Navigating Affordable Health Care

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


Today’s TopicsMountain Project's Role

The MarketPlacePersonalized assistance

Privacy and Protection

Eligibility and Enrollment

Preparing for an Appointment

Contact Information


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


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


http://www.mountainprojects.org


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


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


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)


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


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


MARKETPLACE DETAILSTransparency, Competition, and Choice

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APTC CSR MEDICAID CHIP

Advanced Premium

Tax Credits

Cost Sharing

Reductions

Medicaid Children’s Health

Insurance Program



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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.



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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



Insu

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Prog

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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



Insu

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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


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


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


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


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


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


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


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


HOW THE MARKETPLACE WORKS


WWW.HEALTHCARE.GOV


http://www.healthcare.gov

http://www.healthcare.gov

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


http://www.bcbsnc.com/content/providersearch/index.htm






http://nc.coventryproviders.com/




KAISER SUBSIDY CALCULATOR


FEDERAL POVERTY LEVELS


OPTIONS TO LOWER COSTS


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


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.


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


TAX CREDITSHow much will this cost?


EXPECTED FAMILY $$How much will this cost?


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.



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




MOUNTAIN PROJECTS Serving the Community since 1965


Navigating Affordable Health Care

Health & Medicine

Transcript of Navigating Affordable Health Care