1. Insurance Options under the Affordable Care Act Brendan Riley NC Community Health Center Association January 23, 2014

2.  As of October 1, 2013, you can enroll in new health coverage options  Insurance options based on eligibility: ◦ Employer-sponsored coverage ◦ Medicaid & CHIP ◦ Medicare ◦ Individual/non-group coverage you buy yourself

3.  Medical bills leading cause of bankruptcy  Premium costs rising faster than wages  No protections for people with pre-existing conditions  Insurance companies can deny coverage to sick people, even children

4.  Can’t be denied coverage because of a pre- existing condition  No lifetime limits or annual caps on coverage  Limits on out-of-pocket costs for consumers  Companies can’t charge women more money for same coverage  Companies can’t cancel your policy because of an illness

5.  Plans must cover “essential health benefits”  Plans must provide easy-to-read summaries of benefits and covered services  Children can stay on parents’ plan ‘til age 26  Preventive services with no cost-sharing  Tax credits for small businesses that provide coverage

6.  Single, streamlined application  Determine eligibility for and enroll in nearly all types of coverage  Application and enrollment assistance ◦ Certified in-person assisters ◦ 24-hour call center ◦ Online chat helpers

7. Step 2: Marketplace verifies income, citizenship, and immigration status thru online data from federal and state agencies Step 1: Person can apply in person, by phone, or online Step 3: Marketplace determines eligibility for public or private insurance coverage and subsidies Step 4: Compare plans and enroll 7

8.  Medicare ◦ No eligibility changes ◦ Strengthens program with new benefits  Free preventive services  Closes doughnut hole on Rx drug costs  Medicare Advantage ◦ Premium dollars must go toward improving care per 80/20 rule  Keeps seniors’ costs down & makes plans more efficient

9.  Job-based coverage ◦ >50% of non-elderly North Carolinians ◦ Most will continue on this coverage in 2014  Don’t have to apply, but can shop around to see if better coverage or better costs  Benefit from consumer protections, such as caps on lifetime limits, protections for pre- existing conditions, etc.

10.  Pre-ACA, very difficult and costly to purchase health insurance on individual market  ACA creates Health Insurance Marketplace ◦ Like Expedia or Priceline — consumers can shop for and compare insurance plans and levels of coverage in online Marketplace  www.HealthCare.Gov www.HealthCare.Gov ◦ Plans must provide essential health benefits

11.  Financial help for many to purchase health insurance through Health Insurance Marketplace  Eligible for Premium Tax Credits if: ◦ Between 100% and 400% of Federal Poverty Level ◦ No access to affordable employer-based coverage ◦ Ineligible for Medicaid, CHIP, or Medicare  Amount of tax credit depends varies on sliding scale ◦ Tax credit at 200% FPL will be larger than 300% FPL credit

12.  How do premium tax credits work? ◦ Used to purchase qualified health plan on Marketplace ◦ Eligibility determined by household size and income ◦ Can be claimed fully in advance, in part in advance, or at end of year ◦ Paid directly by the Marketplace to the insurer ◦ Consumer is responsible for the difference each month 12

13. Family SizeEligible for Subsidies in Marketplace (100-400% FPL) 1$11,490 -$45,960 2$15,510 - $62,040 3$19,530 - $78,120 4$23,550 - $94,200 Each additional person$4,020 - $16,080 13 Note: This example is based on the 2013 Federal Poverty Levels (FPL). These income limits will be increased by 2014. Eligibility for Premium Tax Credits

14.  Caps on out-of-pocket expenses ◦ Deductible, co-pays, coinsurance  Eligible if household at or below 250% FPL (~$28,750/household of one)  Must select silver tier plan

15.  CHIP ◦ Public program that covers children in families up to 200% FPL (~$47k for family of four)  Medicaid ◦ Public program that covers some individuals & families ◦ Provides funding to states to expand eligibility for all individuals up to 138% FPL  Supreme Court rendered expansion voluntary for states  12 month eligibility period — can enroll anytime in the year

16.  ACA provides full federal funding for expansion for first three years  Tapers down to 90% in 2020 and years beyond

18.  Marketplace Open Enrollment Period: October 1, 2013-March 31, 2014;  Full year enrollment period for Medicaid & CHIP www.HealthCare.gov www.CuidadoDeSalud.gov 1-800-318-2596 (TTY 1-855-889-4325)

19.  The North Carolina Department of Insurance (NCDOI) consumer information office can help you with questions about your insurance coverage ◦ Health Insurance Smart NC ◦ 1-877-885-0231 ◦ www.ncdoi.com/Smart/ www.ncdoi.com/Smart/  NCDOI can also help you file complaints or appeals with your insurance company 19

20. Brendan Riley Outreach & Enrollment Coordinator North Carolina Community Health Care Association rileyb@ncchca.org rileyb@ncchca.org http://www.ncchca.org/