Fundamentals of the Health Insurance Marketplace 07/03/2013 Fundamentals of the Health Insurance Marketplace September 2013 Betsy L. Thompson, MD, DrPH Chief Medical Officer, Region IX

Objectives This session will help you: 07/03/2013 This session will help you: Explain the Health Insurance Marketplace Understand what it means To you Your practice Your patients Locate Marketplace resources

Health Insurance Marketplace 101 The Problem Insurance companies could turn away 129 million Americans with pre-existing conditions Premiums more than doubled over the last decade, while insurance company profits soared Tens of millions were underinsured, and many who had coverage were afraid of losing it 50 million Americans had no insurance at all 6/20/13 Health Insurance Marketplace 101 Health Insurance Marketplace 101

Health Insurance Marketplace 101 The Health Care Law In March 2010, President Obama signed the Affordable Care Act (ACA) into law 6/20/13 Health Insurance Marketplace 101 Health Insurance Marketplace 101

What is the Health Insurance Marketplace? 07/03/2013 What is the Health Insurance Marketplace? 6/20/13 Understanding the Marketplace

Historic Expansion of Coverage Increased Availability of Private Coverage Health Insurance Marketplaces Enrollment opens October 1, 2013 Coverage starting as earlyas January 1, 2014 Expansion of Medicaid Eligibility Starting January 1, 2014 Coverage for individuals under 133% of federal poverty level States receive additional federal funding 100% funding for first three years 90% funding subsequent years http://www.healthcare.gov/law/timeline/full.html#2013 Health Insurance Marketplace 101

Health Insurance Marketplace 07/03/2013 Provides qualified individuals and employers Access to affordable coverage options Ability to buy certain private health insurance Access to health insurance information Allows apples-to-apples comparison of of Qualified Health Plans Understanding the Marketplace 6/20/13

Marketplace Establishment 05/15/2013 Each state can choose between: State Based Marketplace – State creates and runs its own Marketplace State Partnership Marketplace – State partners with Federal government to run some Marketplace functions Federally Facilitated Marketplace – State has a Marketplace established and operated by the Federal government Health Insurance Marketplace 101

How the Marketplace Works 07/03/2013 Coverage to fit individual needs Marketplace affordability May be eligible for help with premiums and out-of-pocket costs Unbiased help and customer support provided Quality health coverage Easy to use 6/20/13 Understanding the Marketplace

How the Marketplace Works (Continued) 07/03/2013 One process to determine eligibility for Qualified Health Plans through the Marketplace New tax credits to lower premiums Reduced cost sharing Medicaid Children’s Health Insurance Program (CHIP) Offers choice of plans and levels of coverage Insurance companies compete for business 6/20/13 Understanding the Marketplace

Marketplace Basic Rules 07/03/2013 Offer Qualified Health Plans that provide basic consumer protections Ensure high quality and choice of plans Provide information on plan premiums, deductibles, and out-of-pocket costs before you decide to enroll Allow you to compare costs and coverage between health insurance plans 6/20/13 Understanding the Marketplace

Qualified Health Plans 07/03/2013 Offered by issuer that is licensed by the state and in good standing Covers Essential Health Benefits Offered by issuer that offers at least one “silver” and one “gold” level plan Offered by issuer that agrees to charge same premium whether offered through or outside the Marketplace 6/20/13 Understanding the Marketplace

Essential Health Benefits 07/03/2013 Qualified Health Plans cover Essential Health Benefits which include at least these 10 categories Ambulatory patient services Prescription drugs Emergency services Rehabilitative and habilitative services and devices Hospitalization Laboratory services Maternity and newborn care Preventive and wellness services and chronic disease management Mental health and substance use disorder services, including behavioral health treatment Pediatric services, including oral and vision care (pediatric oral services may be provided by stand-alone plan) 6/20/13 Understanding the Marketplace

Plan Levels of Coverage Plan Pays On Average Enrollees Pay On Average* (In addition to the monthly plan premium) Bronze 60% 40% Silver 70% 30% Gold 80% 20% Platinum 90% 10% *Based on the aggregate cost under the plan when benefits are provided to a standard population. This may not be the same for every (or any specific) enrolled person. 6/20/13 Understanding the Marketplace

How Qualified Health Plans Can Vary Plans may cover additional benefits You may have to see certain providers or use certain hospitals Premiums, copays, and coinsurance will be different in different plans Quality of care can vary Some special types of plans will be structured differently (e.g., high-deductible plans) 6/20/13 Health Insurance Marketplace 101 Health Insurance Marketplace 101

Understanding the Marketplace Catastrophic Plans 07/03/2013 Who is eligible? Young adults under 30 years of age Those who obtain a hardship waiver from the Marketplace What is catastrophic coverage? Plans with high deductibles and lower premiums Includes coverage of 3 primary care visits and preventive services with no out-of-pocket costs Protects consumers from high out-of-pocket costs 6/20/13 Understanding the Marketplace

Minimum Essential Coverage 07/03/2013 Starting in 2014, most people must have health coverage or pay a fee If you don’t have a certain level of health coverage you may have to pay a fee with your tax return Starting when you file your 2014 Federal tax return in 2015 Some people may qualify for an exemption 6/20/13 Understanding the Marketplace

Medicaid and the Children’s Health Insurance Program (CHIP) 07/03/2013 Eligibility for health coverage extended under new law Simplifies eligibility Coordinated with Qualified Health Plan coverage No wrong door if you apply through Marketplace Streamlined application for affordability programs New website for program information and enrollment 6/20/13 Understanding the Marketplace

Small Business Health Options Program (SHOP) 07/03/2013 Marketplace for small businesses and their employees Beginning 2014, small businesses will have more choice and control over health insurance spending Choices among Qualified Health Plans to meet every budget Access to tax credits for eligible employers New consumer protections 6/20/13 Understanding the Marketplace

What does the Marketplace Mean to Your Practice? 07/03/2013 What does the Marketplace Mean to Your Practice?

Understanding the Marketplace How SHOP Works 07/03/2013 Small employers with <100 FTE employees can qualify Most states will keep upper limit of 50 FTEs for 2014/2015 Employer accesses SHOP where principal office is located or through employee’s primary work sites Employer must offer coverage to all full-time employees Sole proprietors may buy through individual Marketplace rather than through SHOP 6/20/13 Understanding the Marketplace

Medical Practices as Small Businesses Affordable Healthcare Insurance for Employees Access to the Marketplace through SHOP Simplifies finding health insurance in small group market Choose level of coverage offered Define employee contributions to premiums Small business tax credit Currently 35% for qualifying businesses In 2014, up to 50% http://www.healthcare.gov/using-insurance/employers/small-business/index.html http://www.healthcare.gov/marketplace/small-businesses/index.html Health Insurance Marketplace 101

What does the Marketplace Mean to You? 07/03/2013 What does the Marketplace Mean to You?

Changes in Healthcare Access = More Patients Increased Number of Insured Americans + Increased Public Program Enrollment = Increased Healthcare Access More Patients http://www.healthcare.gov/marketplace/costs/index.html http://www.healthcare.gov/law/timeline/#event38-pane http://cciio.cms.gov/resources/files/ffe-guidance-05-16-2012.pdf

Projected Increase in Demand for Services New Emphasis on Primary Care ACA removing cost barriers to patients for basic preventive care services Marketplace network adequacy requirement Potential new contractual opportunities Insurance plans Federally Qualified Health Centers (FQHCs) Other essential community providers http://onlinelibrary.wiley.com/doi/10.1111/j.1468-0009.2011.00620.x/full

Increased Contact Opportunity via Preventive Services Preventive Services Under the ACA Vital to mitigating high costs of preventable conditions New health insurance plans required to cover recommended services without cost sharing Annual wellness visits Other regularly scheduled recommended checks No cost sharing for preventive services under Medicare No or low cost preventive services for Medicaid http://www.healthcare.gov/news/reports/patients-bill-of-rights09232011a.html

Planning for Capacity Building a Sufficient Healthcare Workforce Additional primary care residency slots Support for additional physician assistants Educational support for nursing students Encouraging states to plan and implement innovative workforce expansion strategies Grants to assist low-income individuals in training for jobs in healthcare http://www.hhs.gov/news/press/2010pres/09/20100927e.html

Medicaid Payment Rate Increases Rate Adjustments Expand Medicaid Beneficiary Care Pay for primary care physicians no less than 100% of Medicare payment rates Fully funded by the federal government For primary care services during 2013 and 2014 Allows primary care physicians to provide services to those without prior access to basic care Arizona (AHCCCS) information at http://www.azahcccs.gov/commercial/ProviderBilling/rat es/PCSrates.aspx http://www.healthcare.gov/law/timeline/

Relationship with Insurers Marketplaces require no changes to how practices currently contract with insurers Potential changes to plans which could affect practices: Changes to offerings Changes to the number or size of plan networks Plan networks to include Essential Community Providers http://cciio.cms.gov/programs/Files/ecp-listing-cover-sheet-03262013.pdf http://www.clinicservice.com/blog/2013/02/medical-practice-management-and-new-exchanges-what-expect-2014

What does the Marketplace Mean to Your Patients? 07/03/2013 What does the Marketplace Mean to Your Patients?

3 Things to Know about the Marketplace… 05/15/2013 1. It’s an easier way to shop for health insurance Simplifies the search for health insurance All options in one place One application and an individual or family can explore every qualified insurance plan in the area 2. Most people will be able to get a break on costs 90% of people currently uninsured will qualify for discounted or free health insurance 3. Clear options with apples-to-apples comparisons All plans in the Marketplace present their price and benefit information in plain language 11/13/2018 The Health Insurance Marketplace 101 Health Insurance Marketplace 101

Eligibility and Enrollment 07/03/2013 Marketplace eligibility requires you to Live in its service area, and Be a U.S. citizen or national, or Be a non-citizen lawfully present in the U.S. for entire period for which enrollment is sought Not be incarcerated Can apply for Marketplace if pending disposition of charge Can apply for Medicaid/CHIP at any time 6/20/13 Understanding the Marketplace

When You Can Enroll in the Individual Market 07/03/2013 Marketplace Initial Open Enrollment Period is October 1, 2013 through March 31, 2014 Annual Open Enrollment Periods after that are October 15 through December 7 Special Enrollment Periods available in certain circumstances during the year 6/20/13 Understanding the Marketplace

Understanding the Marketplace The Application 07/03/2013 Available electronically and on paper English and Spanish Federal form Dynamic online version Streamlined paper version State-run Marketplace may have own version Help available to complete application 6/20/13 Understanding the Marketplace

Marketplace Affordability 07/03/2013 Financial help available for working families includes Tax credits lower premiums for qualified individuals Premium Tax Credits Advanced Premium Tax Credits Reduced cost sharing to lower out-of-pocket spending for health care 6/20/13 Understanding the Marketplace

A New Way to Lower Premium Costs 07/03/2013 Refundable or Advanced Premium Tax Credit lowers cost of Qualified Health Plans Eligibility based on: Household income, and family size (at end of year) Income between 100% to 400% of FPL or Federal Poverty Level ($23,550 – $94,200 for a family of four in 2013) Obtaining qualified health insurance through the Marketplace Ineligibility for government-sponsored coverage, affordable employer-sponsored insurance, or certain other minimum essential coverage 6/20/13 Understanding the Marketplace

How much is the Premium Tax Credit? 07/03/2013 Amount depends on: Household income as a percentage of FPL and family size Premium for second lowest cost silver level Qualified Health Plan (the benchmark plan), adjusted for age of covered person Sliding scale increases taxpayer’s contribution towards premium as household income (as percentage of FPL) increases 6/20/13 Understanding the Marketplace

Do I have to wait until I file my taxes to get the tax credit? 07/03/2013 You can reduce your premium amount up front Choose an Advance Premium Tax Credit (APTC) Choose the amount (up to the maximum) Advance payments paid directly to insurer on your behalf The amount is based on projected household income Reconciled at tax time against actual Premium Tax Credit amount you are eligible for Report income changes immediately to avoid overpayment or balance due 6/20/13 Understanding the Marketplace

Who is Eligible for a Cost-Sharing Reduction? 07/03/2013 Eligibility for reduced cost sharing is based on Incomes ≤ 250% of FPL ($58,875 annually for a family of four in 2013) Receiving the Premium Tax Credit Enrolling in a Marketplace silver-level plan Members of Federally-recognized Indian Tribes No cost sharing if income is <300% FPL 6/20/13 Understanding the Marketplace

Medicaid Eligibility in 2014 07/03/2013 New opportunities for states to expand Medicaid eligibility to adults Ages 19 – 64 with incomes ≤ 133% of FPL ($15,282 for individual, $31,322 for family of 4 in 2013) Ensures Medicaid coverage for all children with incomes ≤ 133% of the FPL Simplifies determination of Medicaid/CHIP eligibility Known as Modified Adjusted Gross Income (MAGI) based method 6/20/13 Understanding the Marketplace

Simplifying Medicaid and CHIP Eligibility process relies primarily on electronic data Apply on-line, by phone, by mail, or in person 12-month eligibility period for Adults Parents Children Simplified process for renewing coverage 6/20/13 Understanding the Marketplace

Application and Eligibility 07/03/2013 Application and Eligibility Premium Tax Credit Cost-sharing Reduction Enroll in Marketplace Qualified Health Plan Submit streamlined application to the Marketplace Verify and determine eligibility Eligible for Qualified Health Plan, Medicaid or CHIP Enroll Medicaid/CHIP Online By Phone By Mail In Person Supported by Data Services Hub 6/20/13 Understanding the Marketplace

Enrollment Assistance 07/03/2013 Help available in Marketplaces Marketplace Toll-Free Call Center Certified Assisters Navigators program Non-Navigator in-person assisters Agents and brokers HealthCare.gov and state Marketplace websites 6/20/13 Understanding the Marketplace

Understanding the Marketplace National Marketplace Toll-Free Call Center for Federally Facilitated and State-Partnership Marketplaces 07/03/2013 1-800-318-2596 (TTY 1-855-889-4325) Customer service representatives - 24/7 English and Spanish Language line for 150 additional languages June – September Provide general information to individuals in Marketplace and employees of SHOP employers SHOP call center for Employers – opened in August Starting October Eligibility, enrollment and referral assistance 6/20/13 Understanding the Marketplace

In Person Assistance To… Help prepare electronic and paper applications to establish eligibility Enroll in coverage through the Marketplace Navigators Other trained enrollment assisters Local community health centers Libraries Hospitals and other locations Agents and brokers 6/20/13 Health Insurance Marketplace 101 Health Insurance Marketplace 101

Understanding the Marketplace HealthCare.gov 07/03/2013 Cuidadodesalud.gov for Spanish The consumer site for info now, application and plan comparison in Oct Social media connections Responsive design Accessible for those with visual disabilities 6/20/13 Understanding the Marketplace

Understanding the Marketplace Marketplace.cms.gov 07/03/2013 Get the latest resources to help people apply, enroll, and get coverage in 2014 6/20/13 Understanding the Marketplace

Affordable Care Act – Coverage Accomplishments 3.1 million young adults gained insurance through parents’ plans 6.1 million people with Medicare received $5.7 billion in prescription drug discounts through 2012 34 million people with Medicare received a free preventive service 71 million privately insured people gained improved coverage for preventive services 105 million Americans have had lifetime limits removed from their insurance 6/20/13 Health Insurance Marketplace 101 Health Insurance Marketplace 101

Affordable Care Act – Cost Savings Slowest sustained national health spending growth in 50 years Low growth continued in 2012 for Medicare and Medicaid Rate increases fell from 75% in 2010 to 14% so far in 2013 $1 billion returned to consumers last summer Plans now must spend 80% on healthcare $4.2 billion recovered in 2012 from anti-fraud efforts – a record high – for a total of nearly $15 billion over the last 4 years, double that of the previous 4 years 6/20/13 Health Insurance Marketplace 101 Health Insurance Marketplace 101

Health Insurance Marketplaces Provide new avenue to coverage for individuals and small businesses beginning January 1, 2013 Expand opportunities to provide primary care More people enrolled in private and public plans Increased access to preventive services for patients Reduced cost burden for patients Medicaid payment adjustment for physicians Protect physician ability to deliver essential care across patient populations

5 Ways to Connect With the Marketplace 07/03/2013 Sign up for email or text updates: HealthCare.gov/subscribe Twitter.com/HealthCareGov - Follow @HealthCareGov Facebook.com/HealthCareGov Youtube.com/HealthCareGov The Health Insurance Blog: http://www.healthcare.gov/blog/ 6/20/13 Understanding the Marketplace

Thank You! betsy.thompson@cms.hhs.gov 415.744.3631