AFFORDABLE

CARE ACT

(ACA) Presented

By

ANDREW H. HOOK, CELA, CFP®, AEP

®

Tel: 757-399-7506 | Fax: 757-397-1267 | www.hooklawcenter.com

295 Bendix Road, Suite 170, Virginia Beach, VA 23452

5806 Harbour View Blvd., Suite 203, Suffolk, VA 23435

1

PURPOSE

Increase number of people with HI

Increase Standards Of Coverage

Tax Credits

Subsidies

Penalties

Complex

2

Expansion Of Medicaid, i.e., 11 Million

$138 FPL

Marketplaces (previously Exchanges)

Individual Mandate

Employer Mandate

Small Employer

Large Employer

MECHANISM

3

MINIMUM ESSENTIAL COVERAGE

(MEC) Medicare Part A

Medicaid

CHIP

TRICARE

VA Plan

Peace Corp

Employer-Sponsored Plan

Offered In State Market

Grandfathered Plan

Other – HHS Approved

4

HI Marketplaces

State

State/Federal

Federal

Assistance - Individuals & Small Groups

Comparison Shop

5

ESSENTIAL HEALTH BENEFITS

(EHB)

Ambulatory Services

Emergency Services

Hospitalization

Maternity/Newborn Care

Mental Health/Substance Abuse

Prescription Drugs

Rehabilitative & Habilitative

Laboratory

Preventive & Wellness

Chronic Disease Management

Pediatric Including Oral & Vision

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Required Through Exchanges

Not Required Outside Exchanges

No Specific Benefits Within Categories

State-by-State Basis

Cost Sharing 2013

Deductibles, Co-Pays, etc.

$12,500 Family

$ 6,250 Individual

ESSENTIAL HEALTH BENEFITS

(EHB) con’t

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COVERAGE LEVELS

Metal Tiers

Platinum - 90%

Gold - 80%

Silver - 70%

Bronze - 60%

Catastrophic Plans

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ELIGIBILITY FOR VARIOUS

PROGRAMS

Are Individuals Eligible To Apply?

Eligible For Affordable Employer HI,

Medicaid, CHIP Or Other Government

Programs?

Qualify For Premium Assistance Credit Or

Cost-Sharing Reduction?

9

PREMIUM ASSISTANCE

Low & Moderate Income

100% – 400% FBL

Exchange Only

Tax Credit

Can Be Applied Toward Premiums

Inapplicable to Employer and Union Plans

10

SUBSITY: METAL TIERS

Silver Plan - 30%

Household Income Increase AV

From100-150% FPL 94%

Over150-300% FPL 87%

Over 200-250% FPL 73%

HHS Pays Insurer The Difference

11

OPEN ENROLLMENT

October 1, 2013 to March 31, 2014

December 15, 2014 = Coverage 1-1

After December 15th –

First Day of 1st or 2nd Month, then,

October 15, 2013 to December 7, 2014

12

INDIVIDUAL MANDATE: WHO MUST BE COVERED & ASSISTANCE

Everyone Except:

Religious Exemption

Non-US Citizens or Nationals & Illegal

Immigrants

Incarcerated Individuals

Assistance

Subsidy

Tax Credits

Exchanges Only

13

INDIVIDUAL MANDATE: PENALTY

The Lesser of:

Flat $ - OR -

% of Income

Flat $ Monthly - Individual

$ 95 – 2014

$325 – 2015

$695 – 2016

1% (for 2014)of Household Income over a

threshold gross amount

14

SMALL EMPLOYER

49 or Fewer Employees

No Penalty

2-Year Tax Credit

15

SMALL EMPLOYER: TAX CREDIT

Two Years Only

Full Credit Up To 50%

10 or Fewer Employees

$25,000 Average Wage

Phase Out

11-25 Employees

Average Wage Of $25,000 - $50,000

Exchange Policies Only

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DEDUCTIBLE

$4,000 Family

$2,000 Individual

Applies To Small Group Plan

Does Not Apply To Large Group Plan

17

LARGE EMPLOYER

50+ FTE

Minimum Essential Coverage (Not EHB)

Affordable

9.5% Household Income - Individual

Coverage

Cover FTE (30 hrs) + Dependents

Penalty

18

LARGE EMPLOYER: PENALTY

Failure to offer Minimum Essential Coverage

(MEC)

Employee-Enrolled Individual Coverage In

Exchange Premium Assistance Credit Or

Cost-Sharing Subsidy

$2,000 For Each Employee Over 30 Threshold

Example: Employers In Medicaid, CHIP, Or

Other Government Programs

19

LARGE EMPLOYER: PENALTY – UNAFFORDABLE COVERAGE

$3,000 Per Year, Per Employee

Per FTE, Enrolled In QHF Through Exchange

Cap Cannot Exceed Penalty For Failure

To Provide Minimum Essential Coverage (MEC)

20

PROVISIONS APPLICABLE

TO ALL PLANS

21

MEDICAL LOSS RATIO

Adjusted Premiums

Large Group

85% Claims & Quality Improvement

15% Overhead

Small Group & Individuals

80% Claims & Quality Improvement

20% Overhead

22

CAPS

Group Plans Only

No Lifetime Caps

No Annual Caps

Restrictions On Number Of Visits & Treatments

23

MISCELLANEOUS Waiting Period - 90 Days Maximum

PRE-EXISTING CONDITIONS

No Rescission Except Fraud

Preventive Coverage – No Co-Pay

Choice of Primary Care Provider

Medical Deductible - 10% AGI

Coverage – Child Under 26-Years-Old

24

CONCLUSION

ACA Evolving

Pre-Existing Conditions

Future Medicals

Coverage

25

Estate Planning

Asset Protection Planning

Life Care Planning

Long-term Care Planning

Veterans Benefits

Financial Planning and Advice

regarding Investments,

Insurance, Annuities, Reverse

Mortgages, and Equity Lines

Tax Planning

Guardianships and

Conservatorships

Estate and Trust Administration

Special Needs Trusts

Care Management Services

Business Planning and

Succession Planning

Tel: 757-399-7506 | Fax: 757-397-1267 | www.hooklawcenter.com

295 Bendix Road, Suite 170, Virginia Beach, VA 23452

5806 Harbour View Blvd., Suite 203, Suffolk, VA 23435

Thank You!

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