VIRGINIA’S HEALTH INSURANCE MARKETPLACE --THE BASICS 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 to expand Medicaid (no decision yet) ◦New Insurance Marketplace – Affordable Private Coverage ◦People/Large Businesses Required to Have/Provide Insurance

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

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) Preventive & Wellness Services Pediatric Services includes Oral & Vision

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

WHO FALLS INTO THE MEDICAID GAP? Individuals with disabilities from 80% FPL to 100% FPL Childless adults below 100% FPL Parents with income from between 30% FPL and 51% FPL to 100% FPL—Medicaid eligibility depends on location Without Medicaid Expansion under the Affordable Care Act, approximately 200,000 Virginians are not able to get health insurance. MEDICAID COVERAGE GAP

Ex: Working single parent with 2 children who makes $9.00/hr ($18,720/yr)

Assistance for those with income under 100% FPL Without Medicaid they must find health services: ◦Community Health Centers ◦Free Clinics ◦Prescription Assistance ◦Medicaid “Plan First” program for family planning only ◦Hospital emergency rooms

Marketplace Eligibility

Basic Eligibility o US citizen or national, or non-citizen who is lawfully present in the US for the entire time coverage is sought o Live in service area o Not incarcerated o No access to affordable and adequate insurance o 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

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 Yearly Income: $17,200/year (150% FPL) Maximum Contribution 4% Income = $688/ yr Premium Tax Credit: $3,312 ($276/mo) Full cost of plan /mo Subtract Tax Credit /mo Elina pays $57.33/mo

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 Coverage Level of Silver Plans to: ◦94% (income 100%-150% FPL) ◦87% (income 150%-200% FPL) ◦73% (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

Health Insurance Terms You Need to Know  Health Insurance: pays part of your medical costs when you get sick or hurt. It will pay 100% of certain preventive care.  Monthly Premium: You and your family get health care in exchange for a monthly fee or premium. You have to pay it monthly on time even if you don’t use medical care that month.  Co-payment or co-pay: Each time to see a doctor, you may have to pay a small amount that is called a co-payment or co-pay, usually about $15 - $25. Your insurance company generally pays the balance of the bill.  Deductible: However, you many need to pay more than the copay if you have a deductible. A deductible is additional money you sometimes have to pay before your insurance pays the remainder of the bill.  Coinsurance: How the total cost of a covered health care service is shared between you and the insurance company. The higher share the insurance company pays, the higher the premium you pay. The lower share that the insurance company pays, (say 60%), the lower premium you pay.

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

New Open Enrollment 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

Renewing Coverage for 2016 Most consumer’s plans will be automatically renewed Insurers are required to inform consumers of ◦Continuation of 2015 plan ◦Changes to 2015 plan ◦Cost increases ◦Changes to financial assistance 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: o Confirm anticipated income for 2016 o Determine if they are enrolled in the best plan o Determine if they are eligible for help or additional help o Update application to reflect any changes in income or household expected in 2016 Remember: o New plans may be available o Some plans premiums may increase more than others o Watch for changes in networks and drug coverage

Information for New Enrollment for 2016

4 Steps to Health Insurance

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

Information Needed to Apply o Availability of Employer-based Coverage o Identity of applicants o Names and contact info o Social Security Numbers o Immigration Status and Documents o Household Size o Using tax code principles to determine household size o Tax dependents o Countable Income (MAGI) o 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

Tax Penalties and Exemptions

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

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 Exemptions from the Penalty

How Can I Apply for an Exemption for 2015? Download the exemption form from the healthcare.gov website. Contact a navigator at to set up an appointment. Upon completion of the application and approval a certificate of exemption will issued with a number to be placed on your taxes for the 2014 tax year.

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.

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