ACA AND THE HEALTH INSURANCE MARKETPLACE: THE CURRENT LANDSCAPE IN PA Emily Van Yuga, M.Ed The Health Federation of Philadelphia 1

HEALTH FEDERATION OF PHILADELPHIA The Health Federation of Philadelphia (HFP) is a nonprofit 501c(3) organization whose mission is to improve access to and quality of health care services for underserved and vulnerable individuals and families. Since 1983, HFP has served as a network of the health centers in southeastern Pennsylvania, providing a forum for the region’s Federally Qualified Health Centers (FQHCs) and FQHC Look-Alikes to collaborate and mobilize resources for their shared goals of improving the health of the population by expanding access to high quality care. Currently, HFP’s network comprises more than 40 community health center sites collectively serving more than 300,000 people each year, approximately 40% of whom are uninsured. 2

HEALTH FEDERATION OF PHILADELPHIA NAVIGATOR PROGRAM HFP is a sub-grantee of the Pennsylvania Association of Community Health Centers (PACHC)’s federal Navigator award. We have been providing ACA-related outreach, education and enrollment across Southeastern PA since the Marketplace opened in Our Navigators offer bilingual services in Spanish, Russian, Khmer (Cambodian), French, Malayalam and Romanian. 3

HEALTH FEDERATION OF PHILADELPHIA NAVIGATOR PROGRAM HFP Navigators provide enrollment assistance at the City of Philadelphia’s 8 FQHC “Look-Alike” health centers City health centers serve over 80,000 people a year Over 50% uninsured Almost 50% of the consumers we enroll speak a language other than English 4

ACA REQUIRES HEALTH INSURANCE COMPANIES TO  Cover certain preventive services without deductibles or cost-sharing  Allow parents to keep adult children up to age 26 on their insurance  Cover all children under the age of 19, regardless of health status  Create an internal and external appeals process to handle consumer complaints and denials  Accept patients regardless of pre- existing conditions  Eliminate lifetime limits on benefits  Spend a minimum of 80 percent of premiums on medical services and quality improvement  Justify unreasonable premium increases  Eliminate the practice of rescissions (when a health plan retroactively cancels coverage after the enrollee gets sick)rescissions 5

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WHO IS ELIGIBLE FOR THE MARKETPLACE? In order to be eligible for the Marketplace, an individual must:  Be a U.S. citizen (by birth or naturalized) or a U.S. national  Be a non-citizen who is lawfully present in the U.S. for the entire period for which they are seeking enrollment  Not be incarcerated  An individual who is pending disposition of charges may apply for coverage through the Marketplace  If an individual is incarcerated, they can still apply for Medicaid/CHIP at any time * If you meet the eligibility requirements you’re considered a qualified individual* 7

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MARKETPLACE AFFORDABILITY Financial assistance is available for eligible individuals and families to curb health care costs, including:  Premium tax credits – which may be used to lower monthly premiums  Cost-sharing reductions– to lower out-of-pocket spending for health care costs 10

PREMIUM TAX CREDITS Eligibility for tax credits are based on:  Family size and income (Household income must be between 138%-400% of the Federal Poverty Level)  Obtaining health insurance through the Marketplace  Ineligibility for other health coverage, such as: government-sponsored coverage (Medicaid, Medicare, CHIP), employer-based coverage, or certain other minimum essential coverage 11

COST-SHARING REDUCTIONS Cost-sharing reductions may reduce your out-of-pocket expenses, including deductibles and copayments.  To be eligible for cost-sharing reductions:  Your income must be below 250% of the Federal Poverty Line (FPL)  This Open Enrollment Period, for a Household Size of 4 the FPL is $59,625  You must enroll in a Marketplace Silver-level plan 12

MARKETPLACE OPEN ENROLLMENT Open enrollment for the Marketplace ended on February 15 th, Next year’s open enrollment runs from November 15 th, 2015-January 31 st, Some consumers may still qualify for the Marketplace if they qualify for a Special Enrollment Period (SEP) Examples of SEPs include: Losing employer insurance or COBRA Getting married Having a baby Having a change in immigration status Getting incorrect information from a Marketplace representative, assister, or insurance company Paying the penalty for not having insurance in 2014 (SEP from March 15 th -April 30 th ) 13

WHO IS ELIGIBLE FOR EXPANDED MEDICAID? Adults age Not qualified for Medicare Income under 138% of the Federal Poverty Line Adults over the 5 year bar Single Person Family of 2 Family of 3 Family of 4 Family of 5 Family of 6 Family of 7 Family of 8 $16,243$21,983$27,724$33,465$39,206$44,947$50,688$56,429 14

THE CURRENT LANDSCAPE IN PA 15

CURRENTLY IN PA Federally-facilitated Marketplace  HMOs, PPOs, HSAs Medicaid expansion 16

CURRENTLY IN PA As of April 19, 2015: 549, 205 eligible for the Marketplace 332,915 eligible to received financial assistance for Marketplace QHP 42,335 assessed by the Marketplace as eligible for Medicaid 318,077 selected a QHP in the Marketplace 17

CURRENTLY IN PA Trends in Marketplace QHPs Tiered networks Restricted provider networks Limited formularies Prescription drugs subject to deductible 18

KEY INSURANCE TERMS Premium : The monthly fee you pay to the insurance company. It must be paid regardless of whether you use the insurance or not. It is separate from the out-of- pocket payments. Out-of-pocket payments: Payments you make when you use your insurance. They include:  Copay : Fixed amount you pay for care, varies based on the type of care.  Coinsurance : % of a medical service cost that you are responsible for paying. Some plans have this instead of copayments.  Deductible : Amount of money you pay for health care before your insurance begins to pay for some treatments. Once you have paid this amount, your insurance will begin to pay a portion or all of your health care costs. Out-of-Pocket Maximum : The most you would ever have to pay in out-of-pocket costs in a year. NOTE: This does not include premium costs. 19

COMPARING COSTS HFP created a resource for consumers needing HIV medications. The guide breaks down the co-pays, tiering, and out-of-pocket costs for the most common HIV medications. Note: Currently only available for all 2015 Marketplace QHP in the Philadelphia market. 20

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THANK YOU! Emily Van Yuga, M.Ed Outreach and Enrollment Coordinator The Health Federation of Philadelphia x