ACA Name Enroll VA Title Work Address T: Work Number

AFFORDABLE CARE ACT “OBAMACARE” Goals: Affordable Insurance Coverage Private Insurance Reform Better Health Delivery Systems Coverage changes on January 1, 2014: State Option for Medicaid Adult Coverage (no decision yet) New Insurance Marketplace – Affordable Private Coverage People/Large Businesses Required to Have/Provide Insurance

New Insurance Marketplace Virginia is served by “Federally Facilitated Marketplace” (FFM) To compare / purchase private health insurance Qualified Health Plans (QHPs) Premium Tax Credits only available with FFM plans Also available to small employers in November Fewer than 50 “full time equivalent” employees Small Business Health Options Program “SHOP”

New Consumer Protections Before ACAAfter ACA Insurance tied to employment Not available to adult children Exclusions for pre-existing conditions Limited preventative services Arbitrary cancellations by insurance companies Inadequate plans Hard to compare plans side by side Caps on benefits Higher risk of bankruptcy No financial assistance Limited consumer protections Insurance available on marketplace Children covered until age 26 FREE preventative services Harder for insurers to cancel coverage 10 Essential Health Benefits covered at all plan levels Side by side comparison across plan levels in simple language Limits on annual consumer costs Reduced risk of bankruptcy Premium tax credits and out-of- pocket costs limits Stronger consumer protections

Enrollment

Open Enrollment for Coverage for 2016 o November 1, 2015-January 31, 2016 Note: Medicaid/FAMIS applications accepted & processed all year o Currently there are several scenarios in which you can qualify for health insurance under a Special Enrollment.

Special Enrollment Periods I lost my existing coverage A family member died I turned 26 I changed jobs I was terminated from my job My COBRA, CHIP or Medicaid benefits expired or I lost eligibility I got a divorce My employer coverage is no longer affordable or adequate Does not include voluntary terminations ex. Non- payment I experienced a life change I got married I moved to a new state I welcomed a child My immigration status changed I left incarceration Other situations Error by Representative Misconduct by a non-exchange entity (ex. Navigator, CAC, insurance company) Native Americans & Alaska Natives

SEPs Triggered for Enrollees Change in income Enrollee is newly eligible or ineligible for Premium Tax Credits Enrollee is newly eligible or ineligible for cost- sharing reductions Individual in Medicaid Gap with hardship exemption whose income goes above 100% FPL Enrollee demonstrates plan violated contract

Marketplace Eligibility

Basic Eligibility US citizen or national, or non-citizen who is lawfully present in the US for the entire time coverage is sought Live in service area Not incarcerated No access to affordable and adequate insurance Income between 100% FPL and 400% FPL to receive financial assistance

2015 Federal Poverty Guidelines Family Size Family’s Annual Income Levels 100% FPL 133% FPL 150% FPL 200% FPL 250% FPL 400% FPL 1$11,770$15,654$17,655$23,540$29,425$47,080 2$15,930$21,187$23,995$31,860$39,825$63,720 3$20,090$26,720$30,135$40,180$50,225$80,360 4$24,250$32,253$36,375$48,500$60,625$97,000 5$28,410$37,785$42,615$56,820$77,025$113,640

Which Companies Can I Choose From, and What Types of Plans/Benefits are Available?

Virginia Health Insurance Marketplace

Qualified Health Plans QHP/4 TIERS of COVERAGE Essential Health Benefits (Standardize Coverage) Bronze = 60% Ambulatory Patient Services Emergency Services Silver = 70% Hospitalization Maternity & Newborn Care Gold = 80% Mental Health & Substance Disorders Prescription Drugs Platinum = 90% Rehabilitative & Habilitative Services Laboratory Services Catastrophic (available for <30 years old) Preventive & Wellness Services Pediatric Services includes Oral & Vision

Examples of Free Preventative Care Regular check-ups and well visits Mammograms Cervical cancer, colon cancer and osteoporosis screenings High blood pressure and cholesterol screenings Bone density measurements Flu shots Developmental screenings, including autism Multiple health screenings for newborns

Eligibility For Financial Assistance Premium tax credits reduce the amount you pay for your premium. Cost sharing reductions lower your deductibles, co- pays and out of pocket costs.

Advanced Premium Tax Credits Income between 100% and 400% FPL Maximum contribution towards premium Based on cost of 2 nd least expensive Sliver Plan Income Level (FPL) Contribution From Income Up to 133%2% %3 – 4% %4 – 6.3% %6.3 – 8.05% %8.05 – 9.5% %9.5%

Premium Tax Credit Example Elina is a 34-year old single female Annual Income of$17,200/year (150% FPL) Maximum Contribution 4% Income = $688/ yr Cost of 2 nd lowest Silver Plan$4,000 ($333.33/mo.) Subtract Max. Contribution- $688 Premium Tax Credit $3,312 ($276/mo) Full cost of plan /mo Subtract Tax Credit /mo Elina pays $57.33/mo

Using the Tax Credit Tax credit can be used for all plans except catastrophic Tax credit can be received as a refund when you file your taxes at the end of the year Or it can be paid in advance directly to the insurance plan to help pay monthly premiums Must report changes in income/family size during the year to ensure an accurate tax credit amount “Reconciliation” will occur when taxes are filed

Cost-Sharing Reductions: The Importance of Silver Plans Special out-of-pocket protections for those with income under 250% FPL Only applies if Silver Plan is purchased! Increases Actuarial Value of Silver Plans to: 94% AV (income 100%-150% FPL) 87% AV (income 150%-200% FPL) 73% AV (income 200%-250% FPL)

Choosing Your Plan Monthly Premium is only one factor Also Consider Deductible Cost sharing – Co-insurance – Co-payments Provider Network - Specialists Drug Formulary Review service descriptions and exclusions or limits on coverage

Standardized Plan Descriptions Summary of Benefits and Coverage (SBC) Uniform Glossary of Terms

Enrollment Process

How to Apply: Multiple “doors” Online Marketplace Medicaid/FAMIS Phone Marketplace – Cover VA – Local assistance Enroll Virginia –

Information Needed to Apply Availability of Employer-based Coverage Identity of applicants Names and contact info Social Security Numbers Immigration Status and Documents Household Size Using tax code principles to determine household size Tax dependents are in the tax filers household Countable Income (MAGI) Using tax code principles & expected 2015 income Databases will verify most information Paper documents used for discrepancies

MAGI: Modified Adjusted Gross Income Count: Taxable wages/salary Profit from self-employment Social Security benefits (SSDI, retirement) Unemployment benefits Alimony received Most retirement benefits (including VA pensions) Interest (including tax- exempt interest) Rental income Do not count: Child support received Supplemental Security Income (SSI) Workers’ compensation payments Veteran’s benefits (service- related disability) Gifts/Inheritances Pre-tax deductions (IRAs, childcare, health) Alimony paid Social Security of dependents who aren’t required to file taxes

Renewing Coverage for 2016 Most consumer’s plans will be automatically renewed Insurers are required to inform consumers of Continuation of previously selected plan Changes to previously selected plan Premium increases Financial assistance the consumer will receive in 2015 The Marketplace will also communicate with consumers enrolled in the Marketplace informing them of the automatic renewal process

What Action Should I Take? Consumers should still review their Marketplace account before December 15 to: Confirm anticipated income for 2016 Confirm continued eligibility Determine if they are enrolled in the best plan Determine if they are eligible for additional assistance Update application to reflect changes in income or household expected in 2016 Notes: New plans may be available Some plans premiums may increase more than others Watch for changes in networks and drug coverage

Tax Penalties & Exemptions

Exemptions & Penalty Everyone is required to have minimum essential coverage (MEC) or pay a “shared responsibility payment,” unless exempt Taxpayer is responsible for dependents Coverage requirement, penalties, and most exemptions apply on a monthly basis One day rule: A person has coverage entire month if covered for at least one day of that month A person is eligible for an exemption entire month if they are exempt for at least one day of that month.

Minimum Coverage Requirements Tax Penalties Individual / Family penalty is much less than cost of insurance. Penalty is the greater of:  $95 /adult + $47.50 /child (up to $285) or 1% family income*  $325/adult + $165.50/child (up to $975) or 2% family income*  $695/adult + $347.50/child (up to $2085) or 2.5% family income* *Some Exemptions Apply

Exemptions from the Penalty Granted by Marketplace Hardship, including: Life circumstances Insurance is unaffordable State failure to expand Medicaid* Eligible for Indian Health services Plan cancellation Member of certain religious sects Granted at Tax Filing Income below filing threshold Insurance is unaffordable Certain noncitizens Short coverage gap (<3 months) Gap before effective date of Marketplace coverage purchased during open enrollment Granted by the Marketplace or at Tax Filing Indian tribe membership Incarceration Health care sharing ministry * A hardship exemption due to a states failure to expand Medicaid can be received by applying for coverage directly at healthcare.gov if you are below 138% FPL

How Can I Apply for an Exemption for 2015? Download the exemption form from the healthcare.gov website. If approved, an exemption certificate with a number to be used on your taxes will be issued Contact a navigator at for assistance

Additional Resources Centers for Medicare & Medicaid Services (CMS): Health Insurance Marketplace: Kaiser Family Foundation: Center on Budget and Policy Priorities:

QUESTIONS? Phone Number Facebook-

Thank you! ENROLL Virginia! is a nonprofit, nonpartisan entity that assists individuals and small businesses to obtain health insurance including commercial health coverage through the federally facilitated health insurance marketplace, to qualify for applicable tax subsidies, and to comply with the U.S. Patient Protection and Affordable Care Act and avoid penalties for failure to do so. The program is paid for by a federal grant (Funding Opportunity Number CA-NAV from the U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services) and administered by the Virginia Poverty Law Center. The contents provided here are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.