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Its a new world!
Health Care Changes and You
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MHC Who we are
Understanding the Problem Understanding the Affordable Care Act
Understanding Insurance Exchanges
Moving Forward
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Todays Agenda
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Montana Health CO-OP: Who We Are
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Who is MHC?
Member-owned health CO-OP
Non-profit organization
Home-grown (Helena-based) Funded via federal start-up loans
CO-OPs currently approved in 24 states
Offering products via the HealthInsurance Exchange
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Health Care: Understanding the Problem
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Health Care Problems
Insurance Situation
50 million uninsured Americans
200,000 uninsured Montanans Premiums double in last 10 years
62% of all bankruptcies medically-related
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Health Care Problems
Insurance Situation
Coverage isnt comprehensive
Affordability
Emphasis on group/employer-providedinsurance.
Pre-existing condition clause
Fear of losing coverage with job loss/change
Insurance denied if no continuity of coverage
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Health Insurance Exchanges & the ACA
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Health Insurance Exchanges
Internet-based marketplaces to shop for and buy healthinsurance
Compare apples to apples (tiers of coverage)
Determine eligibility for premium subsidies
Plans on the exchange must offer Essential Health Benefits 278,000 Montanans could get insurance via the Exchange
Congress and their staff will get insurance from the Exchange
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Exchange = Marketplace
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Health Insurance Exchanges
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Carrier1
Individual
AgentsEnter
applicantinfo
Determineeligibility/taxcredit level
Calculate anddisplay plansw/tax credit
Select plan/premium
Navigator
HSA Vendor
IndividualContribution
How Does the Marketplace Work?
Auto enroll alleligible for
Medicaid/CHIP Approvedtax credit
Direct Access
Assisted
Tax creditpayments
Eligibility and taxcredit validation
Process Flow
Money FlowData Flow
Eligibility data
Qualified Entity
Carriercollects
premium
Carrierenrolls
member
Carrier 2
Carrier 3
Montana Health Marketplace
Health Plans
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Health Insurance Exchanges
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Gold
1
22
Silver
1
2
Bronze
1
2
Metallic Plans
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Solutions
Open Enrollment/Guaranteed Coverage
Subsidies available via exchange
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Gold Silver Bronze$600 Deductible $1,200 Deductible $2,000 Deductible
80/20(1,500 out-of-pocket)
70/30(3,000 out-of-pocket)
50/50(3,750 out-of-pocket)
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Projected Income $34,516(300% of poverty level)
Unsubsidized annual health insurancepremium(adjusted for age)
$7,500
Maximum % of income the person/familymust pay for premium (based on income %of poverty level)
9.50%
Amount person/family pays $3,279
Government tax credit/subsidy $4,221
2014: Subsidies At Work
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*Must purchase from the Exchange/Marketplace to receive subsidy.
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2014: Subsidies At Work
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Projected Income $16,107(140% of poverty level)
Unsubsidized annual health insurance premium(adjusted for age)
$7,500
Maximum % of income the person/family mustpay for premium (based on income % of povertylevel)
3.41%
Amount person/family pays $550
Government tax credit/subsidy $6,950
*Must purchase from the Exchange/Marketplace to receive subsidy.
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Health Insurance Exchanges
Up and running by October 2013
Open Enrollment period for purchasing insurance on theexchange: October 2013 January 2014
Montana will use the Federal Health Insurance Exchange
Montana Health CO-OP plans will be on the exchange
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Understanding the Affordable Care Act (ACA)
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Affordable Care Act (ACA)
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Signed into law March 2010
Expand Medicaid
Encourage employers to offer health insurance. Provide premium subsidies Establish health insurance exchanges Strengthen consumer protections
Impose protections to guard against unreasonable rateincreases. Encourage primary and preventive care. Mandate insurance for everyone.
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Affordable Care Act (ACA)
Insurance companies cannot:
Put a lifetime cap on how much they will pay Cancel coverage by finding a paperwork error.
Deny coverage based on pre-existing conditions
Charge women more for coverage
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Affordable Care Act (ACA)
Making Health Care AffordablePreventative services are free
Cancer screenings: mammograms & colonoscopies
Vaccinations: flu, mumps & measles
Blood pressure and cholesterol screenings
Tobacco cessation counseling
Depression screening
And more
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Affordable Care Act (ACA)
Making Health Care Affordable
The 80/20 Rule
Beforeinsurance companies spent as much as 40cents of every premium dollar on overhead, marketingand salaries.
Nowthey must spend 80 cents of your premiumdollar on your health care or on improvements to care.If they dont, they must repay the money.
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Affordable Care Act (ACA)
Making Health Care Affordable
Starting in 2014
Cannot deny coverage for pre-existingconditions
Insurance exchanges allow you to easilycompare plans
Subsidies for qualified individuals to makepremiums affordable
New small business tax credits
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ACA Subsidies
For qualifying individuals and families withoutemployer-based insurance
Starting in 2014
Subsidies (advanceable tax credits) to offsetmonthly premiums for those with incomebetween 100-400% of the Federal Poverty
Level (FPL). 65% of Montana families have incomesbelow 340% of the FPL.
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Subsidies At Work
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2012 Annual Guidelines Federal Poverty Level
Family
Size
100% 133% 150% 185% 200% 250% 300% 400%
1 $11,170 $14,856 $16,755 $20,664 $22,340 $27,925 $33,510 $44,680
2 $15,130 $20,122 $22,695 $27,990 $30,260 $37,825 $45,390 $60,520
3 $19,090 $25,389 $28,635 $35,316 $38,180 $47,725 $57,270 $76,360
4 $23,050 $30,656 $34,575 $42,642 $46,100 $57,625 $69,150 $92,200
5 $27,010 $35,923 $40,515 $49,968 $54,020 $67,525 $81,030 $108,040
6 $30,970 $41,190 $46,455 $57,294 $61,940 $77,425 $92,910 123,880
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ACA Subsidies
Subsides will ensure qualifying households pay no morethan a specific percentage of income on premiums:
Percentageof household income is a sliding scale based onthe Federal poverty level (FPL) of the family involved:
Up to 133% FPL: 2.0% of income
133-150% FPL: 3.0% 4.0% of income
150-200% FPL: 4.0% 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: Capped to 9.5% of income
Source: (PPACA 1401, 10105; HCERA 1001; IRC 36B)
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2014: Subsidies At Work
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2014: Changes for Employers
Businesses with less than 50 full-time employees areexempt from having to offer health insurance toworkers.
97% of Montana business have fewer than 50 full-time employees.
80% of Montana employers have fewer than 10
workers.
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2014: Changes for Employers
Small employers offering health insurance
with 25 or fewer full-time employees
that have average wages under $50K
are eligible for small business tax credit of 35 percent(increasing to 50% by 2014).
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2014: Changes for Employers
Penalties for large companies (50+ workers):
Not offering minimum essential benefit coverage --
$2,000 per full-time worker (subtracts first 30 full-timeworkers)
Not offering affordable coverage lesser of $3,000 perfull-time employee receiving a subsidyor$2,000 per full-
time employee
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Penalties for the Uninsured
2015: Insurers mail a Notice of Insurance (similar to W-2)for taxes.
Income too low to file a federal tax return? Penaltiesare not meant for you.
2014 $95 per adult and $47.50 per child, up to a familymaximum of $285 or 1 percent of family income,
whichever is greater
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Moving Forward
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Stay informed:Will the MT legislature approve federally-funded Medicaid
expansion?Will other insurers participate on the exchange?
Consider the paradigm shift from group coverage toindividual coverage.
Do we have ample primary care physicians?Expect a dramatic change in the health care market.Anticipate the possibility of an insurance shift (354,000
Montanans may see an insurance change).Know that there will be fine-tuning and clarification of the
ACA.See: www.healthcare.gov
Making the New LawsWork for Montana
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Thank you!
Karen [email protected]
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