Navigating Affordable Health Care

1. Navigating Affordable Health Care
Personal Assistance Within Reach...
Haywood County Library
October 15, 2013
5:00 PM
Jan Plummer
Health Care Navigator Program Coordinator
Mountain Projects, Inc.

2. Today's Topics
Mountain Project's Role
The MarketPlace
Personalized assistance
Privacy and Protection
Eligibility and Enrollment
Preparing for an Appointment
Contact Information

3. Mountain Projects Community Action
Agency
NC Navigator Program: Our Role
• MPI 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

4. The Affordable Care Act
Provisions
GOAL: 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)

5. The 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

6. What is in the Marketplace?
• One stop shopping to determine eligibility for Qualified
Health Plans AND...
New tax credits to lower premiums
Reduced cost sharing
Medicaid
Children's Health Insurance Program (CHIP)
Review choice of plans and levels of coverage
Transparency, Competition, Choice

7. Navigator Assistance
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Unbiased, 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

8. Jan Shuler Plummer
Navigator in Training
Graham/Swain
Patti Deridder
Volunteers certified in
NC Navigator Program
all Counties
Clay/Cherokee
Navigator in
Training
Macon
Jane Harrison
Rebecca Mathis
NC Navigator
Program

9. How Can a Mountain Projects
Navigator Help Me?
• 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

10. Marketplace Consumers
Individuals
Small Businesses
• 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
• Investigate coverage for
employees
• Explore options via the
Marketplace
• Questions about exemptions and
penalties
• Have 50 FTE's or equivalent

11. Eligibility and Enrollment
• Started October 1, 2013
• Enroll by December 15,2013 coverage begins January 1, 2014
• Ends March 31, 2014
First Month
• Special Enrollment Periods
Premium Due
October 1
2013
January 1
2014
December 15
2013

12. How to Prepare
Individuals
Employer
• SSN for Household/Birthdates
• Pay Stubs/W2 Tax Information
for 2013/estimate2014
• Employer insurance information
(handout)
• Additional HH income
information
• Names of employees with DOB
• Expected enrollment
• Existing health coverage?
• Age of Spouse
• Dependent information
• Agent may help enroll/explore

13. Qualified Health Plans
Minimum Essential Benefits
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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

14. Categories of Health Plans
The Four Metal Models
BRONZE: 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.

15. Options to Lower Costs
Premium 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 and CoventryOne

16. 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)
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Incarceration
Indian Status
Religious Conscience
Health Care Sharing Ministry
Past months
Past and Future
Complete IRS Form 4029
Past months

17. Personal Assistance
Mountain Projects: 828-452-1447, ext. 115/1-800-627-1548
Toll Free Number: All NC Counties: 1-855-733-3711
Health Insurance Marketplace: 1-800-318-2596
www.healthcare.gov