Affordable Care Act Marketplace Implementation Briefing PA Association of CHC's 2013 Statewide Conference & Clinical Summit October 10, 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

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

Affordable Care Act Overview Increases the number of Primary Care Practitioners – Provides new investments to increase the number of primary care practitioners, including doctors, nurses, nurse practitioners, and physician assistants Increases the number of Primary Care Practitioners – Provides new investments to increase the number of primary care practitioners, including doctors, nurses, nurse practitioners, and physician assistants Projected to place more than 16,000 health professionals over next 5 years Projected to place more than 16,000 health professionals over next 5 years Community Health Centers - Increases funding for Community Health Centers to allow for nearly a doubling of the number of patients seen by the centers over the next 5 years Community Health Centers - Increases funding for Community Health Centers to allow for nearly a doubling of the number of patients seen by the centers over the next 5 years 38 PA CHC’s received over $4.1 million for outreach and enrollment assistance38 PA CHC’s received over $4.1 million for outreach and enrollment assistance

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 For those who are uninsured or who purchase private health insurance For those who are uninsured or who purchase private health insurance

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

Pennsylvania will be a Federally Facilitated Marketplace Pennsylvania will be a Federally Facilitated Marketplace 600,000 Pennsylvanians eligible to enroll through the marketplace 600,000 Pennsylvanians eligible to enroll through the marketplace Pennsylvania has received $34,832,212 to date Pennsylvania has received $34,832,212 to date 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 ( 45,960 for an individual and $94,200 for a family of 4), and who don’t qualify for other health insurance coverageAvailable to eligible consumers with household incomes between 100% and 400% of the FPL ( 45,960 for an individual and $94,200 for a family of 4), 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

PA Insurance Plans 15 Insurance Companies to Participate 15 Insurance Companies to Participate 56 plans for Pennsylvanians to choose from 56 plans for Pennsylvanians to choose from Family of Four – Bronze Plan Family of Four – Bronze Plan $152 per month after tax credit$152 per month after tax credit Individual – Bronze Plan Individual – Bronze Plan $109 per month after tax credit$109 per month after tax credit

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 Help will be available in the Marketplace Help will be available in the Marketplace  Toll-free call center  24/7 (closed Memorial Day, Independence Day, Labor Day, Thanksgiving Day and Christmas Day)  150 languages  Website chat 24/7 (English and Spanish)  Help in-person  Navigators  Other trained enrollment assisters  Local Community Health Centers, libraries, hospitals and other locations in local communities  Agents and brokers

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

Medicaid Expansion 650,000 Pennsylvanians will be eligible for health insurance if Medicaid is expanded650,000 Pennsylvanians will be eligible for health insurance if Medicaid is expanded 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 $17 billion in first six years$17 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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