VIRGINIA’S HEALTH INSURANCE MARKETPLACE/MEDICAID/FAMIS --THE BASICS-- 2018-2019 ACA Name Healthcare Navigator E-mail VPLC Richmond, VA T: xxx-xxx-xxxx

What is the Marketplace? VA uses the Federally Facilitated Marketplace (FFM) Place where individuals and small businesses can shop for Private health insurance plans Allows for comparisons of Qualified Health Plans Uses plain language to explain coverage options After submitting an application, there is no obligation to enroll in a health plan Financial assistance available only through FFM

Free Preventive Services Well visits (1 per year) Blood pressure & cholesterol screening  Cancer screenings  Depression screening  Diabetes screening  Diet counseling for adults with chronic diseases HIV/STD screening and counseling Obesity screening and counseling Immunizations Alcohol/tobacco use screening and counseling Contraception

Qualified Health Plans in the Marketplace 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

Eligibility for Marketplace Insurance To purchase insurance on the Marketplace: Live in its service area Be a U.S. citizen or national, or be a non-citizen who is lawfully present in the U.S. Not be incarcerated To get financial assistance: Not have access to other affordable and adequate insurance Have income between 100% and 400% of the federal poverty guidelines Not receiving or eligible for “minimum essential coverage”: Medicaid, FAMIS, Medicare “Affordable & Adequate ” job-based coverage Job-based coverage is not affordable/adequate if employee-only plan: cost to employee not ↑9.5% household income; or covers ↓60% healthcare costs & essential health benefits

Premium Tax Credits & Cost-Sharing Reductions Cost Sharing Reductions reduce the amount of your deductibles and out of pocket costs. Available for those with income at or below 250% of FPL. Only applies if Silver Plan is purchased Premium Tax Credits (PTCs) reduce the amount of your monthly insurance premium.

2019 Federal Poverty Guidelines Household/ Family Size 100% 138% 150% 200% 250% 300% 400% 1 $12,140 16,753 18,210 24,280 30,350 36,420 48,560 2 $16,460 22,715 24,690 32,920 41,150 49,380 65,840 3 $20,780 28,676 31,170 41,560 51,950 62,340 83,120 4 $25,100 34,638 37,650 50,200 62,750 75,300 100,400 5 $29,420 40,600 44,130 58,840 73,550 88,260 117,680 6 $33,740 46,561 50,610 67,480 84,350 101,220 134,960 7 $38,060 52,523 57,090 76,120 95,150 114,180 152,240 8 $42,380 58,484 63,570 84,760 105,950 127,140 169,520

Information needed to apply Availability of employer-based coverage Identity of household members, tax filing principles Name and contact information Social security number Immigration status Household size Estimated yearly income Free application assistance available!

2019 Open Enrollment is Coming! Open Enrollment (OE) Period Annual period when anyone can apply and enroll in coverage OE for 2019 coverage: November 1, 2018 – December 15, 2018 Special Enrollment Periods (SEPs) Allow people who experience life changes outside open enrollment to enroll in or change plans Available all year long Those eligible usually have 60 days from the life change to enroll in a plan Note: Medicaid/FAMIS applications are processed all year long

Medicaid and FAMIS in VA MEDICAID AND FAMIS HEALTH INSURANCE IN VIRGINIA Medicaid and FAMIS in VA

Many complexities and rules often change, this is just an overview! Medicaid and FAMIS Many complexities and rules often change, this is just an overview! Eligibility is limited to people in certain categories Financial eligibility varies depending on category Some categories also have a resources test Annual renewal must be completed to maintain coverage If eligible for full benefits Medicaid, cannot get financial assistance on the Marketplace

Coverage Categories Medicaid Newly Eligible (Medicaid Expansion!) Families and Children Children under age 19 (FAMIS Plus)* Pregnant Women* Low Income Families and Children (LIFC)* Foster Care and Adoption Assistance & Children up to 21 Former Foster Care Youth (up to age 26) Aged, Blind and Disabled* Limited Benefits Plan First, Family planning services only Breast & Cervical Cancer Treatment Governor’s Access Plan (GAP), for those with Serious Mental Illness Spend-down Medicare Savings Programs CHIP (CHILDREN’S HEALTH INSURANCE PROGRAM) Children (FAMIS)* Pregnant women (FAMIS MOMS)* * For more details ask for an in-person appointment to discuss further elegibility

Medicaid Expansion!!! Legislature adopted May 30, 2018! “Newly eligible” adults: Aged 19 through 64, Not eligible for an current full- benefit Medicaid category or Medicare MAGI income up to 138% FPL No resource test About 300,000+ will get coverage New coverage begins January 1, 2019

New Income Limit for Medicaid- 138% FPL

Income Limits for FAMIS- 200% FPL

Applications Application Time limits 10 days pregnant women 90 days when disability determination 45 days all others 3 months retroactive coverage available if eligible, Medicaid only (not FAMIS or FAMIS MOMS) Retroactivity cannot go past January 1, 2019 for “newly eligible”

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

COBRA Option & the Marketplace

COBRA vs. Marketplace Coverage Individuals who lose job-based coverage may be offered COBRA, however it is often expensive. Losing job-based coverage qualifies you for a Special Enrollment Period (SEP) to enroll in Marketplace coverage. This means you have 60 days before and 60 days after you lose coverage to enroll in a health plan, even if it’s outside open enrollment. If you enroll in COBRA, voluntarily dropping it will not trigger an SEP. You can only voluntarily drop it and enroll in a Marketplace plan during open enrollment. If COBRA naturally expires, it sparks an SEP. If you qualify for a different SEP, you can drop COBRA and enroll in a Marketplace plan. For example, if you move. If your previous employer is helping you pay for COBRA and then stops, you qualify for a SEP. Once you opt out of COBRA, you will not have the opportunity to opt back into it. It is important to compare plans before making a decision!

Comparing Plans What are the costs of each plan? Premiums Deductibles Co-payments and co-insurances Are your current doctors and hospitals covered? Are your current medications covered? Do you have any planned medical treatment? Do any of your current medications or planned procedures require prior authorization? How much have you already spent on healthcare this year? Have you met your deductible?

Tax Penalties & Exemptions

Minimum Coverage Requirements and Tax Penalties Individual / Family penalty is much less than cost of insurance. Penalty is the greater of: 2018 - $695/adult + $347.50/child (up to $2085) or 2.5% family income above the tax filing threshold (up to the national average price of a bronze plan - $223/mo). For 2018 tax returns: All laws about health coverage and tax penalties still apply. IRS may process returns without health coverage information, but penalties can be assessed later. Some exemptions apply For 2019 the tax penalty does not apply

Exemptions Granted by Marketplace Granted at Tax Filing Hardship, including: Experienced homelessness, an eviction or foreclosure, or received a utility shut off notice. Bankruptcy Victim of domestic violence Determined ineligible for Medicaid in a state that did not expand Medicaid coverage  Plan cancellation Member of certain religious sects Other Insurance in unaffordable based on projected income Granted at Tax Filing Income below filing threshold Insurance is unaffordable, actual income Certain noncitizens Short coverage gap (<3 months) Gap before effective date of Marketplace coverage purchased during open enrollment Having income below 138% FPL in a state that did not expand Medicaid Health care sharing ministry Indian tribe membership Incarceration US citizen living abroad for more than 330 day in the year An exemption for a state’s failure to expand Medicaid can be received by applying for coverage directly at healthcare.gov if your projected income is below 100% FPL

ADDITIONAL HEALTHCARE OPTIONS Sliding Scale Clinics Healthcare coverage is based on income and might have pharmacy help Health Care Centers (FQHC) Have primary care doctors plus more, operate on a sliding scale up to 200% FPL, and do not turn away insured patients Free Clinics Offer free services for the uninsured with little to no income and have volunteer doctors Our education extends to various types of clinics due to not having Medicaid expansion. Private Family Practice This is a typical medical practice NOT a sliding scale or free clinic

Twitter-@EnrollVirginia QUESTIONS? Phone number E-mail 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.