Transcript of ACA AND THE HEALTH INSURANCE MARKETPLACE: THE CURRENT LANDSCAPE IN PA Emily Van Yuga, M.Ed The...
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- ACA AND THE HEALTH INSURANCE MARKETPLACE: THE CURRENT LANDSCAPE
IN PA Emily Van Yuga, M.Ed The Health Federation of Philadelphia
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- HEALTH FEDERATION OF PHILADELPHIA The Health Federation of
Philadelphia (HFP) is a nonprofit 501c(3) organization whose
mission is to improve access to and quality of health care services
for underserved and vulnerable individuals and families. Since
1983, HFP has served as a network of the health centers in
southeastern Pennsylvania, providing a forum for the regions
Federally Qualified Health Centers (FQHCs) and FQHC Look-Alikes to
collaborate and mobilize resources for their shared goals of
improving the health of the population by expanding access to high
quality care. Currently, HFPs network comprises more than 40
community health center sites collectively serving more than
300,000 people each year, approximately 40% of whom are uninsured.
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- HEALTH FEDERATION OF PHILADELPHIA NAVIGATOR PROGRAM HFP is a
sub-grantee of the Pennsylvania Association of Community Health
Centers (PACHC)s federal Navigator award. We have been providing
ACA-related outreach, education and enrollment across Southeastern
PA since the Marketplace opened in 2013. Our Navigators offer
bilingual services in Spanish, Russian, Khmer (Cambodian), French,
Malayalam and Romanian. 3
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- HEALTH FEDERATION OF PHILADELPHIA NAVIGATOR PROGRAM HFP
Navigators provide enrollment assistance at the City of
Philadelphias 8 FQHC Look-Alike health centers City health centers
serve over 80,000 people a year Over 50% uninsured Almost 50% of
the consumers we enroll speak a language other than English 4
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- ACA REQUIRES HEALTH INSURANCE COMPANIES TO Cover certain
preventive services without deductibles or cost-sharing Allow
parents to keep adult children up to age 26 on their insurance
Cover all children under the age of 19, regardless of health status
Create an internal and external appeals process to handle consumer
complaints and denials Accept patients regardless of pre- existing
conditions Eliminate lifetime limits on benefits Spend a minimum of
80 percent of premiums on medical services and quality improvement
Justify unreasonable premium increases Eliminate the practice of
rescissions (when a health plan retroactively cancels coverage
after the enrollee gets sick)rescissions 5
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- WHO IS ELIGIBLE FOR THE MARKETPLACE? In order to be eligible
for the Marketplace, an individual must: Be a U.S. citizen (by
birth or naturalized) or a U.S. national Be a non-citizen who is
lawfully present in the U.S. for the entire period for which they
are seeking enrollment Not be incarcerated An individual who is
pending disposition of charges may apply for coverage through the
Marketplace If an individual is incarcerated, they can still apply
for Medicaid/CHIP at any time * If you meet the eligibility
requirements youre considered a qualified individual* 7
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- MARKETPLACE AFFORDABILITY Financial assistance is available for
eligible individuals and families to curb health care costs,
including: Premium tax credits which may be used to lower monthly
premiums Cost-sharing reductions to lower out-of-pocket spending
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- PREMIUM TAX CREDITS Eligibility for tax credits are based on:
Family size and income (Household income must be between 138%-400%
of the Federal Poverty Level) Obtaining health insurance through
the Marketplace Ineligibility for other health coverage, such as:
government-sponsored coverage (Medicaid, Medicare, CHIP),
employer-based coverage, or certain other minimum essential
coverage 11
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- COST-SHARING REDUCTIONS Cost-sharing reductions may reduce your
out-of-pocket expenses, including deductibles and copayments. To be
eligible for cost-sharing reductions: Your income must be below
250% of the Federal Poverty Line (FPL) This Open Enrollment Period,
for a Household Size of 4 the FPL is $59,625 You must enroll in a
Marketplace Silver-level plan 12
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- MARKETPLACE OPEN ENROLLMENT Open enrollment for the Marketplace
ended on February 15 th, 2015. Next years open enrollment runs from
November 15 th, 2015-January 31 st, 2016. Some consumers may still
qualify for the Marketplace if they qualify for a Special
Enrollment Period (SEP) Examples of SEPs include: Losing employer
insurance or COBRA Getting married Having a baby Having a change in
immigration status Getting incorrect information from a Marketplace
representative, assister, or insurance company Paying the penalty
for not having insurance in 2014 (SEP from March 15 th -April 30 th
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- WHO IS ELIGIBLE FOR EXPANDED MEDICAID? Adults age 19-64 Not
qualified for Medicare Income under 138% of the Federal Poverty
Line Adults over the 5 year bar Single Person Family of 2 Family of
3 Family of 4 Family of 5 Family of 6 Family of 7 Family of 8
$16,243$21,983$27,724$33,465$39,206$44,947$50,688$56,429 14
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- THE CURRENT LANDSCAPE IN PA 15
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- CURRENTLY IN PA Federally-facilitated Marketplace HMOs, PPOs,
HSAs Medicaid expansion 16
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- CURRENTLY IN PA As of April 19, 2015: 549, 205 eligible for the
Marketplace 332,915 eligible to received financial assistance for
Marketplace QHP 42,335 assessed by the Marketplace as eligible for
Medicaid 318,077 selected a QHP in the Marketplace 17
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- CURRENTLY IN PA Trends in Marketplace QHPs Tiered networks
Restricted provider networks Limited formularies Prescription drugs
subject to deductible 18
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- KEY INSURANCE TERMS Premium : The monthly fee you pay to the
insurance company. It must be paid regardless of whether you use
the insurance or not. It is separate from the out-of- pocket
payments. Out-of-pocket payments: Payments you make when you use
your insurance. They include: Copay : Fixed amount you pay for
care, varies based on the type of care. Coinsurance : % of a
medical service cost that you are responsible for paying. Some
plans have this instead of copayments. Deductible : Amount of money
you pay for health care before your insurance begins to pay for
some treatments. Once you have paid this amount, your insurance
will begin to pay a portion or all of your health care costs.
Out-of-Pocket Maximum : The most you would ever have to pay in
out-of-pocket costs in a year. NOTE: This does not include premium
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- COMPARING COSTS HFP created a resource for consumers needing
HIV medications. The guide breaks down the co-pays, tiering, and
out-of-pocket costs for the most common HIV medications. Note:
Currently only available for all 2015 Marketplace QHP in the
Philadelphia market. 20
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- THANK YOU! Emily Van Yuga, M.Ed Outreach and Enrollment
Coordinator The Health Federation of Philadelphia 215-567-8001
x5588 evanyuga@healthfederation.org orevanyuga@healthfederation.org
navigator@healthfederation.org 29