Affordable Care Act Marketplace Implementation Briefing Virginia Association of Counties June 5, 2013 H EALTH C ARE.GOV Joanne Corte Grossi, MIPP Regional Director U.S. Department of Health & Human Services, Region III Pennsylvania, Delaware, District of Columbia, Maryland, Virginia, West Virginia

Critical Need for Health Reform 48.6 million uninsured Americans 48.6 million uninsured Americans $3 trillion spent annually on healthcare $3 trillion spent annually on healthcare 17.9 % of our economic output tied up in the health care system 17.9 % of our economic output tied up in the health care system Without reform, by 2040, 1/3 of economic output tied up in health care Without reform, by 2040, 1/3 of economic output tied up in health care

Affordable Care Act Overview Provides coverage to young adults up to the age of 26 Provides coverage to young adults up to the age of 26 Strengthens Medicare benefits with lower prescription drug costs for those in the ‘donut hole,’ chronic care, and free preventive care Strengthens Medicare benefits with lower prescription drug costs for those in the ‘donut hole,’ chronic care, and free preventive care Prohibits plans from imposing lifetime and annual limits on the dollar value of benefits, and from rescinding coverage when you get sick Prohibits plans from imposing lifetime and annual limits on the dollar value of benefits, and from rescinding coverage when you get sick

Affordable Care Act Overview Rein in insurance premiums rates Rein in insurance premiums rates Prevent denials of coverage, including for pre-existing conditions Prevent denials of coverage, including for pre-existing conditions Make health insurance affordable for middle class families Make health insurance affordable for middle class families Make health insurance affordable for small businesses with tax cuts Make health insurance affordable for small businesses with tax cuts

Health Insurance Marketplace Sometimes called “Exchanges,” the Marketplace is required by the ACA to be created by January 1, 2014 Sometimes called “Exchanges,” the Marketplace is required by the ACA to be created by January 1, 2014 New “marketplace” where small businesses and individuals can select and enroll in a private health insurance plan New “marketplace” where small businesses and individuals can select and enroll in a private health insurance plan Consumers will have Consumers will have the same level of benefits and coverage available to members of Congressthe same level of benefits and coverage available to members of Congress more choice and selection in health plansmore choice and selection in health plans

Three models available Three models available State-Based State-Based Federal-State Partnership Federal-State Partnership Federally-Facilitated Federally-Facilitated States can apply for Marketplace establishment funding at any time and be awarded grants through 2014 States can apply for Marketplace establishment funding at any time and be awarded grants through 2014 HHS to operate marketplaces for States that have not elected to do so HHS to operate marketplaces for States that have not elected to do so Marketplace Implementation

Actuarial Value The ACA requires plans inside the Marketplace to meet particular actuarial value (AV) targets The ACA requires plans inside the Marketplace to meet particular actuarial value (AV) targets Bronze = 60% AVBronze = 60% AV Silver = 70% AVSilver = 70% AV Gold = 80% AVGold = 80% AV Platinum = 90% AVPlatinum = 90% AV “Metal Levels” will enable consumers to compare plans with similar levels of coverage, promote competition on premiums, and allow plans flexibility to design cost sharing structures “Metal Levels” will enable consumers to compare plans with similar levels of coverage, promote competition on premiums, and allow plans flexibility to design cost sharing structures

Financial Assistance Premium tax credits Premium tax credits Will reduce the premium amount the consumer owes each monthWill reduce the premium amount the consumer owes each month Available to eligible consumers with household incomes between 100% and 400% of the FPL ($44,680 for an individual and $92,200 for a family of 4 in 2012), and who don’t qualify for other health insurance coverageAvailable to eligible consumers with household incomes between 100% and 400% of the FPL ($44,680 for an individual and $92,200 for a family of 4 in 2012), and who don’t qualify for other health insurance coverage Based on household income and family size for the taxable yearBased on household income and family size for the taxable year Paid each month to the insurerPaid each month to the insurer

Financial Assistance Cost-sharing reductions: Cost-sharing reductions: Reduce out-of-pocket costs (deductibles, coinsurance, copayments) Reduce out-of-pocket costs (deductibles, coinsurance, copayments) Generally available to those with income 250% FPL or below ($27,925 for an individual and $57,625 for a family of 4 in 2012)Generally available to those with income 250% FPL or below ($27,925 for an individual and $57,625 for a family of 4 in 2012) Based on household income and family size for the taxable yearBased on household income and family size for the taxable year

Essential Health Benefits Essential Health Benefits Ambulatory patient servicesAmbulatory patient services Emergency servicesEmergency services HospitalizationHospitalization Maternity and newborn careMaternity and newborn care Mental health and substance use disorder services, including behavioral health treatmentMental health and substance use disorder services, including behavioral health treatment Prescription drugsPrescription drugs Rehabilitative and habilitative services/devicesRehabilitative and habilitative services/devices Laboratory servicesLaboratory services Preventive and wellness services and chronic disease managementPreventive and wellness services and chronic disease management Pediatric services, including oral and vision carePediatric services, including oral and vision care Quality Insurance

Enrollment Process Consumer submits application to the marketplace Consumer submits application to the marketplace OnlineOnline PhonePhone MailMail In PersonIn Person The marketplace verifies and determines eligibility for The marketplace verifies and determines eligibility for enrollment in a Qualified Health Plan (QHP)enrollment in a Qualified Health Plan (QHP) tax credits and cost-sharing reductionstax credits and cost-sharing reductions Medicaid or CHIPMedicaid or CHIP Consumer enrolls in a QHP or Medicaid/CHIP Consumer enrolls in a QHP or Medicaid/CHIP Online plan comparison tool available to inform health plan choiceOnline plan comparison tool available to inform health plan choice Tax credit is sent to insurer (if eligible) to reduce consumer premium owedTax credit is sent to insurer (if eligible) to reduce consumer premium owed

Enrollment Assistance HHS grant program to fund entities or individuals called “Navigators” that will provide consumer assistance and: HHS grant program to fund entities or individuals called “Navigators” that will provide consumer assistance and: Maintain expertise on MarketplacesMaintain expertise on Marketplaces Provide information to consumers in a fair, accurate and impartial mannerProvide information to consumers in a fair, accurate and impartial manner Facilitate QHP selectionFacilitate QHP selection Refer consumers to other resourcesRefer consumers to other resources Provide information in a culturally and linguistically appropriate mannerProvide information in a culturally and linguistically appropriate manner Navigators cannot accept indirect or direct compensation from issuers for enrolling individuals in QHPs or other health plans offered outside of the Marketplace Navigators cannot accept indirect or direct compensation from issuers for enrolling individuals in QHPs or other health plans offered outside of the Marketplace

Initial Open Enrollment Period October 1, 2013 – March 31, 2014 October 1, 2013 – March 31, 2014 Enroll during the Initial Open Enrollment Period Your coverage is effective* On or before December 15, 2013 January 1, 2014 Between the 1 st and 15 th day of January – March First day of the following month Between the 16 th and the last day of December – March First day of the second month

Highlights for Small Businesses Starting in 2014, all individuals will be required to have health insurance Starting in 2014, all individuals will be required to have health insurance Businesses with fewer than 50 full-time employees are exempt from any requirement to contribute towards employee health coverage Businesses with fewer than 50 full-time employees are exempt from any requirement to contribute towards employee health coverage More than 96 percent of employers with 50 or more employees already offer their employees health insurance coverage More than 96 percent of employers with 50 or more employees already offer their employees health insurance coverage The IRS and Department of Labor have oversight of Employer Responsibility provisions of the ACA The IRS and Department of Labor have oversight of Employer Responsibility provisions of the ACA

Highlights for Small Businesses In 2014, small businesses can participate in Exchanges as part of the Small Business Health Options Program (SHOP) In 2014, small businesses can participate in Exchanges as part of the Small Business Health Options Program (SHOP) More affordable coverage because of access to larger risk poolsMore affordable coverage because of access to larger risk pools Small businesses will have increased bargaining power and reduced administrative costs—just like large companies Small businesses will have increased bargaining power and reduced administrative costs—just like large companies Tax credit of up to 50% available to companies with 25 FTEs or less Tax credit of up to 50% available to companies with 25 FTEs or less

Highlights for Small Businesses Full time is defined as 30 hours per week Full time is defined as 30 hours per week Employer will be liable for Shared Responsibility if: Employer will be liable for Shared Responsibility if: Does not offer cover to 95% of its full-time employees; Does not offer cover to 95% of its full-time employees; And at least one full-time employee receives a premium tax credit to help pay for coverage on Exchange And at least one full-time employee receives a premium tax credit to help pay for coverage on Exchange

Medicaid Expansion 400,000 Virginians would receive coverage400,000 Virginians would receive coverage 100% federally funded for first three years ( )100% federally funded for first three years ( ) Federal funding gradually reduced to 90% in 2020Federal funding gradually reduced to 90% in 2020 $9 billion in first six years$9 billion in first six years

Resources: Affordable Care Act website – Affordable Care Act website – Health Insurance Marketplace – Health Insurance Marketplace –marketplace.cms.gov Center for Consumer Information & Insurance Oversight website – Center for Consumer Information & Insurance Oversight website – Affordable Care Act Spanish Affordable Care Act Spanish website –

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