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What we’ll cover today Overview of the ACA and expanded coverage New coverage Options: Medicaid expansion and the Health Insurance Marketplace Subsidies and the uninsured Enrollment: who will enroll everyone who qualifies? Qualified Health Plans (QHP) Examples of individual and family situations Take Aways Resources 2

The ACA Is Signed into Law March 23, 2010 It is the law of the land 3

The ACA Builds on Our Existing System 4

Four Goals of the ACA Strong emphasis on prevention New regulations of the insurance industry Cost containment Expand access to virtually every American 5

Prevention No financial barriers for clinically appropriate preventive services No co-pays; no deductibles Most private plans and Medicare 6

Preventive Services Examples ◦ Mammography ◦ Cervical cancer screening ◦ Childhood immunizations ◦ Obesity screening/counseling ◦ All FDA-approved contraceptives ◦ Domestic violence screening ◦ Breastfeeding support ◦ Vision screening for children ◦ Many more 7

Insurance Regulations Young adults can stay on their parents’ policy to age 26 No pre-existing condition exclusions No lifetime or annual limits on benefits No gender rating Limit profits/admin to 80/85% 8

Cost Containment USA health costs highest in world Goal: Increase quality and lower rate of increase Reduce Medicare Advantage Costs Change payment/delivery system 9

Expanding Health Insurance Coverage: An Overview 10

The ACA Expands Coverage in Two Primary Ways Expand Medicaid up to 138 percent of the federal poverty level (FPL) Establish the Health Insurance Marketplace that offers subsidized private insurance plans Subsidies for people earning between % of FPL 11

New Coverage Options 12

Medicaid Expansion: Income Eligibility for a Family of Three 13

Medicaid Expansion Governor Tomblin approved the Medicaid expansion in May 133,500 low-income West Virginians become eligible for Medicaid Enrollment begins October 1, 2013 and coverage begins January 1,

Medicaid Expansion Federal government pays 100% of the expansion costs the first three years The federal share gradually reduces but never drops below 90% Medicaid is exempt from sequestration 15

Health Insurance Marketplace 16

Health Insurance Marketplace Offers private insurance policies: Highmark Blue Cross Blue Shield will be the only insurance company in WV’s Marketplace in 2014 Who is eligible? ◦ People without access to employer sponsored plans ◦ Don’t have government plans (Medicaid, Medicare, Tricare, VA, etc.) 17

Health Insurance Marketplace Subsidies for individuals and families on a sliding scale earning between 100% and 400% of the FPL 400% of FPL is $46,000 for a single person and $78,000 for a family of three 18

Subsidy for family of 4 earning $55, Family of four with annual income of $55,000. They pay $337 a month in premiums and the tax credits equal $624 a month, 65% of the total premium. Additional assist with deductibles and copayments plus out-of-pocket maximum protection. Policy Cost = $961 Family Pays = $337 Govt. Subsidy = $624 (65% ) Additional assist with copayments And out-of-pocket maximum

Health Insurance Marketplace Estimated 99,000 West Virginians will qualify for subsidies(2016) 20

Small Business Health Insurance Marketplace(SHOP) Eligibility for SHOP is 50 or fewer employees, About 42,000 West Virginia businesses employing 280,000 people 16,000 employees projected to be enrolled by

Who are the uninsured? 48% Healthy and Young  Take health for granted  Tech savvy  Low motivation to enroll 29% Sick, Active and Worried  Generation X and Baby Boomers 15% Passive and Unengaged  49 and older  Live for today  Don’t understand health insurance 22 Source: HHS Marketing Survey, March 2013

Uninsured in West Virginia, Ages % 52% 63% Live in Families with at least One Full Time Worker A majority of uninsured West Virginians are under age 39 with more than a quarter of the uninsured between ages 19 and 29 Sources: Kaiser Commission on Medicaid and the Uninsured, October 2012

Enrollment Opportunities in West Virginia by

Enrollment: Personal Assistance Needed 78% of people who will qualify for assistance know nothing about it Skeptical and interest framed by past negative experience 75% want personal assistance 25

How Will the Enrollment Process Work? 26

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How Do We Enroll All These People? On the web: By phone: By mail: Personal assistance 28

Personal Assistance Insurance agents and brokers Navigators  Advanced Patient Advocacy/Hospitals  WV Parent Training and Information Center In-person assisters – 270  Maximus  Placement in CAP agencies, free clinics, etc. Community health center employees Certified Application Counselors DHHR Employees 29

Community Assisters Enroll simple cases in Medicaid Connect the uninsured to web site, 800 number, in-person assisters, community health centers, etc. WVAHC is providing small grants to nonprofit organizations to fund community assisters 30

BREAK BREAK 31

The Enrollment Process Single, streamlined application for Medicaid, CHIP and qualified health plans (QHPs) No asset test for Medicaid & QHPs 32

Medicaid Eligibility ◦ Income ◦ Household size ◦ US citizenship ◦ State Residency ◦ Under age < 138% of FPL

What’s Income? Modified adjusted gross income (MAGI) as reported to IRS For Medicaid and CHIP during the month that an application is made to determine income For QHP income is for year in which person is enrolled MAGI income is verified electronically with the IRS database 34

Who is a family (household) for Medicaid? Household for tax filer = all persons the taxpayer expects to claim as a tax dependent ◦ Except: Custodial parent counts child in household even if other spouse claims child as tax dependent Household for non-tax filers = individual plus spouse and children living with individual. 35

Example: Married Couple with Children Reyes family: married couple with 2 children Mom and dad file a joint return and claim both children as dependents HH = 4 If Mrs. Reyes is Pregnant, HH = 5 36

Example: Three generation household Rose lives with and supports her 60- year old mother and 7-year old daughter Rose is the tax filer and claims her daughter and mother as dependents HH = 3 37

Example: Child Claimed by Non-Custodial Parent Lisa lives with her son and files taxes as a single individual Non-custodial dad claims son Household for Medicaid = 2 38

Why Household Size Matters Family Size138% of FPL155% of FPL 1$15,856$17,810 2$21,404$24,040 3$26,951$30,272 4$32,499$36, % applies to children over age one and adults. 155% applies to pregnant women and children under age one.

Note: Changes in CHIP With the increase in Medicaid eligibility, many children currently enrolled in CHIP will become Medicaid eligible and cannot remain on CHIP: 10,800 CHIP kids transfer to Medicaid 2,800 kids gain CHIP coverage under the new MAGI eligibility rules 40

More Medicaid Enrollment Income/household by self-attestation but checked electronically by IRS data Citizenship is verified electronically with the Social Security Administration Documented (legal) immigrants only qualify for Medicaid under limited circumstances Undocumented immigrants do not qualify at all 41

Medicaid’s Two Step Process: If an applicant is determined eligible for Medicaid, the information is transferred to the Bureau for Medical Services, and enrolled “promptly and without undue delay” An enrollment broker (Automated Health) will ask Medicaid eligible to choose a managed care organization (MCO) 42

Beyond Medicaid Expansion An applicant ineligible for MAGI Medicaid: Will be reviewed, if appropriate, for traditional Medicaid Examples : Persons with disabilities, over age 65, long term care and support, etc. 43

Qualified Health Plans(QHP) If an applicant earns too much to qualify for MAGI Medicaid, and does not qualify for traditional Medicaid, they will be screened for eligibility for a qualified health plan Enrollment in a qualified health plan is more complex than Medicaid and requires consumers to make additional decisions 44

Eligibility for (QHPs) ◦ US citizen or lawfully present in the US ◦ State resident ◦ Under age 65 ◦ Not incarcerated 45

Verification of Eligibility for QHPs US citizenship is verified electronically with the Social Security Administration Legal immigrant status is verified electronically with Homeland Security 46

QHPs come with premium subsidies In order to qualify for premium subsidy, an applicant must meet the qualifications for QHPs plus: ◦ Have projected income between 100% and 400% of the FPL in 2014 ◦ Not have access to other insurance coverage (with two exceptions) ◦ Is expected to file income tax at the end of the coverage year 47

QHPs also have subsidies for cost sharing expenses Individuals and families earning less than 250% of the FPL, and Select a silver plan (to be discussed later), then They receive subsidies to reduce the costs of deductibles, copayments and co-insurances 48

FPL for Cost Sharing Subsidies and Premium Subsidies Family Size250% of the FPL400% of the FPL 1$28,725$45,960 2$38,775$62,040 3$48,825$78,120 4$58,875$94, % of the FPL level is the eligibility threshold for cost sharing reductions and 400% of the FPL is the threshold for premium assistance

QHP Choices: 4 Levels Four “metal levels” of plans are offered in the Marketplace and vary based on their actuarial value The actuarial value is what percentage of legitimate claims the insurance company pays and what percentage on average consumers pay 50

4 Levels of Plan Options for QHPs Platinum plan ◦ Insurance company pays 90% of claims and consumers on average pay 10% of the claims. There is unlikely to be a platinum plan in WV’s Marketplace in 2014 Gold plan = 80/20 Silver = 70/30 Bronze = 60/40 51

Premiums in the Various Metal Levels Premiums in a platinum plan would be higher, while deductibles and copayments would be lower Conversely, the premiums in a bronze plan will be lower, while the cost sharing would be higher 52

Selecting a QHP The Marketplace application process ◦ will guide the applicant to make choices of plan level and plan ◦ Provide a calculator and show applicant the premium, co-pay and deductible for each plan ◦ Show the subsidy amount for plan chosen 53

Summary of Benefits and Coverage The Marketplace will have an 8-page summary of benefits and coverage: ◦ What’s covered, what’s not ◦ Costs for a typical Type II diabetic ◦ Costs for a normal delivery All written in plain English 54

Selecting a QHP The Marketplace will also have links to insurance company’s web site Consumers can check to see if their doctor or hospital are in the company’s network Consumers can check to see if the drug(s) they are taking are on the company’s formulary 55

Employer Plans and ACA 56

Employer Responsibility More than 50 employees; offer coverage or pay fine of $2000/FTE ◦ Starting in 2015 Less than 50 employees, no requirement to offer coverage ◦ Potential option for better value plans through the Marketplace 57

QHPs and Employer Sponsored Insurance Generally, if someone is offered employer coverage, they do not qualify for premium tax credits in the Marketplace. Two exceptions: ◦ Employer coverage does not provide minimum value (60% actuarial value) ◦ Premium for the employer’s lowest cost single plan cost an employee’s family more than 9.5% of their income 58

Timelines Enrollment begins October 1, 2013 If someone enrolls by the 15 th of the month, then coverage for Medicaid and qualified health plans begins the first day of the following month. Get people enrolled by December 15 th. If after the 16 th on the month, coverage begins on the first day of the month six weeks later. 59

Coverage Examples 60

Scenario One: Mary Parsons Married One child age 3 Waitress Earns $20,000/year including tips Her husband is unemployed and takes care of their child. Child is on Medicaid Mary/Husband are uninsured 61

Scenario Two: Mollie Brown Mollie lives with her two children and boyfriend, Ken. Ken earns about $46,000 and is insured through his employer. Molly earns $20,000 and receives an additional $12,000 per year in child support. Molly’s children are enrolled In CHIP in Medicaid. Molly is uninsured. 62

Scenario Three: Sam Simpson Sam owns a car repair shop. He is single and makes about $30,000 a year from his business. He has two full- employees who earn about $8 an hour. Neither Sam nor his employees have health coverage. Sam always wanted to provide health coverage but he could not afford it. What would you advise Sam? 63

Scenario Four: Sara Jones Sara is divorced with two children age 8 and 11. She works as a self-employed accountant and earns $60,000 per year. She also receives child support of $6,000 per year, and her children are reported on her tax return. Sara had breast cancer 2 Years ago. The children have health insurance through their father but Sara is uninsured. 64

Scenario Five: Bill and Kate Bill and Kate have a new baby Bill works as a CEO making $90,000 a year and Kate will stay home to raise the baby Bill’s employer pays 100% of the cost of a single plan, but nothing for spousal coverage. They owe $20,000 for the birth The family plan costs Bill $9,000 a year. How would you advise him? 65

Take Aways The uninsured can enroll where ever there is a lap top or iPad with internet connection. They can also use a toll-free call center or personal assistance. 66

Take Aways For the most part, the process will be paperless and will rely on electronic databases or self- attestation to determine eligibility for Medicaid, CHIP or the QHPs 67

Take Aways If income of family size changes, these changes really need to be reported to the Marketplace The IRS will conduct a reconciliation process at the end of If an individual or family received a tax credit more than they were entitled to, they will be required repay some or all of the overpayment 68

Take Aways: Privacy If you are assisting someone with an enrollment application, you may be exposed to personal information: social security numbers, income, immigration status, etc. It is best to avoid knowing personal information, and it is imperative that you keep personal information strictly confidential. 69

Take Aways The numbers are staggering: ◦ 133,500 eligible for Medicaid ◦ 99,000 eligible for premium assistance ◦ 16,000 eligible for the SHOP Marketplace 70

Opportunity We have a once-in-a-lifetime opportunity to improve the lives of thousands of our friends and neighbors. We hope you will join WVAHC in this journey We need… 71

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Important Web Sites wvahc.org enrollwv.org healthcare.gov marketplace.cms.gov kff.org enrollamerica.org familiesusa.org 73

Contact Information Perry Bryant (Home & Office) (Cell) 74

Contact Information Renate Pore 75