Health Insurance Marketplace Brochure
description
Transcript of Health Insurance Marketplace Brochure
What to expect in 2014HealtH insuranceMarketplace
This guide will review:the ways purchasing health insurance in arizona is expanding
changes to health plan benefits • Essentialhealthbenefits • Actuarialvalue • Rating
What individual consumers need to know • Healthinsuranceoptionsforindividualsandfamilies • Costsharingreductionsandpremiumtaxcredits • Incomerequirementsforfederaltaxcreditsand
cost-sharingreductions • Penaltiesforuninsuredindividuals
What businesses need to know • Healthinsuranceoptionsforsmallgroupemployers • Healthinsuranceoptionsforlargegroupemployers • Taxesandfeesforbusinesses • BlueCrossBlueShieldofArizona(BCBSAZ)and
theneweraofhealthcare
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The Affordable Care Act (ACA) includes several provisions geared to extend greater access to health insurance benefits to more people. Beginning in 2014, most Americans must purchase a minimum amount of health insurance or be taxed by the government.
While there is a lot to be done before the ACA is fully implemented, this useful guide provides important information to help you understand the implementation of the ACA in Arizona.
Overview
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Thewayspurchasinghealthinsurance inArizonaisexpandingTheACArequireseachstatetooperateahealthinsurancemarketplace,alsoknownasanexchange,wherepeoplecanpurchasecoverage.Thehealthinsurancemarketplaceisanonlinesitewhereconsumerscan compareplansofparticipatinginsurersandpurchasehealthinsurance.TheU.S.DepartmentofHealthand HumanServices(HHS)runsthemarketplaceinstatesthatchoosenottocreateone,suchasthecaseinArizona.
Thosewhowishtocanstillbuyhealthinsuranceprivately—however,peoplewhodon’thaveahealthinsuranceplanofferedatwork,orwhocan’taffordit,maybeabletogetitthroughthefederalhealthinsuranceexchangestartinginOctober2013atopenenrollment.TheseplanswillbecomeeffectiveonJanuary1,2014.
Individuals and businesses now have more ways to purchase health insurance.
individuals 1. Directpurchasethroughabrokeror insuranceprovider
2. Thosewhoareeligibleandwishtoobtain afederalsubsidyorpremiumtaxcredit maypurchasehealthinsuranceonthe marketplace
3. Thosethatdonotqualifyforafederal subsidyorpremiumtaxcreditstillhave theoptiontopurchasehealthinsurance onthemarketplace
Businesses1. Directpurchasethroughabrokeror insuranceprovider
2. Employersmayuseabrokertoaccessthe SmallBusinessHealthOptionsProgram (SHOP)topurchaseahealthplanonline,or shopdirectforplans
3. Directpurchasethroughaprivate marketplaceoption
Themarketplacewillnotreplaceprivatehealthinsurance.Itissimplyanewplaceforqualifiedindividualsandemployerstoshopforandbuyit.
Brokersandnavigatorswillworkwithindividualsandsmallgroupemployerslookingforcoverageonthe marketplace.TheymayallowbrokersandnavigatorstohelppeopleenrollinQHPsorhelpthemwiththeir applicationsforpremiumtaxcreditsandcostsharingreductions.Asmoreguidanceissharedabouttheseroles,moreinformationwillbeprovided.
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ChangestohealthplanbenefitsInordertosellonthemarketplace,BCBSAZmustofferQualifiedHealthPlans(QHPs)intheindividualandsmallgroupmarkets.Thismeansourplansmustbecertifiedbytheexchangemarketplaceandmeetanumberofcov-erageandotherrequirements,includingaspecificsetofservicesanditemscalledEssentialHealthBenefits(EHB).
Additionally,theACArequiresQHPsofferedofftheexchangemarketplacetoofferstandardizedbenefits packagesintheindividualandsmallgroupmarkets.
Thesepackagesrepresentfourlevelsofvalue,whichmakesiteasiertocompareoptions.
aca requirements for QHps on the exchange marketplaceBeginningin2014,thesmallgroupandindividualinsurancemarketwillofferQHPs.UndertheACA,allnon-grandfatheredplansmustfollownewcoverageandbenefitrules,withrequirementsbasedon:
• Iftheplanisofferedinoroutsidethemarketplace• Iftheplanisfullyinsuredorself-insured• Groupsize
NotonlydoestheACAmandatethatnearlyall Americansmustpurchasehealthcare,thelawalso requireshealthinsurancetobe“guaranteedissue.”Thatmeansaperson(orfamily)can’tbedenied coverageorchargedmorebecauseofapre-existinghealthcondition.
Ratherthanestablishpremiumsbasedonhealthstatus,ratesfortheseindividualandsmallgroupplanswillbebasedonvariablesthatinclude:
• Familytier• Age• Geographicarea• Tobaccouse
Inaddition,thefederalhealthcarelawrequiresQHPstouse3-to-1age-ratingbands.Asaresult,thehighestpremiumcannotbemorethanthreetimesthelowestpremiumforthesameplan.Alloftheserequirementsmayhaveanimpactonrates,althoughthespecific effectsaredifficulttodefineatthistimeasQHPs continuetobedeveloped.
1. Ambulatorypatientservices2. Emergencyservices3. Hospitalization4. Maternityandnewborncare5. Mentalhealthandsubstanceusedisorderservices,includingbehavioralhealthtreatment6. Prescriptiondrugs7. Rehabilitativeandhabilitativeservicesanddevices8. Laboratoryservices9. Preventiveandwellnessservicesandchronicdiseasemanagement10. Pediatricservices,includingoralandvisioncare
“essential health benefits” will become essential components of coverage Whateverthelevelofcoverage,eachofthebenefitplanshastoincludewhatarecalled“essentialhealthbenefits.”AccordingtotheACA,anessentialhealthbenefitspackagemustincludeservicesanditemsinthese10broadcategoriesofcare:
*Healthcare.gov:Essentialhealthbenefits(accessedOctober2012).
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Sometimesreferredtoas“metalplans,”thedifferenttiersaredefinedbythepercentageeachplanwillpaytowardhealthcareexpensesforanaverageperson(knownastheactuarialvalue).Here’showthemetallevelsbreakdown:
Asanexample,aBronzeplanwillgenerallyhavethelowestmonthlypremiumandpay60percentof healthcareservices;enrolleesareresponsibletopay 40percentforhealthcareservicesthroughsome combinationofcostshares.Althoughcostshareswillbejust10percentforPlatinumplans,thistierwillalsohavethehighestmonthlypremium.
Mixing the metals HealthinsurersofferingQHPsmustofferatleastoneplanattheSilverlevelandoneplanattheGoldlevelonorofftheexchangemarketplace.Althoughnotarequirement,theyalsohavetheoptiontoofferachoiceofBronzeorPlatinumplans.Undereachmetalleveltherecanbeseveralplansavailable,whichwillvary accordingtothedeductibles,coinsuranceand copaysoffered.
Bronze
silver
Gold
Platinum
plans provide coverage60%plans provide coverage70%plans provide coverage80%plans provide coverage90%
Standard benefits package
Inside marketplaceOutside marketplace –
fully insured smallgroup and individual
Outside marketplace –fully insured large
group and self-insured
Include essential health benefits • •
Provide 60% actuarial value minimum • • *Adhere to deductible** and out-of-pocket maximum limits • •Comply with “metal levels” (actuarial values – (60, 70, 80 and 90 percent) • •Be certified by the marketplace throughwhich the plan is offered (certificationrequirement to be determined)
•
Out-of-pocket maximum requirements •
at-a-Glance coverage & essential Health Benefits
* Thehealthcarereformlawdoesnotrequirecarrierstoofferplanswithatleasta60percentactuarialvalue,nordoesitrequireemployerstoprovidehealthcoverage. However,itimposespenaltiesonemployerswith50+FTEsthatdonotprovideminimumcoverageifanemployeepurchasescoverageontheexchangeandreceives apremiumtaxcreditorcostsharingreduction.
**Deductiblelimitsapplytosmallgrouphealthplansonly
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1Keep their grandfathered plan 3Go uninsured and pay a
penalty, unless exempt2Buy a plan through either:• Theindividual
marketplace
• Directthroughbroker oraninsurer
WhatindividualconsumersneedtoknowHealth insurance options for individuals and families Consumerspurchasinginsuranceintheindividualmarketwillbeguaranteedcoverageforpre-existing conditions,andtheirpremiumscannotvarybasedontheirgenderormedicalhistory.Herearesomeoptions,benefitsandcriteriaforindividualsandfamiliespurchasinghealthinsurancein2014.
this online marketplace will allow consumers to: • Shopforandcompareavarietyofprivatehealthplans
• Getanswerstoquestionsabouthealthcoverageoptions
• Findoutifthey’reeligibleforhealthprogramslike MedicaidandtheChildren’sHealthInsuranceProgram, premiumtaxcreditsorcostsharingreductions
• Enrollinahealthplanthatmeetstheirneeds
Peoplewhopurchasecoverageinthemarketplaceareeligibleforataxcreditaslongastheirhousehold incomeis up to 400 percentoffederalpovertyguidelines.FiguresbasedonJanuary2013federalpovertyguidelines:
• Foranindividual,thatequals$11,490to$45,960peryear
• Forafamilyoffour,thatequals$23,550to$94,200peryear
Theassistanceamountthatapersoncanreceivevarieswithincome.Thetaxcreditmaybeappliedtoany planlevel(Bronze,Silver,GoldorPlatinum).
cost sharing reductions and premium tax credits for individuals Toaddresstheneedsofthosewhofallincertainincomelevelsandcannotaffordminimumessentialhealthbenefits,thelawincludesprovisionsforfederalsubsidiestoreducethecostofpremiums.
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Income requirements for cost-sharing reductions Thosewhoearnupto250 percentoffederalpovertyguidelinesandenrollat the Silver level onlymayalsobeeligibleforreducedcostsharing.Again,thesubsidyamountwillvaryaccordingtoincome.Examplesofcostsharingthatmaybereducedincludedeductibles,co-insurance,co-paymentsorsimilarchargesanddonotincludebalancebillingfornon-networkprovidersorspendingonnon-coveredservices.
penalties for uninsured individuals In2014,legalU.S.citizenswhodonotcarryaminimumamountofhealthcoveragewillreceiveapenaltyof$95oronepercentoftheirtaxableincome,whicheverisgreater.Penaltieswillincreaseeachyearthrough2016.Infutureyears,thepenaltieswilladjustannually.
penalty timeline
2014Greater of $95 or 1% of
taxable income
2015 Greater of $325 or 2%
of taxable income
2016 Greater of $695 or 2.5%
of taxable income
2017 and beyond Annual
adjustments
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1 2Offer a fully insured plan through either:
• ASHOPmarketplace
• Thetraditionalmarket
WhatbusinessesneedtoknowSmallbusinessesalsocanusethemarketplacetofindinsurancefortheiremployees.ThesearecalledSmallBusinessHealthOptionsPrograms,orSHOPs,forshort.IndividualinsuranceandSHOPprogramsmaybeavailableseparatelyorcombinedinasingleonlinemarketplace.
employers can opt to:
private marketplace for businesses BusinesseshaveanewwaytoshopforinsuranceandcontrolcostswiththeBCBSAZhealthplanmarketplaceanddefinedcontributionplans.Theseplanslettheemployerdeterminehowmuchtocontributetotheiremployees’benefits.Employeesthenapplythecontributionandshopfor10differentBCBSAZplansrightfromtheconvenienceofBCBSAZ’sprivateonlinemarketplace.
Key benefits:
• Monthlycontributionhelpskeepexpensespredictable• Streamlinebenefitsadministrationsavestimeandmoney• Retainthevaluehealthinsurancebringstoemployeerecruitmentandretention
Subsidies for small employers In2014,taxcreditswillincreaseforemployerswith25orfeweremployees(withanaveragewageoflessthan$50,000ayear)whooffercoveragethroughthemarketplace.
• Thecreditwillcoverupto50percentoftheemployer’scost(35percentforsmallnonprofitorganizations)• Employerswillbeeligibleforcreditsinthefirsttwoyearstheyoffercoveragethroughthemarketplace• Creditswilldecreaseonaslidingscaleasgroupsizeandemployeewagesincrease
* Smallemployerisdefineddifferentlyfordifferentpurposes.
** Penaltyriskmayapplytoemployerswith50+FTEs.
stop offering coverage and let employees buy an
individual plan in or outside the marketplace**
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1Offer health insurance (either fully insured or an administrative services
only [asO] plan) that meets the minimum coverage
definition and is affordable 3stop offering coverage, let employees buy insurance
through the individual marketplace, and risk the
employer penalty2Offer some level of coverage that does not meet minimum
requirements and risk the employer penalty
LargegroupemployersHealth insurance options for large group employers
penalties for large group employers
• Ifminimumcoverageisnotofferedtofull-timeemployees,andatleastoneemployeedoesnotmeetminimumvaluerequirementsgetssubsidizedcoveragethroughtheexchangemarketplace,thena$2,000penaltyisassessedforeachemployee(afterthefirst30)
• Ifminimumcoverageisofferedtofull-timeemployees,butisnotaffordableforanemployeeordoesnotmeetminimumvaluerequirements,andthatemployeegetssubsidizedcoveragethroughthemarketplace,thena$3,000penaltyisassessedforeachemployeewhoreceivessubsidizedcoverage
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OthertaxesandfeesIndividualsandemployersmayberesponsibleforothertaxesandfeesrelatedtothehealthcarereformlaw.Thechartbelowhighlightssomeofthem.
Tax/Fee Effective Date Responsible Party Annual Tax/Fee Amount
Comparative effectiveness research fee – thisfeefundsresearchontheeffectiveness,risksandbenefitsofmedicaltreatmentsthroughthePatient-Centered OutcomesResearchInstitute
Plan/policyyearsthatendafterSeptember30,2012,andbeginningbeforeOctober1,2019
Issuersoffully insuredplans
Self-insuredplan
ForplanyearsthatendduringOctober1,2012,throughSeptember30,2013,thisfeeis$1perparticipantperyear.
ForplanyearsthatendduringOctober1,2013,throughSeptember30,2014,thefeeincreasesto$2perparticipantperyear.
Afterthat,therateincreaseseachyearbythemedicalinflationrate.
Tax on high earners and unearned income – anannualtaxonwagesorunearnedincomeofmorethan$200,000forsinglesand$250,000formarriedcouples
TaxyearsbeginningJanuary1,2013,andlater
Individualtaxpayers 0.9%Medicaresurtaxonwagesinexcessof$200,000single/$250,000marriedcouples.
3.8%taxonunearnedincomefortaxpayerswithmodifiedadjustedgrossincomeinexcessof$200,000single/
$250,000marriedcouples.
ACA insurer fee – anannualexcisetaxonhealthinsurancetofundpremiumsubsidiesandMedicaidexpansion
TaxyearsbeginningJanuary1,2014andlater
Issuersoffully insuredplans
Basedontheinsurer’smarketshareofnetpremiumswrittenbasedonthepreviousyear.Forexample,the2014feewillbebasedon2013premiums.
Totalfeeamounttobecollectedacrossallinsurersstartsat$8billionin2014andincreasesto$14.3billionin2018.
After2018thefeeincreasesannuallybasedonpremiumgrowth.
ACA reinsurance fee – thiswill supportthetransitionalreinsuranceprogramthataimstostabilizepremiumsforcoverageintheindividualmarketandlowerthe effectsofadverseselection
Plan/policyyearsbeginninginthe3-yearperiodstartingJanuary1,2014
Issuersoffully insuredplans
Self-insuredplans
Fundswillbeusedtomakereinsurancepaymentstohealthinsuranceissuersthatcoverhigh-costindividualsinnon-grandfatheredindividualmarketplans.
High-cost insurance tax – anannualexcisetaxonhigh-costhealthplans
TaxyearsbeginningJanuary1,2018andlater
Issuersoffully insuredplans
Sponsors/administratorsof self-insuredplans
Taxof40%onhealthplancoststhatexceed“Cadillac”planthresholdsof$10,200forsinglecoverageor$27,500forfamilycoverage.
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BCBSAZ has been hard at work for more than two years to implement the provisions resulting from the Affordable Care Act. We are working to develop qualified health plans that comply with the new 2014 benefit requirements the law sets forth.
Ensuring the value of our products has always been a core focus of our business, and BCBSAZ will continue to work constructively with state and federal officials to provide quality healthcare solutions.
BCBSAZandtheneweraofhealthcare
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Despite the maze of changes brought about by the federal healthcare law, at the end of the day your healthcare needs haven’t wavered.
As we have for more than 73 years, we stand prepared to provide our employers expert guidance and support, while continuing to deliver quality products, competitive pricing and an unmatched level of service to our members. We’re in this time of transition together—and backed by our long history of value, innovation and customer satisfaction—we will continue to earn Arizona’s confidence in BCBSAZ.
Our commitmenttoArizonansremainsunchanged
Last revised March 2013. The information provided may change due to newly government issued regulations.