you pay some, insurance pays some ▪ Deductible ▪ Co-insurance – a percentage ▪ Co-pay – a predetermined amount per visit ▪ Coverage – what services are part of the “package”? ▪ Providers – which ones participate in the plan?

Laboratory Services Prescription Drug Rehabilitative/Habilitative Preventive/Wellness Pediatric (including vision and dental) 10 Essential Benefits Ambulatory Services Emergency Services Hospitalization Maternity/Newborn Care Mental Health and Substance Abuse 11 Key Point

Metal Tiers 12 Bronze LevelSilver Level*Gold LevelPlatinum Level Bronze plan benefit coverage is equivalent to: 60% Silver plan benefit coverage is equivalent to: 70% Gold plan benefit coverage is equivalent to: 80% Platinum plan benefit coverage is equivalent to: 90% Actuarial Value: The amount (%) of the bill that the insurer pays Key Point * All plans are eligible for tax credits.

Health Insurance Premium Tax Credits (HIPTC) ▪ Designed to make premiums affordable for individuals and families with lower incomes ▪ Only available to individuals and families with income up to 400% Federal Poverty Level (FPL) ▪ Can be used to reduce monthly premiums ▪ Can be claimed as a credit on annual tax return ▪ Applications must be completed through Washington Healthplanfinder 13 Key Point

Premium Tax Credit and Cost Sharing Reductions Income LevelPremium as Percent of Income Up to 133% FPL2% of income % FPL3-4% of income % FPL4-6% of income % FPL6-8% of income % FPL8-9% of income % FPL9.5% of income Income LevelReduction in Out-of-Pocket Liability % FPL94% of the actuarial value* % FPL87% of the actuarial value % FPL73% of the actuarial value Premium Tax CreditsCost Sharing Reductions *Of the second lowest cost Silver plan 14 Key Point

Insurance Carriers in Exchange as of September 4, 2013 ▪ Community Health Plan of Washington ▪ Molina Health Care of Washington – King Pierce & Spokane ▪ Group Health Cooperative – Benton, Columbia, Franklin, Island, King, Kitsap, Kittitas, Lewis, Mason, Pierce, San Juan, Skagit, Snohomish, Spokane, Thurston, Walla Walla, Whatcom, Whitman, and Yakima ▪ Lifewise – All 39 counties ▪ Premera Blue Cross – All counties except Clark ▪ Bridgespan – King, Kitsap, Pierce, Skagit, Snohomish, Thurston, and Spokane ▪ Kaiser Foundation Health Plan – Clark and Cowlitz 15

Pediatric Dental Plan Insurance Carriers in the Exchange as of September 4, )Delta Dental of Washington 2)Kaiser Foundation Health Plan 3)LifeWise 4)Premera Blue Cross

Health Insurance Programs and Benefits Individuals or families with income above 400% of the Federal Poverty Level (FPL) can purchase a QHP at the insurance carrier’s published premium cost QHPs are offered through commercial carriers such as Blue Cross Blue Shield, Aetna, etc. Consumers choose a plan that best meets their health and financial needs Families with children under 19 must enroll the children in a pediatric dental plan Parents can cover children up to age 26 under a family plan 17 Competitively Priced Qualified Health Plans (QHP)

Health Insurance Programs and Benefits Individuals or households with income below 400 % of the Federal Poverty Level (FPL) are eligible for free or low-cost options. Based on household size and income, applicants can qualify for either: Washington Apple Health (Medicaid) – no cost Health Insurance Premium Tax Credit (HIPTC) – reduced premium rates (must get a Silver Plan to qualify) Additional reductions are available to those with the lowest incomes (< 250% FPL) to reduce out of pocket expenses such as deductibles and co-pays 18 Free and Low-Cost Opportunities

Eligibility & Enrollment Flow - QHP 19 Eligibility Determination Account Creation Application Data Collection Post Application Shopping QHP Enrollment & Pediatric Dental Enrollment Payment

Primary Applicant Individuals: 1. Myself Household: 2. Myself and others 3. Other household members 20 The primary applicant is an individual who creates an account on Washington Healthplanfinder and initiates one of three types of applications types.

Questions 21

Lesson 1 Application Type ‒ Individual 22

Account Creation 23 Eligibility Determination Account Creation Application Data Collection Post Application Shopping QHP Enrollment & Pediatric Dental Enrollment Payment

Account Creation 24 Projected Plan Options Qualified Health Plan (QHP) Free and Low- Cost Health Insurance Required to Create and Account Not Required to Create Account Create Account Anonymous Browsing Qualified Health Plan (QHP) Free and Low- Cost Health Insurance Required to Create and Account Not Required to Create Account From the homepage there are two paths to creating an account:

Application Data Collection 25 Once an account is created – the first step in applying for coverage is Application Data Collection. The following data pages need to be completed: 1.About You 2.Contact Information 3.Additional Questions 4.Tribal Membership 5.Application Review 6.eSignature

Application Options 26 For Qualified Health Plan (QHP) Programs, the Applicant would select “No.” For Free and Low Cost Health Insurance programs, the Applicant would select “Yes.”

Confidential Information 27 ▪ Personal information must be disclosed throughout the application process ▪ The primary applicant and all household members who reside in the applicant’s household ▪ Income information and tax filing status ▪ Family composition and relationships, including custody

Federal Hub Verification 28 The primary applicant’s social security number will be verified by the Federal Hub. Application Data Collected: Social Security Number IRS INS Homeland Security Federal Hub Response: Verified Unverified Federal Hub Data Verifications are stored in the Healthplanfinder and are not visible to the consumer.

Conditional Eligibility 29 If any member of the household is deemed conditionally eligible, additional documentation will be required as shown in these screens. The primary applicant will have 90 days to submit required documentation.

American Indians/Alaska Natives ▪ Special provisions ▪ Tribal members can be served by a non-tribal In- Person Assister or a Tribal Assister ▪ Training Module for serving AI/AN 30

Eligibility & Enrollment Flow (Qualified Health Plan (QHP)) 31 Eligibility Determination Account Creation Application Data Collection Post Application Shopping QHP Enrollment & Pediatric Dental Enrollment Payment

Eligibility Determination – Federal Hub 32 In order for an individual to be eligible for a Qualified Health Plan (QHP) on Washington Healthplanfinder, he or she must be: 1.A U.S. citizen or lawfully present 2.Not incarcerated 3.A resident of the State of Washington When the Federal Hub verifies the individual’s SSN, it also looks for Citizenship and Incarceration status associated with that SSN. IRS INS Homeland Security

Eligibility Results 33 ▪ Eligibility determined for each family member ▪ Coverage options displayed based on eligibility ▪ If eligible for Qualified Health Plan, the consumer will use tools to compare and select a Plan ▪ Plan details can be viewed side by side ▪ Payment entry finalizes the transaction

Eligibility Rules (what the system uses to “decide” eligibility) Eligibility DeterminationBusiness Rule Eligible SSN verified Citizenship or lawful presence verified Resident of Washington Conditionally Eligible SSN not verified or SSN is verified as “Match for Death” Citizenship or lawful presence not verified Primary applicant has 90 days to provide documentation Denied Incarcerated – unless entered the disposition question as “Yes” Not resident of Washington 34

Knowledge Check 35 What are the three different application types for eligibility on Washington Healthplanfinder? a.Myself b._______________ c.__________________________ Myself and Others Other Members of My Household

Knowledge Check 36 Who creates an account on Washington Healthplanfinder and initiates one of three types of applications types? a.Exchange Administrator (EA) b.Primary Applicant c.Household d.Myself and Others

Knowledge Check 37 What organization verifies the social security number of the primary applicant? a.Federal Hub b.eHealth c.Eligibility Services d.Washington Healthplanfinder

Knowledge Check 38 Which of the following it not true about Qualified Health Plan (QHP) programs? a.Households can claim children up to age 26 under the parents' plan. b.Consumer choice offered through plan selection and metal levels. c.Applicants eligible for QHPs only. d.Applicants automatically enrolled in plans.

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Lesson 2 40 Application Type – Household (All Eligible Members)

Application Types Individuals: 1. Myself Household: 2. Myself and others 3. Other household members 41 The primary applicant is an individual who creates an account on Washington Healthplanfinder and initiates one of three types of applications types.

QHP Eligibility & Enrollment Flow 42 Eligibility Determination Account Creation Application Data Collection Post Application Shopping QHP Enrollment & Pediatric Dental Enrollment Payment

Application Data Collection 43 When the primary applicant enters data for themselves and their household, the data collected will be the same as for an individual. The sections bolded below will be completed for both the primary applicant and the other household members. 1.About You 2.Contact Information 3.About Your Household* 4.Additional Questions* 5.Tribal Membership* 6.Application Review 7.eSignature

Household Composition Rules 44 To be considered part of the same household, the household member must have one of the following relationships to the primary applicant: 1.Legal Guardian 2.Child (up to age 26) 3.Spouse (including same sex marriage) 4.Spouse (including domestic partners) Other family members living in the same home, such as nieces/nephews, aunts/uncles, cousins, and grandmothers/ grandfathers would not be considered part of the household application for eligibility determination.

Children Up to Age ▪ Children up to age 26 are eligible to be covered under their parent’s plans. Common Examples:  College Students  Young Professionals Children do not need to live in the same household or location as the parents to qualify. For instance, a child away at college would still be covered under his or her parent’s plan.

Eligibility Determination 46 Primary Applicant Completes “About You” SSN Verification Primary Applicant Enters Contact Information Primary Applicant Completes “About Your Household” Primary Applicant Completes eSignature SSN Verification Primary Applicant Completes Additional Questions Primary Applicant Completes Application Review Eligibility Results Displayed IRS INS HS IRS INS HS

Eligibility & Enrollment Flow (QHP) 47 Eligibility Determination Account Creation Application Data Collection Post Application Shopping QHP Enrollment & Pediatric Dental Enrollment Payment

QHP & Pediatric Dental Plan Enrollment 48 For household members over the age of 19: The primary applicant will enroll each eligible household member in a QHP. For household members under the age of 19: The primary applicant will enroll each child in a QHP and is required to also enroll each child in a pediatric dental plan.

Knowledge Check In order for an individual to be eligible for a Qualified Health Plan (QHP) on Washington Healthplanfinder, he or she must: A.Live with the individual. B.Not live with the individual. C.Not be incarcerated. D.Be employed. 49

Knowledge Check To be considered part of the same household, the household member must have one of the following relationships to the primary applicant: A.Niece B.Aunt C.Grandparent D.Legal Guardian 50

Knowledge Check The primary applicant will be required to select and enroll their qualifying children (up to age 19) in… A.A health insurance policy of their own. B.A pediatric dental plan C.Pediatric health care coverage D.Summer school 51

Knowledge Check 52 In a Qualified Health Plan (QHP) scenario, which of the following family members qualify as members of the primary applicant’s household? a.Spouse (including same-sex marriage) b.Grandfather c.Child (up to age 26) d.Answers a and c

Knowledge Check 53 The primary applicant is required to enroll any children under 19 in a pediatric dental plan. a.True b.False

Knowledge Check 54 To be eligible for insurance coverage through Washington Healthplanfinder, you must be: a.U.S. Citizen or Lawfully Present b.Not Incarcerated c.Washington Resident d.All of the Above

Agents-Brokers 55 Key partners with IPAs Must complete Exchange training Must be registered with Exchange Listed on Exchange website Receive commission for QHP enrollments (paid by carrier) No charge to consumers

Questions 56

Thank you! Congratulations! You have completed the QHP Rules and Guidelines course!

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