Understanding the Health Insurance Marketplace

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1 Understanding the Health Insurance Marketplace GMR Symposium Brenda Delgado, MPH March, 2015

2 The Health Insurance Marketplace Part of the Affordable Care Act Where qualified individuals and families directly compare private health insurance options Known as qualified health plans (QHPs) Can directly compare on the basis of price, benefits, quality, and other factors Small Business Health Options Program (SHOP) Marketplace for small employers Provides coverage for their employees February 2015 Understanding the Marketplace 2

3 How the Healthcare Marketplace Works It uses one process to determine eligibility for Qualified health plans through the Marketplace Premium tax credits to lower monthly premiums Reduced cost sharing Medicaid Children s Health Insurance Program (CHIP) It offers choice of plans and levels of coverage Insurance companies compete for business February 2015 Understanding the Marketplace 3

4 Everyone Must: 1. Have minimum essential coverage 2. Have an 3. Pay a fee exemption from (shared OR the shared OR responsibility responsibility payment) payment (fee) They re already covered and don t need to do anything. They don t have to get coverage and won t have to pay a fee for not having coverage. They should consider getting coverage. If they don t, they ll pay a fee. February 2015 Understanding the Marketplace 4

5 1. Minimum Essential Coverage If you have coverage from any of the following, you re covered and don t have to do anything related to the Marketplace Employer-sponsored coverage, including COBRA and retiree Medicare Part A (including Medicare Advantage Plans) Medicaid Children s Health Insurance Program (CHIP) Marketplace coverage Individual coverage (outside the Marketplace) TRICARE or certain types of VA coverage February 2015 Understanding the Marketplace 5

6 2. Exemption from the fee You may qualify for an exemption if You re uninsured for less than 3 months of the year The lowest-priced coverage available to you would cost more than 8% of your household income You don t have to file a tax return You re a member of a federally recognized tribe or an Alaska Native Claims Settlement Act (ANCSA) shareholder, or an individual eligible for services through an Indian health care provider You re a member of a recognized health care sharing ministry You re a member of a recognized religious sect with religious objections to health insurance You re incarcerated (unless pending disposition of charges) You re not lawfully present in the U.S. February 2015 Understanding the Marketplace 6

7 Hardship Exemptions You may qualify if you have a circumstance that affects your ability to purchase health coverage You were homeless You were evicted in the past 6 months or were facing eviction or foreclosure You received a shut-off notice from a utility company You recently experienced domestic violence You recently experienced the death of a close family member You experienced a fire, flood, or other natural or human-caused disaster that caused substantial damage to your property You filed for bankruptcy in the last 6 months February 2015 Understanding the Marketplace 7

8 Marketplace Establishment Each state can decide to Create and run its own Marketplace Engage actively with the federal government in operating certain Marketplace functions Have a Marketplace established and operated by the federal government Federal grant support for state s initial costs to plan for and establish a Marketplace February 2015 Understanding the Marketplace 8

9 Eligibility and Enrollment in the Individual Market To be eligible for Marketplace coverage, you must Live in its state, or 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 except when pending disposition of charges Anyone can apply for Medicaid/CHIP at any time, even if incarcerated February 2015 Understanding the Marketplace 9

10 When You Can Enroll in the Individual Market Open Enrollment Period for coverage in 2016 November 1 st January 31st Special enrollment periods are available in certain circumstances during the year February 2015 Understanding the Marketplace 10

11 Special Enrollment Periods Qualifying Life Events Qualifying Life Events Marriage or divorce Having a baby, adopting a child, or placing a child for adoption or foster care Moving your residence, gaining citizenship, leaving incarceration Losing other health coverage Change in income or household status that affects eligibility for premium tax credits or cost-sharing reductions for people enrolled in the Marketplace Indian status as member of a federally recognized tribe February 2015 Understanding the Marketplace 11

12 Special Enrollment Period Screener February 2015 Understanding the Marketplace 12

13 Special Marketplace Protections for Members of Federally Recognized Indian Tribes For AI ANs at income at or below 300% of FPL: Can enroll in a zero cost sharing plan which means no copays, deductibles or coinsurance when receiving care from Indian health care providers or when receiving EHBs through a QHP. No need for a referral from an Indian health care provider when receiving care through the QHP. For AI ANs at income above 300% FPL: Can enroll in a limited cost sharing plan which means no copays, deductibles or coinsurance when receiving care from Indian health care providers. Will need a referral from an Indian health care provider to avoid cost sharing. Eligible for special monthly enrollment periods. Can file an exemption from the shared responsibility payment (fee). February 2015 Understanding the Marketplace 13

14 How the Marketplace Works May apply or change plan during Special Enrollment Period due to certain life changing events. February 2015 Understanding the Marketplace 14

15 Application and Eligibility February 2015 Understanding the Marketplace 15

16 The Coverage Application Available electronically and on paper in English and Spanish Federally-facilitated Marketplace Application form Dynamic online version asks only relevant questions based on your responses Streamlined paper version State-based Marketplaces may have own version Help is available to complete application February 2015 Understanding the Marketplace 16

17 Apply and Shop for Coverage You can also call the Marketplace Call Center, which services Federallyfacilitated and State Partnership Marketplaces (TTY ) February 2015 Understanding the Marketplace 17

18 Get Help Paying for Coverage Applying for insurance affordability programs is optional. February 2015 Understanding the Marketplace 18

19 Eligibility Results February 2015 Understanding the Marketplace 19

20 Enrolling in Coverage February 2015 Understanding the Marketplace 20

21 Premium Payment You must pay the first month s premium by the insurer s deadline Issuers must accept at least these payment methods Paper check Cashier s check Money order Electronic fund transfer (EFT) Pre-paid debit card Some issuers may also accept online, credit card, or debit card payments (check with the plan) February 2015 Understanding the Marketplace 21

22 Marketplace Affordability Financial help is available for eligible families and individuals, including Tax credits that may be used to lower monthly premiums Refundable premium tax credits Advance payment of premium tax credits Reduced cost sharing to lower out-of-pocket spending for health care costs February 2015 Understanding the Marketplace 22

23 Lower Premium Costs Eligibility is based on Household income and family size Household income between 100% to 400% FPL o $23,850 $95,400 for a family of four in 2014 for 2015 coverage Obtaining health insurance through the Marketplace Must be ineligible for government-sponsored coverage, affordable employer-sponsored insurance, or certain other minimum essential coverage February 2015 Understanding the Marketplace 23

24 Cost-Sharing Reductions Lower costs on deductibles, copayments, and coinsurance To be eligible, you must Have income at or below 250% FPL $58,875 annually for a family of 4 in 2013 $59,625 annually for a family of 4 in 2014 Receive the premium tax credit Enroll in a Marketplace Silver-level plan Members of federally recognized Indian tribes or ANSCA shareholders qualify for cost-sharing reductions: When they enroll in any level metal plan. If income is at or below 300% FPL, can enroll in a zero cost sharing plan variation. If income is more than 300% FPL, can enroll in a limited cost sharing plan variation. February 2015 Understanding the Marketplace 24

25 Report on Affordability, Competition and Choice Consumers saved nearly $1.2 billion on their premiums Nearly 7 in 10 are paying $100 a month or less for coverage The average monthly premium dropped from $346 before tax credits to $82 after tax credits across all plans An average of $69 per month after tax credits for Silver plans (the most popular plan type) with a choice of 5 health insurers and 47 plans 266 insurers in the Marketplace by state, offering over 19,000 Marketplace plans across all rating areas February 2015 Understanding the Marketplace 25

26 Marketplace Call Center Services consumers in Federally-facilitated and State Partnership Marketplaces (TTY ) Customer service representatives available 24/7 Help with eligibility, enrollment, and referrals Assistance in English and Spanish Language line for 240+ additional languages State-based Marketplaces have own call centers February 2015 Understanding the Marketplace 26

27 Tips Sheets on Using Your Health Coverage Visit marketplace.cms.gov/outreach-andeducation/outreach-and-education.html Topics CMS Product No. Seeing your doctor Using provider networks Getting prescription medications Getting emergency care Appealing your insurer s decision not to pay Early renewal February 2015 Understanding the Marketplace 27

28 Marketplace.cms.gov Get the latest resources to help people apply, enroll, and get coverage Redesigned Home Page Coming Soon February 2015 Understanding the Marketplace 28

29 Ways to Connect with the Marketplace 1. Sign up for updates at HealthCare.gov/subscribe or CuidadodeSalud.gov/es/subscribe 2. Twitter.com/HealthCareGov 3. Facebook.com/HealthCareGov 4. Youtube.com/HealthCareGov 5. The Health Insurance Blog: HealthCare.gov/blog 6. Federal training for agents and brokers, Navigators, inperson assisters, and certified application counselors Marketplace.medicarelearningnetworklms.com February 2015 Understanding the Marketplace 29

30 2015 Marketplace Results (as of 2/18/15) 11.4 million Americans selected Marketplace plans or were automatically re-enrolled in their health plan On 2/15/15, more new consumers signed up for health coverage than on any day this Open Enrollment or last 15.3 million calls to the call center 33.8 million healthcare.gov users 30

31 Coverage to Care Initiative Written materials and videos available in English and Spanish Marketplace.cms.gov/c2c February 2015 Understanding the Marketplace 31

32 Coverage to Care Roadmap Online at 32

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