Health Reform and You

1. Health Reform and You Insurance Options under the Affordable Care Act Brendan Riley NC Community Health Center Association January 23, 2014

2. Enrolling in Health Coverage • As of October 1, 2013, you can enroll in new health coverage options • Insurance options based on eligibility: • Employer-sponsored coverage • Medicaid & CHIP • Medicare • Individual/non-group coverage you buy yourself

3. Before Health Reform • Medical bills leading cause of bankruptcy • Premium costs rising faster than wages • No protections for people with pre-existing conditions • Insurance companies can deny coverage to sick people, even children

4. Higher Quality Coverage: Consumer Protections • Can’t be denied coverage because of a pre-existing condition • No lifetime limits or annual caps on coverage • Limits on out-of-pocket costs for consumers • Companies can’t charge women more money for same coverage • Companies can’t cancel your policy because of an illness

5. Higher Quality Coverage: Consumer Benefits • Plans must cover “essential health benefits” • Plans must provide easy-to-read summaries of benefits and covered services • Children can stay on parents’ plan ‘til age 26 • Preventive services with no cost-sharing • Tax credits for small businesses that provide coverage

6. Applying for Health Coverage • Single, streamlined application • Determine eligibility for and enroll in nearly all types of coverage • Application and enrollment assistance • Certified in-person assisters • 24-hour call center • Online chat helpers

7. Applying for Health Coverage Step 1: Person can apply in person, by phone, or online Step 4: Compare plans and enroll Step 2: Marketplace verifies income, citizenship, and immigration status thru online data from federal and state agencies Step 3: Marketplace determines eligibility for public or private insurance coverage and subsidies 7

8. What’s in it for You: Medicare & Medicare Advantage • Medicare • No eligibility changes • Strengthens program with new benefits • Free preventive services • Closes doughnut hole on Rx drug costs • Medicare Advantage • Premium dollars must go toward improving care per 80/20 rule • Keeps seniors’ costs down & makes plans more efficient

9. What’s in it for You: Job-Based Coverage • Job-based coverage • >50% of non-elderly North Carolinians • Most will continue on this coverage in 2014 • Don’t have to apply, but can shop around to see if better coverage or better costs • Benefit from consumer protections, such as caps on lifetime limits, protections for pre-existing conditions, etc.

10. What’s in it for You: Buying Individual/Non-Group Coverage • Pre-ACA, very difficult and costly to purchase health insurance on individual market • ACA creates Health Insurance Marketplace • Like Expedia or Priceline — consumers can shop for and compare insurance plans and levels of coverage in online Marketplace • www.HealthCare.Gov • Plans must provide essential health benefits

11. What’s in it for You: More Affordable Coverage • Financial help for many to purchase health insurance through Health Insurance Marketplace • Eligible for Premium Tax Credits if: • Between 100% and 400% of Federal Poverty Level • No access to affordable employer-based coverage • Ineligible for Medicaid, CHIP, or Medicare • Amount of tax credit depends varies on sliding scale • Tax credit at 200% FPL will be larger than 300% FPL credit

12. What’s in it for You: More Affordable Coverage • How do premium tax credits work? • Used to purchase qualified health plan on Marketplace • Eligibility determined by household size and income • Can be claimed fully in advance, in part in advance, or at end of year • Paid directly by the Marketplace to the insurer • Consumer is responsible for the difference each month

13. More Affordable Coverage: Premium Tax Credits Eligibility for Premium Tax Credits Note: This example is based on the 2013 Federal Poverty Levels (FPL). These income limits will be increased by 2014. 13

14. More Affordable Coverage: Cost-Sharing Reductions • Caps on out-of-pocket expenses • Deductible, co-pays, coinsurance • Eligible if household at or below 250% FPL (~$28,750/household of one) • Must select silver tier plan

15. What’s in it for You: Medicaid & CHIP • CHIP • Public program that covers children in families up to 200% FPL (~$47k for family of four) • Medicaid • Public program that covers some individuals & families • Provides funding to states to expand eligibility for all individuals up to 138% FPL • Supreme Court rendered expansion voluntary for states • 12 month eligibility period — can enroll anytime in the year

16. Medicaid Expansion • ACA provides full federal funding for expansion for first three years • Tapers down to 90% in 2020 and years beyond

17. Medicaid Expansion

18. Get Ready for Coverage • Marketplace Open Enrollment Period: October 1, 2013-March 31, 2014; • Full year enrollment period for Medicaid & CHIP www.HealthCare.gov www.CuidadoDeSalud.gov 1-800-318-2596 (TTY 1-855-889-4325)

19. Get Ready for Coverage • The North Carolina Department of Insurance (NCDOI) consumer information office can help you with questions about your insurance coverage • Health Insurance Smart NC • 1-877-885-0231 • www.ncdoi.com/Smart/ • NCDOI can also help you file complaints or appeals with your insurance company

20. Questions? Brendan RileyOutreach & Enrollment CoordinatorNorth Carolina Community Health Care Associationrileyb@ncchca.org http://www.ncchca.org/