Navigating the New Health Insurance Marketplace--What It Does and How To Enroll

Presentation by Alison Hughes, MPA. September 20, 2013

The new health insurance law What the law covers The health insurance plans in Arizona so far How to enroll in a health insurance plan

What this talk will cover

Historic legislation signed into law by President Obama on March 23, 2010.

Includes comprehensive prevention provisions that shift our health system from one that focuses on treating the sick to one that concentrates on keeping people healthy.

Why do we need this?

The Patient Protection and Affordable Care Act

55 million Americans under age 65 are currently uninsured.

Seven in 10 deaths in the U.S. today are related to preventable diseases such as obesity, diabetes, high blood pressure, heart disease, and cancer.

Three quarters of our health care dollars are spent treating such diseases.

Only 3 cents of each dollar spent on health care go toward prevention.

Facts About Healthcare in the U.S.

All Plans Must Cover Essential Services

Medicare program Medicaid Program CHIP Program Veterans and active duty service women and

men Peace Corps volunteers Employer-sponsored plans Plans in the individual market Grandmothered health plans (Source: Cornell University Law School, Legal Information Institute, PL

113-31, Requirement to maintain minimum essential coverage.)

Most Government Sponsored Insurance Programs

Medicaid Expansion: expected to add 11 million Americans through this provision by 2022 (Congressional Budget Office).

Medicaid Expansion

Arizona’s Governor signed Medicaid Expansion bill in June 2013.

The expansion brings $1.6 billion in federal funds to Arizona through the AHA.

It will make about 300,000 additional poor and disabled residents eligible for the Medicaid program.

Adults ages 19-64 with incomes up to 133% of Federal Poverty Level. $15,282/year/individual. $31,322/year/family of 4. All children covered.

Arizona’s and Medicaid Expansion

Virtual marketplaces where individuals and families can comparison shop for health coverage.

Arizonans will access through a Federally managed exchange.

Useful for those without employer-based coverage and who don’t qualify for Medicaid.

Individuals and families with incomes between 100 and 400% of poverty level will receive income-based subsidies for coverage.($23,050-$92,000 for family of 4 in 2012)

Benefits of the Affordable Care Act

Mammograms Screenings for cervical cancer Regular well baby and well child visits Domestic violence screening with no cost

share Family planning and FDA approved

contraceptives Pre-existing conditions are included Others benefits listed in handout

Benefits to Women

Reduction of out-of-pocket costs for drugs and preventive services.

All Medicare beneficiaries will be eligible to receive a personalized health plan that includes an annual comprehensive risk assessment.

Reduced coinsurance rate when in the prescription drug “donut hole.”

A phased-in discount to reduce brand name and generic drug costs. (Source: Kaiser Family Foundation: Implications for Women’s Access to Coverage and Care.)

Benefits to Older Women and Women with Disabilities

Children and young adults under age 30 are eligible to purchase catastrophic coverage through a hardship waiver.

With a catastrophic plan you would pay out-of-pocket for most health services until you reach the annual limit on cost sharing. ($12,700 in 2014)

Preventive services are covered with no cost sharing required.

Benefits (Cont’d.)

Plans with high deductibles and lower premiums

Includes coverage of 3 primary care visits and preventive services with no out-of-pocket costs

Protects consumers from high out-of-pocket costs

Catastrophic plans (Cont’d.)

Small businesses with under 50 employees will receive tax credits of up to 50 percent of premium costs to help them afford coverage for employees if they shop through the Small Business Health Options Program (SHOP).

Benefits (Continued)

If you don’t have coverage for yourselves and your dependents by January 1, 2014, and don’t qualify for an exemption, you will pay a small penalty.

This is not a mandate. The term is not anywhere in the law. This is because you have the option of paying a penalty or requesting an exemption.

Things You Need To Know

The greater of a flat fee or a percentage of income ($695 or 2.5 percent of taxable income for in individual, capped at three times that amount for a family).

Phased in over 2014-2016. Assessed as part of your income taxes.

What is the Penalty?

Starting 2014 most people must have health coverage or pay a fee.

If you don’t have a certain level of coverage you may have to pay a fee when you file your 2014 Federal tax form in 2015. (Coverage includes employer, Medicare, Medicaid, CHGIP. TRICARE, certain VA coverage, individual policy, or a plan in the Marketplace.)

Some people are eligible for exemptions.

Minimal Essential Benefits

Income below 100 percent of Federal poverty level.

Not being required to file income taxes. If the insurance purchase would cause

financial hardship. Having religious objections. Having a coverage gap shorter than three

months. Being American Indian, undocumented

immigrant, incarcerated person.

What are the Exemptions?

About half (48%) of people now buying their own insurance will be eligible for a tax credit that would offset their premium. (Excludes Medicaid recipients.)

Your 2014 Income Tax Form will include a check box for health insurance coverage. (Due April 2015.)

Tax Credits for People Buying Insurance on Their Own

Get an estimate prior to October 1 Kaiser Family Foundation Subsidy Calculator

tool◦ http://kff.org/interactive/subsidy-calculator/

Calculating Your Subsidy Eligibility

Aetna Blue Cross-Blue Shield Cigna Meritus Meritus PPO (Catastrophic Coverage)Note: Plans are based on actuarial values

Insurance Companies in the Arizona Marketplace—Standardization of Plans

Aetna: $79.00/$806.00/$240.00. Blue Cross Blue Shield/AZ: $71/ $1,489/ $264. Cigna: $114/ $1,693/ $314. Health Net: $82/ $897/ $240. Meritus PPO: $131/ $1,749/ $334. Meritus PPO (catastrophic coverage): $106/

$961/ $225.Sources: Arizona Department of Insurance, Republic research

Comparing Monthly Insurance RatesMinimum—Maximum—Average (Based on Silver Plans)

The subsidy is based on the premium for the second lowest-cost silver plan available. A silver plan will cover 70 percent of the average costs, with the enrollee paying, on average, 30 percent. However, if an individual decides to purchase a gold or platinum plan, he or she will need to pay the difference between the premium credit amount and the cost of the more expensive plan. This may be a good choice, since the person will get a more generous level of coverage of, on average, 80 percent of costs. (Source: Community Catalyst and Georgetown University Health Policy Institute: Health Insurance 101.)

Bronze, Silver, Gold & Platinum Plans

For a bronze plan, the insurance would cover 60 percent of all health care costs for an average person. Enrollees, on average, would be responsible for paying 40 percent of the costs. For a platinum plan, an average individual would pay 10 percent out-of-pocket for their covered benefits and the insurer would pay 90 percent. However, individuals with high-cost health conditions could end up paying significantly more than the average person. (Source: Community Catalyst and Georgetown University Health Policy Institute: Health Insurance 101.)

Bronze Plan-Example

For people who have high health care costs there are significant implications for the plan level they choose. Gold and platinum level plans will have lower deductibles, co-payments and co-insurance for health care services, but will likely have higher monthly premiums. Conversely, bronze and silver plans will have lower monthly premiums, but could expose consumers to significant out-of-pocket costs for each health care service over time. (Source: Community Catalyst and Georgetown University Health Policy Institute: Health Insurance 101.)

Plans (Continued)

Actuarial Value: The percentage of health care costs covered by an insurance company for the average enrollee. For example, if a plan has an actuarial value of 70 percent, on average, a patient would be responsible for 30 percent of the costs of all covered benefits. 

Plans are Based on Actuarial Values

Sit tight. Your employer will let you know if you can expect any modifications to your insurance plan.

Already Insured through Your Employer?

Online at Healthcare.gov Next slide shows the Website

Where to Apply

https://www.healthcare.gov/health-insurance-marketplace/

https://www.healthcare.gov/what-is-the-health-insurance-marketplace/#state=arizona

https://www.healthcare.gov/marketplace/individual/#state=arizona

Contact the local agencies with navigators and counselors listed in the handout:◦ El Rio Community Health Center, Pima Community

Access Program, Pima Council on Aging, Tucson Urban League, Center for Rural Health, University of Arizona.

Need Help Applying?