The Health Insurance Marketplace A Consumer Perspective HFMA Tampa, May 19, 2015
The Role of Navigators Provide information on eligibility and how to use insurance Help to choose a plan Provide referrals Outreach and public education All Navigators must pass a federal background check and commit to working in the interest of the consumer.
Starting in 2014 Everyone Must:
General Requirements to Enroll in the Marketplace 1. Live in health plan service area 2. Be a U.S. Citizen or national, or A non-citizen who is lawfully present in the U.S. for the entire period for which enrollment is sought. immigrant parents can enroll their U.S. citizen children and other eligible family members in health insurance programs under the ACA without triggering immigration enforcement activity. 3. Not be incarcerated Can apply for the Marketplace if pending disposition of charges
Financial Assistance Advanced Premium Tax Credit (APTC) Individuals earning between 100% - 400% of the federal poverty level may qualify for a subsidy on premiums (see chart next slide). Cost Sharing Reduction (CSR) Help with deductibles and co-payments. Income has to be less than 2.5 times the poverty level Cap on out-of pocket costs $6,600 for individual policies and $13,200 for family plans in 2015.
Household Income Thresholds to Receive APTCs Advance Premium Tax Credits (APTCs) often called subsidies or financial assistance are available to consumers based on a combination of: Subsidy based on second-lowest cost Silver plan in county Cost of Silver Plans Household Income Available for incomes between 100 400% of the Federal Poverty Level (FPL) Family Size Based on the number and ages of people covered Each of Florida s 67 counties has separate rating factors County of Residence Tax credits must be used to purchase coverage through the Marketplace.
Household Income Thresholds to Receive APTCs
How the Premium Tax Credits Work The tax credits are paid directly to the insurance company each month to offset premium costs for the health plan an individual selects. The insurance company then sends a monthly bill to the individual for any balance due. The individual pays the insurance company any balance due. Monthly Premium Tax Credit Consumer Owes $253 $123 $122 Example based on a 28-year old in Orange county resident with an annual income of $24,000 (205% FPL) who purchases the second lowest cost 2015 Silver plan.
Family Glitch An individual is offered reasonably priced health insurance through their employer Dependent coverage is offered but not well subsidized by the employer Immediate family members are not eligible to receive premium tax credits for insurance in the Marketplace, even if their income is below the federal poverty level.
Tax Reconciliation Many consumers who enrolled on-line or who didn t work with someone who explained the tax credits were not aware of the need to update their income during the year. Consumers did not fully understand the importance of active re-enrollment Process In January/February, consumer receives Form 1095 from the Marketplace showing how much he/she received in tax credits Consumer takes that information and fills out form 8962. Consumers can no longer fill out a 1040 EZ and most would find it hard to complete Form 8962 with the help of a tax professional.
Repayment Caps for Advance Premium Tax Credits Household Income (as percent of FPL) Single Filers Married Filers Less than 200% $300 $600 200 300% $750 $1,500 300 400% $1,250 $2,500 Over 400% Full Amount Full Amount H&R Block found that for the 2014 tax filing season: 66% of its clients had to pay back an average of $729 of the APTC, cutting their potential refund by nearly one-third 25% of its clients were due an additional premium tax credit and saw an average increase of $425 in their refund http://newsroom.hrblock.com/hr-blocks-final-aca-stats-refunds-impacted-received-advance-tax-credit/
Penalty for Remaining Uninsured Without an Exemption **Note: Penalty is pro-rated for the months without insurance. Example: If you re only without insurance 5 months of the year, you d pay 5/12 th of the penalty owed
Exemptions from the Penalty You will not have to pay the penalty if you: Have income low enough that you don t have to file taxes (even if you file to get a refund) Can t get health insurance because your state has not expanded Medicaid (Florida) for anyone earning under 138% of the federal poverty limit Your private insurance plan is cancelled and other private insurance costs more than 8% of household income Do not have eligible immigration status to shop on the Marketplace Are incarcerated, and not awaiting the disposition of charges Member of a health care sharing ministry Had a gap of less than 3 months without insurance Experienced other hardships Domestic violence Homelessness/Eviction Bankruptcy Utility shut-off notice Natural disaster Family Size 138% FPL 1 $16,105 2 $21,707 3 $27,310 4 $32,913 5 $38,516 6 $44,119 7 $49,721 8 $55,324
Marketplace Enrollment Timeline Special Enrollment Period: February 16, 2015 to October 31, 2015 Open Enrollment: November 1, 2015 to January 31, 2016
Robert's Story Robert chose a platinum plan; with the financial assistance available through the Marketplace, it costs him $118 a month. He says without insurance, he would have gone bankrupt or died.