Understanding the ObamaCare Health Insurance Plans in North Carolina Understanding Insurance and Affordable Care Act Terminology: ACA- Marketplace

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1 Understanding the ObamaCare Health Insurance Plans in North Carolina As a result of the Affordable Care Act (a.k.a. ObamaCare) the following provisions are now in place for health insurance policies with an effective date January 1, 2014 or after: Individuals cannot be declined for health insurance or charged more due to their health status or gender. Insurance premiums are based on age, your zip code and tobacco usage. Coverage limitations or exclusions based on pre-existing conditions are not allowed. Elimination of annual and lifetime coverage limits. Prohibition of declining an individual for coverage based on their participation in an approved clinical trial. Maternity and mental health are included on all policies. Preventative dental is covered with a $25 copay for members up to age 19. There is also some vision coverage for this age group. Whether or not your children are students they can stay on your policy until age 26. Introduction of the Medical Loss Ratio (MLR) which ensures that 80% of the premium dollars paid to the health insurance issuer are spend on providing health care. An insurance company that does not do this must provide rebates to their policyholders. In NC both Blue Cross Blue Shield of North Carolina (BCBSNC) and Coventry are selling health insurance policies on the Marketplace (Exchange). Consumers can apply for a government subsidy and after approval enroll in a subsidized health plan of their choice with either Coventry or BCBSNC. Individual policies with a January 1, 2014 effective date, whether they are sold in or outside of the Marketplace, must comply with the above Affordable Care Act requirements. Unless you have a qualifying event you will not be allowed to apply for a plan after March 31 st, If you miss this deadline you will have to apply in November or December of 2014 and your policy will not go into effect until January1, Each state was allowed to decide if they want a State-based Marketplace (where they did their own training and managed the program), a State Partnership Marketplace (where they managed it in partnership with the Federal government) or a Federally- facilitated Marketplace where a state allows the Federal government to manage all aspects of the program. NC chose the federally facilitated option and also decided not to expand Medicaid. This decision means we are one of the states that forfeited a portion of the 8.4 billion a year from the Federal government for this expansion. Understanding Insurance and Affordable Care Act Terminology: ACA-It stands for Affordable Care Act and is often call ObamaCare. Marketplace- An online marketplace where individuals can compare, shop for and buy qualified health insurance plans. It is also called the Exchange. 1

2 EHB- An acronym for the 10 essential health benefits that the Affordable Care Act requires for all policies that are effective January 1, 2014 or later. These are ambulatory patient services, emergency services, maternity, pediatric (including dental & vision), rehabilitative services & devices, mental health & substance use disorder, preventive (including chronic disease management), hospitalization, prescription drugs and laboratory services. QHP- An acronym for Qualified Health Plan which is a health plan that has the 10 essential benefits. Medicaid- State government agency that provides health coverage for low-income people, families, children, the elderly and people with disabilities. You can apply anytime. CHIP- An acronym for Children s Health Insurance Program. This is administered by the state and provides no-cost or low-cost health insurance for children in families who earn too much to qualify for Medicaid, but cannot afford to purchase private insurance. In NC this is known as Health Choice. You can apply anytime. MAGI- An acronym for Modified Adjusted Gross Income, which is the total of your adjusted gross income and tax-exempt interest income. These are found on Lines 8b and 37 of the IRS Form 1040 and are used to determine subsidy eligibility. CMS- An acronym for Centers for Medicare & Medicaid. This agency, which is under the U.S. Department of Health and Human Services, is responsible for Medicare, Medicaid and the implementation of the Affordable Care Act. Broker- This is an insurance agent who represents multiple insurance companies. Agents and brokers who have completed and passed the CMS Marketplace training can assist individuals with enrolling in a government Marketplace plan. They are compensated by the insurance companies they represent. Navigators- Individuals who have completed the CMS training so they can assist consumers with applying for Marketplace Plans. They also provide outreach and education to raise awareness about the Marketplace Plans. Their activities and pay are funded through state and federal grant programs. Certified Application Counselors- Individuals who have completed the CMS training and are involved in educating consumers and helping them complete Marketplace applications. Examples of application counselors are staff at community health centers, hospitals or non-profit organizations. SEP- Special Enrollment Period- This is a period outside of open enrollment when individuals can enroll in or change a plan purchased on the Marketplace within 60 days due to a qualifying event. Qualifying Life Event- Examples are getting married, birth or adoption of a child, permanently moving to a new area that offers different health plan options, losing health coverage due to job loss, divorce, loss of Medicaid or CHIP eligibility, expiration of COBRA, or a health plan being decertified. Note: Voluntarily quitting your current health insurance or being terminated for not paying premiums is not a qualifying event. Step Therapy- Policy holders taking an expensive brand drug are often required by their insurance company to try a generic equivalent. If your doctor thinks this would be a threat to your health he can write a letter to our insurance company explaining why you must continue to take the brand drug. Short Term Medical Policies (STM) As the name implies these are health insurance policies are for individuals who need coverage for a short period. Although some will provide coverage for up to 12 months, this is normally not a good choice since they do not cover any pre-existing 2

3 conditions and are not qualified health plans. STM only covers unexpected illnesses or accidents and since they are not ACA compliant will not prevent one from paying the penalty tax in IRS Qualified High Deductible Health Plans (HSA Plans) - With this health insurance plan the policy holder pays for medical expenses until he reaches his deductible. These plans can be paired with a Health Savings Account (HSA) which can reduce the policy holder s taxable income. The policy holder can withdraw money from his Health Savings Account to pay his medical expenses without a penalty. Individuals who purchase these plans are not required to set up an HSA. If they do set one up, they are not required to use the bank their insurance company recommends. This type of policy is available on the Marketplace. COBRA (Consolidated Omnibus Budget Reconciliation Act of 1985) allows workers and their dependents to purchase group coverage for 18 months (or sometimes longer) when the worker is voluntarily or involuntarily terminated. Workers can pay up to 102 % of the cost of the premium the employer pays for coverage. The former employee can purchase COBRA for a dependent even if he does not purchase it for himself. Marketplace Plans These are the types of plans BCBS and Coventry through the Marketplace: Bronze- Medical costs are covered at approximately 60%. Ideal for people that want low premiums and don t expect to need a lot of medical services. Silver- Medical costs are covered at 70%. Designed for those who want monthly premiums and out-of-pocket medical costs more balanced. Applicants with very low incomes are eligible for silver enhanced plans with lower copays, deductibles and maximum out of pockets. Gold- Medical costs are covered at 80%. These plans are designed for individuals who receive medical attention on a regular basis and are willing to pay a higher premium. Platinum- Medical costs are covered at 90%. This plan is designed for people who receive medical services frequently and prefer higher premiums with lower co-pays and deductibles. Catastrophic- These are the least expensive plans designed for individual who rarely have any medical expenses. Unless you have a special exemption you must be under age 30 to qualify for this plan. If you choose this policy you will not be eligible for a subsidy. Choose your plan before you go to the Marketplace. These are the questions you need to ask: Are your doctors and area hospitals in the network of the plan you choose? Both BCBS and Coventry have a website to answer this question. If you use a broker or agent they can do this for you. BCBS has 3 different networks, Blue Advantage, Blue Select and Blue Value. The Blue Advantage network offers the largest network and these plans have higher premiums. Although Blue Select also has a large network, it has tiers. If your doctor or hospital is tier 2 you pay a higher co-pay or percentage. Blue Value network plans are the least expensive since their network is limited. If your doctors and local hospitals are in this network one these plans is a good option for lowering you premiums. The UNC Hospitals (including Rex) and WakeMed Hospitals are in Blue Value network, but Duke is not. Unlike BCBS, Coventry does not offer the Marketplace plans in all the NC counties. However, they do offer plans in 39 counties which include the major population areas such as Charlotte, the Triad area and the Research Triangle Area. Their tier system is similar to 3

4 BCBS Blue Select Plans. Duke and WakeMed are tier 1 hospitals, but Rex and the UNC hospitals are tier 2. What is the cost of each of your prescription drugs? What is your drug deductible per person? What is your deductible, co-insurance and maximum out of pocket per person? What is your deductible and maximum out of pocket per family? Tip: Dental is offered for adults at an extra cost, but it is not subsidized and not price competitive with what you can purchase outside the Marketplace. Who is eligible for a Marketplace Plan? Individuals or families who are not eligible for employer health insurance and whose household income is between 100% and 400% of the Federal Poverty Level are usually eligible. Also, individuals who are offered health insurance plan from their employer that is not considered a Qualified Health Plan are eligible. As you can see from the chart below, if your income is within a certain range you will probably qualify for a subsidy. Since NC has not expanded Medicaid you will not be eligible for a subsidy if your income is below certain levels unless you have children, are pregnant or are disabled. Even if you do not qualify for Medicaid your children may qualify for Medicaid or CHIP. If you have access to group plan through your spouse you are usually not eligible for a subsidy. However, exceptions are made if purchasing this coverage is considered unaffordable based on your household income. What information will you need when you are applying for a subsidy? You must provide dates of birth and social security numbers of everyone who needs to be covered. Child support, veteran s payment and Supplemental Security Income are not considered part of your income. Income information must be provided for everyone you claim on your 1040 tax form even if they are not applying for coverage. Your income used to calculate your subsidy can be from your tax return from 2012 or 2013 as well as your expected income for If you are not a US Citizen you will be required to provide your immigration documentation. You will be asked if you plan to file an income tax return in If you say no you will be told that you are not eligible for a subsidy. What are the Premiums? 4

5 Older individuals cannot be required to pay more than 3 times what a younger person pays. When consumers apply through the Marketplace they also apply for a government subsidy or other government assistance to ensure their health insurance premium does not exceed 9.5% of their income. Individuals making up to $45,960 may qualify for a subsidy. A family of 4 making up to $94,200 may qualify. Your subsidy can be received in advance or on your 2015 tax return. If you choose to receive it in advance it will be sent directly to your insurance company to reduce the amount you have to pay. Subsidies are not offered to catastrophic policy holders. Here are examples of the premiums and the associated subsidies: A 43 year old single parent with a 13 year old and 16 year old can get a BCBS Blue Value policy with a $25 co-pays and a $3,000 deductible for $ per month. With a $45,000 income they would receive a $ subsidy reducing their premium to $ A 58 year old with a $30,000 income can get this same plan for $ with a subsidy of $ and would only pay $ after the subsidy. In addition to receiving a subsidy, applicants at lower income levels sometimes receive a reduction in their co pays and deductibles. For example, a 40 year old with a $16,000 income can get a Blue Value Enhanced Silver Plan with a $500 deductible and $5 doctor co pays for $68.66 per month after the subsidy. How do you apply? You can apply for a subsidy by mail, online (healthcare.gov), in person or via a call center, which is In person help can be from a Navigator, Certified Application Counselor, insurance agent or insurance broker. The advantage of receiving help from an agent or broker is they can assist with the subsidy application as well as choosing an insurance plan. Like many of the agents I do a 3 way call with healthcare.gov and my clients. Most of the healthcare.gov agents are adept at entering information into the web site, but since they are not licensed agents it is difficult for them to help you choose a plan. Once you been approved for a subsidy and selected your health insurance plan from the Marketplace, your information must be transmitted electronically to your insurance company, BCBS or Coventry. If you have an agent or broker they receive a report which allows them to follow your application through the enrollment process and make sure it is as fast and problem free as possible. Your agent or broker will continue to be available to address your concerns even after you are enrolled at no additional cost to you. What happens if you do not qualify for a government subsidy? Although you can still enroll in a plan through the Marketplace normally it is a waste of your time. A broker can help you select a plan from BCBS and Coventry as well as the companies not participating in the Exchange. These include Assurant, Cigna and Humana. Bronze, Silver, Gold, Platinum, and Catastrophic plans are offered by these insurance. United Healthcare is only selling Short Term Medical, dental and group plans as well as their Medicare plans in North Carolina. When can you apply? 5

6 Enrollment in the Marketplace (Exchanges) began on October 1st. Applications finalized between 10/1/2013 and 12/15/2013 were effective 1/1/2014. Open enrollment for this year ends on 03/31/2014. Applications completed by the 15th will have an effective date of the 1st day of the following month. If the application is finalized between the 16th and the end of the month, the effective date will be the 1st day of the second following month. You can also purchase health insurance during Special Election Periods for a Qualifying Event such as a marriage, divorce, birth or adoption of a child, moving to a new area or loss of health coverage due to loss of a job. What happens if you do not purchase health insurance? For individuals or families with a low income there will be no penalty. However, individuals with higher incomes can pay a penalty of $95 or 1% of their income, whichever is higher. For families the penalty for not purchasing health insurance will be $285 per family or 1% of their family income, whichever is greater. This penalty is expected to increase each year until The IRS will be responsible for administration of the penalties. Insurance companies will provide their clients with documentation that will be included when tax returns are filed. Unless you have a SEP due to a qualifying event you will not be allowed to purchase health insurance until the end of 2014 and it will not be effective until January 1, Therefore you run the risk of a penalty in 2015 if your income is above a certain level. 6

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