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MAKING HISTORY

United States Senator Shelley Moore Capito

SPECIAL EDITIONFIND INSIDE YOUR OF

In FocusHealth Care 2015

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usherIng In the Affordable Care Act (ACA) has presented challenges for con-sumers, as can be expected of a major

public policy change. The National Association of Health Underwriters (NAHU) offers services to help sort through complicated health care options. NAHU is an association of health insurance professionals, the majority of whom are independent agents, brokers and consultants with years of experience in health insurance.

The members of NAHU represent different health insurance companies and plans. They understand a diverse number of options and can assist consumers by reviewing the available choices in light of the con-sumer’s health status, medical needs and budget—all at no charge to the consumer.

NAHU addressed several topics through its educa-tion efforts in 2014 in order to help break down diffi-cult policies and topics, such as enrollment assistance, online enrollment, Medicaid expansion, the advanced premium tax credit and small business trends.

Enrollment AssistanceIn 2014, West Virginia received federal grant money

to provide people assistance with enrolling in the federal marketplace. The West Virginia Offices of the Insur-ance Commissioner (OIC) contracted with MAXIMUS, an international provider of government services, to oversee the In-Person Assister Program. In-person as-sisters are found in county Department of Health and-Human Resources offices, community health centers and other community locations, and their main goal is to educate consumers about their health care options and offer in-person enrollment assistance. As part of the contract, MAXIMUS will hire, train and manage 132 in-person assisters for West Virginia’s OIC.

By DaVe cLULey

NAHU addressed several topics through its education efforts in 2014 in order to help break down difficult policies and topics, such as enrollment assistance, online enrollment, Medicaid expansion, the advanced premium tax credit and small business trends.

Enrolling in the ACAWhat We Learned in 2014

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For 2015, there are also three federal navigator organizations operating throughout the state: West Virginia University’s Help-ing Appalachian Parents and Infants program, Clay-Battelle Health Services Association and Advanced Patient Advocacy group. In both the state-funded and federally funded organi-zations, the agents, assisters and navigators are all focused on non-biased education to help people through the enrollment process. These resources are available at no charge to the con-sumer and are recommended to ensure that individuals and families are aware of all options available to them.

Online EnrollmentDuring the first open enrollment period in West Virginia last

year, 19,856 people enrolled in the marketplace. Participation in the Small Business Health Options Program (SHOP) was minimal since enrollment was not available on www.health-care.gov. The Web site had a particularly buggy launch, which prevented widespread use and availability to new marketplace offerings. This year, open enrollment traffic is increasing, and SHOP enrollment is now available on the Web site.

The second open enrollment phase took place from Novem-ber 15, 2014 to February 15, 2015. While all of the bugs in the ACA’s Web site have not been resolved, reports of people having problems enrolling were markedly fewer in this enroll-ment phase than last year. Existing issues with the site include wait times and changing premiums. However, on December 15, 2014, the cutoff for coverage to take effect January 1, the Web site was experiencing high traffic and handling it well, with av-erage wait times of less than 10 minutes and call center waits of less than three minutes.

Medicaid ExpansionWest Virginia expanded its Medicaid program’s eligibility

regulations under the ACA in 2014. This expansion allowed people who earn up to 138 percent of the federal poverty lev-el—$16,104.60 for an individual or $32,913 for a family of four—to enroll in Medicaid, where they were previously ruled ineligible. Since this expansion, about 150,000 people have en-rolled for benefits. Coverage is now available to many who pre-viously received their health care at hospital emergency rooms instead of from a primary care physician. This extended cov-erage will help reduce both the amount of hospital uncompen-sated care and bad debt incurred by people not being able to pay for services received.

In early 2014, Centers for Medicare and Medicaid Services (CMS) launched the From Coverage to Care initiative to help newly insured consumers understand their medical benefits and how to best use them for a healthy lifestyle. To reach the public, printed resources and video vignettes were developed and distributed through the various locations, such as Depart-ment of Health and Human Resources offices and community health centers in West Virginia. The videos can also be found on the CMS YouTube channel. The program walks the con-sumer through an eight-step process, taking them from the de-cision to make healthy choices to seeing a provider for follow-up appointments.

Advanced Premium Tax CreditFor West Virginians earning above the Medicaid threshold but

below $46,680 for an individual or $95,400 for a family of four, an advanced premium tax credit (APTC) is potentially available to help pay health insurance premiums. Availability of the credit depends on several factors, such as availability of employer-spon-sored coverage and, if so, whether that coverage is considered affordable by the government. For the APTC, accurately report-ing an individual’s modified adjusted gross income (MAGI) is of paramount importance because reporting the wrong amount can mean owing money to the federal government on April 15.

According to www.irs.gov/aca, the APTC for the 2015 health insurance plan year will be based on the actual MAGI for tax year 2015, and individuals will use a 1095-A form to recon-cile their tax credits.

Small Business TrendsA trend is developing in which small businesses are drop-

ping their group health plans, and employees are enrolling in the marketplace. According to Joseph Deacon, III, an agent with Deacon and Deacon Insurance Agency in Charleston, WV, this trend is occurring in small businesses with 10-20 employees with lower-wage workers who qualify for significant subsidies on the marketplace.

“With the employer mandate penalties now in effect for busi-nesses with more than 100 full-time equivalent employees for 2015, businesses in that size range realize they will have to pay a non-deductible penalty for failing to offer minimal essential health insurance coverage that also meets affordability criteria,” explains Deacon.“This creates an incentive to continue offering a group health insurance plan as they always have. Employers of 50 full-time equivalent employees will have to comply in 2016 and need to be preparing now if they are at or around the threshold.”

The year to ComeIn the employer group market, the biggest change expected

from 2015 into 2016 is the transition of employer group sizes of 50-99 from large group to small group. This will greatly limit the availability of plans for these groups and change the rating rules from medically underwritten to guarantee issue. Some very un-healthy groups can be helped by this; however, many groups of that size use customized plans to best fit their employees’ needs. These groups may be negatively impacted from a rate perspective.

In 2016, it is expected that at least one new insurer will enter the individual/family market, as well as the small group mar-ket. If this happens, a positive effect on rates and availability of options to both individuals and small businesses is anticipated.

Whether or not the ACA has been a positive piece of legis-lation depends on who you ask. Like any legislation, there are winners and losers. Many West Virginians have benefited from government subsidies for their new individual health insurance plans; some have experienced higher costs. The ACA has many moving parts, and no two situations are identical. While very complex, with the help of educated and competent advisors, individuals can learn about their options and make an educat-ed decision in obtaining high-quality, affordable coverage.