1. What Will Health Reform Look Like in Tennessee? Christopher Coleman Tennessee Justice Center ccoleman@tnjustice.org

3. Cumulative Changes in Health Insurance Premiums, Inflation, and Workers’ Earnings, 1999-2012

5. The Massachusetts Plan

6. guaranteed coverage personal responsibility actual affordability The three-legged stool

7. Consumer Protections

8. Today2014 Medical Underwriting Denials for pre-existing conditions Guaranteed Issue No denials based on health status Exclusions and Riders Pre-existing conditions are not covered Full Coverage All conditions covered on day one Rating Factors Premiums adjusted for age, tobacco, gender, health status, etc. Modified Community rating Premiums adjusted for age, tobacco, and geography only Rescission Plans can drop enrollees if they get sick No Rescission Plans can only drop coverage for deliberate misrepresentation Benefit Limits Plans can impose annual and lifetime dollar limits No Annual or Lifetime Limits

10. No Wrong Door

11. Marketplace Phone Number 1-800-318-2596

12. Marketplace Plans – Metal Levels Plan LevelActuarial Value Platinum90% Gold80% Silver70% Bronze60% Lower enrollee cost-sharing Higher enrollee cost-sharing

13. If your CLIENT falls between 100-250% of FPL, she should pick a SILVER plan.

14. Individual Responsibility Requirement

15. 2014 – Greater of $95 per adult family member without coverage ($47.50 per child); or 1% of taxable income (family maximum of $285). 2016 – Greater of $695 per adult family member without coverage ($347.50 per child); or 2.5 % of taxable income (family maximum of $2,085).

16. Individual Responsibility Requirement Exemptions: People with low incomes not required to file taxes Certain religious groups Incarcerated people Undocumented residents Members of Indian tribes People who go without coverage for less than 3 months People who do not have an affordable offer of coverage

17. What is “affordable” coverage? Monthly premium < 8 % of household income

18. Premium Tax Credits

19. Who is Eligible? Individuals and families with income between 100% and 400% FPL Must be lawfully present in the U.S. Must not be eligible for other “minimum essential coverage”

20. FPL and Eligibility FPLAffordability Program Annual Income by Household Size 1234 100% FPLMedicaid (?)$ 11,490$ 15,510$ 19,530$ 23,550 138% FPLMedicaid (?)$ 15,856$ 21,404$ 26,951$ 32,499 150% FPLPTC & CSR1$ 17,235$ 23,265$ 29,295$ 35,325 200% FPLPTC & CSR2$ 22,980$ 31,020$ 39,060$ 47,100 250% FPLPTC & CSR3$ 28,725$ 38,775$ 48,825$ 58,875 300% FPLPTC$ 34,470$ 46,530$ 58,590$ 70,650 400% FPLPTC$ 45,960$ 62,040$ 78,120$ 94,200

21. How is the Amount of the Tax Credit Determined? Credit amount = Cost of benchmark plan - Expected premium contribution

22. Benchmark Plan Plan LevelActuarial Value Platinum90% Gold80% Silver70% Bronze60% The benchmark plan is the second-lowest cost silver level plan.

23. How is the Amount of the Tax Credit Determined? Credit amount = Cost of benchmark plan - Expected premium contribution

24. Expected Premium Contribution (for an individual) Annual Household IncomeExpected Premium Contribution % of FPLIncome Amount% of IncomeAnnual Dollar Amount 100-150%$11,490 - $16,7552 - 4%$230 - $670 150-200%$16,755 - $22,3404 - 6.3%$670 - $1,407 200-250%$22,340 - $27,9256.3 – 8.05%$1,407 - $2,262 250-300%$27,925 - $33,5108.05 – 9.5%$2,262 – $3,183 300-400%$33,510 - $44,6809.5%$3,183 - $4,245 > 400%> $44,680n/a

25. Gunnar 25 years old Income of $22,340 (200% FPL) Expected contribution: 6.3% or $1,448 3 Lowest Cost Silver Plans for Gunnar Plan A: $4,800 Plan B: $5,000  Benchmark Plan C: $5,200 Premium Credit $5,000 - $1,448 = $3,552

26. Gunnar Premium Credit $5,000 - $1,448 = $3,552 3 Lowest Cost Silver Plans for Gunnar Plan A: $4,800 Plan B: $5,000  Benchmark Plan C: $5,200 Bronze Plan: $3,500 If Gunnar purchases the Bronze Plan, he would not have to pay any premiums because the tax credit ($3,552) would cover the cost of the entire premium ($3,500).

27. Coleman 62 years old Income of $22,980 (200% FPL) Expected contribution: 6.3% or $1,448 3 Lowest Cost Silver Plans for Coleman Plan A: $14,800 Plan B: $15,000  Benchmark Plan C: $15,200 Premium Credit $15,000 - $1,448 = $13,552

28. Benchmark Premium, $5,000 Benchmark Premium, $15,000

29. Who is Eligible? Individuals and families with income between 100% and 400% FPL Must be lawfully present in the U.S. Must not be eligible for other “minimum essential coverage”

30. Minimum Essential Coverage Most employer sponsored coverage is MEC An offer of coverage - even if it’s not taken - can make someone ineligible for premium tax credits BUT Wait…

31. Exception An individual may be eligible for premium tax credits if the employer plan is unaffordable or inadequate.

32. Is it Affordable? Affordable = employee contribution for self- only coverage is less than 9.5% of household income

33. Affordability of Employee-Only Coverage Example 1: Income: $40,000 Juliette’s share of the premium: $200/month Is the plan affordable? Cost: $2,400 Share of income: 6% Example 2: Income: $25,000 Juliette’s share of the premium: $200/month Is the plan affordable? Cost: $2,400 Share of income: 10.4% Juliette

34. Affordability of Family Coverage (Conrad-James Family) Rayna works at Edgehill Records and earns $35,000. Edgehill offers health insurance. Teddy is a politician and earns about $12,000. Teddy does not have an offer of coverage from his employer. Household Income: $47,000 Premium Cost for Employer-Sponsored Plan Covering Just Rayna: $2,350/year (5% of household income for a family of 4) Premium Cost for Employer-Sponsored Plan Covering the Whole Family: $6,110/year (13% of household income for a family of 4)

35. Affordability of Family Coverage (Conrad-James Family) Household Income: $47,000 Premium Cost for Employer-Sponsored Plan Covering Just Rayna: 5% of household income Premium Cost for Employer-Sponsored Plan Covering the Whole Family: 13% of household income 13% 9.5% - - - - - - - - - - - - - - - - - - - - - Bottom Line: No one is eligible for premium tax credits because family coverage is considered affordable.

36. Affordability of Family Coverage (Conrad-James Family) Household Income: $47,000 Premium Cost for Employer-Sponsored Plan Covering Just Rayna: $2,350/year (5% of household income for a family of 4) Premium Cost for Employer-Sponsored Plan Covering Rayna and kids: $4,700/year (10% of household income for a family of 4) 5% 10% 9.5% - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Rayna and Kids -Rayna + kids plan is considered affordable because employee-only plan is affordable. -Rayna and kids are not eligible for premium tax credits. Teddy -Teddy has no offer of coverage. -He may be eligible for premium tax credits.

37. When is Coverage Adequate? Coverage is adequate if it has a minimum value (MV) of 60% This generally means that the plan pays at least 60% of spending for coverage of essential health benefits for a typical population, after accounting for cost- sharing charges required under the plan.

38. Part-Time Job Cost: $85/month 6% of income MV: 40% Marketplace -$150% FPL Cost: $57/month after premium tax credits MV: 94% after cost- sharing reduction Dad’s Plan Cost: $0 to Juliette (Dad pays for family coverage) Juliette could accept this offer, BUT because the plan has MV under 60%, the offer doesn’t preclude premium tax credit eligibility. Coverage Choices for Young Adults Juliette is 24 years old. She holds two part-time jobs. One of the jobs offers coverage. Income: $17,000 Juliette can apply for premium tax credits & cost- sharing reductions Juliette can join her Dad’s family plan because she is under age 26. Offer does not make her ineligible for a premium tax credit.

39. How Will an Employee Know if Her Offer is Affordable or Adequate? Application has an appendix to be completed by the applicant (with help from his employer to indicate value and cost of the plan)

40. Verification of Employer Offer Final rules issued 7/5 In most cases marketplaces will rely on information presented in the application Federally facilitated marketplace (FFM) will check a sample of cases by contacting employers State marketplaces can rely on information provided in the application until 2015

41. TJC is a non-profit, public interest law and advocacy firm serving Tennessee families. We focus on policies and cases where the basic necessities of life are at stake, and where our advocacy can benefit families statewide. 301 Charlotte Avenue, Nashville, TN 37201 (615) 255-0331 or toll free: 877-608-1009 info@tnjustice.org