Healthcare Financial Management Association
Stonewall ResortsMay 16, 2013
The ACA Signed into Law March 23, 2010
Four Goals of the ACAStrong emphasis on
prevention
New regulations of the insurance industry
Cost containment
Expand access to virtually every American
Expanding Coverage
Expand Medicaid up to 138 percent of the federal poverty level (FPL)
Establish the Health Insurance Marketplace where private insurance plans are offered
Current Eligibility Expansion Eligibility$0
$5,000
$10,000
$15,000
$20,000
$25,000
$30,000
$6,000
$27,000
Medicaid Expansion Income Eligibility for a Family of Three
Medicaid ExpansionNow that Governor Tomblin
has approved the Medicaid expansion, 120,000 low-income West Virginians become eligible
Enroll begins October 1, 2013 and coverage begins January 1, 2014
Medicaid ExpansionFederal government pays
100% of the expansion costs the first three years
The federal share gradually reduces but never drops below 90%
Medicaid is exempt from sequestration
Examples of FPL for Medicaid
Family Size 138% of FPL 155% of FPL
1 $15,856 $17,810
2 $21,404 $24,040
3 $26,951 $30,272
4 $32,499 $36,502
Medicaid EligibilityMedicaid eligibility is
determined by:
◦Income◦Family size◦US citizenship◦State Residency◦Under age 65
Federal Poverty Level
Changes in CHIPWith the increase in Medicaid
eligibility, many children currently enrolled in CHIP will become Medicaid eligible and cannot remain on CHIP:
10,800 kids transfer to Medicaid
2,800 kids picked up under the new MAGI eligibility rules
Beyond MedicaidIf an applicant earns too much to
qualify for MAGI Medicaid, and does not qualify for traditional Medicaid, they will be screened for eligibility for a qualified health plan
Enrollment in a qualified health plan is more complex than Medicaid and requires consumers to make additional decisions
Health Insurance Marketplace
Health Insurance MarketplaceOffers private insurance
policies: Blue Cross Blue Shield, The Health Plan, Carelink, etc.
Who is eligible? People who do not have access to employer sponsored plans or qualify for government plans (Medicaid, Medicare, Tricare, VA, etc.)
Qualified Health Plans (QHPs)Eligibility for a QHP include:
◦Be a US citizen or lawfully present in the US
◦State resident ◦Not being incarcerated
Premium SubsidiesIn order to qualify for
premium tax credits, an applicant must meet the qualifications for QHPs plus:◦Have projected income between 100% and 400% of the FPL in 2014
◦Not have access to other insurance coverage (there are two exceptions for ESI)
◦Are expected to file income tax at the end of the coverage year
Health Insurance Marketplace
An estimated 99,000 West Virginians will qualify for premium tax credits in the Marketplace by 2016.
An Example of the Subsidies
Family of four with annual income of $55,000. They pay $345 a month in premiums and the tax credits equal $840 a month.
Additional assist with deductibles and copayments plus out-of-pocket maximum protection.
Subsidies for Cost Sharing ExpensesIndividuals and families
earning less than 250% of the FPL, and
Select a silver plan (to be discussed later), then
They receive subsidies to reduce the costs of deductibles, copayments and co-insurances
FPL for Cost Sharing Subsidies and Premium Subsidies
Family Size 250% of the FPL 400% of the FPL
1 $28,725 $45,960
2 $38,775 $62,040
3 $48,825 $78,120
4 $58,875 $94,200
250% of the FPL level is the eligibility threshold for cost sharing reductions and 400% of the FPL is the threshold for premium assistance
Levels of Plan Options for QHPsFour “metal levels” of plans
may be offered in the Marketplace and vary based on their actuarial value
The actuarial value is what percentage of claims for essential health benefits the insurance company pays and what percentage on average consumers pay
Levels of Plan Options for QHPsIn a platinum plan, the insurance company pays 90% of claims and consumers on average pay 10% of the claims
Gold plans are split 80/20 between the insurance company and consumers
Siler is a 70/30 split, andBronze is a 60/40 split
Premiums in the Various Metal Levels
Premiums in a platinum plan would be higher, while deductibles and copayments would be lower
Conversely, the premiums in a bronze plan will be lower, while the cost sharing would be higher
Selecting a QHP
Unlike Medicaid, which is a two step process (eligibility and then enrollment), the Marketplace can determine eligibility and provide options for an individual or family to select an insurance plan and enroll in a plan.
Selecting a QHP
The Marketplace will have a calculator showing an individual or family their premium, deductibles, copayments or co-insurances for each insurance company
Summary of Benefits and Coverage
The Marketplace will allow have an 8-page summary of benefits and coverage:
◦What’s covered, what’s not ◦Costs for a typical Type II diabetic
◦Costs for a normal delivery
All written in plain English
Selecting a QHPThe Marketplace will also
have links to insurance company’s web site
Consumers can check to see if their doctor or hospital are in the company’s network
Consumers can check to see if the drug(s) they are taking are on the company’s formulary
Selecting a QHPIn future years, the
Marketplace will have the results of consumer satisfaction surveys for each insurance company
And a rating system for insurance companies
SHOP MarketplaceEligibility for the Small
Business Health Insurance Option Program (SHOP) is 50 or fewer employees, about 42,000 West Virginia businesses employing 280,000 people
Only 16,000 employees projected to be enroll in SHOP Marketplace by 2016
Who are the uninsured?48% Healthy and Young
Take health for granted Tech savvy Low motivation to enroll
29% Sick, Active and Worried Generation X and Baby Boomers
15% Passive and Unengaged 49 and older Live for today Don’t understand health insurance
Source: HHS Marketing Survey, March 2013
Personal Assistance Needed83% of people who will
qualify for assistance in the future know nothing about it
Skeptical and interest framed by past negative experience
75% want personal assistance
How Do We Enroll All These People?
Web site and call center operated by HHS
A number of entities will provide personal assistance
Personal AssistanceInsurance agents and brokers
Navigators
In-person Assisters
Certified Application Counselors
DHHR Employees
Community Assisters
The Enrollment ProcessSingle, Streamline
Application for Medicaid, CHIP and qualified health plans (QHPs) in the Health Insurance Marketplace
There is no asset test for any of theses three insurance policies
Take AwaysThe uninsured can enroll
where ever there is a lap top or iPad with internet connection. They can also use a toll-free call center or personal assistance.
Take AwaysFor the most part, the system
will be paperless and will rely on electronic databases or self-attestation to determine eligibility for Medicaid or the QHPs
Take AwaysThe numbers are staggering:
◦120,000 eligible for Medicaid
◦99,000 eligible for premium assistance
◦16,000 eligible for the SHOP Marketplace
OpportunityWe have a once-in-a-lifetime
opportunity to improve the lives of thousands of our friends and neighbors. I hope you will join WVAHC in this journey
We need…
Contact Information
Perry BryantWest Virginians for Affordable
Health Care1544 Lee Street, EastCharleston, West Virginia