Marketplace in the Affordable Care Act

1. Marketplace in the Affordable Care Act Presentation courtesy of The Comal County Democratic Party with source materials from the

2. Basics • Health Insurance Marketplace • New way to get health insurance with less hassle • Compare private insurance plans based on price, benefits, quality, and other features • Most people will get a break on costs (subsidies to help with insurance premiums)

3. Insurance Rules • Rates are based on age only (except rates increase dramatically for smokers) • Pre-existing conditions do not affect premium pricing or coverage • Insurance cannot be cancelled if people become sick • Insurance coverage continues if you change jobs

4. As of 2010, 6.2 million Texans were uninsured. This is how those individuals could gain coverage under the ACA: Texas Enrollment Opportunity Marketplace with cost sharing with government Marketplace at full cost Medicaid adults: newly eligible If states accept expansion * Medicaid/CHIP kids: eligible now but not enrolled Left uninsured * Texas legislature has not endorsed expansion of Medicaid

5. 2014: ACA Provides Premium Support Fitted to Income Family Income Family income based on 2014 federal poverty income levels for a family of four

6. The Affordability Puzzle • Premium Cost Sharing with Gov. • Help with Out-of-Pocket Costs • Preventive Services • Cost-Sharing Subsidies • Maximum limit on yearly expense

7. Premium Credits: Eligibility Primary Group: Individuals and families between 100 and 400 percent of the Federal Poverty Level (FPL) without access to an employer group plan Also eligible: People who would have to spend more than 9.5% of income to participate in employer plan or whose employer plan has less coverage than the “bronze” exchange plan

8. Premium Subsidies • Sliding scale relative to income (premiums capped at 2-9.5% of income) • Must be used to purchase coverage in the Health Insurance Marketplace

9. Other Cost-Sharing Help • ) Free Recommended Preventive Care (Flu Shots, Mammograms, and much more) • Maximum Limits on Out-of-Pocket Expenses • Lower deductibles and/or copayments for those with incomes between 100% and 250% of the Federal Poverty Level

10. Free Preventative Care • Abdominal Aortic Aneurysm one-time screening for men of specified ages who have ever smoked • Alcohol Misuse screening and counseling • Aspirin use for men and women of certain ages • Blood Pressure screening for all adults • Cholesterol screening for adults of certain ages or at higher risk • Colorectal Cancer screening for adults over 50 • Depression screening for adults • Type 2 Diabetes screening for adults with high blood pressure • Diet counseling for adults at higher risk for chronic disease • HIV screening for all adults at higher risk • Immunization vaccines for adults • Obesityscreening and counseling for all adults • Sexually Transmitted Infection (STI)prevention counseling for adults at higher risk • Tobacco Usescreening for all adults and cessation interventions for tobacco users • Syphilisscreening for all adults at higher risk

11. Free Immunization • Hepatitis A • Hepatitis B • Herpes Zoster(adults) • Human Papillomavirus • Influenza (Flu Shot) • Measles, Mumps, Rubella • Meningococcal • Pneumococcal • Tetanus, Diphtheria, Pertussis • Varicella • Inactivated Poliovirus (children) • Haemophilus influenzae type b (children) • Rotavirus (children)

12. Free Preventative Care for Women • Anemia screening on a routine basis for pregnant women • Bacteriuria urinary tract or other infection screening for pregnant women • BRCA counseling about genetic testing for women at higher risk • Breast Cancer Mammography screenings every 1 to 2 years for women over 40 • Breast Cancer Chemoprevention counseling for women at higher risk • Breastfeeding comprehensive support and counseling from trained providers, as well as access to breastfeeding supplies, for pregnant and nursing women • Cervical Cancer screening for sexually active women • Chlamydia Infection screening for younger women and other women at higher risk • Contraception: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, not including abortifacient drugs • Domestic and interpersonal violence screening and counseling for all women • Folic Acid supplements for women who may become pregnant • Gestational diabetes screening for women 24 to 28 weeks pregnant and those at high risk of developing gestational diabetes

13. Free Preventative Care for Women (continued) • Gonorrhea screening for all women at higher risk • Hepatitis B screening for pregnant women at their first prenatal visit • Human Immunodeficiency Virus (HIV) screening and counseling for sexually active women • Human Papillomavirus (HPV) DNA Test: high risk HPV DNA testing every three years for women with normal cytology results who are 30 or older • Osteoporosis screening for women over age 60 depending on risk factors • Rh Incompatibility screening for all pregnant women and follow-up testing for women at higher risk • Tobacco Use screening and interventions for all women, and expanded counseling for pregnant tobacco users • Sexually Transmitted Infections (STI) counseling for sexually active women • Syphilis screening for all pregnant women or other women at increased risk • Well-woman visits to obtain recommended preventive services

14. Free Preventative Care For Children • Alcohol and Drug Use assessments for adolescents • Autism screening for children at 18 and 24 months • Behavioral assessments for children of all agesAges: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years. • Blood Pressure screening for childrenAges: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years. • Cervical Dysplasia screening for sexually active females • Congenital Hypothyroidism screening for newborns • Depression screening for adolescents • Developmental screening for children under age 3, and surveillance throughout childhood • Dyslipidemia screening for children at higher risk of lipid disordersAges: 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years. • Fluoride Chemoprevention supplements for children without fluoride in their water source

15. Free Preventative Care For Children (continued) • Gonorrhea preventive medication for the eyes of all newborns • Hearing screening for all newborns • Height, Weight and Body Mass Index measurements for childrenAges: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years. • Hematocrit or Hemoglobin screening for children • Hemoglobinopathies or sickle cell screening for newborns • HIV screening for adolescents at higher risk • Immunization vaccines for children from birth to age 18 —doses, recommended ages, and recommended populations vary:

16. Free Preventative Care for Children (continued) • Iron supplements for children ages 6 to 12 months at risk for anemia • Lead screening for children at risk of exposure • Medical History for all children throughout developmentAges: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years. • Obesity screening and counseling • Oral Health risk assessment for young childrenAges: 0 to 11 months, 1 to 4 years, 5 to 10 years. • Phenylketonuria (PKU) screening for this genetic disorder in newborns • Sexually Transmitted Infection (STI) prevention counseling and screening for adolescents at higher risk • Tuberculin testing for children at higher risk of tuberculosisAges: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years. • Vision screening for all children

17. Out-of-Pocket Limits • All new health insurance plans will limit yearly out-of-pocket expenses • Limits apply only to covered services

18. Cost-Sharing Subsidies • Families under 250% FPL receive extra help with cost-sharing – lower deductibles and copays • Must select a silver-level plan to receive this extra benefit

19. Avg. Share of Costs Covered Out of Pocket MAX as % of income (not including premiums) Income for a Family of Four From: To: $23,880 $35820 (150% FPL) 94% $2,117/indiv. $4,233/family $35,820 $47,760 (200% FPL) 85% $47,760 $59,700 (250% FPL) 73% $3,175/indiv. $6,350/family $59,700 $71,640 (300% FPL) 70% $71,640 $83,580 (350% FPL) 70% $4,233/indiv. $8,467/family $83,580 $95,520 (400% FPL) 70% Out-of-Pocket Costs: Share of Health Costs Covered under Exchange Silver Plans 19

20. Coverage Level Options in the Exchange All plans will cover essential benefits: hospital, ER, mental health, maternity, Rx, preventive care, chronic disease management and more. 4 standard levels, (plus a 5th catastrophic plan for people under age 30 or if no other coverage is affordable) % enrollee cost share % covered by plan Platinum Gold Silver Bronze Options vary by % of covered benefits paid by the plan on average vs % covered through out-of-pocket enrollee cost sharing 20

21. You’d be eligible for Medicaid, but for the state’s decision to not expand The ACA’s Individual Mandate to Have Insurance in 2014

22. Individual Penalty Amounts

23. 2013-14 Timeline OPEN ENROLLMENT BEGINS Plan coverage begins Open enrollment ends

24. Types of ACA In-Person Enrollment Assistance • Navigators – More broad based, comprehensive consumer assistance. Grants funded by the Marketplace. • Certified Application Counselors • Based in hospitals, clinics, or community organizations. • Help enroll patients/individuals served by that provider/organization • Provide info about coverage options, and assist with computer process to enroll in Medicaid/Exchange options; but no public outreach/education. • Unfunded

25. More Information: Healthcare.gov www.healthcare.gov/marketplace