AFFORDABLE CAREPENALTY

AHEAD

Navigating the Federal Marketplace

Learning Objectives

I. Highlight the basics of the Affordable Care Act (ACA).

II. Explain common health insurance terms and concepts.

III. Identify approaches for assisting consumers with Marketplace applications.

IV. Highlight best practices for outreach and enrollment strategies in health centers and other consumer assistance entities.

V. Identify strategies for assisting consumers with maintaining health coverage and avoiding the individual shared responsibility payment.

VI. Emphasize the Navigator’s responsibilities post-open enrollment season

• The Patient Protection and Affordable Care Act (ACA) was passed on March 23, 2010 under the Obama administration

• This created:– A new avenue to purchase health insurance coverage—

Marketplace, or Exchange • Accessed through www.healthcare.gov

• Managed by the U.S. Centers for Medicare & Medicaid Service (CMS)

– Tax subsidies to help individuals afford coverage – Tax penalties associated with not having health insurance– Restricted period of the year when coverage is available for

purchase

Basics of the Affordable Care Act (ACA)

Basics of the Affordable Care Act (ACA)

• Eliminated the ability for insurers to deny coverage based on health status

• Coverage is guaranteed available and renewable

• Changed requirements around cost-sharing and the comprehensiveness of offered benefits

Types of Assisters

Indiana Navigator Federal Navigator Certified Application Counselor (CAC)

• Certified by the Indiana Department of Insurance (IDOI)

• Certified to assist with federal Marketplace and Indiana Health Coverage Programs applications

• All Medicaid enrollment staff must be certified as Indiana Navigators

• Recipients of the federal Navigator grant are required to serve as a federal Navigators

• Selected and funded by the federal government

• Also required to become Indiana Navigators in Indiana

• Certified by the Centers for Medicare and Medicaid (CMS)

• Recipients of HRSA grant money are required to complete this training

• Not required to do outreach & education

The Navigator’s Responsibilities

To be an efficient Navigator, one must understand certain health insurance concepts and

have the ability to explain terms to consumers.

Health Insurance Markets

TYPE DEFINITION

Individual Market Policies cover an individual or family

Small Group Market Issued to employers with 50 or fewer eligible employees (30 hours or more per week; met waiting requirement)

At employer’s option to include families/dependents

Large Group Market Issued to employers with over 50 eligible employees

At employer’s option to include families/dependents

Self-insure Employer is responsible for paying health cost of enrollees up to a capped amount (stop loss insurance)

Health Insurance Cost

TERM DEFINITION

Premium Monthly fee to maintain enrollment in coverage regardless of service use

Deductible Base amount that a member pays for services prior to their health insurance paying for coverage

Reset each year

Coinsurance Percentage of the cost of the service the health care provider will expect to have paid at the time of the visit

Copayment Specific dollar amount that an individual will pay for a particular service, regardless of the total cost of service

Out-of-pocket maximums

Maximum amount the enrollee can expect to pay for services in any plan year

$6,350 for an individual plan on individual market ($6,600 in 2015)

$12,700 for family plan on individual market ($13,200 in 2015)

Health Insurance Cost

Out-of-pocket Maximum Increases for 2015

Individual Market Small Group Market

Individuals $6,600 (previously $6,350)

$2,050 (previously $2,000)

Families $13,200 (previously $12,700)

$4,100(previously $4,000)

Test Your Knowledge

The ___________________is the maximum amount the enrollee can expect to pay for services in any given year, while the __________________is the base amount that a member pays for services prior to their health insurance paying for their coverage.

Test Your Knowledge

The ___________________is the maximum amount the enrollee can expect to pay for services in any given year, while the __________________is the base amount that a member pays for services prior to their health insurance paying for their coverage.

out-of-pocket maximum

deductible

• The ACA limits the factors that major medical plans can base the price of their plan on to age, location and tobacco use

• Rating for Age – Limited to a 3 to 1 ratio—Older

adults may be charged no more than 3 times the premium as younger adults

Rating Rules

• Rating for Location – The ACA allows insurers to adjust

their premiums depending on enrollee’s location

– There are 17 rating areas in Indiana

• Rating for tobacco – Up to 1.5 times the premium for

individuals that use tobacco – Tobacco use defined as use of any

tobacco product on average four or more times per week over the past 6 months

– At no point may a rate increase for tobacco based on age contradict the 3 to 1 rating limit

Rating Rules

Help Paying for Health Insurance

Two programs to help qualified individuals afford health insurance and cost-sharing for health services:

1.Premium Tax Credit (PTC)• Lowers the monthly premium amount • Can be used to purchase any plan on the federal Marketplace• Can be paid directly to insurer (Advanced Payment)• Available to consumers 100-400% of the Federal Poverty Level

(FPL)

2.Cost-Sharing Reduction Program (CSR)• Reduces out-of-pocket costs for consumers • Increases the Actuarial Value (AV) of health coverage plans for

low-income consumers (below 250% FPL) • Consumer must select at least a Silver plan

Who is eligible for the PTC and CSR?

Individual must be a citizen, national or legal resident of the U.S. Not currently incarcerated Meet income requirements Meet tax-based requirements

• Plan to file a federal tax return • If married, plan to file jointly • Not eligible to be claimed as a dependent on someone else’s tax return

Lack access to Minimum Essential Coverage (MEC) OR

Have MEC available, but the premium amount is ≥ 9.5% of household income or does not provide minimum value (at least 60% actuarial value)

How to get Help Paying for Health Insurance

1 2 3

456

Apply for health

insurance on the

Marketplace

Provide information

about income, household size,

access to coverage, etc.

Marketplace determines eligibility for

Financial Assistance

Choose a health plan

Report any changes

throughout the year (e.g.

lose job or have baby)

File Taxes- If married,

must file jointly

Premium Tax Credit (PTC)

1. Full Advanced Payment

2. Partial Advanced Payment

Reduces premium costs & likelihood of PTC overpayment

Consumer bears more of the premium cost immediately than if full advancement payment is taken

3. Claim Later

Ensures that PTC is not overpaid and that consumer will not owe at tax filing

Consumer bears the full cost of the premium immediately

Reduces monthly premium cost

Paid in full to insurance carrier

If income increases during the year, consumer may owe some or all of the PTC back at tax filing

Full Advanced Payment

Partial Advanced Payment

Claim Later

Premium Tax Credit (PTC)

Family Size 100% FPL 400% FPL

1 $11,670 $46,680

2 $15,730 $62,920

3 $19,790 $79,160

4 $23,850 $95,400

5 $27,910 $111,640

6 $31,970 $127,880

7 $36,030 $144,120

8 $40,090 $160,360

If an individual or family falls between 100-400% of the Federal Poverty Level (FPL), then they will generally qualify for a PTC.

(Based on the 2014 FPL)

How is the Premium Tax Credit Calculated?

Advanced Premium Tax Credit

Cost of a Benchmark Plan

Expected Family Contribution

“Fills the gap” between what a family is expected to contribute to health insurance and the cost of a benchmark plan.

The cost of the second lowest cost Silver plan adjusted to reflect selected characteristics of the family, such as age and size.

Set on a sliding scale based on income; varies from 2% of income at 100% FPL to 9.5% at 400% FPL.

Premium Tax Credit (PTC) Required Premium Contribution

FPL 2014 Estimated Annual Income (Individual)

Required % of Income

Contribution

2014 Estimated Annual Contribution (Individual)*

100-133% $11,670-$15,521 2% $233-$311

133-150% $15,521-$17,505 3-4% $465-$701

150-200% $17,505-$23,340 4-6.3% $701-$1471

200-250% $23,240-$29,175 6.3-8.05% $1,471-$2,349

250-300% $29,175-$35,010 8.05-9.5% $2,349-$3,326

300-400% $35,010-$46,680 9.5% $3,326-$4,435

*This estimated contribution is for the second lowest-cost Silver plan available on the federal Marketplace; estimated annual contribution could change based on plan metal tier selected

Premium Tax Credit (PTC) Calculation Example

FPL 2014 Estimated Second-Lowest Silver Plan

Premium

Required Contribution

PTC Amount

100% $3,912 $233 $3,679

150% $3,912 $701 $3,211

200% $3,912 $1,471 $2,441

250% $3,912 $2,349 $1,563

300% $3,912 $3,326 $586

400% $3,912 $4,435 $0

In Marion County, IN, the estimated annual premium for a 35-year old non-smoker’s second-lowest Silver plan is $3,912 annually* for 2014. The PTC amount is calculated by taking this total premium cost and subtracting the required contribution.

*Source: Indiana Department of Insurance

Cost-Sharing Reductions (CSR)

Who is eligible?•Individuals who meet all requirements for the PTC

AND•Have household income between 100% to 250% of the Federal Poverty Level (FPL)

AND •Enroll in a Silver plan (70% Actuarial Value) on the federal Marketplace

Cost-Sharing Reductions (CSR)

Benefits: -Increase the Actuarial Value (AV) of health coverage plans for low-income consumers -Reduce out-of-pocket costs for consumers -Offered in addition to PTC-Qualifying individuals do not have to apply for CSR separately

Cost-Sharing Reductions (CSR)

2014 FPL Estimated Annual Income

(Individual)

AV of Silver plan after CSR

(originally 70%)

Individual Annual Out-of-Pocket

Maximum (2014)

100-133% $11,670 - $15,521 94% $2,250

133-150% $15,521 - $17,505 94% $2,250

150-200% $17,505 - $24,340 87% $5,200

200-250% $23,340 - $29,175 73% $6,350

Based on 2014 FPL

Test Your Knowledge

To be considered for cost-sharing reductions, an individual must enroll in a _______________ plan. The ________________ is an insurance affordability program that can be applied to any plan on the Marketplace to lower a monthly premium.

Test Your Knowledge

To be considered for cost-sharing reductions, an individual must enroll in a _______________ plan. The ________________ is an insurance affordability program that can be applied to any plan on the Marketplace to lower a monthly premium.

Silver

Premium Tax Credit

HEALTH INSURANCE PLANS

What’s Offered on the Marketplace?

The Marketplace offers four categories of Qualified Health Plans (QHPs), known as “Metal Levels”• Distinguished by the share of health care costs QHP are expected

to cover

Actuarial Value (AV) The percentage that insurance companies will pay on average for the health services consumers use

Other Plan Options• Catastrophic plans

o APTC cannot be applied

• Stand-alone plans such as dental

Actuarial Value and Metal Tiers

PLATINUM

GOLDSILVERBRONZE

Higher Premiums

Lower Premiums

60% 70% 80% 90% Percent of Total Cost of Care Covered

Lower Consumer Cost-Sharing Higher Consumer Cost-Sharing

Actuarial Value and Metal Tiers

Actuarial Value and Metal Tiers

Test Your Knowledge

1. A plan in the ____________tier will have the lowest premium amount and ___________cost-sharing amount.

2. A plan in the ____________tier will have the _____________ premium amount and the lowest cost-sharing amount.

Test Your Knowledge

1. A plan in the ____________tier will have the lowest premium amount and ___________cost-sharing amount.

2. A plan in the ____________tier will have the _____________ premium amount and the lowest cost-sharing amount.

bronze highest

platinum highest

The Individual Mandate

Also called the Individual Shared Responsibility Requirement– Affordable Care Act (ACA) condition requiring individuals to maintain health coverage for themselves and their dependents• Health coverage must be considered Minimum

Essential Coverage (MEC) as determined by the federal government

• All Qualified Health Plans (QHPs) on the Marketplace must cover certain benefits

• There are 10 Essential Health Benefits (EHBs) set for 2014 and 2015 which must be offered by health plans

• Will change in 2016

Minimum Essential Coverage (MEC)

• Coverage that is considered comprehensive health insurance under the ACA Coverage for one day in the month is considered to be coverage for the entire month

TYPES OF MINIMUM ESSENTIAL COVERAGE

Coverage under a government sponsored program including:The Medicare ProgramThe Medicaid ProgramThe Children’s Health Insurance Program (CHIP) Veteran’s Administration programs including TriCare and CHAMP VACoverage for Peace Corps Volunteers

Coverage under an employer-sponsored health plan

Coverage under a health plan offered in the individual market within a State

Coverage under a grandfathered health plan

Additional coverage as specified such as Refugee medical assistance and Medicare advantage plans

Minimum Essential Coverage (MEC)

NOT CONSIDERED MINIMUM ESSENTIAL COVERAGE Policies that cover only a specified disease or illness

Medi-gap policies

Accidental death and dismemberment coverage

Disability insurance

Workers’ compensation

Coverage for employer-provided on-site medical clinics

Limited-scope dental or vision benefits

Long-term care benefits

Essential Health Benefits (EHBs)

Ambulatory Patient

Services

Laboratory Services

Hospitalization

Maternity &

Newborn Care

Mental Health

Services

Prescription Drugs

Rehabilitative Services

Emergency Services

Preventive &

Wellness Care

Pediatric Services

Qualified Health Plans (QHPs)

Plans sold on the Marketplace must be certified as QHPs

QHPs sold on the Marketplace must• Provide Minimum Essential Coverage (MEC)• Cover Essential Health Benefits (EHBs)• Meet Actuarial Value (AV)• Meet provider network standards

QHPs are the only plans that an individual can purchase that are eligible for the Premium Tax Credit (PTC) or Cost-Sharing Reductions (CSRs)

Catastrophic Coverage

• What is catastrophic coverage?– Plans with high deductibles and lower premiums – Consumer pays all medical costs up to a certain amount – Includes 3 primary care visits per year and preventative services

with no out-of-pocket costs – Protects from high out-of-pocket costs

• Who is eligible? – Young adults under 30 – Those who qualify for a hardship exemption– Those whose plan was cancelled and believe Marketplace plans

are unaffordableNOTE: People who enroll in catastrophic health plans are not

eligible for PTC

• Health plans in existence prior to the passage of the ACA and do not have to comply with some provisions related to:– Benefits – Cost-sharing – Pre-existing condition exclusions – Annual maximum

• Plans may only maintain grandfathered if they do no make substantial changes to their policies

• Individuals offered grandfathered coverage through an employer may choose to not accept the coverage and purchase coverage that meets ACA requirements instead

Grandfathered Plans

• Plans that cover a specific service or condition and do not provide comprehensive health coverage

• Not subject to many of the ACA market reforms • Most common is stand-alone vision

• Stand-alone dental plans are the only excepted benefit plans offered on the Marketplace

• Not offered in the metal tier levels of QHP• Subject to a $700 maximum out of pocket amount for a single

individual and $1,400 for family • May be purchased using the APTC • Not eligible for cost-sharing reductions

Excepted Benefit Plans

• Those who do not have MEC or an exemption will be required to pay a shared-responsibility payment to the IRS upon tax filing

Shared-Responsibility Payment

Test Your Knowledge

Stand-alone ________ plans are the only excepted benefit plans available on the Marketplace, while the most common is stand-alone __________ plans.

Test Your Knowledge

Stand-alone ________ plans are the only excepted benefit plans available on the Marketplace, while the most common is stand-alone __________ plans.

dental

vision

• Introduce yourself as a Navigator– Explain your role and how you can help– Reveal any potential conflicts of interest

• Assess their knowledge– Are they familiar with the Affordable Care Act? Individual Mandate?

Premium Tax Credits?

• Ask about– Household income– Household size– Plans to file taxes

Screening Consumers

• Answer any questions− Direct them to additional resources if necessary

Screening Consumers

You can help individuals compare plans based on:• Quality

• Covered benefits

• Covered providers

• Expected cost-sharing level

To purchase coverage on the Marketplace, individuals must:

• Be a United States citizen or legal resident • Reside in the state they are applying in• Not be incarcerated

Create an account

First obtain some basic information.

Then help the consumer choose

a username, password, and

security questions for added

protection.

ApplyEnter information

about the consumer and

consumer’s family, including household size,

income and more.

Pick a PlanSee all the plans

and programs and compare them side-by-

side. Find out if the consumer can get PTC and/or CSR.

EnrollHelp the

consumer choose a plan

that meets their needs and enroll. Instruct them to

pay their first premium!

Marketplace Functions

Gives individuals an avenue to compare and purchase health insurance

Assesses eligibility for:• Medicaid, Premium Tax Credits (PTCs) Cost-Sharing

Reductions (CSRs), Individual Mandate Exemptions Manages eligibility appeals Facilitates enrollment in Qualified Health Plans (QHPs) Ensures appropriate PTC and CSR payments to health

insurance plans Collects and publishes quality data on health plans Operates consumer assistance call center Starting in 2015: Collects premiums for small businesses

Application Basics: Reporting Household Size

Include Do NOT Include

Consumer Unmarried partner who does not need health coverage

Consumer’s spouse Unmarried partner’s children, if they are not consumer’s dependents

Children who live with the consumer, even if they make enough money to file

a tax return themselves

Parents living with the consumer, but file their own tax return and are not

consumer’s dependents

Unmarried partner needing health coverage

Other relatives who file their own tax return and are not the consumer’s

dependents

Anyone claimed as a dependent on tax return, even if they don’t live with the

consumer

Anyone else under 21 who consumer lives with and takes care of

Application Basics: Estimating Income

Include Do NOT Include Consumer’s and their spouse’s gross income, if they are married and will file a joint tax return

Child support

Any dependent’s gross income who is required to file a tax return

Gifts

Wages Supplemental Security Income (SSI)

Salaries Veterans’ disability payments

Tips Workers’ compensation

Net income from any self-employment or business

Proceeds from loans (like student loans, home equity loans or bank loans)

Unemployment compensation

Social security payments, including disability payments—but not SSI

Alimony

Modified Adjusted Gross Income (MAGI)

• Modified Adjusted Gross Income, or MAGI is the figure used to determine eligibility for lower costs in the Marketplace and for Medicaid and CHIP.

• Generally, modified adjusted gross income is your adjusted gross income plus any tax-exempt Social Security, interest, or foreign income you have.

• When filling out the Marketplace application, MAGI is automatically calculated through the system.

Add up the income of all household members who must file taxes

Modified Adjusted Gross Income (MAGI)

APTC and CSR (as well as Medicaid) rely on the measure of income known as MAGI

Adjusted Gross

Income (AGI)

Any social security

benefits (not included in

AGI)

Tax Exempt Interest or

Foreign Earned Income

MAGI

New applicants: Adults Parents and Caretaker relatives ChildrenPregnant Women

Aged BlindDisabled Those needing long-

term care Former foster children

under age 26 Deemed newborns

IMPACTS DOES NOT IMPACT

Modified Adjusted Gross Income (MAGI)

Apply for Indiana’s Health Coverage Programs

Apply on federal Marketplace

Apply on federal Marketplace or commercial health insurance market

Determining Application Method

Test Your Knowledge

Modified Adjusted Gross Income (MAGI) is your adjusted gross income plus any _____-_______

__________ ___________, _________, or ________ income you have.

Test Your Knowledge

Modified Adjusted Gross Income (MAGI) is your adjusted gross income plus any _____-_______

__________ ___________, _________, or ________ income you have.

tax exempt

Social Security interestforeign

Completing the Application: Disability Questions

• The consumer should answer “yes” to the Marketplace disability question if he or she and/or other household members:• Is blind, dead, or hard of hearing• Receives SSDI or SSI • Has physical, intellectual or mental

health condition causing:• Serious difficult completing

activities of daily living• Difficulty doing errands • Serious difficulty concentrating, remembering or making

decisions• Difficulty walking or climbing stairs

Activities of daily living

Bending Eating

Hearing Lifting

Thinking Breathing

Sleeping Standing

Seeing Walking

Completing the Application: Employer-Sponsored Coverage

• The Marketplace may require consumers who are currently employed with access to employer-sponsored coverage to enter additional information about • Who (with employer) to contact about employee health

coverage (usually HR)• Amount employee pays for premium cost• Any known changes in future employer coverage • Whether employer-sponsored coverage meets minimum

value (whether the policy covers at least 60% of healthcare costs for the covered pool, on average, after premiums)

Assisting Immigrants

There are two categories of immigrants for federal benefits eligibility purposes:

Qualified Lawfully Permanent Residents Refugees, Asylees ,Conditional entrants Cuban and Haitian entrants Parolees (in U.S. for more than 1 year) Certain American Indians Persons granted withholding of

deportation/removal Lawfully present individuals (e.g.

nonimmigrant visa holders; i.e. students or temporary workers)

For Medicaid: Individuals who have met the 5 year waiting period (post-August 22, 1996 with some exceptions)

Not QualifiedUndocumented immigrants

Assisting Immigrants

Eligibility Rules -Undocumented immigrants are ineligible to purchase QHPs and are exempt from the penalty

- May be eligible for Medicaid payment of package E– Emergency Services or services through FQHCs or other health centers -Immigrants must be in a status recognized by HHS as lawfully present -Status can be pending

Assisting Immigrants: Unique Challenges

- Mixed-status families are less likely to enroll because eligibility rules divide them- The Marketplace can’t require applicants to provide information about citizenship or immigration status of any household members who are not applying for coverage- Inform consumers that information obtained on the Marketplace application cannot be used by the Immigration and Customs Enforcement (ICE) Department of Homeland Security (DHS) for immigration enforcement purposes

- Agencies can collect, use and disclose only the information strictly necessary for enrollment in health coverage - Medicaid and Marketplace subsidies are not considered in screening green card applicants for public charge

- The Call Center can connect language lines for immediate interpretation into 150 languages

What do American Indians and Alaskan Natives need to know about the Marketplace?

• A member of a federally recognized tribe can:– Buy private insurance in the Health Insurance Marketplace without

paying out-of-pocket costs if income is up to $70,650 for a family of 4

– Enroll in Marketplace health insurance any month and change their plan up to once a month

• American Indian or Alaska Native otherwise eligible for services from the Indian Health Service, tribal program, or urban Indian health program:– Have special cost and eligibility rules for Medicaid and the Children’s

Health Insurance Program (CHIP) that make it easier to qualify for these programs

– Don’t have to pay the penalty for not having Minimum Essential Coverage (MEC)

Coverage Start Dates

The start date for federal Marketplace coverage:• Based on the date a consumer completes enrollment in a QHP• A consumer is not considered enrolled in a QHP until they pay their

portion of the first months premium In general:

• Coverage purchased before the 15th of the month is effective the 1st of the next month

• Coverage purchased after the 15th is effective the 1st of the following month

2014/2015 Enrollment Date

November 15th- December 15th

December 16th- January 15th

January 16th- February 15th

Effective Coverage Date

January 1, 2015 February 1, 2015 March 1, 2015

Test Your Knowledge

A member of a federally-recognized tribe can change their health plan on the Marketplace up to ____ times a year.

Test Your Knowledge

A member of a federally-recognized tribe can change their health plan on the Marketplace up to ____ times a year. 12

• Offer services for extended hours, including nights and weekends • Monitor wait times• Coordinate consumers’ appointments so they align

with other appointments at your organization • Establish a follow-up process to ensure that

consumers receive health insurance• Ensure that staff and volunteers are familiar with

your organization’s policies regarding outreach, in-reach and using personally identifiable information (PII)

• Set up an organizational reminder system that notifies people about their appointments by texting, emailing, or calling them the day before

Best Practices

• Build trust with consumer by greeting them warmly, smiling and listening carefully throughout the appointment

• Be patient, detail-oriented and take your time • Ensure appropriate accommodations are available for consumers with

disabilities • Have the appointment in a space that is

private and free from distractions • Assist consumers in a culturally sensitive

manner • Check with the consumer frequently to

make sure that he or she understands the information

Best Practices

– Information about the process consumers will need to follow in order to report any life changes throughout the year

– Information about what to do prior to and during the next open enrollment period (renewals)

– Guidance on how to use their health insurance

– Culturally appropriate resources to help them identify primary care physicians in their network, and information on how to setup a first appointment

Best Practices

Provide consumers with a “next steps document” that includes the following:

Navigator’s Responsibility

• There are many reasons adults and children lose coverage despite their eligibility– Administrative barriers – Cost – Not knowing how to navigate the health coverage system

• Consumers are learning to navigate a new coverage system with new rules

• As a Navigator, you should help consumers understand the rules under the Affordable Care Act (ACA) and become aware of their responsibilities as insured

Navigator’s Responsibility

Help consumers:•Understand how and when to report specific life changes to the appropriate agency

– How changes may affect premium tax credits– How changes may affect type of coverage they are eligible to

receive

•How and when to pay premiums (if applicable) •The annual redetermination and open enrollment process

Paying Premiums

• If consumers do not pay their premiums, qualified health plans (QHPs) can cancel their coverage

• Consumers receiving the advanced premium tax credit (APTC) have a three-month grace period before their coverage can be cancelled (as long as they have paid their premiums for at least one month)– Consumer must repay all outstanding premiums by end of grace

period, or QHP may cancel the coverage – Consumer may have to pay for all health care services received

during the second and third months of the grace period

Reporting Life Changes

Once a consumer has Marketplace coverage, they are responsible for reporting certain life changes which may change

the coverage or savings they’re eligible for. Marriage or divorce Having or adopting a child or placing

child for adoption Change in income Getting health coverage through

employment or Medicare/Medicaid Changing place of residence Change in disability status Gain or lose a dependent Becoming pregnant Other changes affecting income or

household size

Change in tax filing status Change in citizenship or

immigration status Incarceration or release Change in status as an

American Indiana/Alaska Native or tribal status

Correction to name, date of birth, or Social Security number

Reporting Life Changes

• Consumers should report changes as soon as possible, which may activate a special enrollment period (SEP)

• SEPs generally last 60 days from the life event • Reporting a change can occur through two methods:

1. Online• Log-in to account. Select the application, then select

“Report a life change”• A new eligibility notice will be generated that will explain

eligibility for a SEP and eligibility or ineligibility for lower costs, or different savings (e.g. Medicaid)

2. By phone•Contact the Marketplace Call Center •A representative will authorize the SEP

Special Enrollment Periods

• Other types of special enrollment periods: – Material contract violations by qualified health plan– Gaining or Losing eligibility for PTC or change in eligibility for cost-

sharing reductions – Enrollment Errors of the Marketplace

• Consumer chose plan, but enrollment wasn’t processed on time, or insurance carrier doesn’t have record of enrollment

– Exceptional circumstances • Serious medical emergencies—unexpected hospitalization or cognitive

incapacitation or disability

– Misrepresentation • Misconduct or misinformation by person(s) providing enrollment assistance

and/or failure to enroll– e.g. enrolled in wrong plan or found ineligible for

PTC or CSR due to error

Special Enrollment Periods

SEP Event QHP Effective Date

Loss of coverage If loss of coverage is in the past, 1st of the month following QHP selection. If loss is in the future, 1st of the month following loss of coverage

Marriage 1st of the next month following plan selectionDenial of Medicaid or CHIP

Birth, Adoption, Foster Care Date of birth, adoption, placement of adoption or placement in foster care

Gaining lawfully present status

Within first 15 days of the month: 1st of the following monthOn or after the 16th of the month: 1st of the month after next

Newly eligible or ineligible for APTC, change in CSRs

Moving & Incarceration Release

Native American status

The Annual Enrollment Period

Annual RedeterminationsInsurer will send information prior to November 15th about updated premiums and benefits

• If consumer is happy with current plan—and income or household size HAVE NOT changed—s/he doesn’t need to do anything. o The Marketplace will auto-enroll the consumer in the same plan for

2015 • If income or household size HAVE changed, the consumer will need to

report it to the Marketplace to get the correct PTC amount o If information is not updated, the PTC from 2014

will be used

2014-2015 OPEN ENROLLMENT PERIOD: NOVEMBER 15—FEBRUARY 15

Where does Indiana stand?

• During the first open enrollment period, 132,423 Hoosiers selected a plan on the Marketplace • 56% female and 44% male • 33% under age 35• 26% between ages of 18 and 34• 67% selected a Silver plan• 89% selected a plan with financial

assistance

• An estimated 880,000 to 909,636 An estimated 880,000 to 909,636 individuals are still uninsured, and individuals are still uninsured, and 181,930 are in the coverage gap. 181,930 are in the coverage gap.

Source: HHS and KFF

Test Your Knowledge

Today is September 8th, and Lilly is applying on the Marketplace because she is losing her health coverage through her employer on September 30th. She is eligible for a Special Enrollment period and selects a plan. When will her new Marketplace coverage begin?

Test Your Knowledge

Today is September 8th, and Lilly is applying on the Marketplace because she is losing her health coverage through her employer on September 30th. She is eligible for a Special Enrollment period and selects a plan. When will her new Marketplace coverage begin?

October 1st (if she pays her first premium)

Exemptions

• Individuals seeking an exemption from the individual shared responsibility requirement may apply for one or more of the exemption types

• Exemptions can be categorical, based on income, or related to other circumstances

• To be eligible for an exemption in any month, the individual must meet the criteria for the exemption for at least one day in that month.

Exemptions

Uninsured for < 3 months of the year (short coverage gap)

Lowest-priced coverage available costs more than 8% of household income

Income below tax filing limit Member of a federal

recognized tribe or eligible for services through an Indian Health Services Provider

Member of a recognized religious sect with religious objects to insurance

Incarcerated and not awaiting disposition of charges

Now lawfully present Suffer from a hardship

(discussed on next slide)

Hardship Exemptions

1. Evicted within past 6 months or facing eviction or foreclosure

2. Received utility shut-off notice 3. Experienced death of a close

family member 4. Experienced flood, fire, or

other natural or human-caused disaster that caused substantial damage to property

5. Determined ineligible for Medicaid because state did not expand

6. Individual insurance plan was canceled and other Marketplace plans are unaffordable

7. Eligible for enrollment in QHP through the Marketplace, CSR, or APTC for a time period when not enrolled in a QHP through Marketplace

Hardship Exemptions

8. Homeless

9. Filed for bankruptcy within last 6 months

10.Domestic violence victim

11.Unable to pay medical expenses within last 24 months

12.Experienced unexpected increases in necessary expenses due to caring for an ill, disabled or aging family member

13. Expect to claim a child as a tax dependent who’s been denied coverage in Medicaid and CHIP, and another person is required by court order to give medical support to the child

14. Another hardship in obtaining health insurance

Exemptions

Tips for helping consumers with an exemption application

1.Read each type of exemption to find best fit for consumer

2.Submit supporting documents with application

3.Do not leave questions blank—this may cause delays

4.Make a copy of the Step 2 page for each adult in the household, even if the adult doesn’t want an exemption

• Include tax-filing information for every adult

5.Consumer should keep a copy of their completed application

Appeals

Consumers may challenge a federal Marketplace decision in the following circumstances:1.He or she disagrees with a federal Marketplace eligibility decision regarding enrollment in a QHP, PTC or CSR 2.He or she disagrees with the amount of PTC or CSR determined by the Marketplace

•Information on how to appeal will be included on most notices, and the consumer should file the instructions or call the Marketplace call center

The Navigator’s Role After Open Enrollment

Indiana Navigator Responsibilities

• Expect to continue to educate consumers about the benefits of the ACA in preparation for the 2015 Enrollment Cycle, including– Building trust in your communities– Building and strengthening community partnerships and local

coalitions– Reflecting on what worked and what didn’t work– Collaborate, brainstorm and plan for the next enrollment period – Recruit volunteers and bilingual staff– Assign a lead Navigator – Involve entire health center staff in ACA awareness and in-reach

strategies

Indiana Navigator Responsibilities

• Expect to continue and enhance efforts to help consumers navigate the health insurance and health care system, including helping consumers to:– Understand and use their health care coverage – Understand their rights as health care consumers – Appeal eligibility and coverage decisions– Report a change in circumstance and navigate subsequent

eligibility redeterminations

Helpful Resources and Tools for Assisters

• CMS Assister Resources Page

• Families USA Enrollment Assister Resource Center

• In The Loop: Connecting the Enrollment Community

• Indiana Family and Social Services Administration (FSSA)

• Indiana Department of Insurance: Navigator Certification

• Enroll America Easy Premium Calculator

• Cover Indiana • Get Covered America• InsureKidsNow.gov• ACA Tax Penalty

Calculator• Enroll America In-Person

Assistance Page • Kaiser Family Foundation