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ConnectorCare:The New Commonwealth Care
Suzanne [email protected]
MLRI Basic Benefit TrainingDecember 10, 2014
Commonwealth Care
o Comprehensive health coverage for adults at or below 300% FPL not eligible for MassHealth
o Created through 2006 Massachusetts health reform law
o Run by the Health Connector
o Sliding scale premiums based on income, copays also based on income: Plan Type 1, 2, 3
o Cannot be offered health insurance from job
o As of December 31, 2013, about 220,000 enrollees
Commonwealth CareAs of January 1, 2014:
o About 130,000 of Commonwealth Care enrollees transitioned to MassHealth
o Due to systems issues, Commonwealth Care coverage for the remaining 90,000 members was extended multiple times and will end on January 31, 2015
oAbout 13,000 former Medical Security Program members also given the option of maintaining MSP coverage under the Commonwealth Care program – coverage is also extended to January 31, 2015
ACA Subsidized Insurance
How does subsidized health insurance work under the Affordable Care Act?
Qualified Health Planso Qualified Health Plan (QHP): insurance plan
certified by health insurance marketplaceso In Massachusetts, the health insurance
marketplace is the Health Connector
Types of QHPs
o QHPS are categorized into different types or metallic tiers, based on how much cost-sharing the plan coverso Platinum (least cost-sharing, highest premiums)o Goldo Silvero Bronze (most cost-sharing, lowest premiums)
Federal Subsidieso ACA offers two types of help paying for health
insurance to purchase a QHP through the health insurance marketplace: Advanced premium tax credits (APTCs) Cost-sharing reductions
o Paid directly to the health plan, consumer pays the rest
Advanced Premium Tax Credits (APTCs)
o Size of credit is based on a percentage of income and cost of 2nd lowest cost “Silver” plan available through the marketplaceo If you buy a more expensive plan (e.g.
Gold, Platinum), pay the differenceo If you buy a cheaper plan (e.g. Bronze),
save the difference
Cost-Sharing Reductions o Lowers out-of-pocket costs, such as
deductibles, co-pays or co-insurance
o Must purchase “Silver” plan to get cost-sharing reductions
Federal Eligibility Requirements
o Income at or below 400% FPLo At or below 250% FPL for cost-sharing
reductionso US Citizen, national or lawfully present immigranto Residento Not incarceratedo Not eligible for or enrolled in:
o Other “minimum essential coverage” (e.g. Medicaid, Medicare)
o Affordable Employer Sponsored Insurance
Employer Sponsored Insuranceo May be eligible for APTCs if ESI available to you:
Costs more than 9.5% of household income for lowest-cost self-only plan
Does not meet “minimum value” (i.e. does not cover 60% of average cost-sharing)
More on ESIo Application asks questions about premium cost of
ESI & minimum value to see if uninsured person offered ESI may be eligible for APTCs
o “Family glitch” – whether ESI is affordable for family members is also based on cost of self-only plan NOT cost of family plano If “self-only” ESI is considered affordable, family
members also cannot receive APTCs
ACA vs. MA Subsidies
ConnectorCareo Plans designed to look more like
Commonwealth Care in terms of premiums & cost-sharing
Federal APTCs + Federal Cost-Sharing Reductions + State Funds = ConnectorCare Subsidies
ACA Subsidized Coverage in Mass.
15
Eligibility for ConnectorCareo Income at or below 300% FPL
o Meet eligibility standards for federal APTCs
o Must choose from subset of plans offered through the Health Connector
Selecting a Plano No automatic assignment, applicant must select
plano ConnectorCare-eligibles can choose any plan
offered through the Health Connector BUT:o Added state subsidies lowering premiums and
cost-sharing to Commonwealth Care levels are only available if choose ConnectorCare plan
ConnectorCare PlansCarriers offering ConnectorCare plans in 2015:oBMC HealthNet Plan oCeltiCare oFallon Health PlanoHealth New EnglandoMinuteman HealthoNeighborhood Health PlanoTufts Health Plan - Network Health
ConnectorCare PlansConnectorCare plan names do not display correctly on
the Health Connector website.ConnectorCare Health Insurance Carriers ConnectorCare plan name as it is
displayed in the system
Boston Medical Center HealthNet Plan BMC HealthNet Plan - Silver ACeltiCare Health Plan Ambetter Balanced Care
Fallon Health Community Care Silver Connector AHealth New England HNE Silver AMinuteman Health MyDoc HMO Silver Basic
Tufts Health Plan-Network Health Tufts Health Direct SilverNeighborhood Health Plan NHP Prime HMO 2000/4000 30/50
Although the names are wrong, the premiums, co-pays and benefits are displayed correctly.
ConnectorCare Premiums
o Base enrollee premiums for members selecting the lowest-cost ConnectorCare plan in their region equals that in Commonwealth Care today
o Plan Type I members will not be charged a premium, regardless of which plan they choose
Premium Paymento Must pay premium by the 23rd of the month
for coverage to be effective for the 1st of the next month
o If payment is received after the 23rd, coverage will not be effective until the 1st of the 2nd month
o Premiums must be received by the 23rd of each month to maintain coverage.
Premium Non-Paymento After 30 days of non-payment, APTCs to the
plan are suspended and plan suspends payment to providers
o If all premiums owed are not paid after 90 days, coverage is terminated retroactively back to the end of the first 30 days of non-payment
o Health Connector has process to apply for premium hardship waivers Same as Commonwealth Care process
ConnectorCare Cost-Sharingo Co-pays only; no deductibles or co-insurance
o Plan Type 1 (at or below 100% FPL): MassHealth-level co-pays for prescription drugs only
o Plan Type 2 (100-200% FPL): Low to moderate co-pays
o Plan Type 3 (200-300% FPL): Moderate co-pays
Open Enrollment Periodo Under federal rules, there is a set open enrollment
period (e.g. for this year, it is November 15, 2014-February 15, 2015) – only time a consumer can enroll in plan through marketplaceo Exception – experiencing a “triggering event”o In Massachusetts, being determined eligible for
ConnectorCare is considered “triggering event”o Can enroll in ConnectorCare any time during the
year
What about people over 300% FPL?
oPeople with incomes between 300-400% FPL may be eligible to receive help paying for health insurance Must meet federal eligibility guidelines May be eligible for APTCs Choice of all plans offered through the
Health Connector
Reconciliationo APTCs are based on annual income and
“reconciled” at tax timeo IRS compares amount of premium tax credits you
qualify for at end of year with those you received in advance
o Final premium tax credit is calculated based on actual income reported on federal taxeso If APTC is less than amount of final premium tax
credit, you will receive the difference as a credito If APTC is more than amount of final premium
tax credit, you must repay the difference through your tax return
Reconciliationo Reconciliation amounts are capped for individuals
and families at or below 400% FPL
o Additional subsidies provided by the state are not subject to reconciliation
Thank you!
Questions?
