Transcript
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The Affordable Care Act and You

How to Navigate the New Healthcare Landscape

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Sponsored by SMARTvt and

Presented by Jean S. Twombly

Member Academy Health

Consulting Partner with PCResourcesVT.com

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ACA

How do I get better health coverage?

Can I get a subsidy?

When is open enrollment?

Will I pay a penalty if I don’t buy coverage?

My employer’s plan costs too much. I need a break.

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ACA Fast Facts

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The ACA is short for the Patient Protection and Affordable Care Act

It was passed into law on March 23, 2010.

Many people who purchased healthcare plans after that date are affected by the PPACA Individual Mandate and will need to enroll in an ACA – Compliant insurance plan in 2014.

ACA Fast Facts

Many individuals and families with incomes between 133-400% of the Federal Poverty Level qualify for a subsidy to help pay for health insurance.

Subsidies can only be obtained by enrolling On Exchange.

States are mandated to furnish residents access to an Exchange, a health insurance marketplace.

Open Enrollment for ACA health plans begins October 1, 2013.

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All new ACA – compliant plans are mandated to furnish the following ten essential benefits.

Prescription Drug Coverage

Hospitalization

Emergency Care

Laboratory Services

Ambulatory Patient Services

Mental Health and Substance Abuse Benefits

Pediatric Dental and Vision Services

Maternity Services

Wellness and Preventive Care

Habilitative and Rehabilitative Benefits

Insurance carriers have reworked both plans and rates to comply

with the mandate. The State and Federal healthcare marketplaces are designed to foster competition among plans and to facilitate comparison between plans which are similarly priced.

ACA Plans are ranked by actuarial value and are grouped by

metal level: Platinum, Gold, Silver, and Bronze.

ACA Ten Essential Benefits

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ACA Plan Metal Levels

Plans with higher monthly premiums offer the benefit of lower coinsurance when care is received. Plans with lower monthly premiums have higher deductibles, coinsurance, copays and out-of-pocket maximums. The insured can choose a plan which fits the anticipated use of the healthcare system.

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ACA Plan Actuarial Values

Each ACA plan must meet the following actuarial values with a variance of +/- 2%.

Platinum = 90% AV Gold = 80% AV Silver = 70% AV Bronze = 60% AV Actuarial values are based on standard EHB costs and population measurements.

This means that a plan with 70% AV pays approximately 70% of the cost of healthcare. The insured will be responsible for the 30% remainder.

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Healthcare Plan Subsidies

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The Individual Mandate also requires the Federal government to provide subsidies to make health insurance affordable for low and middle income individuals and families.

A new Federal Data Hub will determine subsidy eligibility based on income as % of Federal Poverty Level (FPL).

Beginning in 2014, applicants seeking coverage on-exchange may qualify for two types of subsidies:

Individuals and families with incomes between 100-250% of the FPL qualify for BOTH the Cost-Sharing Reduction subsidy and the Advance Premium Tax Credit.

Exchange Subsidy Overview

– Advance Premium Tax Credit (APTC)

• Applicants who qualify for the APTC will owe a reduced premium.

• The Federal Government will advance the difference in premium amounts to the carriers monthly.

– Cost-Sharing Reductions (CSR)

• Applicants who qualify for CSR will be enrolled in a specific plan with reduced cost-sharing.

• Federal Government will advance an estimated cost-sharing reduction monthly. e Premium Tax Credit.

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Income Guidelines for Subsidies The amount of subsidy depends on family size and income level. In general, applicants at the

following income levels will qualify to save in 2014*. The lower the income, the greater the savings.

If the expected 2014 income you report is too high, you might not get the correct amount of savings.

If you make more money than predicted, you might have to repay some or all of the subsidy amount on the next tax return.

Family of Income level Family of Income Level

1 $45,960 5 $110,280

2 $62,040 6 $126,360

3 $78,120 7 $142,440

4 $94,200 8 $158,520

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Subsidy Calculator

The Kaiser Family Foundation subsidy calculator prompts individuals to enter the following information:

o Income

o Whether employer coverage is available

o Family size

o Ages of applicants

Applicants then receive an estimate of the subsidies they are eligible for and expected health insurance costs.

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APTC – Premium Subsidy Details

Availability:

Available to individuals/families with incomes between 133% and 400% of FPL .

Vermont has expanded Medicaid up to 133% of federal poverty level.

The APTC subsidy is calculated as a premium cap based on income level.

Eligibility:

No employer coverage or

Employer coverage either

– Does not have an actuarial value of 60% or more

– The cost of the coverage would exceed 9.5% of income.

Income Level Premium Cap as % of Income Income Level Premium Cap as % of Income

< 133% of FPL Medicaid 201-250% FPL 6.3-8.05% of income

133% -150% FPL 3-4% of income 251-300% FPL 8.05-9.5% of income

151-200% FPL 4-6.3% of income 301-400% FPL 9.5% of income

Note: In 2013 the Federal Poverty Limit is $11,490 for an individual and $23,550 for a family of four.

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APTC Computation Example

The subsidy is tied to the premium of the “average” of plan choices – the Silver Plan.

The subsidy calculator on the Exchange computes the APTC, applying a premium cap as a % of household income.

For Example:

John is an individual with household income at 275% FPL.

Premium cap for a taxpayer at 275% FPL is 8.775% (halfway between 8.05% and 9.5%)

In our example, a 275% FPL equals a monthly income of $2,560 for a household of one

Note: The FPL is updated annually, and will likely be different in 2014. The chart for 2013 can be found at http://www.familiesusa.org/resources/tools-for-advocates/guides/federal-poverty-guidelines.html

Income Level Premium Cap as a % of Income

< 133% FPL* Medicaid

133%-150% FPL 3-4% of income

151-200% FPL 4-6.3% of income

201-250% FPL 6.3-8.05% of income

251-300% FPL 8.05-9.5% of income

301-400% FPL 9.5% of income

> 400% FPL No subsidies

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APTC Computation Example continued

If the Silver Plan costs $384/month and John has a monthly income of $2,560 :

– His premium subsidy equals the difference between plan cost and $224.64 [8.775% x $2,560 monthly income]

Individuals may select any plan and still receive the tax credit.

The amount of the tax credit may not exceed the plan premium. Since John is eligible for a $159.36/month tax credit:

– If he selects a less expensive plan with a cost of $150/month, John can only receive a tax credit of $150/month

– If he selects a more expensive plan with a cost of $500/month, he will owe $340.64 monthly:

Tax credit: $384 minus $224.64 = $159.36/month

His plan cost: $500 minus $159.36 = $340.64/month

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CSR – Cost Sharing Reductions

Available to families and individuals

o With incomes up to 250% FPL AND

o Enrolled in a Silver plan on the Exchange

Cost-sharing reductions include lowered deductibles, coinsurance and copayments.

Carriers must create three variations of the basic silver metal plan – essentially increasing the actuarial value by decreasing cost sharing – to accommodate the cost sharing bands by FPL.

There are three CSR bands:

o Medicaid-eligible to 150% of FPL

o 151 to 200% of FPL

o 201 to 250% of FPL

If FPL changes during the year, cost sharing reductions must be updated.

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MVP Healthcare

Silver Base Plan (.70 AV)

Deductible: $1,300

OOP Max: $6,350

Copay: $30 PCP / $40 Specialist after deductible

Coinsurance: 20% after deductible

Rx: Integrated Medical/Drug Deductible. All Generics: 20% after deductible.

Preferred Brand: 30% after deductible. Non-Preferred Brand: 50% after deductible.

Specialty: 50% after deductible

Example of a Silver Metal Base Plan

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Silver Base Plan (.70 AV)

Deductible: $1,300

OOP Max: $6,350

Copay: $30 PCP / $40 Specialist after deductible

Coinsurance: 20% after deductible

Rx: Integrated Medical/Drug Deductible. All Generics: 20% after deductible. Preferred Brand: 30% after deductible. Non-Preferred Brand: 50% after deductible. Specialty: 50%

after deductible

201%-250% FPL (.73 AV)

Deductible: $900

OOP Max: $5,200

Copay: $30 PCP / $40 Specialist after deductible

Coinsurance: 20% after deductible

Rx: Integrated Medical/Drug Deductible All Generics: 20% after deductible

Preferred Brand: 30% after deductible Non-Preferred Brand: 50% after deductible

Specialty: 50% after deductible

151%-200% FPL (.87 AV)

Deductible: $0

OOP Max: $2,250

Copay: $5 PCP / $ 25 Specialist copay

Coinsurance: 20%

Rx: All Generics: 10% coinsurance Preferred Brand: 30% coinsurance Non-Preferred Brand: 50% coins

Specialty: 50% coinsurance

100%-150% FPL (.94 AV)

Deductible: $0

OOP Max: $2,250

Copay: $0 PCP / $10 Specialist copay

Coinsurance: 10%

Rx: All Generics: No charge Preferred Brand: 10% coinsurance

Non-Preferred Brand: 20% coinsurance

Specialty: 20% coinsurance

Silver Plan Cost Sharing

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The Federal Data Hub and Penalties for the Uninsured

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The Federal Data Hub

HHS

Homeland Security

SSA

IRS

CMS

Treasury

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The IRS and Treasury will manage the Advance Premium Tax Credit Subsidy which will be based on the applicant’s Modified Adjusted Gross Income (MAGI).

The APTC Subsidy will be sent by the U.S. Treasury Department to insurance carriers to fulfill premium payments each month.

Any changes in income will be reconciled with the insured when filing the following year’s taxes.

Health and Human Services (HHS) will manage the Federal Data Hub and the Federally Facilitated Exchange (FFE).

Who Manages Subsidies and the Hub?

HHS will also manage the Cost-Sharing Reducation

Subsidy. Once a member has enrolled in a new plan and is eligible for a subsidy, the insurance carrier will be sent a monthly subsidy amount.

Note that Vermont has expanded Medicaid to 133% of Federal Poverty Level through federal funding.

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Overview of ACA Uninsured Penalties

The ACA requires most Americans to have or obtain health coverage starting in 2014 or pay a penalty fee.

The fee increases every year. The fee in 2014 is 1% of yearly income or $95 per person for the year, whichever is higher.

Family maximum is $285. In 2016 the penalty fee is 2.5% of income or $695 per person, whichever is higher. The family

maximum has now risen to $2,085

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Exemptions from the Penalty

Uninsured individuals and families will not have to pay the penalty fee if they:

Are uninsured for less than 3 months of the year

Are determined to have very low income and coverage is considered unaffordable

Are not required to file a tax return because their income is too low

Would qualify under the new income limits for medicaid, but their state has chosen not to expand medicaid eligibility

Are a member of a recognized religious sect with religious objections to health insurance

Are a member of a federally recognized indian tribe

Participate in a health care sharing ministry

These individuals are automatically exempt if low income. Otherwise, they may file with an exchange for an exemption.

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Vermont Health Connect

http://healthconnect.vermont.gov/

Vermonters may only enroll On Exchange. No Off Exchange business.

Subsidies are only available On Exchange.

Open Enrollment: October 1, 2013 through March 31, 2014. Outside these dates you will not be able to buy health insurance either on or Off Exchange without a “life event” such as moving, loss of employer coverage, or certain changes in family status.

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Chittenden County Organizations of Vermont Health Connect Association of Africans Living in Vermont (802) 985-3106 20 Allen St., Burlington, VT 05401 Champlain Valley Office of Economic Opportunity (802) 860-1417 x115 255 S. Champlain St. #9, Burlington, VT 05401 Community Health Centers of Burlington (802) 264-8124 617 Riverside Ave., Burlington, VT 05401 Lake Champlain Lifelong Learning Fund (Chamber of Commerce) (802) 863-3489 ext. 208 60 Main St., Suite 100, Burlington, VT 05401 Planned Parenthood of Northern New England 1-866-476-1321 128 Lakeside Ave., Suite 301, Burlington, VT 05401 Spectrum Youth & Family Services (802) 864-7423 ext. 222 31 Elmwood Ave., Burlington, VT 05401

Connecting Organizations at the County Level

Vermont Businesses for Social Responsibility (802) 324-1920 or (802) 989-4844 255 South Champlain St., Burlington, VT 05401 Fletcher Allen Health Assistance Program (802) 847-6984 128 Lakeside Ave., Suite 106, Burlington, VT 05401 Vermont Family Network 1 800 800-4005 or (802) 876-5315 600 Blair Park Rd., Suite 240, Williston, VT 05495 Vermont Campaign for Health Care Security Donna Sutton Fay 879-8604 [email protected] Blueprint Community Health Team – Burlington Hospital Service Area, Community Health Improvement Fletcher Allen Health Care (802) 847-1601

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On-Exchange Consumer Assistance

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Overview of Consumer Assistance

Consumers will have assistance as they apply for new insurance options through

o Navigators

o In Person Assisters

o Certified Application Counselors.

The ACA governs who may provide consumer assistance and

o What approval, registration, and/or training is required

o What activities each may perform

o What funds may be used to pay for these activities

o Provides that state law cannot impede Title I of the ACA (such as require Navigators to be licensed agents or brokers, or carry errors and omissions coverage)

HHS has final rules and has announced funding opportunities to guide these efforts.

Activities and funding depend on whether ACA assistors are working with a State-based Marketplace, State Partnership Marketplace, or Federally Facilitated Exchange (FFE).

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Description of Consumer Assistors

These efforts do not include the volunteer ground game being organized by Health and Human Services Centers for Medicare and Medicaid Enroll America,

and other partners to drive people to consumer assistance and facilitate enrollment.

For example, the Obama administration is looking to partner with professional sports organizations like the NFL to get the word out.

Entities Description

Navigators Employees of the Exchange

In-Person Assistors Employees of the Exchange

Non-Licensed “Customer Service Representatives”

Employees of the Exchange

Certified Application Counselors and Health Center Assistors

“Trusted community-based organizations, providers, or other organizations with expertise in social service programs” Employees of a Federally Qualified Health Center (FQHC)

Application Filers/Authorized Representatives Individuals who are permitted to assist persons with disabilities in making informed decisions

Agents/Brokers Work with all issuers in a marketplace

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