September 2013 Betsy L Thompson MD DrPH Chief Medical Officer Region IX This session will help you Explain the Health Insurance Marketplace Understand what it means To you Your practice ID: 935624
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Slide1
Fundamentals of the Health Insurance Marketplace
September 2013
Betsy L. Thompson, MD, DrPHChief Medical Officer, Region IX
Slide2This session will help you:
Explain the Health Insurance Marketplace
Understand what it means
To you
Your practiceYour patientsLocate Marketplace resources
Objectives
2
Slide3Insurance 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 it50 million Americans had no insurance at allThe Problem6/20/13Health Insurance Marketplace 101
3
Slide4In March 2010, President Obama signed the Affordable Care Act (ACA) into law
The Health Care Law
6/20/13
Health Insurance Marketplace 101
4
Slide5What is the Health Insurance Marketplace?
6/20/13
Understanding the Marketplace
5
Slide6Increased Availability of Private Coverage
Health
Insurance MarketplacesEnrollment
opens
October 1, 2013Coverage starting as earlyas January 1, 2014Expansion of Medicaid Eligibility Starting January 1, 2014Coverage for individuals under 133% of federal poverty levelStates receive additional federal funding
100% funding for first three years90% funding subsequent years
Historic Expansion of Coverage
6
http://
www.healthcare.gov/law/timeline/full.html#2013
7
Understanding the Marketplace
6/20/13
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
Health Insurance Marketplace
Slide8Each 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 governmentMarketplace Establishment
Slide9Coverage to fit individual needs
Marketplace affordability
May be eligible for help with premiums and out-of-pocket costsUnbiased help and customer support provided
Quality health coverage
Easy to useHow the Marketplace Works6/20/13
Understanding the Marketplace9
Slide10One process to determine eligibility for
Qualified Health Plans through the Marketplace
New tax credits to lower premiumsReduced cost sharing Medicaid
Children’s Health Insurance Program (CHIP)
Offers choice of plans and levels of coverageInsurance companies compete for businessHow the Marketplace Works (Continued)6/20/13Understanding the Marketplace
10
Slide11Offer 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 plansMarketplace Basic Rules 6/20/13Understanding the Marketplace
11
Slide12Offered 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 planOffered by issuer that agrees
to charge same premium
whether offered through or outside the Marketplace
Qualified Health Plans
6/20/13
Understanding the Marketplace
12
Slide1313
Understanding the Marketplace
6/20/13
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)
Qualified Health Plans
cover Essential Health
Benefits which include at least these 10 categories
Essential Health Benefits
Slide1414
Understanding the Marketplace
6/20/13
*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.
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%
Plan Levels of Coverage
Slide15Plans may cover additional benefits
You may have to see certain providers or use certain hospitalsPremiums, copays, and coinsurance will be different in different plansQuality
of care can vary Some special types of plans will be structured differently (e.g., high-deductible plans)
How Qualified Health Plans Can Vary
6/20/13Health Insurance Marketplace 10115
Slide1616
Understanding the Marketplace
6/20/13
Who is eligible?
Young adults under 30 years of ageThose who obtain a hardship waiver from the MarketplaceWhat is catastrophic coverage?Plans with high deductibles and lower premiumsIncludes coverage of 3 primary care visits and preventive services with no out-of-pocket costsProtects consumers from high out-of-pocket costsCatastrophic Plans
Slide17Starting in 2014, most people must have health coverage or pay a feeIf
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
Minimum Essential Coverage6/20/13Understanding the Marketplace17
Slide18Eligibility 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 programsNew website for program information and enrollmentMedicaid and the Children’s Health Insurance Program (CHIP)6/20/13Understanding the Marketplace
18
Slide19Marketplace 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 budgetAccess to tax credits for eligible employers
New consumer protections
Small Business Health Options Program (SHOP)6/20/13
Understanding the Marketplace
19
Slide20What does the Marketplace Mean to
Your Practice?
20
Slide21Small 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 sitesEmployer must offer coverage to all full-time employees
Sole proprietors m
ay buy through individual Marketplace rather than through SHOPHow SHOP Works 6/20/13Understanding the Marketplace
21
Slide22Affordable Healthcare Insurance for Employees
Access to the
Marketplace through SHOPSimplifies finding health insurance in
small
group marketChoose level of coverage offeredDefine employee contributions to premiumsSmall business tax creditCurrently 35% for qualifying businessesIn 2014, up to 50% Medical Practices as Small Businesses
22
http://www.healthcare.gov/using-insurance/employers/small-business/index.html
http://www.healthcare.gov/marketplace/small-businesses/index.html
What does the Marketplace Mean to You?
23
Slide24Increased Number of Insured
Americans +
Increased Public Program Enrollment
=
Increased Healthcare Access=More PatientsChanges in Healthcare Access = More Patientshttp://www.healthcare.gov/marketplace/costs/index.html
http://www.healthcare.gov/law/timeline/#event38-pane
http://cciio.cms.gov/resources/files/ffe-guidance-05-16-2012.pdf
Slide25Projected Increase in
Demand for Services
New Emphasis
on Primary Care
ACA removing cost barriers to patients for basic preventive care servicesMarketplace network adequacy requirementPotential new contractual opportunities
Insurance plans Federally Qualified Health Centers (FQHCs)
Other essential community providers
http://onlinelibrary.wiley.com/doi/10.1111/j.1468-0009.2011.00620.x/full
Increased Contact Opportunity
via Preventive Services
http://www.healthcare.gov/news/reports/patients-bill-of-rights09232011a.html
Preventive Services Under the ACA
Vital to mitigating high costs of preventable conditionsNew 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
Slide27Planning for Capacity
http://www.hhs.gov/news/press/2010pres/09/20100927e.html
Building a Sufficient Healthcare Workforce
Additional
primary care residency slotsSupport for additional physician assistantsEducational support for nursing students
Encouraging states to plan and implement innovative workforce expansion strategiesGrants to assist low-income individuals in training for jobs in healthcare
Slide28Medicaid Payment Rate Increases
http://www.healthcare.gov/law/timeline/
Rate Adjustments
Expand
Medicaid Beneficiary CarePay for primary care physicians no less than 100% of Medicare payment ratesFully funded by the federal governmentFor 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
http://www.azahcccs.gov/commercial/ProviderBilling/rates/PCSrates.aspx
Relationship with Insurers
http://cciio.cms.gov/programs/Files/ecp-listing-cover-sheet-03262013.pdf
http
://www.clinicservice.com/blog/2013/02/medical-practice-management-and-new-exchanges-what-expect-2014
Marketplaces require no changes to how practices currently contract with insurersPotential changes to plans which could affect practices:
Changes to offeringsChanges to the number or size of plan networks
Plan networks to include Essential Community Providers
Slide30What does the Marketplace Mean to
Your Patients?
30
Slide311.
It’s an easier way to shop for health
insurance Simplifies the search for health insurance
All options
in one placeOne application and an individual or family can explore every qualified insurance plan in the area2. 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
o
ptions
with
apples-to-apples comparisons
All plans
in the Marketplace present their price and benefit information in
plain language
3 Things
to
Know about the Marketplace…
31
9/27/2013
The Health Insurance Marketplace 101
Slide32Marketplace 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 soughtNot be incarceratedCan apply for Marketplace if pending disposition of chargeCan apply for Medicaid/CHIP at any time
Eligibility and
Enrollment
6/20/13
Understanding the Marketplace
32
Slide33Marketplace 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
When You Can Enroll in the Individual Market
6/20/13Understanding the Marketplace33
Slide34Available electronically and on paper
English and Spanish
Federal form
Dynamic
online version Streamlined paper versionState-run Marketplace may have own versionHelp available to complete application
The Application6/20/13
Understanding the Marketplace
34
Slide35Financial 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 careMarketplace Affordability6/20/13
Understanding the Marketplace35
Slide36Refundable 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 MarketplaceIneligibility for government-sponsored coverage, affordable employer-sponsored insurance, or certain other minimum essential coverageA New Way to Lower Premium Costs6/20/13Understanding the Marketplace
36
Slide37Amount depends on:
Household income as a percentage
of FPL and family sizePremium for second lowest cost silver
level Qualified Health Plan (the
benchmark plan), adjusted for age of covered personSliding scale increases taxpayer’s contribution towards premium as household income (as percentage of FPL) increasesHow much is the Premium Tax Credit?
6/20/13Understanding the Marketplace
37
Slide38You can reduce your premium amount up frontChoose an Advance Premium Tax Credit (APTC)
Choose the amount (up to the maximum)Advance payments paid directly to insurer on your behalfThe 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
Do I have to wait until I file my
taxes to get the tax credit?6/20/13Understanding the Marketplace38
Slide39Eligibility 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 planMembers of Federally-recognized Indian TribesNo cost sharing if income is <300% FPL
Who is Eligible for a Cost-Sharing Reduction?
6/20/13
Understanding the Marketplace
39
Slide40New 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 FPLSimplifies determination of Medicaid/CHIP eligibility Known as Modified Adjusted Gross Income (MAGI) based methodMedicaid Eligibility in 2014
6/20/13
Understanding the Marketplace
40
Slide41Eligibility process relies primarily on
electronic
data
Apply on-line
, by phone, by mail, or in person12-month eligibility period for AdultsParentsChildren
Simplified process for renewing coverage
41
Understanding the Marketplace
6/20/13
Simplifying Medicaid and CHIP
Slide42Application and Eligibility
42
Understanding the Marketplace
6/20/13
Enroll
Medicaid/CHIP
Premium Tax Credit
Cost-sharing Reduction
Enroll in
Marketplace
Qualified Health Plan
Eligible for Qualified Health Plan,
Medicaid or CHIP
Supported by Data Services Hub
Online
By Phone
By Mail
In Perso
n
Application
and Eligibility
Slide43Help available in Marketplaces
Marketplace Toll-Free Call Center
Certified AssistersNavigators programNon-Navigator in-person assisters
Agents and brokers
HealthCare.gov and state Marketplace websitesEnrollment Assistance6/20/13Understanding the Marketplace
43
Slide4444
Understanding the Marketplace
6/20/13
1-800-318-2596 (TTY 1-855-889-4325)
Customer service representatives - 24/7English and SpanishLanguage line for 150 additional languages June – September Provide general information to individuals in Marketplace and employees of SHOP employersSHOP call center for Employers – opened in AugustStarting October
Eligibility, enrollment and referral assistanceNational Marketplace Toll-Free Call
Center
for Federally Facilitated and State-Partnership Marketplaces
Slide45Health Insurance Marketplace 101
6/20/13
In Person Assistance To…
45
Help
prepare electronic and paper applications to establish eligibilityEnroll in coverage through the
Marketplace
Navigators
Other trained enrollment assisters
Local community health
centers
Libraries
Hospitals
and other
locations
Agents
and brokers
Slide4646
Understanding the Marketplace
6/20/13
Cuidadodesalud.gov for Spanish
The consumer site for info now, application and plan comparison in OctSocial media connectionsResponsive
designAccessible for those with visual disabilities
HealthCare.gov
Slide4747
Understanding the Marketplace
6/20/13
Get the latest resources to help people apply, enroll, and get coverage in
2014Marketplace.cms.gov
Slide483.1
million young adults gained insurance through parents
’ plans6.1 million people with Medicare received $5.7 billion in prescription drug discounts through 2012
34 million people with Medicare received a free preventive
service71 million privately insured people gained improved coverage for preventive services105 million Americans have had lifetime limits removed from their insuranceAffordable Care Act – Coverage Accomplishments6/20/13
Health Insurance Marketplace 10148
Slide49Slowest
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
Affordable Care Act – Cost Savings6/20/13
Health Insurance Marketplace 101
49
Slide50Health Insurance Marketplaces
Provide new
avenue to coverage for individuals and small businesses beginning January 1, 2013
Expand
opportunities to provide primary careMore people enrolled in private and public plansIncreased access to preventive services for patientsReduced cost burden for patients
Medicaid payment adjustment for physicians
Protect physician ability to deliver essential care across patient populations
Slide5151
Understanding the Marketplace
6/20/13
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:
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5 Ways to Connect With the Marketplace
Slide52Thank You!
betsy.thompson@cms.hhs.gov
415.744.3631