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Fundamentals of the  Health Insurance Marketplace Fundamentals of the  Health Insurance Marketplace

Fundamentals of the Health Insurance Marketplace - PowerPoint Presentation

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Fundamentals of the Health Insurance Marketplace - PPT Presentation

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

Slide2

This session will help you:

Explain the Health Insurance Marketplace

Understand what it means

To you

Your practiceYour patientsLocate Marketplace resources

Objectives

2

Slide3

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 it50 million Americans had no insurance at allThe Problem6/20/13Health Insurance Marketplace 101

3

Slide4

In March 2010, President Obama signed the Affordable Care Act (ACA) into law

The Health Care Law

6/20/13

Health Insurance Marketplace 101

4

Slide5

What is the Health Insurance Marketplace?

6/20/13

Understanding the Marketplace

5

Slide6

Increased 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

Slide7

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

Slide8

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 governmentMarketplace Establishment

Slide9

Coverage 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

Slide10

One 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

Slide11

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 plansMarketplace Basic Rules 6/20/13Understanding the Marketplace

11

Slide12

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 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

Slide13

13

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

Slide14

14

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

Slide15

Plans 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

Slide16

16

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

Slide17

Starting 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

Slide18

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 programsNew website for program information and enrollmentMedicaid and the Children’s Health Insurance Program (CHIP)6/20/13Understanding the Marketplace

18

Slide19

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 budgetAccess to tax credits for eligible employers

New consumer protections

Small Business Health Options Program (SHOP)6/20/13

Understanding the Marketplace

19

Slide20

What does the Marketplace Mean to

Your Practice?

20

Slide21

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 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

Slide22

Affordable 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

Slide23

What does the Marketplace Mean to You?

23

Slide24

Increased 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

Slide25

Projected 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

Slide26

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

Slide27

Planning 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

Slide28

Medicaid 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

Slide29

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

Slide30

What does the Marketplace Mean to

Your Patients?

30

Slide31

1.

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

Slide32

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 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

Slide33

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

When You Can Enroll in the Individual Market

6/20/13Understanding the Marketplace33

Slide34

Available 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

Slide35

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 careMarketplace Affordability6/20/13

Understanding the Marketplace35

Slide36

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 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

Slide37

Amount 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

Slide38

You 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

Slide39

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 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

Slide40

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 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

Slide41

Eligibility 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

Slide42

Application 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

Slide43

Help 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

Slide44

44

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

Slide45

Health 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

Slide46

46

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

Slide47

47

Understanding the Marketplace

6/20/13

Get the latest resources to help people apply, enroll, and get coverage in

2014Marketplace.cms.gov

Slide48

3.1

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

Slide49

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

Affordable Care Act – Cost Savings6/20/13

Health Insurance Marketplace 101

49

Slide50

Health 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

Slide51

51

Understanding the Marketplace

6/20/13

Sign

up for email or text updates: HealthCare.gov/subscribe Twitter.com/HealthCareGov - Follow

@HealthCareGovFacebook.com/HealthCareGov

Youtube.com/HealthCareGov

The

Health Insurance Blog

:

http

://www.healthcare.gov/blog

/

5 Ways to Connect With the Marketplace

Slide52

Thank You!

betsy.thompson@cms.hhs.gov

415.744.3631