How Does the Iowa Health Insurance Marketplace Work?

1. How Does the Iowa Health Insurance Marketplace Work? Changes under the Healthcare Reform

2. The Individual Mandate

3. First there were two choices • Under the Affordable Care Act every individual must have Minimum Essential Health care Coverage or Pay a Tax Penalty.

4. Minimum Essential Coverage • Minimum Essential Coverage is some form of major medical healthcare coverage such as: • Medicare • TRICARE or VA Medical Benefits – Must be comprehensive, not limited in scope. • Medicaid • hawk-i • Employer based health insurance • Major medical health insurance purchased on the individual market

5. Tax Penalty • If an individual does not have Minimum Essential Coverage they must pay the greater of the two penalties on their taxes. • In years after 2016 the penalty is indexed to the rate of medical inflation. • Parents are responsible for their children too!

6. There are a number of exceptions to the requirement for Minimum Essential Coverage • If a person is incarcerated • If a person is an undocumented immigrant • If a person is a member of an Indian Tribe • If a person qualifies for a religious exemption • If a person is a member of a healthcare sharing Ministry • If premiums for health insurance would cost more than 8% of your annual household income • If your income is below the filing threshold for taxes • If paying for health insurance would be a hardship for your household

7. Do I need to make any changes to avoid the penalty? • Are you uninsured? – Call the Marketplace • Do you like your current health insurance? • You can only qualify for tax credits on plans purchased on the Health Insurance Marketplace. • You may be able to keep your current plan. • Or you can shop on the marketplace to see if there is a better deal. • Are you on Medicare? – No change needed • Are you on Medicaid? – No change needed • Are you on IowaCare? – IowaCare ends on December 31, 2013. All IowaCare members will receive instructions on how to find new health care coverage.

8. What IS the Iowa Health Insurance Marketplace?

9. The Iowa Health Insurance Marketplace • Iowa is using the Federal Health Insurance Marketplace. • The Marketplace is a place for people to look for affordable minimum essential coverage • There is a single application process for Medicaid (including the Iowa Health and Wellness Plan), hawk-i Tax Credits, and Cost Sharing Subsidies. • Applicants shopping for insurance on the Marketplace will have the choice of multiple private insurers.

10. Who can use the Marketplace? Generally: Anyone can use the Iowa Health Insurance Marketplace. Only people who meet certain income, and health coverage conditions can qualify for government programs and tax credits. If you’re interested you can apply and see if you qualify for any help.

11. What Plans and Programs are Included on the Marketplace?

12. Medicaid • Medicaid provides low-cost or free health care coverage for low income individuals, such as: • Children • Adults • People with disabilities • Elderly people • Not available to non-citizens • Medicaid provides comprehensive health care coverage, such as: • Hospitals, physicians, prescriptions drugs, therapy, dental • Covers long term care services • Medicaid members can go to most Iowa health care providers. • You may apply for Medicaid on the Marketplace.

13. How Medicaid Fits with the Health Insurance Marketplace Income Level for an Individual • Medicaid provides coverage to children with family income up to 300% of the Federal Poverty Level • Medicaid provides coverage to adults with income up to 133% of the Federal Poverty Level • Individuals whose income is higher than Medicaid allows may be eligible for tax credits on the Health Insurance Marketplace Purchase Private Coverage from Health Insurance Marketplace: Not Eligible for Tax Credits 400% of the Federal Poverty Level May Be Eligiblefor Tax Credits to Purchase Private Coverage from Health Insurance Marketplace Medicaid Coverage for Children (0-18) Medicaid Coverage for Adults (19-64) Population

14. Iowa Health &Wellness Plan • New plan beginning January 1, 2014. • Available for adults age 19-64: • Not eligible for other Medicaid or Medicare coverage. • With income up to 133% of the Federal Poverty Level, or $15,282 per year for a family of one. • Created to provide comprehensive health care coverage for low-income adults. • Program will provide local access to doctors, hospitals, and other providers. • Will cover many services like hospitals, physicians, preventive care, prescriptions drugs, therapy, dental • Many members previously enrolled in IowaCare, may be eligible for this program • You may apply for the Iowa Health and Wellness Plan on the Marketplace.

15. hawk-i • Provides health care coverage for uninsured children of working families. • Family income must be below 300% of the Federal Poverty Level • No family pays more than $40 per month. • Children are covered through commercial health care and dental plans. • To qualify, children must: • Be under 19 • Have no other health insurance • Live in Iowa • Be a U.S. citizen • Not qualify for Medicaid • Not be a dependent of a State of Iowa Employee • You may apply for hawk-i on the Marketplace.

16. What will insurance plans on the Marketplace Look Like? • Bronze - Lowest premium and highest out of pocket costs. Cost sharing of 60% paid by insurer and 40% by the individual. • Silver - Lower premiums than gold and platinum, but with higher out of pocket costs. Cost sharing of 70% paid by insurer and 30% by the individual. • Gold - Lower premiums than platinum, but with higher out of pocket costs. Cost sharing of 80% paid by the insurer, and 20% by the individual. • Platinum - Highest premium with lowest out of pocket costs. Cost sharing of 90% by insurer, and 10% by the individual. • Catastrophic Plans – Certain people up to the age of 30 may select to purchase plans with very high deductibles and low premiums.

17. What will insurance plans on the Marketplace Look Like? • Benefits will include • Prescription drugs • Emergency services • Hospitalization • Maternity & newborn care • Pediatric services • Laboratory Services • Ambulatory Patient Services • Mental health & substance abuse services • Rehabilitative & habilitative services and devices • Preventative & wellness services and chronic disease management

18. Premium Assistance & Cost Sharing

19. Federal Poverty Level Guidelines (FPL) 2013 If your income and household size fall within this chart you may get benefits. * Based on Modified Adjusted Gross Income 19

20. Modified Adjusted Gross Income? • Modified Adjusted Gross Income is the amount of gross income earned, with a few things added in and deducted. • There are some deductions taken away, such as business expenses. • There is some money that is normally non-taxed added in, such as non-taxable interest. • The take away is that if you are near the income cut off, you still might qualify for assistance. • The only way to find out is to apply.

21. Health Premium Tax Credits • Certain people may qualify for tax credits to help them purchase insurance • The tax credit can reduce what you owe in taxes OR what you pay for health insurance premiums. • They must: • Have a household Modified Adjusted Gross Income between 100% and 400% of the federal poverty guidelines. • Not be eligible for Minimum Essential Coverage from some other source, for example Medicaid. • Be lawfully present in the U.S., and may not be incarcerated. • Must purchase health insurance through the exchange. • A person might still qualify for tax credits if coverage from their employer is not Affordable or does not provide Minimum Value.

22. What is considered Affordable under the law? What is Minimum Value? • An Employer’s plan is Affordable if the cost to insure the employee only is less than 9.5% of the employee’s household income. • An Employer’s plan provides Minimum Value if it covers 60% of the expected medical expenses.

23. How do I save with a Health Premium Tax Credit? • The tax credit can reduce what you owe in taxes OR what you pay for health insurance premiums. • Tax Credit = cost of the Silverbenchmark plan – a households required contribution. • The Silverbenchmark plan is the second least expensive Silver plan in the marketplace.

24. Required Contribution? • A household’s required contribution is a fixed percentage of the household income. This is a sliding scale based upon the annual income. (see table) • The goal is to keep healthcare spending to a limited portion of a households income. • Go to http://kff.org/interactive/subsidy-calculator/ to estimate your tax credit!

25. Things to Consider with Health Premium Tax Credits • The tax credit may be taken and applied towards any of the plans available on the market place. • The tax credit may be paid monthly to the insurance company to reduce the monthly premium or taken at the end of the year as a lump sum. • The amount of the tax credit is capped at the cost of the actual plan purchased.

26. The Final Tax Credit is Figured at the End of the Year • If you overestimate your income you may get a refund at the end of the year. • If you underestimate your income you may owe the government money. • The amount you need to pay back is limited by income and household size. (see table*) • If your income changes during the year, let the Marketplace know! *26 CFR 1.36B-4(a)(3)

27. Cost Sharing Subsidies • If a consumer is enrolled on a Silver plan they may qualify for cost sharing subsidies to decrease their share of costs. • A Silver plan has coinsurance of 30% paid by the consumer and 70% paid by the insurance company. With Cost Sharing Subsidies, the coinsurance is instead reduced to the following:

28. Where Can I Sign Up for the Marketplace?

29. You can enroll in the Marketplace at: Healthcare.gov 1-800-318-2596 With a paper application

30. Enrolling in the Marketplace

31. When can I sign up? • You can only enroll in an insurance plan during Open Enrollment or Special Enrollment. • Open Enrollment for the first year is from October 1st 2013 till March 31st, 2014. • Open Enrollment for 2015 starts October 15th 2014, through December 7th 2014. • If you don’t sign up during the open enrollment you may only sign up during a Special Enrollment period. • Programs such as Medicaid and hawk-i, may be enrolled in year round.

32. Special Enrollment Period • May enroll or change Qualified Health Plan • Within 60 days in individual market and 30 days in small group market from qualifying event * May be granted on a case by case basis.

33. What if I need help signing up? Insurance Agents and Brokers Navigator Certified Application Counselor • Their job is to help people select insurance plans. • Must be trained in health insurance • Must be licensed by the state of Iowa • Must act in the interest of their clients. • Funded by federal grants to help people enroll in the marketplace • Cannot have a conflict of interest • Must provide information in an impartial manner • Must provide consumer education and outreach programs • Must be trained and have passing scores on certification test • May not charge a fee for their services • Do not receive funding to help enroll people. • Must disclose any potential conflicts of interest to applicants • Must act in the best interest of the applicant • Must complete trainings and receive passing scores • May not charge for consumer services

34. Other Sources of Help • You can call the marketplace, 1-800-318-2596 • Or you can shop online at healthcare.gov

35. When can an Insurance Company Cancel a Policy? • If the consumer qualifies for Medicare • If the consumer does not pay their monthly premiums • If the consumer commits fraud on their application. • If the policy is no longer offered or is removed from the Marketplace.

36. Watch out for Fraud • If you are suspicious about a request for personal information DO NOT GIVE IT OUT! • The ONLY website for the Marketplace is healthcare.gov • If you get a suspicious phone call. DO NOT give out your personal information. • Call the Marketplace and let them know. • 1-800-318-2596

37. Other Changes

38. Other Consumer Protections Under the Healthcare Reform Coming in 2014 • Health Insurance Companies cannot refuse to cover you during open enrollment. • They can’t charge you more because you have chronic or pre-existing conditions. • They can’t charge more for women than men.

39. What Can Affect My Insurance Rates? • Insurance companies can now only vary their rates based upon; • Age (limited ratio of 3 to 1) • Tobacco Use (limited ratio of 1.5 to 1) • Number of person on the policy • Where you live

40. Additional Consumer Protections • These Reforms are in Effect • Plans must be presented in a uniform manner to make easy “apple to apple” comparisons of coverage. • Medical Loss Ratio Rebates • Dependant coverage extended up to age 26. • Insurers may only rescind policies in the case of fraud • Insurance Companies can no longer set lifetime or yearly spending limits. • These Reforms are Coming in 2014 • The waiting period to get on group plans is limited to 90 days.

41. Things to Remember? • All individuals will face a tax penalty if they don’t have minimum essential coverage and they don’t have an exception. • Low and Middle income individuals may qualify for government programs or tax credits to help them get health insurance. • The change in laws may expand the benefits you receive on new policies and it will change the way premiums are calculated. • Open enrollment runs Oct.1, 2013 – March 31, 2014!!!!!!! • Individuals may select Marketplace policies on healthcare.gov .

42. Question & Answer

43. Thank You! Go to healthcare.gov to shop or enroll Call 1-800-318–2596 Presented By: State Interagency Team: Iowa Insurance Division Iowa Department of Human Services Iowa Department of Public Health

44. Tax Penalty Example 1 • Eric has the option to get affordable minimum essential health insurance in 2014, and decides not to get it. In 2014 Eric earned $14,000. • Eric has a filing threshold of $12,000. • Eric must pay the greater of; • $95, the minimum flat amount or • $20, 1% of his income past the tax filing threshold. • ($14,000 - $12,000) = $2,000 * 1% = $20 • Eric must pay a tax penalty of $95

45. Penalty Example 2 • In 2014 Jenny had the option to purchase affordable health insurance, that provides minimum value, and did not. She earned $120,000 in 2014. • Jenny has a filing threshold of $12,000. • She has to pay the greater of; • $95, the minimum flat amount or • $1,080, 1% of her income past the tax filing threshold. • ($120,000 - $12,000) = $108,000 * 1% = $1,080 • Jenny must pay a $1,080 tax penalty.

46. Silver Benchmark Example: • Silver plans: A, B, C, and D. • A costs $100 a month, • B costs $110 a month, • C costs $120 a month, and • D costs $130 a month. • B is the Silver benchmark.

47. Example 1 • Household of 2 adults making $60,000 per year. Their required contribution is 9.5% or $5,700 per year. The Silver benchmark premium is $7,000 per year. • Tax Credit = $7,000 (Silver Benchmark) - $5,700 (Required Contribution) = $1,300 • Tax Credit = $1,300

48. Example 2 • Family of 4, two adults and two children making $40,000 annually. The Silverbenchmark premium is $10,781, their required contribution is 5.89% or $2,650 per year. • Tax Credit = $10,781 (SilverBenchmark) - $2,650 (Required Contribution) = $8,131 • Tax Credit = $8,131