Two Choices. The Affordable Care Act requires every individual to either: 1. Maintain Minimum Essential Coverage, or

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1 Information last updated September 9,

2 Two Choices The Affordable Care Act requires every individual to either: 1. Maintain Minimum Essential Coverage, or 2. Make a Shared Responsibility Payment. Information last updated September 9,

3 Minimum Essential Coverage Minimum Essential Coverage is some form of major medical health care coverage such as: Medicare TRICARE or VA Medical Benefits Medicaid hawk-i Employer based health insurance, including from a family member s employer Major medical health insurance purchased on the individual market Must be comprehensive, not limited in scope. Information last updated September 9,

4 Shared Responsibility Payment If an individual does not have Minimum Essential Coverage (or an exemption), he or she must pay the greater of the two penalties on his or her taxes*. In years after 2016 the penalty is indexed to the rate of medical inflation. Parents are responsible for their children Minimum $95 $325 $695 Percent of Income After Filing Threshold 1% 2% 2.5% *Capped at $285 for 2014, $975 for 2015, and $2,085 for 2016 Information last updated September 9,

5 There are a number of exemptions to the requirement to maintain Minimum Essential Coverage For the months a person is incarcerated For the months a person is a member of a healthcare sharing Ministry For the months paying for health insurance would be a hardship for a person s household For the months a person has a short gap in coverage For the year if premiums for health insurance would cost more than 8% of a person s annual household income For the year if a person s income is below the filing threshold for taxes If a person is an undocumented immigrant If a person is a member of an Indian Tribe If a person qualifies for a religious exemption Information last updated September 9,

6 Does a person need to make any changes to avoid the penalty? Is the person uninsured? Shop on the Marketplace or individual market, contact the Department of Human Services, an Insurance Agent or Broker, a Navigator or Certified Application Counselor. Does the person like his or her current health insurance? The person may be able to keep it, or shop on the Marketplace Is the person on Medicare? No change needed Is the person on Medicaid? No change needed Was the person on IowaCare? IowaCare ended on December 31, All IowaCare members received instructions on how to find new health care coverage, under the Iowa Health and Wellness Plan or the Health Insurance Marketplace. Information last updated September 9,

7 The Iowa Health Insurance Marketplace Iowa is using the Federal Health Insurance Marketplace. The Marketplace is a way for people to look for minimum essential coverage* There is a single application process for Medicaid (including the Iowa Health and Wellness Plan), hawk-i, Tax Credits, and Cost Sharing Subsidies. Applicants shopping for insurance on the Marketplace have the choice of multiple private insurers. *People who qualify for Medicare and undocumented individuals cannot use the Marketplace. Information last updated September 9,

8 Health Premium Tax Credits Certain people may qualify for tax credits to help them purchase insurance The tax credit can reduce what a household owes in taxes OR what the household pays for health insurance premiums. They must: Have a household Modified Adjusted Gross Income between 100% and 400% of the federal poverty guidelines. Be lawfully present in the U.S., and may not be incarcerated. Must purchase health insurance through the Marketplace. Not be eligible for Minimum Essential Coverage from an employer or government program. A person may still qualify for tax credits if coverage from his or her employer is not Affordable or does not provide Minimum Value. Information last updated September 9,

9 What is considered Affordable under the law? What is Minimum Value? An Employer s plan is Affordable if the employee s contribution to insure the employee only is less than 9.56% of the employee s household income. An Employer s plan provides Minimum Value if it covers 60% of the expected medical expenses. Information last updated September 9,

10 Cost Sharing Reductions Cost Sharing Reductions are only available to those whose household income is between 100% and 250% of the FPL that elect to enroll in a Silver plan. Cost sharing reductions decrease the consumer s share of costs. A Silver plan has coinsurance of 30% paid by the consumer and 70% paid by the insurance company. With Cost Sharing Reductions, the coinsurance is instead reduced to the following: Federal Poverty Level Covered Consumer Pays 200% to 250% 73% 27% 150% to 200% 87% 13% 100% to 150% 94% 6% Information last updated September 9,

11 Information last updated September 9,

12 How do I sign up? Go to or call Persons can only sign up during Open Enrollment or Special Enrollment. Open Enrollment for 2015 starts November 15 th 2014, through February 15 th Navigators, Certified Application Counselors and Insurance Agents are available to assist people with enrollment, be it in person or over the phone. If people don t sign up during open enrollment, they might be able to sign up during a special enrollment period. Information last updated September 9,

13 Special Enrollment Period May enroll or change Qualified Health Plan Within 60 days in individual market and 30 days in small group market from qualifying event Special Enrollment Period Qualifying Events Loss of minimum essential Coverage (other than by nonpayment) Gaining or becoming a dependent Gaining lawful presence Enrollment errors of the Marketplace * Granted on a case by case basis. Material contract violations by Qualified Health Plans Gaining or losing eligibility for premium tax credits or cost sharing reductions Relocation resulting in new or different Qualified Health Plan selection Exceptional circumstances* Information last updated September 9,

14 1-24 Full Time Equivalent Employees, 40 Hour Full Time Work Week. * This is intended to give general guidance and explain the legal frame work. The Iowa Insurance Division is not an expert on Federal Tax law. This presentation is not intended to be legal or tax advice. Attendees are encouraged to seek assistance from their tax advisor or the IRS. Information last updated September 9,

15 What does the ACA do for Businesses? The ACA does two big things for small employers Creates the Small Business Health Insurance Tax Credit. Creates the SHOP Marketplace for small employers to share risks and costs. The ACA does one big thing for large employers Mandates they offer health insurance coverage meeting certain requirements for full time employees and their dependants starting in or Fewer FTEs Tax Credits 50 or Fewer FTEs SHOP Marketplace 50 or More FTEs Employer Mandate Information last updated September 9,

16 Reinsurance, Risk Corridors, and Risk Adjustment Premium stabilization programs established by the Affordable Care Act Information last updated September 18,

17 The Three Rs The Affordable Care Act established (1) Reinsurance, (2) a Risk Corridors Program, and (3) Risk Adjustment Programs. The purpose and goal of these programs is to provide certainty and protect against adverse selection in the market, while stabilizing premiums in the individual and small group markets. Information last updated September 18,

18 State-Based Transitional Reinsurance Established in each State (the U.S. Department of Health and Human Services, HHS, administers Iowa s) to help stabilize premiums for coverage in the individual market from 2014 through All health insurance issuers and third party administrators on behalf of self-insured group health plans, must make contributions to support reinsurance payments that cover high-cost individuals in nongrandfathered plans in the individual market. The uniform reinsurance contribution rate is $44 per capita for Information last updated September 18,

19 Transitional Reinsurance Contributions Reinsurance contributions are allocated in the following manner: Reinsurance payments: $10 billion in 2014, $6 billion in 2015, and $4 billion in 2016 U.S. Treasury $2 billion in years 2014 and 2015, and $1 billion in 2016 Administrative expenses Information last updated September 18,

20 Transitional Reinsurance Payments Eligibility is based on total annual medical costs for covered benefits of an enrollee in an individual market plan. Payments compensate a portion of those costs (coinsurance rate, 50% for 2015) incurred above an attachment point ($70,000 in 2015), subject to a cap ($250,000 in 2015) announced in the annual HHS notice of benefit and payment parameters. Information last updated September 18,

21 Temporary Risk Corridors Program Established by the Affordable Care Act, applies to qualified health plans in the individual and small group markets during the years 2014 through Protects against inaccurate rate-setting by sharing risk (gains and losses) on allowable costs between HHS and qualified health plans to help ensure stable health insurance premiums. Federal program, administered by HHS. Information last updated September 18,

22 Temporary Risk Corridors Program Relationship between plans allowable costs (essentially, claims and quality improvement activities) and target amount (premiums earned less allowable administrative costs) determines risk corridors charges and payments. Charges and payments are on percentage basis (not first dollar basis). If issuer s allowable costs are less than 97 percent of its target amount, it pays HHS a percentage of the difference. If issuer s allowable costs are more than 103 percent of its target amount, HHS pays it a percentage of the difference. Information last updated September 18,

23 Permanent Risk Adjustment Program The Affordable Care Act provides for a permanent risk adjustment program that applies to nongrandfathered individual and small group plans inside and outside Marketplaces (Exchanges). Provides payments to health insurance issuers that disproportionately attract higher-risk populations (such as individuals with chronic conditions). Transfers funds from plans with relatively lower risk enrollees to plans with relatively higher risk enrollees to protect against adverse selection. Administered by HHS, in Iowa. Information last updated September 18,

24 Permanent Risk Adjustment Program Uses a risk adjustment model Risk adjustment model is an actuarial tool used to predict health care costs based on relative actuarial risk of enrollees in risk adjustment covered plans Developed by HHS. The risk adjustment model is used to predict the risk of each plan, and to calculate the appropriate funds to be transferred from lower risk plans to higher risk plans. Information last updated September 18,

25 Iowa s Rate Hearing Process Major medical health insurance carriers licensed in Iowa must notify policyholders of any application for a rate increase exceeding the average annual health spending growth rate stated in the most recent national health expenditure projection published by the Centers for Medicare & Medicaid Services (6.1% in 2014). Commissioner holds a public hearing related to such hearings. Consumer Advocate solicits public comments and presents them to the Commissioner for consideration in determining whether to approve, disapprove or modify such health insurance rate increase proposals. All information related to the application for the proposed rate increase, including the application, consumer comments, and actuarial findings are public information and are posted on the rate hearing website at Information last updated September 18,

26 Rate Hearing Notice Notice is issued to potentially affected policyholders on the same day as application is filed with the Division. Notice follows a model and forms for Notice are approved by the Division prior to being issued to potentially affected policyholders. Notice contains: The contact information for the Consumer Advocate. The time, date, and location of the public hearing on the proposed rate increase. The specific rate increase proposed that is applicable to each policyholder. A ranking and quantification of the factors responsible for the amount of the rate increase. Information last updated September 18,

27 Rate Hearing Open to the public. Must take place no less than 45 days after the proposed rate increase application has been filed with the Division. Applicant contacts the Division in advance of filing to secure date, time, and location. Opportunity for members of the public to comment and testify. Consumer Advocate testifies as to comments received from members of the public prior to the hearing. Information last updated September 18,

28 Illustrative Health Insurance Premium Projections for Family Coverage, Assuming Average Growth Rate of 9.2% * 23% $66,474 Employer Portion Employee Portion Avg HHI** 47 $68,483 $70,553 $72,686 $74,882 $77,146 $14,981 $16,359 $17,864 $4,794 $5,235 $5,716 $19,508 $21,303 $6,243 $6,817 $27,739 $25,402 $23,262 $8,876 $8,129 $7,444 $36,121 $30,291 $33,078 $11,559 $10,585 $9,693 $10,187 $11,124 $12,148 $13,265 $14,486 $15,818 $17,273 $18,863 $20,598 $22,493 $24, Note: Health insurance premiums projected for assuming the average growth in premiums between 2010 and 2014 continues at 9.2% (average annual reported increase before benefit plan changes were made). ** 1.5% Annual Household Income Growth (Source: U.S. Census Bureau for Iowa in 2012) Copyright , David P. Lind Benchmark, LC. All Rights Reserved

29 Importance of Healthcare Delivery Performance Indicators (Based on a 10-point scale, with 10 being Most Important ) Performance Indicators < Overall Keeping Costs Reasonable Keeping Quality of Care Consistent Safety of Care Delivered to Patients Concern for Patient Satisfaction Focus on Wellness and Health Promotion Coordination of Care Between Providers Access to Services Ability to Engage Patients Transparency of Medical Outcomes Transparency of Costs Health Providers Embracing Electronic Health Records Efficiency in Care Delivered Copyright David P. Lind Benchmark. All Rights Reserved.

30 Overall Hospital and Physician Grades Performance Indicators Hospitals Physicians Access to Services B B- Trust Hospitals/Physicians B- B Concern for Patient Satisfaction C+ B- Electronic Health Records C+ C+ Consistent Quality of Care C+ C+ Ability to Engage Patients C C+ Focus on Wellness & Health Promotion C C Efficiency C C Coordination of Care Among Providers C C Transparency in Medical Outcomes C- C Cost Transparency D+ C- Keeping Cost Reasonable D- D Copyright 2013 Heartland Health Research Institute. All Rights Reserved.

31 29,163 individuals enrolled on the Marketplace 84% with tax credits 107,123 in Medicaid Expansion and Marketplace Choice 82,615 Enrolled in Iowa Wellness Plan 24,508 Enrolled in Marketplace Choice outside Marketplace Non-ACA 271,561 ACA Compliant off-exchange 56,859 Information last updated September 9,

32 Increasing costs Look at plan design Look at inputs driving costs ACO s and Physicians taking risk Focus on wellness Technology Information last updated September 9,

33 Contact Info o o 1 (800) o SHOP 1 (800) o Medicaid 1 (855) o SHIIP (Medicare Questions) 1 (800) or o Attorney General (Fraud/Complaints) o o (515) or (888) o Iowa Insurance Division o 1 (877) o Information last updated September 9,

34 Go to Healthcare.gov to shop or enroll Call Presented By: The Iowa Insurance Division Information last updated September 9,

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