navigating affordable health care
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NAVIGATING AFFORDABLE HEALTH CAREPersonal Assistance Within Reach
Thursday, October 31, 13
Mountain Projects Inc.
Graham County Presentation
October 29, 2013
6-7:30 pm
Graham and Swain County Navigator: Julia Buckner
Thursday, October 31, 13
Today’s TopicsMountain Project's Role
The MarketPlacePersonalized assistance
Privacy and Protection
Eligibility and Enrollment
Preparing for an Appointment
Contact Information
Thursday, October 31, 13
Mountain Projects Inc.A Community Action AgencyMPI awarded a grant to implement a Navigator program in the seven counties in WNC
Counties: Clay, Cherokee, Haywood, Graham, Jackson, Swain, Macon
Local and personal assistance
Community education and partnership agencies
5.5 employees- covering the 7 counties of WNC-Navigators
Volunteers trained and more needed
Thursday, October 31, 13
FINDING A CERTIFIED NAVIGATOR?Far -Western North Carolina
Thursday, October 31, 13
FINDING A CERTIFIED NAVIGATOR?Far -Western North Carolina
Jan Plummer: Project Coordinator & Haywood
Julia Buckner: Graham & Swain
Patti DeRidder and Claire
Tiernan: Cherokee & Clay
Cindy Solesbee: Macon
Rebecca Mathis: Jackson
Jane Harrison: Haywood & Jackson Personal Assistance
Within Reachwww.mountainprojects.org
Thursday, October 31, 13
How do Mountain Projects’ Navigators Assist You?
Certified to assist through enrollment
Explain insurance terminology; choices; implications
Unbiased, impartial, and free
Privacy/Confidentiality
No rush, no pressure, no affiliation
Resource for questions
May complete on-line or paper applications
Thursday, October 31, 13
Navigator AssistanceUnbiased, free, impartial
Individuals or Small Employers
Assigned to Counties
Block Times at partner Agencies, i.e. DSS, Mountain Projects
Community Events
Can not go door to door
Refer to state agencies if appropriate
Appointments available
Thursday, October 31, 13
Provisions of the ACAGOAL: Affordable health care for millions
TOOLS: The Marketplace/An Insurance Exchange
Shop, compare and purchase insurance based on income and household size.
Medicaid Expansion: NC did not expand
Individual Mandate beginning 2014/Exemption
Employer Shared Responsibility:
Must offer a plan that meets ACA minimum essential benefits or pay a fee (ESRP)
Thursday, October 31, 13
Affordable Care Act Protections
Prohibits higher premiums due to health/gender
Extend coverage for dependents up to age 26
Prohibits discrimination against consumers seeking coverage with pre-existing conditions
Eliminated Insurance Annual Coverage Limits
Thursday, October 31, 13
Marketplace ConsumersSmall Businesses
Investigate coverage for employees
Explore options via the Marketplace
Questions about exemptions and penalties
Have 50 FTE's or equivalent
Individuals
Need health insurance
Have health insurance they can't afford
Have dependents or a spouse that make insurance unaffordable
Employed by a small employer getting health insurance through the Marketplace
Thursday, October 31, 13
MARKETPLACE DETAILSTransparency, Competition, and Choice
Insu
ran
ce A
ffo
rdab
ilit
y
APTC CSR MEDICAID CHIP
Advanced Premium
Tax Credits
Cost Sharing
Reductions
Medicaid Children’s Health
Insurance Program
Thursday, October 31, 13
MARKETPLACE DETAILSTransparency, Competition, and Choice
Insu
ranc
e Affo
rdab
ility
Prog
rams
APTC
Advanced Premium
Tax Credits
NEW federal program that uses tax credits to reduce premium costs for QHP enrollees.
For people who meet financial criteria and don’t have access to other coverage.
Can be paid in “advance” to provide immediate help in paying premiums.
IRS reconciles over/under payments of advance premium tax credits when people file taxes.
Thursday, October 31, 13
MARKETPLACE DETAILSTransparency, Competition, and Choice
Insu
ranc
e Affo
rdab
ility
Prog
rams
Cost Sharing
Reductions
NEW federal program
Helps reduce out-of-pocket costs for enrollees in QHPs.
Payments are made directly to issuers to reduce deductibles, co-insurance, and/or copayments (out-of-pocket) costs.
CSR
Thursday, October 31, 13
MARKETPLACE DETAILSTransparency, Competition, and Choice
Insu
ranc
e Affo
rdab
ility
Prog
rams
Medicaid
Existing federal-state health insurance program for low income people.
Expanded to more low-income adults by the ACA. States can opt out of expansion.
Provides comprehensive health care benefits.
Minimal out-of-pocket costs.
MEDICAID
Thursday, October 31, 13
MARKETPLACE DETAILSTransparency, Competition, and Choice
Insu
ranc
e Affo
rdab
ility
Prog
rams
Children’s Health
Insurance Program
Existing federal-state health insurance program for low- and moderate-income children.
Provides comprehensive health care benefits.
Modest out-of-pocket costs.
CHIP
Thursday, October 31, 13
Eligibility and Enrollment
Started October 1, 2013
Enroll by December 15,2013 coverage begins January 1, 2014
Ends March 31, 2014
Special Enrollment Periods
Premium by Dec. 15
Coverage by Jan. 1
Thursday, October 31, 13
How to PrepareEmployer
Expected enrollment
Existing health coverage?
Age of Spouse
Dependent information
Agent may help enroll/explore
Individuals
SSN for Household/Birthdates
Pay Stubs/W2 Tax Information for 2013/estimate2014
Employer insurance information (handout)
Additional HH income information
Thursday, October 31, 13
Qualified Health PlansMinimum Essential Benefits
Ambulatory Patient Services
Emergency Services
Hospitalization
Maternity and Newborn Care
Mental Health/Substance Abuse/Behavioral Health Treatment
Prescription Drugs
Rehabilitation: physical or mental
Labs
Wellness/Chronic Disease Management (Asthma, diabetes)
Pediatric Services including dental
Thursday, October 31, 13
Health Plan CategoriesBRONZE: Minimum Essential Benefits/Insurance pays 60% of covered expenses
SILVER: Minimum Essential Benefits/Insurance pays 70% of covered expenses
GOLD: Minimum Essential Benefits/Insurance pays 80% of covered expenses
PLATINUM: Minimum Essential Benefits/Insurance pays 90% of covered expenses
CATASTROPHIC: Meet all QHP requirements but only cover 3 primary care visits annually until deductible is met. Must be under 30 or receive a hardship exemption.
70%
30%
insurance
you
Silver
Thursday, October 31, 13
Health Plan CategoriesBRONZE: Minimum Essential Benefits/Insurance pays 60% of covered expenses
SILVER: Minimum Essential Benefits/Insurance pays 70% of covered expenses
GOLD: Minimum Essential Benefits/Insurance pays 80% of covered expenses
PLATINUM: Minimum Essential Benefits/Insurance pays 90% of covered expenses
Premiums increase
Out of Pocket
increase
Thursday, October 31, 13
Options to Lower CostsPremium Tax Credits
Lower monthly premiums/HH income, size, cost of available plans
Cost Sharing Reductions
Limits out-of-pocket costs (deductibles and co-pays)/HH income/size
MAY REQUIRE SILVER PLAN SELECTION
Competition in the Marketplace: Blue Cross & CoventryOne
Thursday, October 31, 13
Exemptions to Individual Responsibility Requirement
Investigate first
Hardships: Homelessness, eviction, foreclosure, utility shut-off, domestic violence victim, death of close family member, recent bankruptcy, unexpected caretaker expenses, eligibility denials, coverage exceeding 8% of projected annual income, ineligible for Medicaid/no state expansion
Navigators can not assist with the exemption application. (IRS)Incarceration Past monthsIndian Status Past and FutureReligious Conscience Complete IRS Form 4029Health Care Sharing Ministry Past months
Thursday, October 31, 13
HOW THE MARKETPLACE WORKS
Thursday, October 31, 13
Window Shoppingwww.healthcare.gov
Look at Plans
Kaiser Health Calculator
BCBS Site: http://www.bcbsnc.com/content/providersearch/index.htm
Coventry Site: http://nc.coventryproviders.com
Thursday, October 31, 13
KAISER SUBSIDY CALCULATOR
Thursday, October 31, 13
Thursday, October 31, 13
FEDERAL POVERTY LEVELS
Thursday, October 31, 13
OPTIONS TO LOWER COSTS
Thursday, October 31, 13
NC Medicaid EligibilityNC Medicaid covers only 30% of adults in poverty
Medicaid for Families** & Medicaid for Aged, Blind, Disabled
The Affordable Care Act, as written, expands Medicaid eligibility to all US citizens under 138% of the Federal Poverty Line (FPL).
Because ACA assumed Medicaid expansion, those under 100% of FPL do not qualify for APTC.
COVERAGE GAPS
0
25
50
75
100
Medicaid Eligibility
21-64: non-disabled, no child, No Medicaid
Thursday, October 31, 13
NC Medicaid ExpansionMany more can get Medicaid/CHIP, due to higher income limits, income exclusions, choices re claiming dependents.
A few will LOSE Medicaid/CHIP due to changes. First recertification after 3/31/14. e.g. stepparent with income, sibling with taxable income, separated but file jointly.
Often child will be enrolled in Medicaid or CHIP while parent is enrolled in private insurance.
This will lead to different provider networks, different coverage, and different copays/deductibles (which are very low for Medicaid and CHIP) for parent vs. child.
Thursday, October 31, 13
NC Coverage Gaps
Consumers not eligible for Medicaid/Chip will not receive tax credits unless their projected 2014 income is higher than 100% of FPL.
There is no risk (and significant benefit) to honestly, reasonably projecting 2014 income over 100% of FPL.
IRS will waive overpayment if actual 2014 income turns out to be under 100% of FPL.
Federal Poverty Levels
Thursday, October 31, 13
TAX CREDITSHow much will this cost?
Thursday, October 31, 13
EXPECTED FAMILY $$How much will this cost?
Thursday, October 31, 13
BENCHMARK PLANSHow much will this cost?
REMEMBER: The size of the tax credit equals the silver benchmark plan minus a family’s expected contribution.
The higher the cost of the benchmark plan, the larger the APTC.
Benchmark plan costs will change based on where the family lives, the ages of the family members seeking coverage,and the number of household members enrolled in QHP.
Even when the benchmark plan changes, the family’s expected contribution amount remains the same.
Thursday, October 31, 13
FINDING A CERTIFIED NAVIGATOR?Far -Western North Carolina
Personal Assistance
Within Reach
www.mountainprojects.org
828-452-1447, ext. 115
1-800-627-1548
All NC Counties: 1-855-733-3711
Health Insurance Marketplace: 1-800-318-2596
Thursday, October 31, 13
MOUNTAIN PROJECTS Serving the Community since 1965
Thursday, October 31, 13
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