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Anticipating the Health Insurance Marketplace in Texas Pearland Chamber of Commerce August 29, 2013

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About Community Health Choice

• Non-profit Health Maintenance Organization licensed by the Texas Department of Insurance

• Affiliate of the Harris Health System • Serves over 230,000 Members with the following

programs: • Medicaid: State of Texas Access Reform (STAR) program for low-

income children and pregnant women • CHIP: Children’s Health Insurance Program for the children of low-

income parents—includes CHIP Perinatal benefits for unborn children of pregnant women who do not qualify for Medicaid STAR

• 3-Share Plan: TexHealth Harris County 3-Share Plan that subsidizes the premiums of a limited benefit plan for previously uninsured, low-income employees of small businesses

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CHC Service Area Map

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Membership and Revenue

$0

$100

$200

$300

$400

$500

$600

$700

-

50,000

100,000

150,000

200,000

250,000

2004 2005 2006 2007 2008 2009 2010 2011 2012

Rev

enue

(Mill

ions

)

Mem

bers

hip

(Tho

usan

ds)

Membership Total Revenue

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Our Mission

At Community Health Choice, our mission is to improve the health of underserved residents of Southeast Texas by facilitating access

to coordinated, high quality, affordable healthcare services. Our mission is achieved through:

Community Collaborating with community-based Providers and organizations to

improve access, quality, coordination and cost effectiveness of services

Health Developing programs to establish medical homes, manage health

conditions and promote wellness and preventive care

Choice Encouraging personal accountability and educated choices for individual

and family health

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Federal Reforms with Medicaid Expansion

$19,090

$76,360

$38,180

Family of 3:

$25,390

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Federal Reforms without Medicaid Expansion Federal Reforms without

Medicaid Expansion

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Potential Exchange Market Size

2% 19%

79%

72,917 Uninsured Children

Newborns Ages 1-5 Ages 6-18

25%

27% 23%

17%

8%

457,938 Uninsured Adults

Ages 19-26 Ages 27-34 Ages 35-44 Ages 45-54 Ages 55-64

Includes • all legal residents < 5 years between 0-400% FPL • child citizens and legal residents > 5 years between 200-400% FPL • adult citizens and legal residents > 5 years between 100-400% FPL

20 County SDA Eligible for Exchange Coverage

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Individual Mandate

• Effective January 1, 2014 most individuals will be required to purchase insurance or pay penalties

• Exceptions: • Individuals covered under an ER sponsored plan • Individuals already enrolled in an individual insurance plan meeting all ACA

requirements • Individuals who are eligible for Medicaid or CHIP • Individuals who would have to pay more than 9.5% of their income for health

insurance • Individuals below the threshold required to file an income tax return (2012 = $9,750 single) • Undocumented Immigrants • Individuals who are incarcerated • Members of Indian Tribes

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Penalties

• 2014: The greater of 1% of total family income or $95

adult and $47.50 per child up to $285 for a family

• 2015: The greater of 2% of total family income or $325 per adult and $162.50 per child up to $975 for family

• 2016: The greater of 2.5% of total family income or $695 per adult and $347.50 per child up to $2,085 for family

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Consumer Protections

• Guarantee issue • Guarantee renewable • No pre-existing limitation exclusions • No waiting periods • No cost sharing for covered preventive care/wellness • Dependent children can be covered up to age 26

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Products to be Offered

• Products offered in (or out) of the Exchange must include the ten categories of Essential Health Benefits specified in the ACA:

Ambulatory patient services Emergency services

Hospitalization Maternity and newborn care

Mental health and substance use disorder services

Prescription drugs

Rehabilitative and habilitative services and devices

Laboratory services

Preventive and wellness services* and chronic disease management

Pediatric services, including oral and vision care**

* At no cost to members ** Can be excluded in States with enough Stand Alone Dental Plans

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Plan Levels of Coverage

Level of

Coverage

Plan Pays

on Average (actuarial value)

Enrollees Pay on Average

(In addition to the monthly plan premium)

Bronze 60 percent 40 percent

Silver 70 percent 30 percent

Gold 80 percent 20 percent

Platinum 90 percent 10 percent

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Financial Assistance

Two forms of assistance available through the Exchanges

Eligibility

2013 Individual/Family of 4 Income Estimate Details

Advance Premium Tax Credits

Between 100% and 400% FPL

$11,490 to $45,960/ $23,550 to $94,200

Sliding scale basis to reduce the cost of the monthly member portion of premium

Cost-Sharing Reductions

Between 100% and 250% FPL

$11,490 to $28,725/ $23,550 to $58,875

Only available for silver plans; effectively raises the AV of the plan

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Premium Tax Credit Reconciliation

• Premium tax credits are applied to the monthly premium in advance

• Reconciliation of tax credits done on tax returns • If advance payments exceed the amount of credit

individuals are eligible, repayment is required • Advance credits provided in 2014 will be reconciled

on tax returns due on April 2015

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Sample Product Designs

Illustrative Bronze Benefit Plan

60% Actuarial Value

Illustrative Silver Benefit Plan

70% Actuarial Value

Illustrative Silver Benefit Plan with Cost Sharing

Reductions 94% Actuarial Value

Deductible $2,500 $0 $0

Coinsurance 0% 0% 0%

Out of Pocket Maximum (in network)

$6,350 $6,350 $1,000

Office Visits $35/$70 copays after deductible

$40/75 copays $10/$20 copays

Inpatient Hospitalization

$400 per day for first five days after deductible

$400 per day for first five days $200 per day for first five days

Prescription Drugs $25/$75/$100 copays $25/$75/$100 $5/$20/$40

Emergency Care $250 after deductible $250 $100

Premium $240 $290 $290

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• Determine eligibility for: • Enrollment in a

qualified health plan • Tax credits and cost-

sharing reductions • Medicaid or CHIP

Consumer Submits application to the

Marketplace

The Marketplace verifies and

determines (or assesses eligibility)

Eligible Consumer enrolls in a qualified

health plan or Medicaid/CHIP

Enrollment Overview

• Online • Phone • Mail • In Person

• Online plan comparison tool available to inform health plan choice

• Premium tax credit and cost-sharing reductions are sent to insurer (if eligible)

• Enrollment in a qualified health plan or Medicaid/CHIP

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Plan Comparison

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Certified

Navigators

Community Based Groups, Health Centers

Insurance Agents, Brokers

Medicaid eligibility workers

Consumer Assistance Programs

Certified Application Counselors

In-Person Assistance Programs

Who Can Help?

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Key Points to Remember

You have choices Employer-based coverage will continue Insurance will continue to be sold outside of the

Marketplace • Purchase from the Marketplace is not required

The Marketplace is the only place to get • New premium tax credits • Cost-sharing reductions

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Key Deadlines

October 1, 2013 2014 Open enrollment begins

January 1, 2014 Coverage begins

March 31, 2014 2014 Open enrollment ends

October 15th – December 7th

Annual open enrollment period for future years

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QUESTIONS? Karen Love, Senior VP karen.love@chchealth.org 713.295.5195 www.chcaffordablehealthcare.com

For more information on the Health Insurance Marketplace, sign up to get email and text alerts at signup.healthcare.gov