Countdown to Coverage: the Health Insurance Marketplace

International Society of Certified Employee Benefits Specialists

Trey Daly, Ohio State Director, Enroll Americatdaly@enrollamerica.org 513-659-0187

172 days3

WHAT IS ENROLL AMERICA•IDENTIFY THE UNINSURED

•INFORM THE UNINSURED ABOUT ACA

•INSPIRE THE UNINSURED TO ENROLL

Lucas County’s Uninsured

• Lucas County Uninsured (under 65) 57,994o 18 – 64 51,981 89.6%o Under 19 6,742 11.6%

o Male 32,128 55.4%o Female 25,866 44.6%

o White n/ao Black n/ao Hispanic n/a

o <= 138% fpl 25,745 44.4%o <= 400% fpl 52,228 90.1%

http://www.census.gov/did/www/sahie/data/interactive/

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Cuyahoga County’s Uninsured

• Cuyahoga County Uninsured (under 65) 160,828o 18 – 64 146,816 91.3%o Under 19 15,977 9.9%

o Male 89,810 55.8%o Female 71,019 44.2%

o White n/ao Black n/ao Hispanic n/a

o <= 138% fpl 72,196 44.9%o <= 400% fpl 143,915 89.5%

http://www.census.gov/did/www/sahie/data/interactive/

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New Health Coverage Options in 2014

3 different options are available to the uninsured based on income.

- Medicaid- The Marketplace (with financial

assistance)- The Marketplace or private plan (without

financial assistance)

Medicaid• The federal government sets

requirements minimum requirements

• States have the option to expand coverage

• Historically – Low-income parents, children, and pregnant women, low-income elderly, and disabled individuals

• Medicaid doesn’t cover:

Undocumented immigrants  • The ACA allows states to expand

their Medicaid programs to cover all individuals who have incomes less than 138% of poverty

Coverage levels dependent upon Medicaid expansion…

MedicaidMarketplace

(“Exchange") with Tax Credits

Marketplace or Private Plan

138% 400% + 0%STATES WITH MEDICAID EXPANSION:

STATES WITHOUT MEDICAID EXPANSION:

Potential Gap in Eligibility for Assistance

Marketplace (“Exchange") with

Tax CreditsMarketplace or

Private Plan

138% 400% + 0% 100%

Ohio Medicaid Expansion•Governor Kasich included in Budget

•Republican Leadership Removed from Budget

•Speaker Bill Batchelder says House will take up Medicaid Reform language in October

•Controlling Board

•Executive Order

More Will Qualify for Medicaid Without Expansion

•MAGI Income Guidelines•5% Income Disregard• Children / Pregnant Women up to 205% fpl• Parents up to 95% fpl

•New Income Exemptions• Child Support / Social Security Income

•New Household Formation Rules• Stepparents and their income included

Most Uninsured Kids Eligible

111,511 out of 177,870 (62.7%) uninsured Ohio children are currently

income eligible for Medicaid

Connecting to Coverage• Can enroll online, by phone, in person, or using paper

application– Data-driven system that integrates eligibility across programs

• Give basic info about self and household– Contact information and who’s applying for coverage– Income/types of income– Number of people in household– Citizenship/immigration status– If have affordable coverage now

• Process will vary from state to state

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If applyi

ng online…

Enter essen

tial information

System pulls

existing data

about applican

t(s)

Supplement or correct info, if

needed

System determ

ines eligibili

ty

Pick a plan,

amount of tax

credit to receive in advance,

enroll!

Or, enroll in Medicaid or CHIP

Who Is Eligible for Financial Assistance?•Income <400% of poverty

• 400% of poverty = $44,680 for a single adult, $92,200 for a family of four

•Must not have a offer of job-based coverage•Are immigrants eligible?

• Legal immigrants, yes• Undocumented immigrants, no

•Refundable, advance-payment federal tax credit (“APTC”)• Do not have to wait until file taxes to get the tax credit – it can be

applied to the cost the coverage when they enroll • If taken in advance, tax credit goes directly to health plan consumer

chooses• Pays a portion of consumer’s monthly premium

How much will coverage cost

(for those with financial assistance)?• Cost is based on sliding-fee scale for people with income <400% FPL:

• Tax credit picks up difference between required contribution and premium for second lowest cost silver plan.

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Income Percent of income required to pay toward premiums

Up to 133% of poverty 2%133-150% of poverty 3-4%150-200% of poverty 4-6.3%200-250% of poverty 6.3-8.05%250-300% of poverty 8.05-9.5%300-400% of poverty 9.5%

How Much Will Coverage Cost•27 year old single male making $17,235 a year•150% federal poverty guidelines•C = S – (M x P)•C = Tax Credit•S = $2,798•M = $17,235•P = 4.0%•$2,798 - ($17,235 x .04)•$2,798 – ($689) = $2,109 yr / $175.75 mos Tax Credit

How Much Will Coverage Cost•40 year old man with wife and two children•$50,000 annual income•212% federal poverty guidelines• C = S – (M x P)•C = Tax Credit•S = $9,453•M = $50,000•P = 6.72%

•$9,453 - ($50,000 x .0672)•$9,453 – ($3,360) = $6,093 yr / 507.75 mos Tax Credit

Average Cuyahoga County Premiums•Without subsidies

Premium Adult Individual Age

27Premium Adult Individual

Age 50Bronze $207.00 $352.57Silver $252.16 $429.74Gold $293.07 $499.46Platinum N/a n/aCatastrophic $147.81 $251.90

Average Cuyahoga County Premiums•Without subsidies

 Premium Family

Premium Single Parent Family

Premium Couple

Premium Child

Bronze $699.23 $474.04 $504.87 $125.43Silver $851.78 $578.68 $615.01 $152.79Gold $989.97 $672.56 $714.79 $177.58Platinum n/a n/a n/a n/a

Maximum Out-of-Pocket Limit (OOP)

•Puts a cap on what the enrollee pays in cost-sharing charges each year• Set on a yearly basis

• Applies to in-network services

•2014 amounts: $6,350 individual/$12,700 family•OOP limit is not the amount that an enrollee must spend each year

Cost Sharing Reduction•People with income up to 250% FPL•Must enroll in a silver plan through the Health Insurance Marketplace (also called the exchange)•Cost Sharing Reduction pegged to Actuarial Value (AV)• Income > 150% fpl = 94% AV

• Income 151% >200% fpl = 87%

• Income 201% > 250% fpl = 73%

Essential Benefits•Ambulatory patient services•Emergency services. •Hospitalization. •Maternity and newborn care. •Mental health and substance use disorder services, including behavioral health treatment. •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.

Different Types of Plans•Plan that covers 100% of actuarial value would have no cost-sharing other than premium

•Platinum 90% actuarial – 10% cost sharing•Gold 80% actuarial – 20% cost sharing•Silver70% actuarial – 30% cost sharing•Bronze 60% actuarial – 40% cost sharing•Catastrophic

• Under 30 yo

• Coverage kicks in after deductible = cost sharing limits

Enrollment – The Players

Consumer

Assistance

Programs

Medicaid eligibility workers

Insurance Agents, Brokers

Community Based Groups

Certified Application Counselors

In-Person Assistance Programs*

Navigators

Navigators•Maintain expertise in eligibility, enrollment, and program specifications;•Conduct public education activities to raise awareness about the Exchange;•Provide fair, accurate, impartial Facilitate selection of a Qualified Health Plan;•Provide referrals regarding health plan, coverage, or a determination under such plan or coverage; and•Provide culturally and linguistically appropriate information

Ohio Navigators•Ohio Association of Foodbanks• Anticipated grant amount: $1,958,961

• Access Health Mahoning Valley

• Asian Services in Action, Inc.

• Carmella Rose Health Foundation• Cuyahoga Health Access Partnership• Community Action Committee of Pike County

• Disability Rights Ohio

Ohio Navigators•Ohio Association of Foodbanks cont’

• Health Care Access Now

• Heart of Ohio Family Health Center

• Hospital Council of Northwest Ohio

• Ohio Association of Free Clinics

• Ohio Department of Health

• United Way of Greater Cleveland 2-1-1

• Community Action of Washington Morgan Counties

• Western Reserve Area Agency on Aging

Ohio Navigators•Children's Hospital Medical Center• Anticipated grant amount: $124,419

•Clermont Recovery Center, Inc.• Anticipated grant amount: $44,938

•Helping Hands Community Outreach Center• Anticipated grant amount: $230,920

•Neighborhood Health Association• Anticipated grant amount: $684,630

FQHC Outreach and EnrollmentHealth Centers•Hire and train O/E assistance workers as certified application counselors•Conduct in-reach and outreach and assist with the enrollment process•Share barriers and successes •Report metrics, successes, and barriers to HRSA quarterly

Cuyahoga County FQHCs•CARE ALLIANCE $137,280

•NEIGHBORHOOD HEALTH CARE INCORPORATED $89,969

•NORTHEAST OHIO NEIGHBORHOOD HLTH. SVCS. $246,411

•THE FREE MEDICAL CLINIC OF GREATER CLEVELAND $107,701

Which Organizations May Be Certified Application Counselors•(1) Processes in place to screen staff and volunteers to ensure that they protect personally identifiable information, •(2) Engage in services that position them to help those they serve with health coverage issues, and •(3) Have experience providing social services to the community.

• Community health centers such as FQHCs;• Hospitals; • Health care providers;

• Behavioral health or mental health providers;

• Agencies that have experience providing social services to the community such as Supplemental Nutrition Assistance Program (SNAP) outreach, energy assistance, or tax assistance; and

• Other local governmental agencies that have similar processes and protections in place such as other health care providers, health departments and libraries.

Process for Becoming Certified Application Counselor

•Must submit an application http://

www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-Marketplaces/assistance.html

•Must enter into written agreement with FFM

•Must disclose potential conflicts of interest

•Successfully complete training

Ohio State Law Issues•Sec. 3905.01(D) "In-person assister" means any person, other than a navigator, who receives any funding from, or who is selected or designated by, an exchange, the state, or the federal government to perform any of the activities and duties identified in . . . the Affordable Care Act. •Sec. 3905.474. No person shall act as, perform the duties of, or hold one's self out to be an in-person assister unless that person is either a licensed insurance agent certified to sell insurance through an exchange . . . or an insurance navigator certified under . . . the Revised Code.

Ohio State Law Issues•Sec. 3905.471. (A) No individual or entity shall act as or hold itself out to be an insurance navigator unless that individual or entity is certified as an insurance navigator under this section and is receiving funding under division (i) of section 1311 of the Affordable Care Act.

O.A.C. 3901-5-13(F) Exemptions•Licensed health care provider or a hospital

•FQHC or look a like

•Non profit organization whose primary purpose is the distribution of food stuffs, groceries, donated goods or purchased goods

•A state agency

ODI Assistant Director Farley•"We're not exempting them per se; we're giving an example of safe harbor, . . . If you do not hold yourself out (as a navigator), you will not trigger the statute.”• JCARR August 12, 2103