Health Insurance Marketplaces

Presented by Cobbs Allen© 2013 Zywave, Inc. All rights reserved.

What is Health Care Reform?

• The Affordable Care Act (ACA) was enacted in March 2010.– Biggest overhaul of the United States’ health care

system since Medicare and Medicaid in 1965– Requires most individuals to obtain health care

coverage – Requires insurance companies and employers to

provide consumer protections related to health coverage, like covering pre-existing conditions and not charging more for coverage based on an individual’s gender

Goals of the Affordable Care Act

• Increase the quality and affordability of health insurance

• Lower the uninsured rate• Reduce costs of health care

What are the Marketplaces?

• Health Insurance Marketplaces (Exchanges) create alternative markets for buying health insurance.

• They will: – Offer a choice of different health plans– Certify plans that participate – Provide information to help consumers understand their

coverage options.

• Individuals can purchase insurance through a Marketplace if they are:– Not currently incarcerated– A lawful citizen or U.S. resident– Living in the service area of the Marketplace

Important dates

– Oct. 1, 2013: Marketplace open enrollment starts– Dec. 15, 2013: Election deadline for having coverage

that begins on Jan. 1, 2014– Jan. 1, 2014: Health coverage can start– March 31, 2014: Open enrollment ends

Employer coverage

• Employer Coverage vs. Exchange Coverage– The coverage offered through is likely more

affordable than coverage purchased through the Exchange.

– Exchange coverage is a good option if you are ineligible for coverage through .

Shopping for coverage

• To apply for coverage, compare plans and enroll, most people will access the Exchange (Marketplace) through www.HealthCare.gov.

• For states with their own health insurance marketplaces, you will access your state-specific portal.

• If you reside outside of the 50 states, check with your territory’s government offices to learn about health coverage options.

Exchange map

What types of plans will be available?

• There are four categories of Marketplace insurance plans: – Bronze– Silver– Gold– Platinum

• Catastrophic plans available to people under 30 and those with very low incomes

What do the plans cover

• All plans will cover a comprehensive package of items and services known as essential health benefits:1. Ambulatory patient services

2. Emergency services

3. Hospitalization

4. Maternity and newborn care

5. Mental health and substance use disorder services, including behavioral health treatment

6. Prescription drugs;

7. Rehabilitative and habilitative services and devices

8. Laboratory services

9. Preventive and wellness services and chronic disease management

10. Pediatric services, including oral and vision care

How will I know which plan is right for me?

• Premiums are usually higher for plans that pay more of your out-of-pocket medical costs when you get care. – If you have a Platinum plan, you'll likely pay a higher premium

and have lower costs when you go to the doctor.

• When choosing your health plan, keep these general rules in mind: – The lower the premium, the higher the out-of-pocket costs

when you need care. – The higher the premium, the lower the out-of-pocket costs

when you need care.

• Do you need regular prescriptions or expect a lot of doctor visits?– If so, then you may want a Platinum or Gold plan. – If you don’t, you may prefer a Silver or Bronze plan.

How to enroll

• Open enrollment starts Oct.1, 2013, and medical coverage begins as early as Jan. 1, 2014. Open enrollment ends March 31, 2014.

• There will be four steps to obtain coverage through the Marketplaces:– Set up an account.– Fill out an online application.– Compare your options.– Enroll.

• You can also apply for Marketplace coverage by mail, or in person with the help of a Navigator or other qualified helper.

Required information

• Marketplace Application Checklist—items required to enroll include:– Social Security numbers – Employer and income information for every member

of your household who needs coverage– Policy numbers for any current health insurance plans

covering members of your household– A completed worksheet—called an Employer

Coverage Tool—for every job-based plan you or someone in your household is eligible for.

Assistance

The Marketplace is complex, but will offer several kinds of assistance to help you apply for coverage and choose a plan that meets your needs:

– Online questions and answers – Online chat – A toll-free call center

In all states, there will be people trained and certified to help you understand your health coverage options and enroll in a plan:

– Your broker & insurance agents– Navigators– Application assistors– Certified application counselors

Completing the application

The Marketplace website walks you step by step through the online health coverage application.

– Keeps track of where you are and guides you through to the end

– Lets you re-start where you left off

Each page explains the questions being asked, how much time each step might take and whether you'll need any forms or other documents.

– If you want live help while you apply, you can call the toll-free support center or chat with someone online.

Subsidies

• Subsidized coverage is available to some individuals and families with incomes up to 400 percent of the federal poverty level.

• You can save money in the Marketplaces in two different ways: – Tax credits to help you pay premiums– Reduced out-of-pocket costs

• Eligibility for subsidies will depend on your household income and family size

Eligibility for subsidies

• To be eligible for the subsidies, a taxpayer:– Must have household income for the year within the

federal limits– May not be claimed as a tax dependent of another

taxpayer– Must file a joint return, if married

• You are not eligible for subsidies if:– Your employer offers affordable, minimum value

health coverage– You enroll in your employer’s health plan

Subsidies: tax credits

• The Advanced Premium Tax Credit covers the amount between what households are required to pay and the cost of the insurance policy.

• The credit is available for people with somewhat higher incomes (up to 400 percent of the federal poverty line (FPL)).

Subsidies: reduced out-of-pocket costs

• Health insurance companies offering coverage through the Marketplace must reduce the amount you pay out of pocket for essential health benefits.

• Available if your household income is at or below 250 percent of the federal poverty level.

Subsidies: Medicaid

• Medicaid is the nation's health insurance program for low-income individuals and families.

• To qualify for Medicaid long-term care services and supports, individuals must be low-income or must have incurred health expenses that have caused them to “spend down” their incomes to Medicaid eligibility levels.

• Be sure to check your state’s documentation; Medicaid benefits vary from state to state.

Subsidies: CHIP

• CHIP provides low-cost health coverage to children in families that earn too much money to qualify for Medicaid.

• The benefits covered through CHIP are different in each state, but all states provide comprehensive coverage, including:– Routine check-ups– Immunizations– Doctor visits– Prescriptions– Dental and vision care– Inpatient and outpatient hospital care– Laboratory and X-ray services– Emergency services

• Tax Credits– Up to $45,960 for individuals– Up to $62,040 for a family of two– Up to $78,120 for a family of three– Up to $94,200 for a family of four– Up to $110,280 for a family of five– Up to $126,360 for a family of six– Up to $142,440 for a family of seven– Up to $158,520 for a family of eight

• Reduced out-of-pocket costs– Up to $28,725 for individuals– Up to $38,775 for a family of two– Up to $48,825 for a family of three– Up to $58,875 for a family of four– Up to $68,925 for a family of five– Up to $78,975 for a family of six– Up to $89,025 for a family of seven– Up to $99,075 for a family of eight

Who’s eligible?

Income Level

Premium as a Percent of Income

Up to 133% FPL

2% of income

133-150% FPL

3 – 4% of income

150-200% FPL

4 – 6.3% of income

200-250% FPL

6.3 – 8.05% of income

250-300% FPL

8.05 – 9.5% of income

300-400% FPL

9.5% of income

How to apply for subsidies

• Your application in the Marketplace will determine whether or not you qualify for various subsidies.

• When applying:– You will be required to provide specific information

about your current income. – If your income is not steady or if it’s expected to

change, you will have to project your 2014 income. If you provide no financial information, the Marketplace will rely on your federal income tax return from the previous year.

– If income has increased from the amount reported to the Marketplace, you may have to repay part of your subsidy.

Reporting

• Marketplaces will be required to report certain information to both the IRS and the taxpayer.

• The information that the Marketplace will have to report includes:– The level of coverage (bronze, silver, gold or platinum)– Identifying information for the primary insured and each enrollee

(such as Social Security number or birthdate)– The amount of premiums and advance credit payments for

coverage– Information provided to the Marketplace necessary to determine

eligibility for and amount of subsidies– Other information necessary to determine whether the taxpayer

received the appropriate subsidies.

• The Marketplace will provide a copy of the cumulative annual report to each taxpayer before Jan. 31 of the year following the year of coverage.

Other resources

• www.healthcare.gov/subscribe– With these updates, you’ll know when there's

important new information about the Marketplace and receive reminders about important dates.

• www.facebook.com/healthcare.gov • @healthcaregov on Twitter• http://www.youtube.com/HealthCareGov

– Watch and share videos about the Marketplace.

• www.healthcare.gov/blog– The Health Insurance Blog has tips for consumers

and small businesses, top things to know about the Marketplace, frequently asked questions and more.