1. Affordable Care Act Marketplace Implementation Briefing PA Refugee Resettlement Program Annual Meeting June 11, 2013 H EALTH C ARE.GOV Aryanna Abouzari, Esq. Executive Officer U.S. Department of Health & Human Services, Region III Pennsylvania, Delaware, District of Columbia, Maryland, Virginia, West Virginia

3. Critical Need for Health Reform 48.6 million uninsured Americans 48.6 million uninsured Americans $3 trillion spent annually on healthcare $3 trillion spent annually on healthcare 17.9 % of our economic output tied up in the health care system 17.9 % of our economic output tied up in the health care system Without reform, by 2040, 1/3 of economic output tied up in health care Without reform, by 2040, 1/3 of economic output tied up in health care

4. Affordable Care Act Overview Creates Consumer Protections Creates Consumer Protections Prevents denials of coverage for pre-existing conditions Prevents denials of coverage for pre-existing conditions Make health insurance more affordable for middle class families and small businesses with tax credits Make health insurance more affordable for middle class families and small businesses with tax credits Expands access to care through Marketplaces and Medicaid expansion Expands access to care through Marketplaces and Medicaid expansion

5. Health Insurance Marketplace Sometimes called “Exchanges,” the Marketplace is required by the ACA to be created by January 1, 2014 Sometimes called “Exchanges,” the Marketplace is required by the ACA to be created by January 1, 2014 New “marketplace” where small businesses and individuals can select and enroll in a private health insurance plan New “marketplace” where small businesses and individuals can select and enroll in a private health insurance plan Consumers will have Consumers will have the same level of benefits and coverage available to members of Congressthe same level of benefits and coverage available to members of Congress more choice and selection in health plansmore choice and selection in health plans

6. Three models available Three models available State-Based State-Based Federal-State Partnership Federal-State Partnership Federally-Facilitated Federally-Facilitated States can apply for Marketplace establishment funding at any time and be awarded grants through 2014 States can apply for Marketplace establishment funding at any time and be awarded grants through 2014 HHS to operate marketplaces for States that have not elected to do so HHS to operate marketplaces for States that have not elected to do so Marketplace Implementation

7. Health Insurance Marketplace Regional Snapshot PA – No enabling legislation; Federally-facilitatedPA – No enabling legislation; Federally-facilitated DE – No enabling legislation; Federal-State PartnershipDE – No enabling legislation; Federal-State Partnership MD – Passed enabling legislation; State-basedMD – Passed enabling legislation; State-based DC – Passed enabling legislation; State-basedDC – Passed enabling legislation; State-based WV – Passed enabling legislation; Federal-State PartnershipWV – Passed enabling legislation; Federal-State Partnership VA – No enabling legislation; Federally-facilitatedVA – No enabling legislation; Federally-facilitated

8. Marketplace Eligibility  Marketplace eligibility requires You live in the service area, You live in the service area, Are a U.S. citizen or national, or Are a U.S. citizen or national, or Are a non-citizen who is lawfully present in the U.S. for the entire period for which enrollment is sought Are a non-citizen who is lawfully present in the U.S. for the entire period for which enrollment is sought Are not incarcerated Are not incarcerated

9. Financial Assistance Premium tax credits Premium tax credits Will reduce the premium amount the consumer owes each monthWill reduce the premium amount the consumer owes each month Available to eligible consumers with household incomes between 100% and 400% of the FPL ($44,680 for an individual and $92,200 for a family of 4 in 2012), and who don’t qualify for other health insurance coverageAvailable to eligible consumers with household incomes between 100% and 400% of the FPL ($44,680 for an individual and $92,200 for a family of 4 in 2012), and who don’t qualify for other health insurance coverage Based on household income and family size for the taxable yearBased on household income and family size for the taxable year Paid each month to the insurerPaid each month to the insurer

10. Financial Assistance Cost-sharing reductions: Cost-sharing reductions: Reduce out-of-pocket costs (deductibles, coinsurance, copayments) Reduce out-of-pocket costs (deductibles, coinsurance, copayments) Generally available to those with income 250% FPL or below ($27,925 for an individual and $57,625 for a family of 4 in 2012)Generally available to those with income 250% FPL or below ($27,925 for an individual and $57,625 for a family of 4 in 2012) Based on household income and family size for the taxable yearBased on household income and family size for the taxable year

11. Quality Insurance The ACA requires plans inside the Marketplace to meet particular actuarial value (AV) targets The ACA requires plans inside the Marketplace to meet particular actuarial value (AV) targets Bronze = 60% AVBronze = 60% AV Silver = 70% AVSilver = 70% AV Gold = 80% AVGold = 80% AV Platinum = 90% AVPlatinum = 90% AV “Metal Levels” will enable consumers to compare plans with similar levels of coverage, promote competition on premiums, and allow plans flexibility to design cost sharing structures “Metal Levels” will enable consumers to compare plans with similar levels of coverage, promote competition on premiums, and allow plans flexibility to design cost sharing structures

12. Essential Health Benefits Essential Health Benefits Ambulatory patient servicesAmbulatory patient services Emergency servicesEmergency services HospitalizationHospitalization Maternity and newborn careMaternity and newborn care Mental health and substance use disorder services, including behavioral health treatmentMental health and substance use disorder services, including behavioral health treatment Prescription drugsPrescription drugs Rehabilitative and habilitative services/devicesRehabilitative and habilitative services/devices Laboratory servicesLaboratory services Preventive and wellness services and chronic disease managementPreventive and wellness services and chronic disease management Pediatric services, including oral and vision carePediatric services, including oral and vision care Quality Insurance

13. Marketplace for Small Business Starting in 2014, a Small Business Health Options Program (SHOP) will be available in each state Starting in 2014, a Small Business Health Options Program (SHOP) will be available in each state To enroll, employers must To enroll, employers must have fewer than 100 employees; a state SHOP may limit eligibility to employers with 50 or less employees for the first two yearshave fewer than 100 employees; a state SHOP may limit eligibility to employers with 50 or less employees for the first two years have an office within the service area of the SHOPhave an office within the service area of the SHOP offer SHOP coverage to all full-time employeesoffer SHOP coverage to all full-time employees Sole proprietors must purchase through the Marketplace, not through SHOP Sole proprietors must purchase through the Marketplace, not through SHOP

14. Tax Credits for Small Business Tax credits to small employers with up to 25 employees and average annual wages less than $50k that provide health insurance for their employees Tax credits to small employers with up to 25 employees and average annual wages less than $50k that provide health insurance for their employees Currently, 35% for profit; 25% non-profitCurrently, 35% for profit; 25% non-profit In 2014, 50% for companies that participate in SHOPIn 2014, 50% for companies that participate in SHOP Visit www.irs.gov for Form 8941 and calculator tool to help determine whether you are eligible to claim the creditVisit www.irs.gov for Form 8941 and calculator tool to help determine whether you are eligible to claim the creditwww.irs.gov

15. Enrollment Process Consumer submits application to the marketplace Consumer submits application to the marketplace OnlineOnline PhonePhone MailMail In PersonIn Person The marketplace verifies and determines eligibility for The marketplace verifies and determines eligibility for enrollment in a Qualified Health Plan (QHP)enrollment in a Qualified Health Plan (QHP) tax credits and cost-sharing reductionstax credits and cost-sharing reductions Medicaid or CHIPMedicaid or CHIP Consumer enrolls in a QHP or Medicaid/CHIP Consumer enrolls in a QHP or Medicaid/CHIP Online plan comparison tool available to inform health plan choiceOnline plan comparison tool available to inform health plan choice Tax credit is sent to insurer (if eligible) to reduce consumer premium owedTax credit is sent to insurer (if eligible) to reduce consumer premium owed

16. Enrollment Assistance Help available in each Marketplace Help available in each Marketplace Toll-free call centerToll-free call center WebsiteWebsite Navigator programNavigator program Certified Application CounselorsCertified Application Counselors In-Person AssistorsIn-Person Assistors Community-based organizationsCommunity-based organizations Agents and brokersAgents and brokers

17. Marketplace Call Center A single 1-800 number for the call center A single 1-800 number for the call center A single TTY number for hearing impaired callers A single TTY number for hearing impaired callers Services will be available in English and Spanish Services will be available in English and Spanish A separate language line will be available for translation services (over 150 additional languages available)A separate language line will be available for translation services (over 150 additional languages available) A special “assistor” phone line to support Navigators, IPAs, and Medicaid Offices A special “assistor” phone line to support Navigators, IPAs, and Medicaid Offices June – September 2013: June – September 2013: The call center will launch in conjunction with the re-launch of HealthCare.govThe call center will launch in conjunction with the re-launch of HealthCare.gov

18. Initial Open Enrollment Period October 1, 2013 – March 31, 2014 October 1, 2013 – March 31, 2014 Enroll during the Initial Open Enrollment Period Your coverage is effective* On or before December 15, 2013 January 1, 2014 Between the 1 st and 15 th day of January – March First day of the following month Between the 16 th and the last day of December – March First day of second following month

19. Consumers may enroll or change QHP: Consumers may enroll or change QHP: Within 60 days in individual market and 30 days in small group market from qualifying eventWithin 60 days in individual market and 30 days in small group market from qualifying event Special Enrollment Period 19 Special Enrollment Period Qualifying Events Loss of minimum essential coverage Material contract violations by Qualified Health Plans Gaining or becoming a dependent Gaining or losing eligibility for premium tax credits or cost sharing reductions Gaining lawful presenceRelocation resulting in new or different Qualified Health Plan selection Enrollment errors of the Marketplace Exceptional circumstances

20. Medicaid Expansion in PA  650,000 Pennsylvanians will be eligible for health insurance if Medicaid is expanded  Federal Government pays 100% of costs 2014 thru 2016; 90% from 2020 onwards  PA will receive $17 billion in federal funding in first six years Medicaid Expansion

21. Resources: Affordable Care Act website – www.healthcare.gov Affordable Care Act website – www.healthcare.gov www.healthcare.gov Health Insurance Marketplace – Health Insurance Marketplace – http:// marketplace.cms.gov http:// marketplace.cms.gov Center for Consumer Information & Insurance Oversight website – Center for Consumer Information & Insurance Oversight website – http://cciio.cms.gov Affordable Care Act Spanish Affordable Care Act Spanish website – www.cuidadodesalud.gov

22. Thank you! Contact: aryanna.abouzari@hhs.gov