THE AFFORDABLE CARE ACT IN VIRGINIA --THE BASICS-- MARY FRANCES CHARLTON Attorney and ACA Coordinator LEGAL AID JUSTICE CENTER
Overview
Affordable Care Act, aka Obamacare Goals Affordable Insurance Coverage Private Insurance Reform Better Health Delivery System Coverage changes State option for Medicaid Adult Coverage (no decision yet) New Insurance Marketplace Affordable Private Coverage People and Businesses are required to have/provide insurance
New Insurance Marketplace Federally Facilitated Marketplace (FFM) To compare / purchase private health insurance Qualified Health Plans (QHPs) Premium Tax Credits only available with FFM plans Also available to small employers Fewer than 50 full time equivalent employees Small Business Health Options Program SHOP
Eligibility Guidelines & Enrollment Process
Eligibility Marketplace eligibility requires you to: Live in its service area Be a US citizen or national, or be a non-citizen who is lawfully present in the US for the entire time coverage is sought. Not be incarcerated Can apply for Marketplace if pending disposition of charge Can apply for Medicaid/CHIP at any time Not have access to affordable and adequate insurance
Application and Eligibility
Basic Eligibility for Marketplace Insurance with Premium Tax Credits Income between 100%-400% federal poverty line Some legal immigrant under 100% FPL can get tax credits IF not eligible for current Medicaid because of immigration status. Most under 100% FPL will fall into Virginia s Medicaid GAP until expansion. Family Size 100% FPL 400% FPL 1 $11,490 $45,960 2 $15,510 $62,040 3 $19,530 $78,120 4 $23,550 $94,200
Basic Eligibility for Marketplace Insurance with Premium Tax Credits Not receiving or eligible for minimum essential coverage : Medicaid, FAMIS, Medicare Affordable & Adequate job-based coverage Job-based coverage is not affordable/adequate if employee-only plan: costs 9.5% family income; or covers 60% costs
Open Enrollment November 15, 2014-February 15, 2015 If enrolled by December 15, coverage can begin January 1, 2015 Special Enrollment after February 15 to enroll/change plan Loss of other coverage (except for non-payment, rescission) Birth, adoption, marriage Change in immigration status Error by FFM Other exceptional circumstances Note: Medicaid/FAMIS applications accepted & processed all year
What to Consider When Choosing a Plan
Qualified Health Plans (QHPs) Covered Services Standardized coverage - Essential Health Benefits (EHB) 1.Ambulatory patient services 2.Emergency services 3.Hospitalization 4.Maternity & newborn care 5.Mental health & substance use disorder services, including behavioral health treatment 6.Prescription drugs 7.Rehabilitative & habilitative services & devices 8.Laboratory services 9.Preventive & wellness services & chronic disease management, & 10.Pediatric services, including oral & vision care
QHPs Grouped by Value Premium Rates & Cost-sharing establish actuarial value (AV) of each plan: 4 Tiers of Coverage Bronze 60% AV - low overall coverage, lower premiums but higher out-of-pocket costs Silver 70% AV Gold 80% AV Platinum 90% AV - best coverage, highest premiums None in VA Catastrophic coverage for people under age 30 Very high deductible
Insurance Marketplace: Tax Credits Reduce Premium Costs Financial assistance (tax credits) Based on family s income and cost of the 2 nd lowest cost silver plan. Maximum contribution towards premium Income Level (FPL) Up to 133% 2% 133-150% 3 4% Contribution From Income 150-200% 4 6.3% 200-250% 6.3 8.05% 250-300% 8.05 9.5% 300-400% 9.5%
Premium Tax Credit Example John is 32-year old single male Annual Income of $17, 200/year (150% FPL) Maximum Contribution 4% Income = $688/ yr Cost of 2 nd lowest Silver Plan $4,000 ($333.33/mo.) Subtract Contribution - $688 Annual Federal Tax Credit $3,312 John pays $ 57.33/mo Tax Credit $276.00/mo (goes to QHP)
Using the Tax Credits Can use same tax credit for other tier plans Tax credit is fully refundable with tax return (even if no taxes owed) Or you can receive credit (or partial credit) in advance to help pay monthly premiums. Must report changes in income / family size to adjust during year Reconciliation at tax time Subsidy Calculator - http://kff.org/interactive/subsidycalculator/
Limits on Out-Of-Pocket Costs for Low Income People Special cost-sharing protections for those with income under 250% FPL Only applies if Silver Plan is purchased Effectively increases Actuarial Value of Silver Plan to: 94% AV (income 100%-150% FPL) 87% AV (income 150%-200% FPL) 73% AV (income 200%-250% FPL)
Other Limits on Out-Of-Pocket Costs Overall limits on total cost-sharing for Essential Health Benefits. Tied to out-of-pocket limits for Health Savings Accounts. Plans now must have out of pocket maximums that reflect the MOST an individual/family can be charged for out of pocket costs in a plan year.
Minimum Coverage Requirements Tax Penalties Individual / Family penalty is much less than cost of insurance. Penalty is the greater of: 2014 - $95 /adult + $47.50 /child (up to $285) or 1% family income* 2015 - $325/adult + $165.50/child (up to $975) or 2% family income* 2016 - $695/adult + $347.50/child (up to $2085) or 2.5% family income* Exemptions to the penalty Large Employer Penalty in 2015 if affordable coverage not offered. [*Income is amount over tax filing threshold]
If you signed up for a plan in 2013-2014 Open Enrollment To continue health coverage in 2015, you can renew your current health plan or choose a new health plan through the Marketplace during the 2015 Open Enrollment period. Your insurance company will send you information this Fall about updated premiums and benefits. If you re happy with your current plan and want to keep it--and your income or household size haven t changed - you don t need to do anything. The Marketplace will autoenroll you in the same plan for 2015.
If you signed up for a plan in 2013-2014 Open Enrollment (continued) If you want to change plans, you can: Choose any other Marketplace health plan your company offers in your service area if you want to stay with your current insurance company. Choose a new health plan from a different insurance company through the Marketplace. Buy a new private health plan outside of the Marketplace. If you do this, you won t be eligible for premium tax credits and cost-sharing reductions offered through the Marketplace
Thank you! ENROLL Virginia! is a nonprofit, nonpartisan entity that assists individuals and small businesses to obtain health insurance including commercial health coverage through the federally facilitated health insurance marketplace, to qualify for applicable tax subsidies, and to comply with the U.S. Patient Protection and Affordable Care Act and avoid penalties for failure to do so. The program is paid for by a federal grant (Funding Opportunity Number CA-NAV-13-001 from the U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services) and administered by the Virginia Poverty Law Center. The contents provided here are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.