VIRGINIA’S HEALTH INSURANCE MARKETPLACE --THE BASICS-- 2016-2017 Affordable Care Act Susan Nolan & Katherine Garcia Navigators www.enrollva.org 703-647-4748

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 ACA After 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 2017 November 1, 2016-January 31, 2017 Note: Medicaid/FAMIS applications accepted & processed all year Currently there are several scenarios in which you can qualify for health insurance under a Special Enrollment.

Special Enrollment Periods 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 Income increased above 100% FPL 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 & lost coverage My employer coverage is no longer affordable or adequate Does not include voluntary terminations ex. Non-payment

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 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 Some immigrants who are not eligible for Medicaid due to immigration status may qualify for the financial assistance through marketplace despite having income below 100% FPL, however most will fall into the coverage gap.

2016 Federal Poverty Level (FPL) 250% FPL (Silver Plan w/ Reduction) Family Size Annual Family Income – 2016 Maximum 80% FPL (Medicaid – ABD: resources < $2k) Minimum 100% FPL (Marketplace) 133% FPL (Exemption) 200% FPL (FAMIS) 250% FPL (Silver Plan w/ Reduction) 400% FPL (Marketplace) 1 $9,604 $11,880 $15,800 $23,760 $29,700 $47,520 2 $12,816 $16,020 $21,307 $32,040 $40,050 $64,080 3 $16,128 $20,160 $26,813 $40,320 $50,400 $80,640 4 $19,440 $24,300 $31,319 $48,600 $60,750 $97,200 5 $22,752 $28,440 $37,825 $56,880 $71,100 $113,760 MAINTAIN: All correspondence from the Marketplace Document from Employer with Insurance Premium Source: 2015 Federal Poverty Guidelines, U.S. Dept. of Health and Human Services (703) 647-4748

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

Virginia Health Insurance Marketplace 12/17/2013 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 Bronze – 60% AV - low overall coverage, lower premiums but higher out-of-pocket costs. Platinum - 90% AV - best coverage, highest premiums. Catastrophic coverage for people under age 30 with very high deductible

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 2nd least expensive Sliver Plan Income Level (FPL) Contribution From Income Up to 133% 2% 133 - 150% 3 – 4% 150 - 200% 4 – 6.3% 200 - 250% 6.3 – 8.05% 250 - 300% 8.05 – 9.5% 300 - 400% 9.5% $306 = $25.50 $5000 Policy – $417/mo Tax credit - $391/mo

Premium Tax Credit Example Elina is a 34-year old single female Annual Income of $17,820/year (150% FPL) Maximum Contribution 4% Income = $712.80/ yr Cost of 2nd lowest Silver Plan $4,000 ($333.33/mo.) Subtract Max. Contribution - $712.80 Premium Tax Credit $3,287.20 ($273.93/mo) Full cost of plan 333.33/mo Subtract Tax Credit -273.93/mo Elina pays $59.40/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 12/17/2013 Standardized Plan Descriptions Summary of Benefits and Coverage (SBC) Uniform Glossary of Terms

Enrollment Process

How to Apply: Multiple “doors” Online Marketplace www.healthcare.gov Medicaid/FAMIS www.coverva.org Phone Marketplace – 1-800-318-2596 Cover VA (Medicaid/FAMIS)– 1-855-242-8282 Local assistance Enroll Virginia – 1-888-392-5132

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 2017 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 2017 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 2017 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 2017 Notes: New plans may be available Some plans premiums may increase more than others Watch for changes in networks and drug coverage

Dates to remember during open enrollment Apply and enroll: November 1 – January 31 Effective dates: Enroll/update by December 15: new coverage starts January 1* Enroll/update between December 16 and January 15: new coverage starts February 1 Enroll/update between January 16 and January 31: new coverage starts March 1 *Very important: new rates will apply and have to be paid to maintain 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: 2014 - $95 /adult + $47.50 /child (up to $285) or 1% family income* 2015 - $325/adult + $165.50/child (up to $975) or 2% family income* 2016 - $695/adult + $347.50/child (up to $2085) or 2.5% family income* Future penalty amounts will be the 2016 amounts adjusted for inflation.* *Some Exemptions Apply

Exemptions from the Penalty Granted by Marketplace Hardship, including: Life circumstances (homelessness) Recent death of close family member Bankruptcy in the last 6 months Debt from medical expenses in last 24 months Domestic violence Plan cancellation + MORE Insurance is considered unaffordable at beginning of year (projected) See www.healthcare.gov/health-coverage-exemptions/hardship-exemptions/ Granted at Tax Filing Income below filing threshold Member of tax household born, adopted or died Incarceration Certain noncitizens Short coverage gap (<3 months) In a state that did not expand Medicaid Insurance is considered unaffordable (based on actual household income (more than 8.16%) Member of Indian tribe or eligible for Indian Health services Citizens living abroad for 330 days of the year Religious conscience

How Can I Apply for an Exemption for 2017? Hardship Exemptions Download the exemption form from the healthcare.gov website. If approved, an exemption certificate with an Exemption Code Number to be used on your taxes will be issued. Insurance is unaffordable based on projected income Complete a Marketplace Application during Open Enrollment If approved for an exemption, an Exemption Code Number will be generated on your Eligibility Notice to be used on your taxes. IRS Granted Exemptions These are granted when you file your taxes, see IRS form 8965 for more details. Contact a navigator at 1-888-392-5132 for assistance

Additional Resources Centers for Medicare & Medicaid Services (CMS): http://marketplace.cms.gov/ Health Insurance Marketplace: http://www.healthcare.gov Kaiser Family Foundation: http://KFF.org Center on Budget and Policy Priorities: http://www.healthreformbeyondthebasics.org/

Twitter-@EnrollVirginia QUESTIONS? 703-647-4748 Susan@enroll-Virginia.com Katie@enroll-Virginia.com www.enrollva.org Facebook-www.facebook.com/enrollva Twitter-@EnrollVirginia

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-13-001 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.