Affordable Care ActAffordable Care ActMarketplace Implementation Briefing Marketplace Implementation Briefing

Virginia Association of CountiesVirginia Association of Counties

June 5, 2013June 5, 2013

HEALTHCARE.GOV

Joanne Corte Grossi, MIPPJoanne Corte Grossi, MIPPRegional DirectorRegional Director

U.S. Department of Health & Human U.S. Department of Health & Human Services, Region III Services, Region III

Pennsylvania, Delaware, District of Columbia, Pennsylvania, Delaware, District of Columbia, Maryland, Virginia, West VirginiaMaryland, Virginia, West Virginia

Critical Need for Health ReformCritical Need for Health Reform

48.6 million uninsured Americans 48.6 million uninsured Americans

$3 trillion spent annually on healthcare$3 trillion spent annually on healthcare

17.9 % of our economic output tied up 17.9 % of our economic output tied up in the health care system in the health care system

Without reform, by 2040, 1/3 of Without reform, by 2040, 1/3 of economic output tied up in health careeconomic output tied up in health care

Affordable Care Act Affordable Care Act OverviewOverview

Provides coverage to young adults up to Provides coverage to young adults up to the age of 26the age of 26

Strengthens Medicare benefits with lower Strengthens Medicare benefits with lower prescription drug costs for those in the prescription drug costs for those in the ‘donut hole,’ chronic care, and free ‘donut hole,’ chronic care, and free preventive carepreventive care

Prohibits plans from imposing lifetime and Prohibits plans from imposing lifetime and annual limits on the dollar value of annual limits on the dollar value of benefits, and from rescinding coverage benefits, and from rescinding coverage when you get sickwhen you get sick

Affordable Care Act OverviewAffordable Care Act Overview Rein in insurance premiums ratesRein in insurance premiums rates

Prevent denials of coverage, including for Prevent denials of coverage, including for pre-existing conditionspre-existing conditions

Make health insurance affordable for Make health insurance affordable for middle class familiesmiddle class families

Make health insurance affordable for Make health insurance affordable for small businesses with tax cutssmall businesses with tax cuts

Health Insurance MarketplaceHealth Insurance Marketplace

Sometimes called “Exchanges,” the Sometimes called “Exchanges,” the Marketplace is required by the ACA to be Marketplace is required by the ACA to be created by January 1, 2014created by January 1, 2014

New “marketplace” where small businesses and New “marketplace” where small businesses and individuals can select and enroll in a private individuals can select and enroll in a private health insurance plan health insurance plan

Consumers will have Consumers will have • the same level of benefits and coverage the same level of benefits and coverage

available to members of Congressavailable to members of Congress• more choice and selection in health plansmore choice and selection in health plans

Three models availableThree models available State-BasedState-Based Federal-State PartnershipFederal-State Partnership Federally-FacilitatedFederally-Facilitated

States can apply for Marketplace States can apply for Marketplace establishment funding at any time and be establishment funding at any time and be awarded grants through 2014 awarded grants through 2014

HHS to operate marketplaces for States HHS to operate marketplaces for States that have not elected to do so that have not elected to do so

Marketplace Implementation Marketplace Implementation

Actuarial ValueActuarial Value The ACA requires plans inside the Marketplace The ACA requires plans inside the Marketplace

to meet particular actuarial value (AV) targetsto meet particular actuarial value (AV) targets• Bronze = 60% AVBronze = 60% AV• Silver = 70% AVSilver = 70% AV• Gold = 80% AVGold = 80% AV• Platinum = 90% AVPlatinum = 90% AV

““Metal Levels” will enable consumers to Metal Levels” will enable consumers to compare plans with similar levels of coverage, compare plans with similar levels of coverage, promote competition on premiums, and allow promote competition on premiums, and allow plans flexibility to design cost sharing plans flexibility to design cost sharing structuresstructures

Financial AssistanceFinancial Assistance

Premium tax creditsPremium tax credits• Will reduce the premium amount the consumer Will reduce the premium amount the consumer

owes each monthowes each month• Available to eligible consumers with household Available to eligible consumers with household

incomes between 100% and 400% of the FPL incomes between 100% and 400% of the FPL ($44,680 for an individual and $92,200 for a family ($44,680 for an individual and $92,200 for a family of 4 in 2012), and who don’t qualify for other health of 4 in 2012), and who don’t qualify for other health insurance coverageinsurance coverage

• Based on household income and family size for the Based on household income and family size for the taxable yeartaxable year

• Paid each month to the insurerPaid each month to the insurer

Financial AssistanceFinancial Assistance

Cost-sharing reductions:Cost-sharing reductions: Reduce out-of-pocket costs (deductibles, Reduce out-of-pocket costs (deductibles,

coinsurance, copayments)coinsurance, copayments)• Generally available to those with income 250% Generally available to those with income 250%

FPL or below (FPL or below ($27,925 for an individual and $27,925 for an individual and $57,625 for a family of 4 in 2012)$57,625 for a family of 4 in 2012)

• Based on household income and family size for Based on household income and family size for the taxable yearthe taxable year

Essential Health BenefitsEssential Health Benefits• Ambulatory patient servicesAmbulatory patient services• Emergency servicesEmergency services• HospitalizationHospitalization• Maternity and newborn careMaternity and newborn care• Mental health and substance use disorder Mental health and substance use disorder

services, including behavioral health treatmentservices, including behavioral health treatment• Prescription drugsPrescription drugs• Rehabilitative and habilitative services/devicesRehabilitative and habilitative services/devices• Laboratory servicesLaboratory services• Preventive and wellness services and chronic Preventive and wellness services and chronic

disease managementdisease management• Pediatric services, including oral and vision Pediatric services, including oral and vision

carecare

Quality InsuranceQuality Insurance

Enrollment ProcessEnrollment Process Consumer submits application to the marketplaceConsumer submits application to the marketplace

• OnlineOnline• PhonePhone• MailMail• In PersonIn Person

The marketplace verifies and determines The marketplace verifies and determines eligibility foreligibility for• enrollment in a Qualified Health Plan (QHP)enrollment in a Qualified Health Plan (QHP)• tax credits and cost-sharing reductionstax credits and cost-sharing reductions• Medicaid or CHIPMedicaid or CHIP

Consumer enrolls in a QHP or Medicaid/CHIPConsumer enrolls in a QHP or Medicaid/CHIP• Online plan comparison tool available to inform health plan Online plan comparison tool available to inform health plan

choicechoice• Tax credit is sent to insurer (if eligible) to reduce consumer Tax credit is sent to insurer (if eligible) to reduce consumer

premium owed premium owed

Enrollment AssistanceEnrollment Assistance

HHS grant program to fund entities or individuals HHS grant program to fund entities or individuals called “Navigators” that will provide consumer called “Navigators” that will provide consumer assistance and:assistance and:• Maintain expertise on MarketplacesMaintain expertise on Marketplaces• Provide information to consumers in a fair, accurate and Provide information to consumers in a fair, accurate and

impartial mannerimpartial manner• Facilitate QHP selectionFacilitate QHP selection• Refer consumers to other resourcesRefer consumers to other resources• Provide information in a culturally and linguistically Provide information in a culturally and linguistically

appropriate mannerappropriate manner

Navigators cannot accept indirect or direct Navigators cannot accept indirect or direct compensation from issuers for enrolling compensation from issuers for enrolling individuals in QHPs or other health plans offered individuals in QHPs or other health plans offered outside of the Marketplaceoutside of the Marketplace

Initial Open Enrollment PeriodInitial Open Enrollment Period

October 1, 2013 – March 31, 2014October 1, 2013 – March 31, 2014

Enroll during the Initial Open Enrollment Period

Your coverage is effective*

On or before December 15, 2013

January 1, 2014

Between the 1st and 15th day of January – March

First day of the following month

Between the 16th and the last day of December – March

First day of the second month

Highlights for Small Highlights for Small BusinessesBusinesses

Starting in 2014, all individuals will be required to Starting in 2014, all individuals will be required to have health insurancehave health insurance

Businesses with fewer than 50 full-time employees Businesses with fewer than 50 full-time employees are are exemptexempt from any requirement to contribute from any requirement to contribute towards employee health coveragetowards employee health coverage

More than 96 percent of employers with 50 or more More than 96 percent of employers with 50 or more employees already offer their employees health employees already offer their employees health insurance coverage insurance coverage

The IRS and Department of Labor have oversight of The IRS and Department of Labor have oversight of Employer Responsibility provisions of the ACAEmployer Responsibility provisions of the ACA

Highlights for Small Highlights for Small BusinessesBusinesses

In 2014, small businesses can participate in In 2014, small businesses can participate in Exchanges as part of the Small Business Exchanges as part of the Small Business Health Options Program (SHOP)Health Options Program (SHOP)• More affordable coverage because of access to More affordable coverage because of access to

larger risk poolslarger risk pools

Small businesses will have increased Small businesses will have increased bargaining power and reduced administrative bargaining power and reduced administrative costs—just like large companiescosts—just like large companies

Tax credit of up to 50% available to Tax credit of up to 50% available to companies with 25 FTEs or lesscompanies with 25 FTEs or less

Highlights for Small BusinessesHighlights for Small Businesses Full time is defined as 30 hours per weekFull time is defined as 30 hours per week

Employer will be liable for Shared Employer will be liable for Shared Responsibility if:Responsibility if:

• Does not offer cover to 95% of its full-Does not offer cover to 95% of its full-time employees;time employees;

• And at least one full-time employee And at least one full-time employee receives a premium tax credit to help receives a premium tax credit to help pay for coverage on Exchangepay for coverage on Exchange

Medicaid ExpansionMedicaid Expansion

• 400,000 Virginians would receive 400,000 Virginians would receive coveragecoverage

• 100% federally funded for first three 100% federally funded for first three years (2014-2016)years (2014-2016)

• Federal funding gradually reduced to Federal funding gradually reduced to 90% in 2020 90% in 2020

• $9 billion in first six years$9 billion in first six years

Resources:

Affordable Care Act website –Affordable Care Act website –www.healthcare.gov

Health Insurance Marketplace –Health Insurance Marketplace –

marketplace.cms.govmarketplace.cms.gov

Center for Consumer Information & Insurance Center for Consumer Information & Insurance Oversight website – Oversight website – http://cciio.cms.gov

Affordable Care Act Spanish Affordable Care Act Spanish website website – – www.cuidadodesalud.gov

Thank you!Contact:

joanne.grossi@hhs.gov