What this training will cover

1. Produced for the U.S. Department of Health and Human Services, Health Resources and Services Administration by the National AHEC Organization under Contract # HHSH250200900063C. The views expressed in this presentation are solely the opinions of the author(s) and do not necessarily reflect the official policies of the U.S. Department of Health and Human Services or the Health Resources and Services Administration, nor does mention of the department or agency names imply endorsement by the U.S. Government. AHEC Health Insurance Marketplace Continuing Education

2. What this training will cover • The Affordable Care Act • Major Goals of the Affordable Care Act • Pathways to Affordable Quality Coverage • Individual Shared Responsibility • Medicaid • State Option to Expand Medicaid • Medicaid Coverage • How to Access Medicaid Coverage • Children’s Health Insurance Program (CHIP) • CHIP Coverage • How to Access CHIP Coverage • The Health Insurance Marketplace • State Options for Marketplace Structures • How Individuals & Families Access the Health Insurance Marketplace AHEC Health Insurance Marketplace Continuing Education

3. What this training will cover • Qualified Health Plans (QHPs) Sold in The Marketplace • QHPs Subject to Insurance Reforms • QHPs Cover Ten Categories of Essential Health Benefits (EHBs) • QHPs Grouped into Metal Levels • Catastrophic Coverage Plans • Federal Subsidies for QHPs through Insurance Affordability Program • QHP Summary of Benefits & Coverage (SBC) • QHPs Maintain Provider Network Adequacy • How to Access QHP Coverage • Important Marketplace Enrollment Dates • Small Businesses and the Marketplace • Small Business Health Options Plan (SHOP) • How Small Businesses Access SHOP • Conclusions & Resources AHEC Health Insurance Marketplace Continuing Education

4. The affordable care Act AHEC Health Insurance Marketplace Continuing Education

5. Major goals of the affordable care act AHEC Health Insurance Marketplace Continuing Education

6. Pathways to affordablequality coverage • The Marketplace Provides Access to All Pathways of Coverage Complete One Enrollment Application for All Forms of Coverage AHEC Health Insurance Marketplace Continuing Education

7. Individual shared responsibility MOST EVERYONE IS REQUIRED TO CARRY MINIMUM ESSENTIAL COVERAGE (MEC) • Some exemptions: • Individuals who cannot afford coverage • Taxpayers below the Federal income tax filing threshold • Members of American Indian tribes • Short coverage gaps (less than three consecutive months) • Hardship AHEC Health Insurance Marketplace Continuing Education

8. Questions ?????? AHEC Health Insurance Marketplace Continuing Education

9. MEDICAID AHEC Health Insurance Marketplace Continuing Education

10. State option to expand Medicaid AHEC Health Insurance Marketplace Continuing Education

11. Medicaid coverage If Medicaid Expansion State: • Previously required coverage of children, pregnant women, disabled and the elderly is still in place • New coverage of all adults between the ages of 18 and 64 with incomes up to 133% of the Federal Poverty Level (FPL) If Non-Medicaid Expansion State: • Previously required coverage of children, pregnant women, disabled and the elderly is still in place • Any possible coverage of adults is subject to state law Coverage Gap in Non-Medicaid Expansion States Adults who cannot qualify for Medicaid and cannot qualify for Federal subsidies to buy QHPs. AHEC Health Insurance Marketplace Continuing Education

12. How to access Medicaid coverage • One Enrollment Application for All Forms of Coverage • Go to: www.healthcare.gov or Call: 1-800-318-2596 AHEC Health Insurance Marketplace Continuing Education

13. CHILDREN’S HEALTH INSURANCE PROGRAM (chiP) AHEC Health Insurance Marketplace Continuing Education

14. Children’s Health insurance program (CHIP) coverage CHIP is for children in families that earn too much to qualify for Medicaid but not enough to afford private insurance coverage • Offered in all states • Not tied to state Medicaid program expansion • Comprehensive CHIP coverage funded through 2015 • Open enrollment and immediate coverage • States may choose to: • Integrate CHIP into Medicaid program • Operate CHIP separately from Medicaid • (with different income eligibility thresholds) • Cover additional benefits • Cover pregnant women and parents AHEC Health Insurance Marketplace Continuing Education

15. How to access CHIP coverage • One Enrollment Application for All Forms of Coverage • Go to: www.healthcare.gov or Call: 1-800-318-2596 AHEC Health Insurance Marketplace Continuing Education

16. questions ?????? AHEC Health Insurance Marketplace Continuing Education

17. The Health INSURANCE MARKETPLACE AHEC Health Insurance Marketplace Continuing Education

18. Important marketplace enrollment dates OPEN ENROLLMENT DATES • For coverage in 2015: Nov. 15, 2014 – Feb. 15, 2015 • For coverage in 2016 and after: Oct. 15 – Dec. 7 each year COVERAGE START DATES • Enroll between 1st and 15th of the month: Coverage starts first day of the next month • Enroll between 16th and last day of the month: Coverage starts first day of the second following month SPECIAL ENROLLMENT PERIOD • Any time a qualifying life event occurs (such as: moving to new state, loss of a job, change in family size) • Triggers 60 days to enroll in coverage AHEC Health Insurance Marketplace Continuing Education

19. State Options for Marketplace structures AHEC Health Insurance Marketplace Continuing Education

20. How individuals and families access the Health Insurance Marketplace • The Marketplace Provides Access to All Pathways of Affordable Coverage Complete One Enrollment Application for All Forms of Coverage • Go to: www.healthcare.gov or Call: 1-800-318-2596 AHEC Health Insurance Marketplace Continuing Education

21. Qualified Health Plans (QHPs) sold in the MARKETPLACE AHEC Health Insurance Marketplace Continuing Education

22. QHPs subject to insurance reforms AHEC Health Insurance Marketplace Continuing Education

23. QHPs cover ten Categories of essential health benefits (EHBs) • Ambulatory Patient Services • Emergency Services • Hospitalization • Maternity & Newborn Care • Mental Health & Substance Use Disorder Services • Including behavioral health treatment • Laboratory Services • Pediatric Services • Including oral and vision care • Prescription drugs • Special rules for prescription drug benefit including formulary exceptions • Preventive & Wellness Services and Chronic Disease Management • No out-of-pocket costs • Rehabilitative & Habilitative Services and Devices • EHB services must be balanced across all categories. These services can be included but do not count as Essential Health Benefits: • Adult routine dental and eye exams • Cosmetic orthodontia • Long-term/custodial nursing home care AHEC Health Insurance Marketplace Continuing Education

24. QHPs grouped into metal levels METAL LEVELS CORRELATE TO ACTUARIAL VALUE (AV) (AV is the average percentage of costs a plan will cover for EHBs) Insurance carriers must offer: child-only plans, at least one silver and gold plan and a catastrophic plan. Stand-alone dental plans have different costs. AHEC Health Insurance Marketplace Continuing Education

25. Catastrophic coverage plans • EACH INSURANCE CARRIER IN THE MARKETPLACE • MUST OFFER ONE CATASTROPHIC PLAN AHEC Health Insurance Marketplace Continuing Education

26. Federal Subsidies for QHPs through insurance affordability program LOWER OUT-OF-POCKET COSTS WITH COST SHARING REDUCTION PLANS (CSR) TO BE ELIGIBLE: • Must be enrolled in a Silver Level plan through a Marketplace • Must earn between 100% and 250% of the FPL: $11,490 to $28,725 for individuals $23,550 to $58,875 for a family of four IF QUALIFIED: • Insurance carrier charges lower out-of-pocket costs (deductibles, copays, coinsurance) • Total charges are less than the standard annual limit ($6,350/individual and $12,700/family) • To determine eligibility go to: www.healthcare.gov • Fill out an application • Use the Cost and Savings Calculator • Consult the Quick Check Chart AHEC Health Insurance Marketplace Continuing Education

27. Federal Subsidies for QHPs through insurance affordability program LOWER PREMIUMS WITH ADVANCE PAYMENT TAX CREDIT (APTC) TO BE ELIGIBLE: • Must be enrolled in a Metal Level plan through a Marketplace • Must earn between 100% and 400% of the FPL: $11,490 to $45,960 for individuals $23,550 to $94,200 for a family of four IF QUALIFIED: • Premium assistance paid on a sliding scale • Insurers receive premium assistance payments directly from Federal Government • To determine eligibility go to www.healthcare.gov • Fill out an application • Use the Cost and Savings Calculator • Consult the Quick Check Chart AHEC Health Insurance Marketplace Continuing Education

28. QHP Summary of benefits & coverage (SBC) • EVERY QHP MUST HAVE A CORRESPONDING • SUMMARY OF BENEFITS & COVERAGE (SBC) • Insurance carriers required to provide standardized information to allow • apples-to-apples comparison of plans SBC is a summary of answers to general questions regarding: • The QHP’s deductible, provider network, non-covered services • Common medical events that the QHP covers and does not cover • Copay and coinsurance costs for care from network providers and non-network providers AHEC Health Insurance Marketplace Continuing Education

29. QHPs Maintain Providernetwork adequacy AHEC Health Insurance Marketplace Continuing Education

30. Questions ?????? AHEC Health Insurance Marketplace Continuing Education

31. How to access QHP coverage • TRAINED NAVIGATORS, ASSISTORS & OTHERS AVAILABLE TO HELP ENROLL • Go to: www.healthcare.gov or Call: 1-800-318-2596 AHEC Health Insurance Marketplace Continuing Education

32. Important marketplace enrollment dates OPEN ENROLLMENT DATES • For coverage in 2015: Nov. 15, 2014 – Feb. 15, 2015 • For coverage in 2016 and after: Oct. 15 – Dec. 7 each year COVERAGE START DATES • Enroll between 1st and 15th of the month: Coverage starts first day of the next month • Enroll between 16th and last day of the month: Coverage starts first day of the second following month SPECIAL ENROLLMENT PERIOD • Any time a qualifying life event occurs (such as: moving to new state, loss of a job, change in family size) • Triggers 60 days to enroll in coverage AHEC Health Insurance Marketplace Continuing Education

33. Questions ?????? AHEC Health Insurance Marketplace Continuing Education

34. SMALL BUSINESSES ANDThe Marketplace AHEC Health Insurance Marketplace Continuing Education

35. Small business health options plan (SHOP) SMALL BUSINESSES CAN ENROLL IN SMALL GROUP PLANS THROUGH SHOP SHOP QHPs ARE METAL LEVEL PLANS: • Subject to all insurance reforms and QHP requirements • Options for level of employer contribution • Options for level of employee out-of-pocket costs TO ENROLL IN SHOP: • Maximum allowable employees is 50 full-time equivalent employees (FTEs) (varies by state) • Must offer coverage to all full-time employees • Must meet employee participation rate (varies by state) • Enroll between Nov. 15th and Dec. 15th each year to be exempt from employee participation requirements • Must meet employer premium contribution requirement (varies by state) AHEC Health Insurance Marketplace Continuing Education

36. Small business health options plan (SHOP) SMALL BUSINESSES TAX CREDITS AVAILABLE FOR SHOP QHPs TO BE ELIGIBLE: • Fewer than 25 employees • Average salary of $50,000 or less • Employer pays 50% of full-time employees premium costs IF QUALIFIED: • Credit covers up to 50% of monthly employer premium contribution • Allows the deduction of premium costs not covered by the credit • Credit highest for businesses with fewer than 10 employees and average salaries of $25,000 or less AHEC Health Insurance Marketplace Continuing Education

37. How small businesses access shop • SHOP HAS OPEN ENROLLMENT – HOWEVER: • Enrollment through Federal Marketplace postponed until 2015 • Not all State SHOP Marketplaces operational • SHOP MARKETPLACE IN EVERY STATE • Business enrolls in a state where it has an office or work site AHEC Health Insurance Marketplace Continuing Education

38. Questions ?????? AHEC Health Insurance Marketplace Continuing Education

39. conclusions AHEC Health Insurance Marketplace Continuing Education

40. Federal Resources Health Insurance Marketplace Individual, family, small business coverage options/enrollment • www.healthcare.gov • www.cuidadodesalud.gov Medicaid • www.medicaid.gov Children’s Health Insurance Program (CHIP) • www.insurekidsnow.gov AHEC Health Insurance Marketplace Continuing Education

41. More Federal Resources Internal Revenue Service Section on all Affordable Care Act tax provisions • www.irs.gov The Center for Consumer Information and Insurance Oversight (CCIIO) Section on Affordable Care Act rules for private insurance and marketplaces • www.cms.gov/CCIIO BusinessUSA Section on all health care changes of interest to businesses • www.business.usa.gov AHEC Health Insurance Marketplace Continuing Education

42. State Resources AHEC Health Insurance Marketplace Continuing Education