1. VIRGINIA’S HEALTH INSURANCE MARKETPLACE/MEDICAID/FAMIS --THE BASICS--
ACA
Name
Healthcare Navigator
VPLC Richmond, VA
T: xxx-xxx-xxxx

2. What is the Marketplace?
VA uses the Federally Facilitated Marketplace (FFM)
Place where individuals and small businesses can shop for Private health insurance plans
Allows for comparisons of Qualified Health Plans
Uses plain language to explain coverage options
After submitting an application, there is no obligation to enroll in a health plan
Financial assistance available only through FFM

3. Free Preventive Services
Well visits (1 per year)
Blood pressure & cholesterol screening 
Cancer screenings 
Depression screening 
Diabetes screening 
Diet counseling for adults with chronic diseases
HIV/STD screening and counseling
Obesity screening and counseling
Immunizations
Alcohol/tobacco use screening and counseling
Contraception

4. Qualified Health Plans in the Marketplace
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

5. Eligibility for Marketplace Insurance
To purchase insurance on the Marketplace:
Live in its service area
Be a U.S. citizen or national, or be a non-citizen who is lawfully present in the U.S.
Not be incarcerated
To get financial assistance:
Not have access to other affordable and adequate insurance
Have income between 100% and 400% of the federal poverty guidelines
Not receiving or eligible for “minimum essential coverage”:
Medicaid, FAMIS, Medicare
“Affordable & Adequate ” job-based coverage
Job-based coverage is not affordable/adequate if employee-only plan:
cost to employee not ↑9.5% household income; or
covers ↓60% healthcare costs & essential health benefits

6. Premium Tax Credits & Cost-Sharing Reductions
Cost Sharing Reductions reduce the amount of your deductibles and out of pocket costs. Available for those with income at or below 250% of FPL.
Only applies if Silver Plan is purchased
Premium Tax Credits (PTCs)
reduce the amount of your monthly insurance premium.

7. 2019 Federal Poverty Guidelines Household/ Family Size
100%
138%
150%
200%
250%
300%
400% 1
$12,140
16,753
18,210
24,280
30,350
36,420
48,560 2
$16,460
22,715
24,690
32,920
41,150
49,380
65,840 3
$20,780
28,676
31,170
41,560
51,950
62,340
83,120 4
$25,100
34,638
37,650
50,200
62,750
75,300
100,400 5
$29,420
40,600
44,130
58,840
73,550
88,260
117,680 6
$33,740
46,561
50,610
67,480
84,350
101,220
134,960 7
$38,060
52,523
57,090
76,120
95,150
114,180
152,240 8
$42,380
58,484
63,570
84,760
105,950
127,140
169,520

8. Information needed to apply
Availability of employer-based coverage
Identity of household members, tax filing principles
Name and contact information
Social security number
Immigration status
Household size
Estimated yearly income
Free application assistance available!

9. 2019 Open Enrollment is Coming!
Open Enrollment (OE) Period
Annual period when anyone can apply and enroll in coverage
OE for 2019 coverage: November 1, 2018 – December 15, 2018
Special Enrollment Periods (SEPs)
Allow people who experience life changes outside open enrollment to enroll in or change plans
Available all year long
Those eligible usually have 60 days from the life change to enroll in a plan
Note: Medicaid/FAMIS applications are processed all year long

10. Medicaid and FAMIS in VA
MEDICAID AND FAMIS HEALTH INSURANCE IN VIRGINIA
Medicaid and FAMIS in VA

11. Many complexities and rules often change, this is just an overview!
Medicaid and FAMIS
Many complexities and rules often change, this is just an overview!
Eligibility is limited to people in certain categories
Financial eligibility varies depending on category
Some categories also have a resources test
Annual renewal must be completed to maintain coverage
If eligible for full benefits Medicaid, cannot get financial assistance on the Marketplace

12. Coverage Categories Medicaid Newly Eligible (Medicaid Expansion!)
Families and Children
Children under age 19 (FAMIS Plus)*
Pregnant Women*
Low Income Families and Children (LIFC)*
Foster Care and Adoption Assistance & Children up to 21
Former Foster Care Youth (up to age 26)
Aged, Blind and Disabled*
Limited Benefits
Plan First, Family planning services only
Breast & Cervical Cancer Treatment
Governor’s Access Plan (GAP), for those with Serious Mental Illness
Spend-down
Medicare Savings Programs
CHIP (CHILDREN’S HEALTH INSURANCE PROGRAM)
Children (FAMIS)*
Pregnant women (FAMIS MOMS)*
* For more details ask for an in-person appointment to discuss further elegibility

13. Medicaid Expansion!!! Legislature adopted May 30, 2018!
“Newly eligible” adults:
Aged 19 through 64,
Not eligible for an current full-
benefit Medicaid category or
Medicare
MAGI income up to 138% FPL
No resource test
About 300,000+ will get coverage
New coverage begins January 1, 2019

14. New Income Limit for Medicaid- 138% FPL

15. Income Limits for FAMIS- 200% FPL

16. Applications Application Time limits
10 days pregnant women
90 days when disability determination
45 days all others
3 months retroactive coverage available if eligible,
Medicaid only (not FAMIS or FAMIS MOMS)
Retroactivity cannot go past January 1, 2019 for “newly eligible”

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

18. COBRA Option & the Marketplace

19. COBRA vs. Marketplace Coverage
Individuals who lose job-based coverage may be offered COBRA, however it is often expensive.
Losing job-based coverage qualifies you for a Special Enrollment Period (SEP) to enroll in Marketplace coverage. This means you have 60 days before and 60 days after you lose coverage to enroll in a health plan, even if it’s outside open enrollment.
If you enroll in COBRA, voluntarily dropping it will not trigger an SEP. You can only voluntarily drop it and enroll in a Marketplace plan during open enrollment.
If COBRA naturally expires, it sparks an SEP.
If you qualify for a different SEP, you can drop COBRA and enroll in a Marketplace plan. For example, if you move.
If your previous employer is helping you pay for COBRA and then stops, you qualify for a SEP.
Once you opt out of COBRA, you will not have the opportunity to opt back into it.
It is important to compare plans before making a decision!

20. Comparing Plans What are the costs of each plan? Premiums Deductibles
Co-payments and co-insurances
Are your current doctors and hospitals covered?
Are your current medications covered?
Do you have any planned medical treatment?
Do any of your current medications or planned procedures require prior authorization?
How much have you already spent on healthcare this year? Have you met your deductible?

21. Tax Penalties & Exemptions

22. Minimum Coverage Requirements and Tax Penalties
Individual / Family penalty is much less than cost of insurance.
Penalty is the greater of:
$695/adult + $347.50/child (up to $2085) or 2.5% family income above the tax filing threshold (up to the national average price of a bronze plan - $223/mo).
For 2018 tax returns:
All laws about health coverage and tax penalties still apply.
IRS may process returns without health coverage information, but penalties can be assessed later.
Some exemptions apply
For 2019 the tax penalty does not apply

23. Exemptions Granted by Marketplace Granted at Tax Filing
Hardship, including:
Experienced homelessness, an eviction or foreclosure, or received a utility shut off notice.
Bankruptcy
Victim of domestic violence
Determined ineligible for Medicaid in a state that did not expand Medicaid coverage 
Plan cancellation
Member of certain religious sects
Other
Insurance in unaffordable based on projected income
Granted at Tax Filing
Income below filing threshold
Insurance is unaffordable, actual income
Certain noncitizens
Short coverage gap (<3 months)
Gap before effective date of Marketplace coverage purchased during open enrollment
Having income below 138% FPL in a state that did not expand Medicaid
Health care sharing ministry
Indian tribe membership
Incarceration
US citizen living abroad for more than 330 day in the year
An exemption for a state’s failure to expand Medicaid can be received by applying for coverage directly at healthcare.gov if your projected income is below 100% FPL

24. ADDITIONAL HEALTHCARE OPTIONS
Sliding Scale Clinics
Healthcare coverage is based on income and might have pharmacy help
Health Care Centers (FQHC)
Have primary care doctors plus more, operate on a sliding scale up to 200% FPL, and do not turn away insured patients
Free Clinics
Offer free services for the uninsured with little to no income and have volunteer doctors
Our education extends to various types of clinics due to not having Medicaid expansion.
Private Family Practice
This is a typical medical practice NOT a sliding scale or free clinic

25. Twitter-@EnrollVirginia
QUESTIONS?
Phone number
Facebook-

26. 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.