Affordable Care Act Community ForumSeptember 2013
David Evans Chief Executive Officer
Welcome
Affordable Care Act (ACA) Marketplace 101
Agenda
www.CentralHealth.net 4
• Introduction to the ACA and the Health Insurance Marketplace
• Eligibility• Application Process• Coverage• Affordability• Responsibility for Coverage• Key Points to Remember• Local Resources
What is the ACA?
www.CentralHealth.net 5
The Patient Protection and Affordable Care Act,
More commonly known as:
The Affordable Care Act (ACA) is the national health reform law passed by Congress and signed by
the President in March 2010.
What is the goal of the ACA?
www.CentralHealth.net 6
Increase the rate of healthcare coverage for Americans while addressing overall healthcare costs.•Establishing consumer rights and protections•Increasing insurance options•Providing assistance for healthcare costs
What is the Health InsuranceMarketplace?
www.CentralHealth.net 7
Also known as the “Exchange”, the Health Insurance Marketplace is a new way to purchase health insurance.
The “Marketplace” will provide a way for consumers to:
• Look for and compare health plan options• Complete one application for multiple plans• Determine eligibility for tax credits & cost sharing
subsidies• Enroll in health insurance plan
Who Manages the Marketplace?
www.CentralHealth.net 8
Each State can choose to:• Create and manage their own marketplace• Partner with the federal government to manage
their marketplace jointly• Have the federal government manage the
marketplace for their State
Who is Eligible to Participate?
www.CentralHealth.net 9
• Individuals and Small Businesses with up to 100 employees can purchase health insurance through the Marketplace.
Eligibility requirements:• Must live in the U.S.; within service area• Must be a U.S. citizen or national, or• Be lawfully present in U.S.• Cannot be currently incarcerated
Application Process
www.CentralHealth.net 10
One streamlined process to determine potential eligibility for: • Medicaid • Children's Health Insurance Program (CHIP)• Private health insurance offered by Qualified Health Plans
(possible tax credits and cost sharing subsidies)
Can apply:• On-line• Phone• Mail• In person -receive personal assistance
Qualified Health Plans
www.CentralHealth.net 11
• Private insurance companies certified by the Marketplace in each respective State, who:• Have adequate provider networks• Provide Essential Health Benefits • Offer at least one plan at the “Silver” level and
one plan at the “Gold” level • Agree to charge the same premium rates
whether offered through the Marketplace or outside of the Marketplace
Coverage: Essential Health Benefits
www.CentralHealth.net 12
Qualified Health Plans participating in the Marketplace will be required to offer benefits that meet a minimum set of standards called Essential Health Benefits.
•Ambulatory services•Emergency services •Hospitalization•Maternity and newborn care•Mental health and substance use disorder services, including behavioral health treatment•Prescription drugs•Rehabilitative and habilitative services and devices•Laboratory services•Preventive and wellness services and chronic disease management•Pediatric services, including oral and vision care
Coverage: Plan Levels
www.CentralHealth.net 13
Levels of Coverage Plan Pays on Average
Consumer Pays on Average*
(In addition to the monthly premium)
Bronze 60% 40%
Silver 70% 30%
Gold 80% 20%
Platinum 90% 10%
*Based on average cost of an individual under the plan – may not be the same for every enrolled person.
Coverage: Catastrophic Plans
www.CentralHealth.net 14
Who is Eligible?• Young adults under age 30• Those who cannot afford coverage and obtain a
hardship waiver from the Marketplace
What is Catastrophic Coverage?• Plans with high deductibles and low premiums• Includes coverage of 3 primary care visits and
preventive services at no cost• Protects consumers from high out-of-pocket costs
Coverage: Enrollment
www.CentralHealth.net 15
• Initial Enrollment Period (1st year only): October 1, 2013 – March 31, 2014
• Beginning October 2014 - Annual Enrollment Period October 15th – December 7th
If you enroll: Your coverage will begin:
October 1 – December 15 January 1, 2014
December 16 – January 15 February 1, 2014
January 16 – February 15 March 1, 2014
February 16 – March 15 April 1, 2014
March 16 – March 31 May 1, 2014
Examples of Qualifying Events
Birth/Death Loss of Minimum Essential Coverage
Adoption Gain of a dependent or becoming a dependent through marriage
Legal separation or divorce Error in enrollment
Becoming a U.S. citizen, national, or lawfully present individual
Financial change impacting eligibility for tax credit
Move out of service area Exceptional circumstances such as a natural disaster
Coverage: Qualifying Events
www.CentralHealth.net 16
• Certain qualifying events will allow individuals to enroll during the year
Affordability: Advanced Premium Tax Credits
www.CentralHealth.net 17
• Advanced Premium Tax Credit is a new kind of tax credit that can be used to lower monthly health plan premiums
• Through the Marketplace individuals can apply for advance payment of this tax credit
• Advance payments will be sent directly to the insurance company and applied towards monthly premiums
Affordability: Advanced Premium Tax Credits
www.CentralHealth.net 18
• Monthly amounts owed by individuals can be reduced
Example:• Monthly premium: $300• Advance payment: $240 a month• Monthly amount owed by individual: $60
Affordability: Advanced Premium Tax Credits
• The Marketplace will estimate the amount of advance payments based on projected income
• Report income changes immediately to avoid overpayments
• Advance payments will be reconciled at tax time against the actual Premium Tax Credit amount individuals are eligible for based upon actual income
www.CentralHealth.net 19
Affordability: Advanced Premium Tax Credits
• Option to pay total monthly premiums and claim tax credit on income tax return
Example:• Monthly premium: $300• Projected advance payment: $240 month• Individual can choose to pay: $300
monthly and receive $2,880 refund ($240 x 12); instead of advance payments
www.CentralHealth.net 20
Affordability: Advanced Premium Tax Credits
www.CentralHealth.net 21
Who is Eligible?•Individuals/Families with household incomes between 100-400% of Federal Poverty Level (FPL) who do not have access to public health benefits or affordable employer coverage. •Affordable employer coverage exists as long as the lowest cost "individual" plan offered by an employer does not exceed 9.5 % of the employee's household income
Affordability: Cost-Sharing Subsidies
www.CentralHealth.net 22
Cost Sharing Subsidies•A provision of the ACA requires that individuals with lower income levels have their cost sharing amounts reduced •Health plans will be responsible to pay a greater share of the covered benefits for qualifying individuals
Who is Eligible?• Individuals/Families with household incomes
between 100 - 250% of FPL • Who enroll in a Silver-Level plan
Affordability: Cost-Sharing Subsidies
• Qualifying subsidies will be automatically reflected in individual cost sharing amounts
Example:(Silver Plan)
• Co-pays for households at 250% FPL may be $10 for Dr. Visit, $7 for prescriptions
• Co-pays for households at 100% FPL may be $5 for Dr. Visit, $3 for prescriptions
www.CentralHealth.net 23
Responsibility for Coverage
www.CentralHealth.net 24
• A provision of the ACA requires that all individuals have health insurance beginning in 2014.
• Exceptions may be given for: • Financial hardships • Religious objections• Qualifying Indian tribes • Those for whom the lowest cost health plan exceeds 8% of their
household income • Those whose income is below the tax filing threshold
• Those who do not qualify for an exception and do not have qualifying coverage will be required to pay an annual financial penalty.
Responsibility for Coverage: Penalties
www.CentralHealth.net 25
Penalty amounts will be phased in and will gradually increase from 2014 to 2016
Key Points to Remember
www.CentralHealth.net 26
There will be multiple options for health care coverage –•Public Programs – Medicare, Medicaid, CHIP•Health insurance plans offered thru Employers•Health insurance plans offered outside of the Marketplace•Health insurance plans offered by Qualified Health Plans through the Marketplace•Tax Credits and Cost-Sharing Subsidies available through the Marketplace
2013 Federal Poverty Guidelines
www.CentralHealth.net 27
Persons in family/household
100% 250% 400%
1 $11,490 $28,725 $45,960
2 $15,510 $38,775 $62,040
3 $19,530 $48,825 $78,120
4 $23,550 $58,875 $94,200
5 $27,570 $68,925 $110,280
6 $31,590 $78,975 $126,360
7 $35,610 $89,025 $142,440
8 $39,630 $99,075 $158,520
For family units of more than 8 members, add $4,020 for each additional member Sources: medicaid.gov and FamiliesUSA
www.CentralHealth.net 28
Application Assistance Available to General Public Travis County
Organization Address City Zip Code1 CommUnityCare – North Central 1210 W. Braker Lane Austin 78758
2 CommUnityCare – Pflugerville 15822 Foothill Farms Loop Pflugerville 78660
3 CommUnityCare – Rundberg 825 E. Rundberg, Suite B1 Austin 78753
4 CommUnityCare – UT Family Wellness 2901 N. IH-35, Suite 101 Austin 78722
5 CommUnityCare – Hancock 1000 E. 41st Street, Suite 925 Austin 78751
6 CommUnityCare – Manor 600 W. Carrie-Manor Street Manor 78653
7 CommUnityCare – East Austin 211 Comal Street Austin 78702
8 CommUnityCare – Rosewood-Zaragosa 2802 Webberville Road Austin 78702
9 CommUnityCare – South Austin 2529 S. 1st Street Austin 78704
10 CommUnityCare – UT Children’s Wellness 5301 Ross Road, Suite H Del Valle 78617
11 CommUnityCare – Oak Hill 8656-A Hwy 71 West, Suite C Austin 78735
12 CommUnityCare – William Cannon 6801 S. IH-35, Suite 1-E Austin 78744
13 LoneStar Circle of Care – Seton Northwest 11111 Research Blvd., Suite 230 Austin 78759
14 LoneStar Circle of Care – Ben White 1221 W. Ben White Blvd. Suite B200 Austin 78704
15 Foundation Communities – North Highland Mall – 6001 Airport Blvd Austin 78752
16 Foundation Communities – Southwest 2600 W. Stassney Lane Austin 78745
CommUnityCare – 512.978.9015 ▪ LoneStar Circle of Care – 1.877.800.5722 ▪ Foundation Communities – 2-1-1
www.CentralHealth.net 29
Application Assistance to Existing Client Base
Central Health Eligibility Services Seton Community Clinics Austin Travis County Integral Care
(ATCIC) People’s Community Clinic
www.CentralHealth.net 30
Education and Referrals for Existing Client Base
Child Inc./HeadStart Program Easter Seals Project Access WIC Program SIMS & HAAM Foundations
www.CentralHealth.net 31
Additional Services
Central Health has committed to fund additional outreach & education efforts
These efforts will: Compliment services provided by Enroll America Coordinated culturally competent, community
based approach Data driven activities, directed at targeted
populations and underserved areas of county Allow for assistance in non-traditional settings
such as schools, community events or even personal residents
www.CentralHealth.net 32
Additional Services
Central resource for local information & referrals
United Way for Greater Austin Manages the local 2-1-1 Center 10 County Central Texas region Central Health Healthcare
Navigation Center
www.CentralHealth.net 33
United Way 2-1-1 Center
www.CentralHealth.net 34
Summary
www.CentralHealth.netwww.CentralHealth.net
Questions?Questions?Questions?Questions?
Enrollment and Outreach for Integral Care
ACA and Integral Care• Champion for Coverage and Certified
Application Counselor Organization– Training staff and volunteers to assist with enrollment
• Consumer Benefits Office will enroll eligible people using Integral Care services
• Additional Open Enrollment for the public– 1631 East 2nd Street
– 1702 South Lamar, Large Training Rm
– 5225 North Lamar Professional Building
– Dove Springs
Enrollment Information for People Currently Using Services• Approximately 1,200 People are Eligible
• Provide Technical Assistance
• Begin October 1st – March 31st
• Currently Recruiting Volunteers for Enrollment Assistance for the Public (Limited Space)
• Offering Extended Hours
Additional Outreach Efforts • Working with partner organizations for referrals
to enrollment sites
• Traditional marketing and social media activities
• Online information and resources
• Participation in fairs and community events:– Binational Health Week fair
– Community Connections Health Fairs
Mental Health & Substance Use Parity• Parity means insurance companies can not
discriminate against mental health and substance use treatment in coverage decisions
• ACA designates mental health coverage as an essential health benefit
• All plans offered in the Marketplace must offer coverage and you cannot be denied due to a preexisting condition
Prevention, Wellness & Chronic Disease Management• Essential Health Benefit
• Profound disparity in life expectancy for persons with serious mental illness:– Persons with a serious mental illness are more than
twice as likely to smoke cigarettes
– People with major depressive disorder are at higher risk for cardiovascular disease and stroke
• Includes smoking cessation and other programs to help people get and stay healthy
Questions?
Q & A Session
David Evans Chief Executive Officer
Closing Remarks
Top Related