1. Fundamentals of the Health Insurance Marketplace
07/03/2013
Fundamentals of the Health Insurance Marketplace
September 2013
Betsy L. Thompson, MD, DrPH
Chief Medical Officer, Region IX

2. Objectives This session will help you:
07/03/2013
This session will help you:
Explain the Health Insurance Marketplace
Understand what it means
To you
Your practice
Your patients
Locate Marketplace resources

3. Health Insurance Marketplace 101
The Problem
Insurance companies could turn away 129 million Americans with pre-existing conditions
Premiums more than doubled over the last decade, while insurance company profits soared
Tens of millions were underinsured, and many who had coverage were afraid of losing it
50 million Americans had no insurance at all
6/20/13
Health Insurance Marketplace 101
Health Insurance Marketplace 101

4. Health Insurance Marketplace 101
The Health Care Law
In March 2010, President Obama signed the Affordable Care Act (ACA) into law
6/20/13
Health Insurance Marketplace 101
Health Insurance Marketplace 101

5. What is the Health Insurance Marketplace?
07/03/2013
What is the Health Insurance Marketplace?
6/20/13
Understanding the Marketplace

6. Historic Expansion of Coverage
Increased Availability of Private Coverage
Health Insurance Marketplaces
Enrollment opens October 1, 2013
Coverage starting as earlyas January 1, 2014
Expansion of Medicaid Eligibility
Starting January 1, 2014
Coverage for individuals under 133% of federal poverty level
States receive additional federal funding
100% funding for first three years
90% funding subsequent years
Health Insurance Marketplace 101

7. Health Insurance Marketplace
07/03/2013
Provides qualified individuals and employers
Access to affordable coverage options
Ability to buy certain private health insurance
Access to health insurance information
Allows apples-to-apples comparison of of Qualified Health Plans
Understanding the Marketplace
6/20/13

8. Marketplace Establishment
05/15/2013
Each state can choose between:
State Based Marketplace – State creates and runs its own Marketplace
State Partnership Marketplace – State partners with Federal government to run some Marketplace functions
Federally Facilitated Marketplace – State has a Marketplace established and operated by the Federal government
Health Insurance Marketplace 101

9. How the Marketplace Works
07/03/2013
Coverage to fit individual needs
Marketplace affordability
May be eligible for help with premiums and out-of-pocket costs
Unbiased help and customer support provided
Quality health coverage
Easy to use
6/20/13
Understanding the Marketplace

10. How the Marketplace Works (Continued)
07/03/2013
One process to determine eligibility for
Qualified Health Plans through the Marketplace
New tax credits to lower premiums
Reduced cost sharing
Medicaid
Children’s Health Insurance Program (CHIP)
Offers choice of plans and levels of coverage
Insurance companies compete for business
6/20/13
Understanding the Marketplace

11. Marketplace Basic Rules
07/03/2013
Offer Qualified Health Plans that provide basic consumer protections
Ensure high quality and choice of plans
Provide information on plan premiums, deductibles, and out-of-pocket costs before you decide to enroll
Allow you to compare costs and coverage between health insurance plans
6/20/13
Understanding the Marketplace

12. Qualified Health Plans
07/03/2013
Offered by issuer that is licensed by the state and in good standing
Covers Essential Health Benefits
Offered by issuer that offers at least one “silver” and one “gold” level plan
Offered by issuer that agrees to charge same premium whether offered through or outside the Marketplace
6/20/13
Understanding the Marketplace

13. Essential Health Benefits
07/03/2013
Qualified Health Plans cover Essential Health
Benefits which include at least these 10 categories
Ambulatory patient services
Prescription drugs
Emergency services
Rehabilitative and habilitative services and devices
Hospitalization
Laboratory services
Maternity and newborn care
Preventive and wellness services and chronic disease management
Mental health and substance use disorder services, including behavioral health treatment
Pediatric services, including oral and vision care (pediatric oral services may be provided by stand-alone plan)
6/20/13
Understanding the Marketplace

14. Plan Levels of Coverage
Plan Pays
On Average
Enrollees Pay
On Average*
(In addition to the monthly plan premium)
Bronze
60%
40%
Silver
70%
30%
Gold
80%
20%
Platinum
90%
10%
*Based on the aggregate cost under the plan when benefits are provided to a standard population. This may not be the same for every (or any specific) enrolled person.
6/20/13
Understanding the Marketplace

15. How Qualified Health Plans Can Vary
Plans may cover additional benefits
You may have to see certain providers or use certain hospitals
Premiums, copays, and coinsurance will be different in different plans
Quality of care can vary
Some special types of plans will be structured differently (e.g., high-deductible plans)
6/20/13
Health Insurance Marketplace 101
Health Insurance Marketplace 101

16. Understanding the Marketplace
Catastrophic Plans
07/03/2013
Who is eligible?
Young adults under 30 years of age
Those who obtain a hardship waiver from the Marketplace
What is catastrophic coverage?
Plans with high deductibles and lower premiums
Includes coverage of 3 primary care visits and preventive services with no out-of-pocket costs
Protects consumers from high out-of-pocket costs
6/20/13
Understanding the Marketplace

17. Minimum Essential Coverage
07/03/2013
Starting in 2014, most people must have health coverage or pay a fee
If you don’t have a certain level of health coverage you may have to pay a fee with your tax return
Starting when you file your 2014 Federal tax return in 2015
Some people may qualify for an exemption
6/20/13
Understanding the Marketplace

18. Medicaid and the Children’s Health Insurance Program (CHIP)
07/03/2013
Eligibility for health coverage extended under new law
Simplifies eligibility
Coordinated with Qualified Health Plan coverage
No wrong door if you apply through Marketplace
Streamlined application for affordability programs
New website for program information and enrollment
6/20/13
Understanding the Marketplace

19. Small Business Health Options Program (SHOP)
07/03/2013
Marketplace for small businesses and their employees
Beginning 2014, small businesses will have more choice and control over health insurance spending
Choices among Qualified Health Plans to meet every budget
Access to tax credits for eligible employers
New consumer protections
6/20/13
Understanding the Marketplace

20. What does the Marketplace Mean to Your Practice?
07/03/2013
What does the Marketplace Mean to Your Practice?

21. Understanding the Marketplace
How SHOP Works
07/03/2013
Small employers with <100 FTE employees can qualify
Most states will keep upper limit of 50 FTEs for 2014/2015
Employer accesses SHOP where principal office is located or through employee’s primary work sites
Employer must offer coverage to all full-time employees
Sole proprietors may buy through individual Marketplace rather than through SHOP
6/20/13
Understanding the Marketplace

22. Medical Practices as Small Businesses
Affordable Healthcare Insurance for Employees
Access to the Marketplace through SHOP
Simplifies finding health insurance in small group market
Choose level of coverage offered
Define employee contributions to premiums
Small business tax credit
Currently 35% for qualifying businesses
In 2014, up to 50%
Health Insurance Marketplace 101

23. What does the Marketplace Mean to You?
07/03/2013
What does the Marketplace Mean to You?

24. Changes in Healthcare Access = More Patients
Increased Number of Insured Americans +
Increased Public Program Enrollment =
Increased Healthcare Access
More Patients

25. Projected Increase in Demand for Services
New Emphasis on Primary Care
ACA removing cost barriers to patients for basic preventive care services
Marketplace network adequacy requirement
Potential new contractual opportunities
Insurance plans
Federally Qualified Health Centers (FQHCs)
Other essential community providers

26. Increased Contact Opportunity via Preventive Services
Preventive Services Under the ACA
Vital to mitigating high costs of preventable conditions
New health insurance plans required to cover recommended services without cost sharing
Annual wellness visits
Other regularly scheduled recommended checks
No cost sharing for preventive services under Medicare
No or low cost preventive services for Medicaid

27. Planning for Capacity Building a Sufficient Healthcare Workforce
Additional primary care residency slots
Support for additional physician assistants
Educational support for nursing students
Encouraging states to plan and implement innovative workforce expansion strategies
Grants to assist low-income individuals in training for jobs in healthcare

28. Medicaid Payment Rate Increases
Rate Adjustments Expand Medicaid Beneficiary Care
Pay for primary care physicians no less than 100% of Medicare payment rates
Fully funded by the federal government
For primary care services during 2013 and 2014
Allows primary care physicians to provide services to those without prior access to basic care
Arizona (AHCCCS) information at es/PCSrates.aspx

29. Relationship with Insurers
Marketplaces require no changes to how practices currently contract with insurers
Potential changes to plans which could affect practices:
Changes to offerings
Changes to the number or size of plan networks
Plan networks to include Essential Community Providers

30. What does the Marketplace Mean to Your Patients?
07/03/2013
What does the Marketplace Mean to Your Patients?

31. 3 Things to Know about the Marketplace…
05/15/2013
1. It’s an easier way to shop for health insurance
Simplifies the search for health insurance
All options in one place
One application and an individual or family can explore every qualified insurance plan in the area
2. Most people will be able to get a break on costs
90% of people currently uninsured will qualify for discounted or free health insurance
3. Clear options with apples-to-apples comparisons
All plans in the Marketplace present their price and benefit information in plain language
11/13/2018
The Health Insurance Marketplace 101
Health Insurance Marketplace 101

32. Eligibility and Enrollment
07/03/2013
Marketplace eligibility requires you to
Live in its service area, and
Be a U.S. citizen or national, or
Be a non-citizen lawfully present in the U.S. for entire period for which enrollment is sought
Not be incarcerated
Can apply for Marketplace if pending disposition of charge
Can apply for Medicaid/CHIP at any time
6/20/13
Understanding the Marketplace

33. When You Can Enroll in the Individual Market
07/03/2013
Marketplace Initial Open Enrollment Period is October 1, 2013 through March 31, 2014
Annual Open Enrollment Periods after that are October 15 through December 7
Special Enrollment Periods available in certain circumstances during the year
6/20/13
Understanding the Marketplace

34. Understanding the Marketplace
The Application
07/03/2013
Available electronically and on paper
English and Spanish
Federal form
Dynamic online version
Streamlined paper version
State-run Marketplace may have own version
Help available to complete application
6/20/13
Understanding the Marketplace

35. Marketplace Affordability
07/03/2013
Financial help available for working families includes
Tax credits lower premiums for qualified individuals
Premium Tax Credits
Advanced Premium Tax Credits
Reduced cost sharing to lower out-of-pocket spending for health care
6/20/13
Understanding the Marketplace

36. A New Way to Lower Premium Costs
07/03/2013
Refundable or Advanced Premium Tax Credit lowers cost of Qualified Health Plans
Eligibility based on:
Household income, and family size (at end of year)
Income between 100% to 400% of FPL or Federal Poverty Level ($23,550 – $94,200 for a family of four in 2013)
Obtaining qualified health insurance through the Marketplace
Ineligibility for government-sponsored coverage, affordable employer-sponsored insurance, or certain other minimum essential coverage
6/20/13
Understanding the Marketplace

37. How much is the Premium Tax Credit?
07/03/2013
Amount depends on:
Household income as a percentage of FPL and family size
Premium for second lowest cost silver level Qualified Health Plan (the benchmark plan), adjusted for age of covered person
Sliding scale increases taxpayer’s contribution towards premium as household income (as percentage of FPL) increases
6/20/13
Understanding the Marketplace

38. Do I have to wait until I file my taxes to get the tax credit?
07/03/2013
You can reduce your premium amount up front
Choose an Advance Premium Tax Credit (APTC)
Choose the amount (up to the maximum)
Advance payments paid directly to insurer on your behalf
The amount is based on projected household income
Reconciled at tax time against actual Premium Tax Credit amount you are eligible for
Report income changes immediately to avoid overpayment or balance due
6/20/13
Understanding the Marketplace

39. Who is Eligible for a Cost-Sharing Reduction?
07/03/2013
Eligibility for reduced cost sharing is based on
Incomes ≤ 250% of FPL ($58,875 annually for a family of four in 2013)
Receiving the Premium Tax Credit
Enrolling in a Marketplace silver-level plan
Members of Federally-recognized Indian Tribes
No cost sharing if income is <300% FPL
6/20/13
Understanding the Marketplace

40. Medicaid Eligibility in 2014
07/03/2013
New opportunities for states to expand Medicaid eligibility to adults
Ages 19 – 64 with incomes ≤ 133% of FPL ($15,282 for individual, $31,322 for family of 4 in 2013)
Ensures Medicaid coverage for all children with incomes ≤ 133% of the FPL
Simplifies determination of Medicaid/CHIP eligibility
Known as Modified Adjusted Gross Income (MAGI) based method
6/20/13
Understanding the Marketplace

41. Simplifying Medicaid and CHIP
Eligibility process relies primarily on electronic data
Apply on-line, by phone, by mail, or in person
12-month eligibility period for
Adults
Parents
Children
Simplified process for renewing coverage
6/20/13
Understanding the Marketplace

42. Application and Eligibility
07/03/2013
Application and Eligibility
Premium Tax Credit
Cost-sharing Reduction
Enroll in
Marketplace
Qualified Health Plan
Submit streamlined application to the Marketplace
Verify and determine eligibility
Eligible for Qualified Health Plan,
Medicaid or CHIP
Enroll
Medicaid/CHIP
Online
By Phone
By Mail
In Person
Supported by Data Services Hub
6/20/13
Understanding the Marketplace

43. Enrollment Assistance
07/03/2013
Help available in Marketplaces
Marketplace Toll-Free Call Center
Certified Assisters
Navigators program
Non-Navigator in-person assisters
Agents and brokers
HealthCare.gov and state Marketplace websites
6/20/13
Understanding the Marketplace

44. Understanding the Marketplace
National Marketplace Toll-Free Call Center for Federally Facilitated and State-Partnership Marketplaces
07/03/2013
(TTY )
Customer service representatives - 24/7
English and Spanish
Language line for 150 additional languages
June – September
Provide general information to individuals in Marketplace and employees of SHOP employers
SHOP call center for Employers – opened in August
Starting October
Eligibility, enrollment and referral assistance
6/20/13
Understanding the Marketplace

45. In Person Assistance To…
Help prepare electronic and paper applications to establish eligibility
Enroll in coverage through the Marketplace
Navigators
Other trained enrollment assisters
Local community health centers
Libraries
Hospitals and other locations
Agents and brokers
6/20/13
Health Insurance Marketplace 101
Health Insurance Marketplace 101

46. Understanding the Marketplace
HealthCare.gov
07/03/2013
Cuidadodesalud.gov for Spanish
The consumer site for info now, application and plan comparison in Oct
Social media connections
Responsive design
Accessible for those with visual disabilities
6/20/13
Understanding the Marketplace

47. Understanding the Marketplace
Marketplace.cms.gov
07/03/2013
Get the latest resources to help people apply, enroll, and get coverage in 2014
6/20/13
Understanding the Marketplace

48. Affordable Care Act – Coverage Accomplishments
3.1 million young adults gained insurance through parents’ plans
6.1 million people with Medicare received $5.7 billion in prescription drug discounts through 2012
34 million people with Medicare received a free preventive service
71 million privately insured people gained improved coverage for preventive services
105 million Americans have had lifetime limits removed from their insurance
6/20/13
Health Insurance Marketplace 101
Health Insurance Marketplace 101

49. Affordable Care Act – Cost Savings
Slowest sustained national health spending growth in 50 years
Low growth continued in 2012 for Medicare and Medicaid
Rate increases fell from 75% in 2010 to 14% so far in 2013
$1 billion returned to consumers last summer
Plans now must spend 80% on healthcare
$4.2 billion recovered in 2012 from anti-fraud efforts – a record high – for a total of nearly $15 billion over the last 4 years, double that of the previous 4 years
6/20/13
Health Insurance Marketplace 101
Health Insurance Marketplace 101

50. Health Insurance Marketplaces
Provide new avenue to coverage for individuals and small businesses beginning January 1, 2013
Expand opportunities to provide primary care
More people enrolled in private and public plans
Increased access to preventive services for patients
Reduced cost burden for patients
Medicaid payment adjustment for physicians
Protect physician ability to deliver essential care across patient populations

51. 5 Ways to Connect With the Marketplace
07/03/2013
Sign up for or text updates: HealthCare.gov/subscribe
Twitter.com/HealthCareGov - Follow @HealthCareGov
Facebook.com/HealthCareGov
Youtube.com/HealthCareGov
The Health Insurance Blog:
6/20/13
Understanding the Marketplace

52. Thank You!