PowerPoint Presentation

Marketplace 101:A Guide for ESS CACsJanuary 29, 2014

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Purpose

This web training will provide basic information to help all ESS CACs better understand the landscape of the new health insurance Marketplace and how it functions across the country.

Will be helpful for new hires & also hopefully add some info that will also be useful to the ones whove been here from the beginning, as well.The terms Marketplace and Exchange are used interchangeably in this presentation.2

AgendaDefinitionOperationKey FunctionsIndividual MarketplaceQualified Health PlansTax Credits and Cost Sharing ReductionsResources and Questions

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DefinitionMarketplace [mahr-kit-pleys]

n. a resource where individuals, families, small business owners, and their employees, can learn about their health coverage options, compare health insurance plans based on costs and benefits, choose a plan, and enroll in health coverage

There are two Marketplaces one for individuals and families, and one for small businesses (SHOP). ESS is assisting in the individual marketplace.

Also known as Health Insurance Exchange (HIX)

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Key Functions of the MarketplaceDeciding if consumers are eligible for enrollment in a QHP (Qualified Health Plan)

Determining consumers' eligibility for financial assistance in a QHP through a premium tax credit and/or cost-sharing reduction

Determining or assessing consumers' eligibility for enrollment in Medicaid/CHIP

Helping consumers select QHP Not enrolled until they pay premium directly to insurer

Overseeing and monitoring companies selling QHPs

Not everyone is eligible e.g., if incarcerated, if US citizen but dont live in US, if not US citizen or lawfully presentCannot pay premium anywhere in Marketplace (either online or over phone). Must pay insurer directly.Overseeing and monitoring: to see if health plans meet certification requirements5

Operation of the Marketplace

The ACA mandated that By January 1, 2014, all states must have an operational individual and small-business exchange. But they had the option to decide what type of exchange they wanted to operate.SBM can also be SBE for State Based Exchange main thing to determine is if its federal, partnership, state, or state hybridState Hybrid is term were using, not official termSHOP = Small Business Health Options ProgramEX: In NM, CACs are called Health Care Guides, and in KY they are called Kynectors6

Where States Stand on Exchanges

Map updated 12/9/13https://www.statereforum.org/where-states-stand-on-exchanges

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Annual ChangesThe answer to this question can change every year.

States can decide to change their Marketplace type FFM, SPM, SBM, or Hybrid on a yearly basis.

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Where is the Marketplace?Healthcare.gov or the National Call Center at 1-800-318-2596

For these Marketplaces:Federally-FacilitatedState PartnershipState Hybrid

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Where is the Marketplace?

State PortalsFor State Based Marketplaces

KY: KynectCACs are KynectorsNM: Be Well NMCACs are Health Care GuidesOR: Cover OregonWA: Washington Healthplanfinder

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Healthcare.gov and StateReforum.orgIf youre not sure whether the online Marketplace for a state is at healthcare.gov or a state portal, check one of these two resources.https://www.healthcare.gov Apply Now Choose Your State

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Healthcare.gov and StateReforum.orgIf youre not sure whether the online Marketplace for a state is at healthcare.gov or a state portal, check one of these two resources.https://www.statereforum.org/state-exchange-websites

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Example of a Hybrid: New MexicoSBM operating as hybrid

SHOPs use http://bewellnm.com/

Individuals use https://www.healthcare.gov/

Hybrids: MS, NM, UT13

Information Provided in the Marketplace:

Eligibility and How to Enrollin Qualified Health Plans (QHPs)

https://www.healthcare.gov/find-premium-estimates/

Premium estimator shows eligibility for QHP vs. Medicaid/CHIP.[Go through these scenarios.]To enroll in QHP: Healthcare.gov Apply Now Choose State14

Information Provided in the Marketplace:

Eligibility and How to Enrollin Medicaid/CHIP

https://www.healthcare.gov/find-premium-estimates/

[Go through these scenarios.]15

Information Provided in the Marketplace:

Ways to Save Kaiser FamilyFoundationSubsidy Calculator

https://www.healthcare.gov/how-can-i-get-an-estimate-of-costs-and-savings-on-marketplace-health-insurance/

http://kff.org/interactive/subsidy-calculator/

[Go through these scenarios.]16

Information Provided in the Marketplace:

Ways to Save Quick Check Chart

https://www.healthcare.gov/how-can-i-save-money-on-marketplace-coverage/

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Federal Data Services Hub (FDSH)Routing tool to securely send information from various trusted government databases through secure networksVerifies accuracy of specific information entered in the applicationDoes not retain or store dataAgencyInformation VerifiedSSASSN & CitizenshipVA, Medicaid, MedicareIf already have insuranceIRSIncome (if seeking financial assistance)Dept. of Homeland SecurityCitizen or Legal Resident

Not everyone is eligible e.g., if incarcerated, if US citizen but dont live in US, if not US citizen or lawfully presentCannot pay premium anywhere in Marketplace (either online or over phone). Must pay insurer directly.Overseeing and monitoring: to see if health plans meet certification requirementsExamples of a few (NOT ALL) agencies18

The Role of ESS CACsEducators

Subject Matter Experts

Objective Assisters to help consumers make informed decisions without offering recommendations and without making eligibility or enrollment determinations

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Marketplace and Risk PoolsOpen to consumers regardless of: medical historypre-existing conditionsRisk pool Group of consumers whose estimated medical costs are combined in order to calculate health insurance premiumsNeeds both high-risk and low-risk consumersPeople who have greater healthcare needs are more likely to buy the insurance, but, if only those people were included in the risk pool, it would not be affordablePenalty causes more and healthier people to buy coverage, which balances out the risk

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Premium VariationsMakeup of risk pool directly affects cost of premiumsPremiums for the same QHP can vary significantlyWithin established limits:Age 3:1 ratioFamily composition 3:1 ratioGeographic area 3:1 ratioTobacco use 1.5:1 ratioCannot charge more than 3x more for the same plan based on differences in the first 3Cannot charge more than 1.5x more for the same plan based on tobacco useFactors NOT considered:GenderEx: charging higher premiums for mothers or men with heart diseaseMedical history or pre-existing condition

Factors Not Considered: This is what makes it part of the Patient Protection and Affordable Care Act21

Eligibility RequirementsLive in the Marketplace geographical area (state)Based on the state of residency claimed on taxes

U.S. citizen or national or lawfully presentCannot be currently incarcerated

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Qualified Health Plansaka QHPsDefinition:

An insurance plan* that: is certified by the Health Insurance Marketplace provides essential health benefitsfollows established limits on cost-sharing between the insurance company and consumers through copays, deductibles, and out-of-pocket maximum amountsfollows any additional state requirements

A qualified health plan will have a certification by each Marketplace in which it is sold.

* Under the Affordable Care Act* Starting in 2014

https://www.healthcare.gov/glossary/qualified-health-plan/QHPs

Accept subsidies

Only found inside Marketplace

Renewed yearly

These are the plans that accept subsidies and are only found in the Marketplace. 23

QHPsCertified by the Marketplace:Sold by licensed insurance companiesOffers at least one Silver and one Gold planIncludes at least minimum Essential Health Benefits Meet requirements for non-discrimination and provider network adequacyPremium is same whether sold inside or outside the MarketplaceCan only receive financial assistance if purchased inside the Marketplace

https://www.healthcare.gov/what-does-marketplace-health-insurance-cover/

4 distinct metal levels offered, but to be certified must offer at least one Silver & one Gold Some plans offered on the exchange are also offered off of the exchange generally at the discretion of the insurance carrier. Cannot get financial assistance if purchased outside of Marketplace24

10 Essential Health BenefitsComprehensive package of items and services required by the ACA

Required for plans sold both inside and outside of the Marketplace

Required for all Medicaid plans

Hence individual & job-based plans being canceled b/c they dont provide EHB25

10 Essential Health BenefitsTen categories of items and services that must be provided:Ambulatory patient services (e.g., outpatient care you get without being admitted to a hospital, such as doctor visits and clinics) Emergency services (e.g., ambulance, first aid services, and rescue squad) Hospitalization (such as surgery)Maternity and newborn care (care before and after your baby is born)Mental health and substance use disorder services, including behavioral health treatment (such as counseling and psychotherapy)Prescription drugs Rehabilitative and habilitative services and devices (services and devices - such as therapy sessions, wheelchairs, and oxygen - that help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills) Laboratory services (X-rays, blood work, etc.)Preventive and wellness services and chronic disease management (e.g., blood pressure screening, immunizations) Pediatric services for children, including dental and vision care

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Health Plan Categories5 Levels4 Metal Levels Catastrophic (not for everyone)People under 30People with hardship exemptionshttps://www.healthcare.gov/can-i-buy-a-catastrophic-plan/Do not refer to the quality or amount of care, just how much of the cost the plan will pay for (aka Actuarial Value)Percentages are just an averageAmounts vary depending on actual health care needsSame category can have several plans offered by different companies

Higher categories have higher monthly premiums but charge less for cost-sharing expenses like deductibles and copays27

Consumer ResponsibilityCan be spread across 3 different areasDeductiblesAmount you owe before insurance paysExample: $1,000CopaysFixed amount you owe for service up frontExample: $15CoinsurancePercentage you owe of total costsExample: 20% after deductibleCan be front-loadedCopays and deductiblesCan be back-loadedCoinsuranceLevelPlan PaysConsumer PaysCatastrophic< 60%> 40%Bronze60%40%Silver70%30%Gold80%20%Platinum90%10%

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Dental CoverageCan be offered as part of a QHP or as a stand-alone planChildren 18 and under:Dental is an EHBAll Marketplace QHPs must offer pediatric dental plansAdults:Not considered EHBDo not need to have dental coverage to avoid the penaltyCan choose:One premium via a QHP that includes dentalORTwo premiums via a stand-alone dental plan

https://www.healthcare.gov/can-i-get-dental-coverage-in-the-marketplace/

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Prescription Drug CoverageVery significant concern for many consumers!

Does the QHP they choose cover the prescription drugs they need?Formularies and drug tiers can vary for each QHP

PDF: What Consumers Should Know About Getting Prescriptions

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How Tax Credits WorkAKA Subsidy, Advanced Premium Tax Credit, or APTC Eligible if income is 100-400% of Federal Poverty Level (FPL)Based on INCOMETax credit is the SAME regardless of what plan level you chooseMarketplace will give consumers a dollar amount they can apply toward their premiums in the form of a tax creditConsumers choose how much of this amount they want to apply toward monthly premiumsMust be reconciled when they file taxes for the yearRefund if you used less tax credit than qualified forOwe taxes if used more tax credit than qualified forNo financial assistance if not at least 100% FPL

https://www.healthcare.gov/glossary/premium-tax-credit/

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How Tax Credits Are CalculatedBased on:Cost of premium for the Second Lowest Cost Silver Plan (SLCSP)Premium Cap (limit on % of income premium is allowed to cost based on FPL)Ex: If 100% FPL, premium cannot cost more than 2% of income

http://obamacarefacts.com/costof-obamacare.phpOOP = Out of Pocket

Tax Credit = Premium for SLCSP Premium Cap

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Tax Credit ExampleHH Size: 4Income: 200% FPL or $47,000Cost of SLCSP (Second Lowest Cost Silver Plan): $1,000/monthPremium Cap for 200% FPL = 6.3% of Income

Premium Cap = $47,000 x .063 = $2961 per year or $247/monthTax Credit = $1,000 Premium - $247 Premium Cap = $753Amount is the same regardless of what plan or plan level actually chosenBased solely on a) income and b) premium for SLCSPConsumer then chooses a plan and decides how much of the tax credit to use

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How Cost Sharing Reductions (CSR) WorkCost sharing is between consumer and insurance companyCSR available for:Consumers 100-250% FPLWho choose Silver Plans OnlyCost sharing is reduced so that the insurer pays more of total costConsumers pay less for copays, deductibles, and/or coinsuranceActuarial Value (AV) of Silver Plan increasesActuarial Value (AV) = percentage of total average costs for covered benefits that a plan will coverRemainder is consumer out of pocket costsEx: If AV = 70% on average (Silver), consumer pays 30% of total costs

https://www.healthcare.gov/glossary/actuarial-value/

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How Cost Sharing Reductions WorkThose between 100% and 250% FPL who choose a Silver Plan can get more costs covered for the Silver price. Those between 100% and 200% FPL who choose a Silver Plan can get higher than Gold or Platinum costs covered for the Silver price.http://obamacarefacts.com/costof-obamacare.phpOOP = Out of Pocket

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Moral of the Story:Choose Silver!

Pay attention to incomeIf between 100-250% FPL, consumers can receive both:Tax CreditsCost Sharing ReductionsIf so, Silver is by far the best optionMore for your moneyThere is no advantage to choosing Gold or Platinum if:Between 100-250% FPLChoosing Silver PlanEducate consumers about the difference.But be careful not to influence them.

Remember that our role is not to sway or influence consumers.36

More ResourcesSee what plans are offered in your area and exactly what they cover before you applyCustomer Service phone numbers for the national QHPsOfficial CAC training moduleESS Intranet Education CAC TrainingNavigator SOP ManualPages 32-33 for tax credits and cost sharing reductions

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Questions?Please submit via the Ask a Question feature!

Thank You!

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