ACA's Fourth Enrollment Period: Key Issues & Insights

1. Web Briefing: Key Issues Ahead of the Affordable Care Act’s Fourth Open Enrollment Period Presented by the Kaiser Family Foundation Tuesday, October 25, 2016 1 p.m. ET to 2 p.m. ET

2. Today’s Speakers Cynthia CoxAssociate Director, Program for the Study of Health Reform and Private Insurance Kaiser Family Foundation Karen Pollitz Senior Fellow Kaiser Family Foundation Larry Levitt Senior Vice President for Special Initiatives Kaiser Family Foundation Rachel Garfield Senior Researcher & Associate Director, Kaiser Commission on Medicaid and the Uninsured Kaiser Family Foundation

3. Larry Levitt Senior Vice President for Special Initiatives Kaiser Family Foundation

4. Rachel Garfield Senior Researcher & Associate Director, Kaiser Commission on Medicaid and the Uninsured Kaiser Family Foundation

5. Cynthia Cox Associate Director, Program for the Study of Health Reform and Private Insurance Kaiser Family Foundation

6. Karen Pollitz Senior Fellow Kaiser Family Foundation

7. Rachel Garfield Senior Researcher & Associate Director, Kaiser Commission on Medicaid and the Uninsured Kaiser Family Foundation

8. The uninsured rate has dropped to a historic low. Uninsured Rate Among the Nonelderly Population, 1995-2016 Note: 2016 data is for Q1 only. Source: CDC/NCHS, National Health Interview Survey, reported in http://www.cdc.gov/nchs/health_policy/trends_hc_1968_2011.htm#table01 and https://www.cdc.gov/nchs/data/nhis/earlyrelease/insur201609.pdf

9. Nearly 12 million remaining uninsured are eligible for financial help for coverage. Eligibility for ACA Coverage Among Nonelderly Uninsured as of 2016 Eligible for Financial Assistance 43% Total = 27.2 Million Nonelderly Uninsured NOTES: Numbers may not sum to totals due to rounding. Tax Credit Eligible share includes adults in MN and NY who are eligible for coverage through the Basic Health Plan. Medicaid/Other Public also includes CHIP and some state-funded programs for immigrants otherwise ineligiblefor Medicaid. SOURCE: Kaiser Family Foundation analysis based on 2016 Medicaid eligibility levels and 2016 Current Population Survey.

10. Patterns of eligibility vary by state Medicaid expansion status. Eligibility for ACA Coverage Among Nonelderly Uninsured as of 2016, by State Medicaid Expansion Status Total = 13.1 Million Nonelderly Uninsured Total = 14.1 Million Nonelderly Uninsured NOTES: Totals may not sum to 100% due to rounding. Tax Credit Eligible share in expansion states includes adults in MN and NY who are eligible for coverage through the Basic Health Plan. Medicaid/Other Public also includes CHIP and some state-funded programs for immigrants otherwise ineligible for Medicaid. SOURCE: Kaiser Family Foundation analysis based on 2016 Medicaid eligibility levels and 2016 Current Population Survey.

11. Cost and perceptions of cost remain a major barrier to coverage. Primary reason for being uninsured among remaining uninsured adults in California: SOURCE: Wave 4 of the Kaiser Family Foundation California Longitudinal Panel Survey, 2016.

12. Cynthia Cox Associate Director, Program for the Study of Health Reform and Private Insurance Kaiser Family Foundation

13. Marketplace plan selections (millions) Source: HHS data and Kaiser Family Foundation estimate.

14. Churn in marketplace enrollment (millions) Source: HHS data

15. Use of Care Among Low- and Middle-Income Nonelderly Adults, by Insurance Coverage in Fall 2014 NOTE: Includes adults ages 19-64. “Previously Insured” includes people who were insured as of interview date and have been insured since before January 2014. “Newly Insured” include people who were insured as of interview date and gained coverage since January 2014. “Uninsured” includes people who lacked coverage as of the interview date. * Significantly different from Newly Insured at the p<0.05 level. SOURCE: 2014 Kaiser Survey of Low-Income Americans and the ACA.

16. Reasons for Insurer Losses in the Individual Market • Sicker-than-expected risk pool • Underpricing (competition to offer low-cost plan) • Lower-than-expected benchmark premiums • Changes to risk corridors payments • Losses not offset by lower-than-expected payments • Insufficient control over costs • Trend toward narrow networks, HMOs Kaiser Family Foundation. “What to Look for in 2017 ACA Marketplace Premium Changes” http://kff.org/private-insurance/perspective/what-to-look-for-in-2017-aca-marketplace-premium-changes/

17. Fewer insurers will participate in 2017 Marketplaces, though most people likely still have choice of 3 or more Source: Kaiser Family Foundation. Preliminary Data on Insurer Exits and Entrants in 2017 Affordable Care Act Marketplaces. http://kff.org/health-reform/issue-brief/2017-premium-changes-and-insurer-participation-in-the-affordable-care-acts-health-insurance-marketplaces/

18. Factors Driving Premiums in 2017 Driving premiums up: • Losses and Underpricing • Sicker-than-expected risk pool (varies by insurer) • Inadequate premiums (benchmarks 12% below CBO projections) • Phasing out of reinsurance payments (4 to 6%) • Underlying medical prices (about 3 to 9%) Driving premiums down: • Health insurance tax waived for 2017 (about 3%) • Trend toward narrow networks (varies by market) • Competition Kaiser Family Foundation. For more information see: “How ACA Marketplace Premiums Measure Up to Expectations” and “What to Look for in 2017 ACA Marketplace Premium Changes”

19. Premium changes vary tremendously across the country, but less so after considering tax credits Source: Kaiser Family Foundation. Preliminary Data on Insurer Exits and Entrants in 2017 Affordable Care Act Marketplaces. http://kff.org/health-reform/issue-brief/2017-premium-changes-and-insurer-participation-in-the-affordable-care-acts-health-insurance-marketplaces/

20. What to Expect from 2017 ACA Marketplaces • Lower insurer participation • Some areas have 1 exchange insurer • Most enrollees will have choice of 3+ exchange insurers • Higher premiums • Premiums rising faster in most parts of country • Many factors driving growth are temporary or one-time • Beyond 2017 • Long-term effects of premium increases and exits? • Trend toward narrow networks, HMOs • Ultimately the market needs to grow

21. Karen Pollitz Senior Fellow Kaiser Family Foundation

22. Individual Mandate • Most people are required to have health insurance (minimum essential coverage) or pay a tax penalty. Exemptions for • Those who can’t afford coverage (lowest cost plan more than 8.16% of income) • Member of Indian tribe • Undocumented immigrant • Incarcerated • Hardship • Other • Full-year penalty in 2016 is greater of 2.5% of household income above tax filing threshold or $695 per adult and $347.50 per child, up to $2,085 per family • Penalty capped at cost of national average premium for Marketplace bronze plan ($2,676 for single individual in 2016) • Penalty assessed monthly • Report coverage months in 2016 and pay applicable penalty on 2016 federal tax return, due April 15, 2017

23. For First Time Marketplace Participants • Open Enrollment is time to sign up for private, nongroup coverage in 2017. • November 1, 2016 – January 31, 2017 • For coverage that starts on January 1, sign up by December 15, 2016 • Qualified health plans (QHP) offered at bronze, silver, gold, platinum level • Also “catastrophic” plans for young adults (to age 30) • All plans cover essential health benefits, free preventive care • Financial help available through the Marketplace only • Most in QHPs (>80%) qualify for help paying premiums • Advanced premium tax credits (APTC) reduce your monthly cost of coverage • APTC for people with income 100%-400% FPL ($11,880-$47,520 for single person in 2017) • Most in QHPs (>50%) also qualify for help paying deductibles, cost sharing • Special cost sharing reduction (CSR) Silver plans have lower deductibles than regular silver plans • CSR for people with income 100% - 250% FPL ($11,880-$29,700 for single person in 2017) • In most states, people with income under 138% FPL qualify for Medicaid. Medicaid enrollment open year-round.

24. Application Process • Apply online or seek in-person help from Navigator, other assister program, or broker • www.HealthCare.gov is website for most state marketplaces, with links to marketplace sites in all other states • “Find Local Help” lists in-person assisters by zip code • Start early! As December 15 / January 31 deadlines approach, can be harder to make appointments, Marketplace call center wait times lengthen • Two part process: (1) application for financial help; (2) plan selection, enrollment • Application seeks information about you, family members, citizenship status, household income. To prepare, gather driver’s license, social security numbers, immigration documents, copy of your most recently filed tax return (usually, for 2015), notices from Marketplaces and insurance company • Marketplace will verify application information in real time using trusted, secure data sources (IRS, SSA, Homeland Security). If can’t, applicants can usually enroll and receive financial help provisionally, then provide documents within 90 days. • Eligibility for financial help determined in real time for most people; then continue to pick health plan.

25. How Premium Tax Credits Work • Available to those with incomes from 100% to 400% FPL • Who aren’t eligible for Medicaid, Medicare or other public coverage • Who aren’t eligible for “affordable” job-based plans that meet other coverage standards • Individual/family required contribution for benchmark silver plan limited to lesser of percent of income or actual premium • <133% FPL, maximum premium contribution = 2.04% of 2017 household income • 150% FPL, maximum premium contribution = 4.08% of 2017 household income • 200% FPL, maximum premium contribution = 6.43% of 2017 household income • 250% FPL, maximum premium contribution = 8.21% of 2017 household income • 300% - 400% FPL, maximum premium contribution = 9.69% of 2017 household income • Amount of PTC = benchmark silver plan premium minus required contribution • Tax credit amount can be applied to any plan sold through Exchange (except Catastrophic) • Credit can be claimed at year end when file tax return, or during year (advanced premium tax credit or APTC) to reduce monthly premium payment

26. Estimating 2017 Income • Application for 2017 financial assistance asks your projected 2017 income • Careful estimation matters; APTC claimed during a year may have to be repaid on tax return next year • 2017 tax credit recipients must file 2017 federal income tax return, with Form 8962 • Recipients who don’t file will be ineligible for help in 2019. • Marketplace will compare information on your application to available trusted income data (most often, your 2015 federal tax return) • If application information is more than the greater of $6,000 or 25% different from trusted source information, you may be asked to provide documentation • If no trusted information available to Marketplace, you may also be asked to provide documentation • Marketplace eligibility notice will indicate if additional documentation required within 90 days. • If so, be sure to provide by deadline or risk losing all or part of your financial help • Navigators and other marketplace assister programs can help with verification

27. Comparing and Selecting Health Plans • Compare total costs (monthly premium + out-of-pocket cost sharing for health care services) • New Simple Choice (standardized) plan designs on HealthCare.gov • Consider cost sharing reduction (CSR) Silver plans if eligible • Consider network type • HMO, EPO generally won’t cover non-emergency care out-of-network • PPO, POS generally will provide some out-of-network coverage • Check if providers are in network, Rx drugs on formulary • Plan compare tools • Summary of benefits and coverage

28. Most Marketplace Enrollees Say Shopping Was Easy AMONG NON-GROUP ENROLLEES WITH MARKETPLACE PLANS:Thinking about when you signed up for your current health plan, how easy or difficult was it for you to do each of the following? NOTE: Don’t know/Refused and Not Applicable responses not shown. SOURCE: Kaiser Family Foundation Survey of Non-Group Health Insurance Enrollees, Wave 3 (conducted Feb. 9-Mar. 26, 2016)

29. Most Marketplace Enrollees Satisfied With Plans • AMONG NON-GROUP ENROLLEES WITH MARKETPLACE PLANS:Thinking about your current health insurance plan, how satisfied are you with each of the following? SOURCE: Kaiser Family Foundation Survey of Non-Group Health Insurance Enrollees, Wave 3 (conducted Feb. 9-Mar. 26, 2016)

30. For Returning Marketplace Participants • Health plan coverage and financial assistance must be renewed annually during Open Enrollment • Important to actively renew in order to pick best plan for you, claim most accurate APTC possible • Important to actively renew by December 15 for coverage starting January 1 • After that, in most cases, Marketplace will automatically renew your coverage under same or similar plan to take effect January 1, 2017 • In most cases, Marketplace will also automatically update your APTC to take effect January 1, 2017. APTC cannot be automatically continued if: • income reported on 2015 tax return exceeds 500% FPL • you claimed APTC in 2015 but did not file a 2015 tax return with Form 8962 • Even if auto-renewed, all returning consumers can still update their information, change plans through January 31, 2017

31. Important Notices* for All Returning Consumers • Marketplace letter – before November 1 • Information about Open Enrollment • Explains how to update 2017 application to get most accurate premium tax credit • Indicates if action or documents (e.g., tax filing information) needed to continue 2017 APTC (if so, no auto-renewal, must actively reapply for 2017 APTC) • Insurance company letter – before November 1 • Explains whether your 2016 plan is available in 2017 • If not, whether the insurer will offer other plans • Explains any changes to the plan for 2017 • Includes 2017 premium information, including your estimated cost after premium tax credit applied • Explains whether you will be auto-renewed if you don’t take action by December 15 • Auto-enrollment letter – December 16-31, 2016 • Only for consumers who do not pick plan by December 15 and who are auto-enrolled, explains the auto-enrollment and how to update plan choice by January 31 * Dates and content may vary somewhat in State-run Marketplaces

32. Additional Notices* for Returning Consumers Whose Insurance Company Will Exit Marketplace after 2016 • Letter from your current insurer – before November 1 • Gives notice that it will not offer Marketplace coverage in 2017 • Letter from Marketplace – mid-November • Explains automatic re-assignment process • Identifies new, similar plan the Marketplace will auto-reassign for you • Explains how to take action to select your own 2017 plan • Letter from new insurer – mid-November • From the insurer the Marketplace will otherwise auto-reassign you if you don’t affirmatively select a plan by December 15 • Describes new plan coverage and premium, taking into account your estimated APTC • Describes how and when to make first premium payment so coverage takes effect • Importantly, even if auto-reassigned to new plan for January 1, consumers have until January 31 to pick a new plan and update subsidy information • Additional notices – December 16-31 • Loss of 2016 plan also triggers Special Enrollment Period (SEP) process, deadlines * Dates and content may vary somewhat in State-run Marketplaces

33. Key Dates for Consumers

34. Kaiser Family Foundation Resources Health Reform FAQs kff.org/health-reform/faq/health-reform-frequently-asked-questions/ Marketplace Subsidy Calculator (2017 updates coming soon) kff.org/interactive/subsidy-calculator/ Comparison Shopping Issue Brief kff.org/health-costs/press-release/in-73-percent-of-counties-healthcare-gov-enrollees-could-lower-their-silver-plan-premiums-by-comparison-shopping/ Health Insurance Explained (animated video) kff.org/health-reform/video/health-insurance-explained-youtoons/

35. Ask Questions At Any Time Via Chat Type your questions via chat at any time. See the bottom left hand corner of your screen.

36. Larry Levitt Senior Vice President for Special Initiatives Kaiser Family Foundation

37. Rachel Garfield Senior Researcher & Associate Director, Kaiser Commission on Medicaid and the Uninsured Kaiser Family Foundation

38. Cynthia Cox Associate Director, Program for the Study of Health Reform and Private Insurance Kaiser Family Foundation

39. Karen Pollitz Senior Fellow Kaiser Family Foundation

40. Today’s Speakers Cynthia CoxAssociate Director, Program for the Study of Health Reform and Private Insurance Kaiser Family Foundation Karen Pollitz Senior Fellow Kaiser Family Foundation Larry Levitt Senior Vice President for Special Initiatives Kaiser Family Foundation Rachel Garfield Senior Researcher & Associate Director, Kaiser Commission on Medicaid and the Uninsured Kaiser Family Foundation

41. Today’s Web Event Will Be Archived http://kff.org/health-reform/event/web-briefing-key-issues-ahead-of-the-affordable-care-acts-fourth-open-enrollment-period/ This conversation will be archived and posted online by tomorrow morning. Slides are now available to download.

42. Contact Information Craig Palosky, Director of Communications Kaiser Family Foundation | Washington, DC Email: craigp@kff.org

43. Thank you! Until the next event, keep up with the Kaiser Family Foundation online: Facebook: /KaiserFamilyFoundation Twitter: @KaiserFamFound LinkedIn: /company/kaiser-family-foundation Email alerts: kff.org/email