1. VIRGINIA’S HEALTH INSURANCE MARKETPLACE --THE BASICS--
Affordable Care Act
Name
Certified Health Care Navigators
Phone Number

2. AFFORDABLE CARE ACT “OBAMACARE”
Goals:
Affordable Insurance Coverage
Private Insurance Reform
Better Health Delivery Systems
Coverage changes on January 1, 2014:
State Option for Medicaid Adult Coverage (no decision yet)
New Insurance Marketplace – Affordable Private Coverage
People/Large Businesses Required to Have/Provide Insurance

3. New Insurance Marketplace
Virginia is served by
“Federally Facilitated Marketplace” (FFM)
To compare / purchase private health insurance
Qualified Health Plans (QHPs)
Premium Tax Credits only available with FFM plans
Also available to small employers in November
Fewer than 50 “full time equivalent” employees
Small Business Health Options Program “SHOP”

4. New Consumer Protections
Before ACA
After ACA
Insurance tied to employment
Not available to adult children
Exclusions for pre-existing conditions
Limited preventative services
Arbitrary cancellations by insurance companies
Inadequate plans
Hard to compare plans side by side
Caps on benefits
Higher risk of bankruptcy
No financial assistance
Limited consumer protections
Insurance available on marketplace
Children covered until age 26
FREE preventative services
Harder for insurers to cancel coverage
10 Essential Health Benefits covered at all plan levels
Side by side comparison across plan levels in simple language
Limits on annual consumer costs
Reduced risk of bankruptcy
Premium tax credits and out-of-pocket costs limits
Stronger consumer protections

5. ENROLLMENT

6. Open Enrollment for Coverage for 2018
November 1, 2017-December 15, 2017
Note: Medicaid/FAMIS applications accepted & processed all year
Currently there are several scenarios in which you can qualify for health insurance under a Special Enrollment.

7. Special Enrollment Periods
I experienced a life change
I got married
I moved to a new state
I welcomed a child
My immigration status changed
I left incarceration
Other situations
Error by Representative
Misconduct by a non-exchange entity (ex. Navigator, CAC, insurance company)
Native Americans & Alaska Natives
Income increased above 100% FPL
I lost my existing coverage
A family member died
I turned 26
I changed jobs
I was terminated from my job
My COBRA, CHIP or Medicaid benefits expired or I lost eligibility
I got a divorce & lost coverage
My employer coverage is no longer affordable or adequate
Does not include voluntary terminations ex. Non-payment

8. SEPs Triggered for Enrollees
Change in income
Enrollee is newly eligible or ineligible for Premium Tax Credits
Enrollee is newly eligible or ineligible for cost-sharing reductions
Enrollee demonstrates plan violated contract

9. Marketplace Eligibility

10. Basic Eligibility
US citizen or national, or non-citizen who is lawfully present in the US for the entire time coverage is sought
Live in service area
Not incarcerated
No access to affordable and adequate insurance
Income between 100% FPL and 400% FPL to receive financial assistance
Some immigrants who are not eligible for Medicaid due to immigration status may qualify for the financial assistance through marketplace despite having income below 100% FPL, however most will fall into the coverage gap.

11. 2017 Federal Poverty Level (FPL)
MAINTAIN:
All correspondence from the Marketplace
Document from Employer with Insurance Premium

12. Qualified Health Plans
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

13. Examples of Free Preventative Care
Regular check-ups and well visits
Mammograms
Cervical cancer, colon cancer and osteoporosis screenings
High blood pressure and cholesterol screenings
Bone density measurements
Flu shots
Developmental screenings, including autism
Multiple health screenings for newborns

14. Eligibility For Financial Assistance
Premium tax credits
reduce the amount you pay for your premium.
Cost sharing reductions lower your deductibles, co-pays and out of pocket costs.

15. Advanced Premium Tax Credits
Income between 100% and 400% FPL
Maximum contribution towards premium
Based on cost of 2nd least expensive Sliver Plan
Income Level
(FPL)
Contribution
From Income
Up to 133% 2% %
3 – 4% %
4 – 6.3% %
6.3 – 8.05% %
8.05 – 9.5% %
9.5%
$306 = $25.50
$5000 Policy – $417/mo
Tax credit - $391/mo

16. Using the Tax Credit
Tax credit can be used for all plans except catastrophic
Tax credit can be received as a refund when you file your taxes at the end of the year
Or it can be paid in advance directly to the insurance plan to help pay monthly premiums
Must report changes in income/family size during the year to ensure an accurate tax credit amount
“Reconciliation” will occur when taxes are filed

17. Cost-Sharing Reductions: The Importance of Silver Plans
Special out-of-pocket protections for those with income under 250% FPL
Only applies if Silver Plan is purchased!
Increases Actuarial Value of Silver Plans to:
94% AV (income 100%-150% FPL)
87% AV (income 150%-200% FPL)
73% AV (income 200%-250% FPL)

18. Choosing Your Plan Monthly Premium is only one factor Also Consider
Deductible
Cost sharing – Co-insurance – Co-payments
Provider Network - Specialists
Drug Formulary
Review service descriptions and exclusions or limits on coverage

19. Standardized Plan Descriptions
12/17/2013
Standardized Plan Descriptions
Summary of Benefits and Coverage (SBC)
Uniform Glossary of Terms

20. Enrollment Process

21. How to Apply: Multiple “doors”
Online
Marketplace
Medicaid/FAMIS
Phone
Marketplace –
Cover VA (Medicaid/FAMIS)–
Local assistance
Enroll Virginia –

22. Information Needed to Apply
Availability of Employer-based Coverage
Identity of applicants
Names and contact info
Social Security Numbers
Immigration Status and Documents
Household Size
Using tax code principles to determine household size
Tax dependents are in the tax filers household
Countable Income (MAGI)
Using tax code principles & expected 2017 income
Databases will verify most information
Paper documents used for discrepancies

23. MAGI: Modified Adjusted Gross Income
Count:
Taxable wages/salary
Profit from self-employment
Social Security benefits (SSDI, retirement)
Unemployment benefits
Alimony received
Most retirement benefits (including VA pensions)
Interest (including tax-exempt interest)
Rental income
Do not count:
Child support received
Supplemental Security Income (SSI)
Workers’ compensation payments
Veteran’s benefits (service-related disability)
Gifts/Inheritances
Pre-tax deductions (IRAs, childcare, health)
Alimony paid
Social Security of dependents who aren’t required to file taxes

24. Renewing Coverage for 2018
Most consumer’s plans will be automatically renewed
Insurers are required to inform consumers of
Continuation of previously selected plan
Changes to previously selected plan
Premium increases
Financial assistance the consumer will receive in 2015
The Marketplace will also communicate with consumers enrolled in the Marketplace informing them of the automatic renewal process

25. What Action Should I Take?
Consumers should still review their Marketplace account and sign up by December to:
Confirm anticipated income for 2018
Confirm continued eligibility
Determine if they are enrolled in the best plan
Determine if they are eligible for additional assistance
Update application to reflect changes in income or household expected in 2018
Notes:
New plans may be available
Some plans premiums may increase more than others
Watch for changes in networks and drug coverage

26. Dates to remember during open enrollment
Apply and enroll: November 1 – December 15, 2017
Effective dates:
Enroll/update by December 15: New coverage starts January *
*Very important: new rates will apply and have to be paid to maintain coverage

27. Tax Penalties & Exemptions

28. Exemptions & Penalty
Everyone is required to have minimum essential coverage (MEC) or pay a “shared responsibility payment,” unless exempt
Taxpayer is responsible for dependents
Coverage requirement, penalties, and most exemptions apply on a monthly basis
One day rule:
A person has coverage entire month if covered for at least one day of that month
A person is eligible for an exemption entire month if they are exempt for at least one day of that month.

29. Minimum Coverage Requirements Tax Penalties
Individual / Family penalty is much less than cost of insurance.
Penalty is the greater of:
$95 /adult + $47.50 /child (up to $285) or 1% family income*
$325/adult + $165.50/child (up to $975) or 2% family income*
$695/adult + $347.50/child (up to $2085) or 2.5% family income*
Future penalty amounts will be the amounts adjusted for inflation.*
*Some Exemptions Apply

30. Exemptions from the Penalty
Granted by Marketplace
Hardship, including:
Life circumstances (homelessness)
Recent death of close family member
Bankruptcy in the last 6 months
Debt from medical expenses in last 24 months
Domestic violence
Plan cancellation
+ MORE
Insurance is considered unaffordable at beginning of year (projected)
See
Granted at Tax Filing
Income below filing threshold
Member of tax household born, adopted or died
Incarceration
Certain noncitizens
Short coverage gap (<3 months)
In a state that did not expand Medicaid
Insurance is considered unaffordable (based on actual household income (more than 8.16%)
Member of Indian tribe or eligible for Indian Health services
Citizens living abroad for 330 days of the year
Religious conscience

31. How Can I Apply for an Exemption for 2018?
Hardship Exemptions
Download the exemption form from the healthcare.gov website.
If approved, an exemption certificate with an Exemption Code Number to be used on your taxes will be issued.
Insurance is unaffordable based on projected income
Complete a Marketplace Application during Open Enrollment
If approved for an exemption, an Exemption Code Number will be generated on your Eligibility Notice to be used on your taxes.
IRS Granted Exemptions
These are granted when you file your taxes, see IRS form 8965 for more details.
Contact a navigator at for assistance

32. Additional Resources
Centers for Medicare & Medicaid Services (CMS): 
Health Insurance Marketplace:
Kaiser Family Foundation:
Center on Budget and Policy Priorities:

33. Twitter-@EnrollVirginia
QUESTIONS?
Phone Number
Facebook-

34. 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 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.