1. PA Health Insurance Navigator Program
Public Health Management Corporation (PHMC)
(adapted from The Health Insurance Marketplace PPT, OE3: )

2. Christine Simon Public Health Project Coordinator
PA Health Insurance Navigator Outreach Coordinator

3. Overview PA Health Insurance Navigator Program
Open Enrollment and the Marketplace
Medicaid Eligibility
Medical Assistance for Workers with Disabilities (MAWD)
Children’s Health Insurance Program (CHIP)
Health Insurance Terminology

4. PA Health Insurance Navigator Program
PHMC received funding from CMS to provide health insurance enrollment services
Integrates financial counseling and health insurance services, partners include:
Clarifi
Advantage Consumer Credit Counseling Services
Pennsylvania Health Access Network (PHAN)
Navigators are certified through the CMS training portal and licensed in PA to assist in enrollment

5. PHMC Navigators
Provide comprehensive, accessible health insurance education, outreach and enrollment support to consumers
Services to the following counties: Philadelphia, Bucks, Chester, Delaware, Montgomery, NEPA
Offer services (at no cost to consumers) to apply for Medicaid, Children’s Health Insurance Program (CHIP), & the Marketplace
Remain unbiased about plans and providers to find the best option for the consumer’s health needs and budget

6. Refer your Clients/Patients to us!
Navigator Toll Free Line
Have your uninsured patients call to schedule enrollment appointments with one of our Navigators

7. Marketplace Applications
For those who are not eligible for Medical Assistance (Medicaid, Medicare, CHIP)
Marketplace provides a set of government-regulated and standardized health care plans
May be be eligible for federal subsidies, assistance in paying your monthly premiums:
Premium Tax Credits (PTC)
Cost Sharing Reductions (CSR)
Open Enrollment 2018:
Nov 1, Dec 15, 2017

8. Marketplace Eligibility Requirements
State resident, US citizen
Not currently incarcerated
Report income with the Internal Revenue Service (IRS)
Have projected annual household income between 138% and 400% of the FPL

9. How Much Will Health Insurance Cost Through The Marketplace?
Prices will depend on:
Reported Income
W-2
Pay Stubs
Household Size
The plan you choose
Bronze, Silver, Gold, Platinum*
The deductions you qualify for
Cost Sharing
Advanced Premium Tax Credits

10. Special Enrollment Period
Outside of the open enrollment your clients might have a right to sign up for health coverage.
In the Marketplace, qualify for a special enrollment period 60 days following certain life events that involve a change in:
Family status (ex: Marriage or birth of a child)
Loss of other health coverage
One of many hardships

11. Medicaid States were given the option to expand Medicaid – PA in 2015
Medicaid provides health coverage to children, pregnant women, parents, seniors, individuals with disabilities, low-income adults
Consumers can apply year round; applications are processed through the state (compass.pa.gov)
Medicaid options available to households with income up to 138% of Federal Poverty Line (FPL)

12. Medicaid Income Guidelines
Number of People in Household
138% of Federal
Poverty Line 1
$16,242 2
$21,983 3
$27,724 4
$33,465 5
$39,205 6
$44,946 7
$50,687 8
$56,428

13. Medicaid Eligibility
US citizen or meet immigration status requirements, 5 year bar
Pennsylvania resident
Already have or will need to get a Social Security Number
Meet certain financial requirements – below the 138% Federal Poverty Line

14. Services Include (EHB):
Primary Care Services
Emergency Services
Hospitalizations
Maternity and Newborn care
Mental Health and Substance Use Disorder services
Prescription Drugs
Rehabilitative and Habilitative services and devices
Laboratory services
Preventive and wellness services and chronic disease management
Pediatric services, oral and vision care

15. Medical Assistance for Workers with Disabilities (MAWD)
Below 250% of the Federal Poverty Line
Qualifying chronic disability
Need a physician to fill out Employee Assessment Form
Monthly premium, unlike Medicaid
Benefits may include: 
Doctor visits
Durable medical equipment
Prescription drugs
Emergency care
Mental health services
Dental services
Drug and alcohol treatment
Hospital stays
Rehabilitation services
Hospice services
Medical transportation services 

16. Children’s Health Insurance Program (CHIP): for uninsured children and teens (19 years and younger) who are not eligible for or enrolled in Medical Assistance, households that are above 138% FPL Benefits Include:
Durable Medical Equipment
Up to 90 days Hospitalization/year
Substance abuse treatment
Rehabilitation therapies
Home Health care
Medically necessary Orthodontia
Immunizations
Routine check-ups
Prescription drugs
Dental care
Vision & Eye care
Maternity Care
Mental Health Benefits

17. CHIP Income Eligibility and Costs
Free or low premium payments depending on income and household size
Higher income, premiums and copayments increase
Household Size
Income
Premium
Copayments
1 (ages 6-18)
$15,655-$24,482 $0
3 (ages 0-10)
$41,788-52,636
$50
$5-$25
2 (ages 0-18)
$50,021+
$217
$10-$50

18. Health Insurance Terminology
Premium is a payment made, usually monthly, to an insurance company for your coverage.
Deductible is the amount you owe for health care services before your plan will start paying for your care. Note: May not apply to all services.
Copayment (Copay) is a fixed amount you pay for a covered health care service or supply.
Coinsurance is your share (a percent) of the costs of a covered service.

19. Medicaid vs. Marketplace
Premium – most likely will not have a monthly payment; if so, no more than 2% of annual income
Deductible – none
Copayment – range $1-$10
Coinsurance – not likely
Premium – if qualify for premium tax credit, payment could be between $0 and $300 due each mos
Deductible – if $1,500, not all services will be paid by insurance until $1,500 is met by OOP expenses
Copayment – primary $10 v. specialty care $30, varies
Coinsurance – 20%, and the service cost $100, you pay $20.

20. Navigator Toll Free Line
Questions?
Navigator Toll Free Line
Christine Simon