The Health Insurance Marketplace

Transcription

1 The Health Insurance Marketplace A CONSUMER S INTRODUCTION BY DAVID STEWART HYNDMAN/BEDFORD HEALTH CENTERS PRESENTED BY MICHELLE BAKER FULTON COUNTY MEDICAL CENTER

2 What is it? What did it do? THE AFFORDABLE CARE ACT

3 What did the new law actually do? Created the Health Insurance Marketplace. Provided a tax credit and income-based support to make insurance more affordable. Created standards for value, affordability and services provided.

4 What is the Minimum Value Standard? What is affordable? A plan meets this requirement if it is designed to cover at least 60% of the total cost of medical services for a standard population. If the employee s premium for individual coverage is 9.5% or less of the employee s adjusted gross income, it is considered affordable. Premiums for spouse or dependents are NOT included.

5 9.5% is too high for me! If the health insurance premium costs you 8% or more of your adjusted gross family income, you can get an exemption from penalties for not having insurance.

6 Minimum Essential Coverage Prescriptions, hospital, emergencies, prevention, doctors, specialists and tests.

7 What else does the law do? Children can stay on parents health insurance until age 26. More preventive care with no out of pocket expense. Pre-existing conditions won t stop you from getting coverage. Requires most people to get and maintain health insurance.

8 But how much is the penalty? 2014: $95 or 1% of income (max $285) 2015: $325 or 2% of income (max $975) 2016: $695 or 2.5% of income (max $2,085) Children cost is ½ of adult Adjusted for inflation from 2017 onwards

9 I have insurance from my work. Can I get help from the Marketplace? It will depend on whether your work insurance: Is considered affordable Meets Minimum Value Standard Meets Minimum Essential Coverage Use Employer Coverage Tool

10 How does it work? HEALTH INSURANCE MARKETPLACE

11 One Application Multiple Results The Marketplace screens for eligibility for other health care programs.

12 A New Doorway to Health Insurance Employer Individual Sponsored Marketplace Market All Doors Lead to Insurance Provided by Private Health Insurance Companies.

13 Only available through the Marketplace Employer Sponsored Marketplace Individual Market Essential Health Benefits Preventive Care No Pre-existing Conditions Help to Lower Premiums Help to Spend Less At Time of Service

14 What is the help? A tax credit paid in advance each month to the insurance company to reduce what the consumer pays as a premium. People with certain income levels get lower deductibles, co-pays, coinsurances, and out-of-pocket maximums.

15 How does the tax credit work? Advance Premium Tax Credit = $250 ALL $300 -$250 $50 Full Premium Less Tax Credit Your Share of the Premium $0 Possible Refund Has no effect on your normal refund and will NOT make it lower

16 How does the tax credit work? Advance Premium Tax Credit = $250 SOME $300 -$200 $100 Full Premium Less Tax Credit Your Share of the Premium $600 Possible Refund You can leave some of it on the table

17 How does the tax credit work? Advance Premium Tax Credit = $250 NONE $300 -$0 $300 Full Premium Less Tax Credit Your Share of the Premium $3,600 Possible Refund You can leave all of it on the table

18 Plan Categories Platinum Gold Silver Bronze 90/10 Split Highest Premiums Lowest Out of Pocket Costs 80/20 Split Higher Premiums Lower Out of Pocket Costs 70/30 Split Higher Premiums Lower Out of Pocket Costs 60/40 Split Lowest Premiums Highest Out of Pocket Costs On Average Actuarial Value Must pick a Silver plan to receive cost-sharing reductions. Catastrophic plan available for under 30 and hardship.

19 Effects of Cost Sharing Reductions 73% 87% 94% Silver can turn into gold or platinum!

20 Who can get help with the costs? Eligibility for the help is based on your income and the number of tax dependents. Note: it s not your gross income before taxes, but a modified adjusted gross income called MAGI.

21 Are You in the Help Zone? You Could Get Help Paying for Insurance If Your Income Is On the Chart Below If your income is: People on your tax return: Close to or above: But no more than: 1 $11,670 $46,680 2 $15,730 $62,920 3 $19,790 $79,160 4 $23,850 $95,400 5 $27,910 $111,640 6 $31,970 $127, % FPL 400% FPL { Help Zone Most can purchase insurance through the Marketplace. Not everyone will qualify for help with the costs.

22 Medicaid Expansion Enrollment begins December 1, 2014 for coverage that starts on January 1, 2015.

23 Pay Back Limits: Individual There are limits to what you have to pay back. % of FPL Individuals Payback Cap Below 100% $11,490 No Payback 100% to 200% $22,980 $ % to 300% $34,470 $ % to 400% $45,960 $1, % and up $45,960 + Full Amount That said, if you estimate your income above 100% of FPL and it comes in below, there are no penalties and no payback is required

24 Pay Back Limits: Family There are limits to what you have to pay back. % of FPL Family of 4 Payback Cap Below 100% $23,550 No Payback 100% to 200% $47,100 $ % to 300% $70,650 $1, % to 400% $94,200 $2, % and up $94,200 + Full Amount That said, if you estimate your income above 100% of FPL and it comes in below, there are no penalties and no payback is required

25 Cost factors Tobacco Use Location Average Actuarial Value Age Pre-existing Conditions

26 Questions?

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35 Local Resources Fulton County Medical Center Michelle Baker, CAC Tristate Community Health Center