Health Insurance Marketplace Basics

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1 Health Insurance Marketplace Basics Amanda Ptashkin, JD Outreach and Advocacy Director

2 WHY SHOULD I GET COVERAGE? Access to the health care system Financial protection against high medical costs Overwhelming evidence that insurance facilitates better access to care and better health outcomes; increases productivity; saves lives

3 WHO IS ELIGIBLE TO PURCHASE IN THE MARKETPLACE? Individuals and families who DON T already have access to an affordable health insurance plan through their workplace (or other coverage such as Medicare) Individuals who ARE offered insurance BUT the employee-only premium exceeds 9.5% of household income or the plan does not meet a 60% minimum actuarial value Individuals with pre-existing conditions (who meet the above criteria)

4 WHO IS ELIGIBLE TO PURCHASE IN THE MARKETPLACE? Marketplace eligibility requires you to: Live in its service area, and Be a U.S. citizen or national, or Be a non-citizen who is lawfully present in the U.S. for the entire period for which enrollment is sought Not be incarcerated Can apply for Marketplace if pending disposition of charge Can apply for Medicaid/PeachCare at any time

5 WHEN CAN I PURCHASE COVERAGE? The open enrollment period is October 1 st, 2013 March 31 st, 2014 If you enroll between October 1st and December 15 th, coverage will begin January 1 st If you enroll after the 15 th of the month, coverage will begin the first day of the second month After open enrollment closes, consumers may still be able to enroll if there is a qualifying event

6 WHAT IS A QUALIFYING EVENT? After March 31 st and without a qualifying event, individuals and families will have to wait until the next open enrollment period which will begin October, 2014

7 WHAT IS A HEALTH INSURANCE MARKETPLACE? Transparency Competition & Accountability Navigation & Assistance Information & Tools Affordability

8 WHAT IS A HEALTH INSURANCE MARKETPLACE? Online marketplaces designed to help individuals and small employers obtain private-market coverage Like Orbitz, Travelocity, E- Insurance.com you have a matrix of options, facilitates apples to apples comparison ALL insurance plans sold on the exchange must include essential health benefits Advanced premium tax credits and cost-sharing subsidies available for individuals and families

9 WHAT IS A HEALTH INSURANCE MARKETPLACE? PLATINUM: 90% of costs covered by plan, 10% covered by consumer; higher premium, low out-of-pocket costs GOLD: 80% of costs covered by plan, 20% covered by consumer SILVER: 70% of costs covered by plan, 30% covered by consumer BRONZE: 60% of costs covered by plan, 40% covered by consumer; low premium, higher out-of-pocket costs

10 WHAT IS COVERED IN MY PLAN? Essential health benefits must include items and services within at least the following 10 categories: Ambulatory patient services Emergency services Hospitalization Maternity and newborn care Mental health and substance use disorder services, including behavioral health treatment Prescription drugs Rehabilitative and habilitative services and devices Laboratory services Preventive and wellness services and chronic disease management, and Pediatric services, including oral and vision care

11 WHO SELLS ME THE INSURANCE PLAN? Georgia s Health Insurance Marketplace will feature five carriers the first year, more can be added in subsequent years. The five insurers are: Blue Cross Blue Shield Alliant Kaiser Permanente Peach State Humana

12 HOW MUCH WILL COVERAGE COST ME? Qualifying individuals and families with incomes between 100% and 400% of the federal poverty level (FPL) will be eligible for tax credits that can be applied directly to the plan premiums at the time of enrollment or taken later at tax time 100% Federal Poverty Level % Federal Poverty Level % Federal Poverty Level % Federal Poverty Level 2013 Family Size Annual Income Family Size Annual Income Family Size Annual Income Family Size Annual Income 1 $11,490 1 $22,980 1 $34,470 1 $45,690 2 $15,510 2 $31,020 2 $46,530 2 $62,040 3 $19,530 3 $39,060 3 $58,590 3 $78,120 4 $23,550 4 $47,100 4 $70,650 4 $94,200

13 HOW MUCH WILL COVERAGE COST ME? For individuals making up to 250% FPL there is also assistance with out-of-pocket costs If you qualify for out-of-pocket savings, you must choose a Silver plan to get the savings. If you qualify for these savings, you'll get the out-of-pocket savings benefits of a Gold or Platinum plan for a Silver plan price. You can choose any category of plan, but you'll get the out-of-pocket savings only if you enroll in a Silver plan.

14 WHAT IF I DON T PURCHASE COVERAGE? All Americans must carry health insurance but there are some exceptions For 2014, the fee is $95 per adult and $47.50 per child, up to $285 per family. Or the penalty could be 1% of family income, if that results in a larger fine. Eventually, the fine will be $695 or 2.5% of income, whichever is greater, capped at the lowest priced plan on the marketplace

15 WHO IS EXEMPT FROM THE INDIVIDUAL MANDATE PENALTY? PEOPLE WHO: are uninsured for less than 3 months of the year are determined to have very low income and coverage is considered unaffordable (coverage would be more than 8% of income) are not required to file a tax return because their income is too low would qualify under the new income limits for Medicaid, but their state has chosen not to expand Medicaid eligibility are a member of a federally recognized Indian tribe participate in a health care sharing ministry are a member of a recognized religious sect with religious objections to health insurance

16 HOW DO I ENROLL? ONLINE Go to HealthCare.gov to search for plans and enroll in insurance on the new marketplace. BY PHONE Call (800) to get help as you shop, compare, and apply for health insurance online. IN PERSON Call (855) to find a local community organization near you where you can receive free, in-person assistance from a trained and certified Navigator. Our Navigators can help you find out if you qualify for lower cost coverage, explain your choices, and choose the insurance plan that is best for you and your family. Navigators don t work for an insurance company their only job is to help you.

17 WHO ARE NAVIGATORS? The Department of Health and Human Services (HHS) has allocated $3.8 million for navigator grants in Georgia; grants have been awarded to the University of Georgia, Cooperative Extension Services, and the Structured Employment Economic Development Corporation (SEEDCO) The Human Resource Service Administration (HRSA) has also awarded $3.4 million in grants to federally qualified health centers (FQHCs) in Georgia for outreach and enrollment All navigators must: Maintain expertise in eligibility, enrollment, and program specifications; Conduct public education activities to raise awareness about the Exchange; Provide information and services in a fair, accurate, and impartial manner; Facilitate selection of a qualified health plan; Provide referrals for grievances, complaints, or questions; Provide information in a manner that is culturally and linguistically appropriate

18 WHO MAKES UP THE SEEDCO CONSORTIUM OF NAVIGATORS? Boat People SOS Center for Black Women s Wellness Emory-Grady Urban Health Initiative Georgia Equality & The Health Initiative Georgia Refugee Health and Mental Health Georgia Watch Georgians for a Healthy Future Healthy Mothers Healthy Babies Coalition of Georgia Jewish Family & Career Services Latin American Association Mental Health America of Georgia Parent to Parent Quality Med-Care Inc. Spring Creek Health Cooperative

19 QUESTIONS? Contact me: Amanda Ptashkin or

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