What Healthcare Providers, Staff and Students Need to Know about the Health Insurance Marketplace Presented By: Krystal Ardayfio, MICI-AHEC Sandy Behrens, RN, MBA NW IN AHEC Julia Holloway, MBA Aspin Health Navigator

“The ASPIN Health Navigator Project was supported by Funding Opportunity Number CA-NAV from the U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents of oral, written, and electronic communications are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies unless cited otherwise.”

Objectives for this Sessions: Participants will learn: How the Marketplace Works What types of coverage options are available Learn what resources are available to help patients make an informed decision

Why should we help our patients understand the marketplace? 50 Million Americans are Uninsured Health care providers are a trusted source of information about healthcare Gain more patients Sustain your practice CMS Website. [1]

What is the Marketplace? Place for qualified individuals and employers to directly compare private health insurance options a ◦Known as Qualified Health Plans (QHPs) A new way to get health insurance a First Open Enrollment was from October 1, 2013 – March 31, 2014 a Next Open Enrollment begins November 15, 2014 First plan coverage began January 1, 2014 SEPs (Special Enrollment Periods) a. CMS website [1] b. CMS website [2]

What is the Marketplace? (cont.) Can directly compare plans on the basis of price, benefits, quality, and other factors About 25 million Americans will have access to quality health coverage a ◦Up to 20 million may qualify for help to make it more affordable Nobody can be turned away or charged more because of their gender or preexisting condition b a. CMS website [1] b. CMS website [2]

What types of questions will patients be asked? Demographic information about themselves and their family Whether they currently have coverage or are eligible for coverage Household income Through the Marketplace, patients seeking coverage will be directed to the right path for them ◦Medicaid/CHIP coverage for adults and families with low incomes ◦Private insurance plans, with financial assistance for eligible enrollees CMS website [4]

Features of the Affordable Care Act Goal: Increase number of individuals with Health Insurance Coverage ◦Subsidize coverage for lower incomes ◦Cannot be denied coverage for preexisting conditions ◦Institutes penalties for:  Individuals that do not have health insurance coverage Requires consumer considerations ◦Review insurance rate increases ◦Requires insurance companies spend a certain percentage of premiums on direct medical care  Guaranteed to be available  Guaranteed to be renewable

Determining health insurance premiums Health insurance plans may only use three factors: ◦Age- limited to 3:1 ratio ◦Tobacco use- limited to 1.5:1 ratio ◦Geographic are Health insurance plan premiums CANNOT be based on: ◦Gender ◦Health status  Insurers may not exclude individuals or health conditions from their health coverage based on pre- existing conditions

Actuarial Value (AV) Actuarial Value (AV) is: ◦The average percentage of allowed medical cost expected to be paid by the health plan over all covered enrollees Beginning in 2014, AV applies to health plans that are: ◦Non-grandfathered ◦In the individual & small group markets ◦On and off the federal Marketplace ◦Required to offer Essential Health Benefits (EHB) In Indiana, the Platinum Plan is not offered. There is also a Catastrophic Plan.

Who can use the Health Insurance Marketplace?

Other functions of the federal Marketplace The federal Marketplace is a website for individuals to compare and purchase health insurance Assesses eligibility for ◦Medicaid  If consume may be eligible for Medicaid, will send application to state Medicaid agency ◦Advance Premium Tax Credits (APTCs) ◦Cost Sharing Reductions (CSRs) ◦Individual Mandate exemptions Manages eligibility appeals Facilitates enrollment in qualified health plans (QHPs) Ensures appropriate APTC and CSR payments to health insurance plans Collects and publishes quality data on health plans Operates customer assistance call center Starting in 2015: Collects premiums for small businesses

Who will qualify for Premium Tax Credits? Purpose: ◦Reduces premium costs for eligible individuals  Can be paid directly to insurance company to reduce premiums, OR  Consumers can claim the credit later when taxes are filed

How does the Marketplace lower premium costs for Low-Income patients? Advanced Premium Tax Credits lower the cost of Qualified Health Plans Eligibility based on: ◦Household income and family size (at end of year) ◦Income between 100% and 400% of the Federal Poverty Level (FPL) ($23,550 for a family of 4 in 2013) ◦Obtaining qualified health insurance through the marketplace ◦Ineligibility for government-sponsored coverage, affordable employer-sponsored insurance, or certain other minimum essential coverage APTC is claimed immediately through lower premiums or late reconciled on you patient’s income tax return

What are the essential health benefits? Essential health benefits are minimum requirements for all plans in the Marketplace. Ambulatory patient services Emergency services Hospitalization Maternity and newborn care Mental health and substance use disorder services, including behavioral health treatments (includes counseling and psychotherapy) Prescription drugs Laboratory services Preventive and wellness services and chronic disease management Plans MAY offer additional services Patients can see exactly what each plan offers when they compare them side-by-side in the Marketplace CMS website. [1]

Indiana’s Four Federal Navigator Grant Recipients 1. Affiliated Service Providers of Indiana, Inc. 2. Plus One Enterprises, LTD, LLC. 3. Health and Hospital Corporation of Marion County 4. United Way Worldwide (211)

Yes No Would you be interested in meeting with a healthcare navigator to explore options on the Federal Marketplace? There is no charge for this service and information is kept confidential. Call to schedule an appointment Do you currently have healthcare insurance? Do you consider it affordable? If you ever need assistance with healthcare coverage, please feel free to contact one of our healthcare navigators Yes We want to make sure you are aware of the healthcare marketplace and how to enroll. Per the ACA, you will be required to pay $95 or 1% of your income (whichever is greater) if you do not seek health insurance. If you change your mind or have questions, please contact a healthcare navigator at: No “The ASPIN Health Navigator Project was supported by Funding Opportunity Number CA-NAV from the U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents of oral, written, and electronic communications are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies unless cited otherwise.”

Enrollment Process Navigators can provide in-person assistance ◦Consumer can apply by phone, mail, or internet ◦First two do not require an address ◦All require a mailing address Necessary information: ◦Identity and insurance needs of household residents ◦Household income Eligibility determination received immediately and outlines: ◦Next Steps ◦Premium Tax Credits (PTCs) and Cost- Sharing Reductions (CSRs)

Indiana Market Place Health Plans Physicians Health Plan (PHP) Managed Health Services (MHS) MDwise Anthem Blue Cross 17 Regions

Rating Area AnthemMHSPHPMDwise 1XXX 2XXXX 3XXXX 4XXXX 5XXX 6XXX 7XXX 8XXX 9XX 10XXX 11XXX 12XX 13XX 14X 15XX 16XX 17XX

What is Medicaid? Funded by state and federal government ◦Percentage of federal cost share  Varies by state  Re-calculated annually Provides free or low-cost health insurance to low-income: ◦Children ◦Parents and caretakers ◦Pregnant women ◦Aged ◦Blind ◦Disabled ◦Adults age (at state option) Offer many different programs, which vary by state ◦Eligibility criteria ◦Costs to participate ◦Benefits

Medicaid changes due to the ACA

Other Healthcare Resources Healthy Indiana Plan (HIP) The Healthy Indiana Plan (HIP) is an affordable health insurance program for uninsured adult Hoosiers. The program is sponsored by the State and only requires minimal monthly contributions from the participant. HIP is for uninsured Hoosiers between the ages of It offers full health benefits including hospital services, mental health care, physician services, prescriptions and diagnostic exams. Sliding Fee Scales Most FQHC’s, CHC’s, and Rural Health Clinics offer some sort of sliding fee scale for patients that are low-income and have no insurance coverage. Patients will pay a reduced fee according to their income. This rate can vary in each clinic.

Providing Advice on Health Plans  Federal Navigators, Indiana Navigators, and Application Organizations (AOs) cannot provide specific plan selection advice  They may provide consumers with general information that will help them make the best personal choice Be careful on the advice you give! Be safe and refer to the Navigators

Questions?