Women and ACA: How to Use Your New Health Coverage (Like a Pro)

© 2014 Enroll America and Get Covered America
EnrollAmerica.org | GetCoveredAmerica.org
Women and ACA:
How to Use Your New Health
Coverage (Like a Pro)
May 6, 2014

EnrollAmerica.org | GetCoveredAmerica.org2
Agenda
I.  Introduction and Special Enrollment Periods
•  Ambar Calvillo, Women’s Engagement, Enroll America
II. Health Insurance 101: Understanding Your Health Plan
•  Lauren Birchfield Kennedy, Senior Health Policy Counsel,
National Partnership for Women & Families
III. Guaranteed Benefits Important to Women
•  Karen Davenport, Director of Health Policy,
National Women’s Law Center
•  Mara Gandal-Powers, Counsel for Health and Reproductive
Rights, National Women’s Law Center
IV. Questions
•  Submit at any time via chat.

BASICS OF SPECIAL
ENROLLMENT PERIODS

Marketplace vs Medicaid
Health Insurance in the Marketplace:
•  Must be a U.S. citizen or legal immigrant and not
incarcerated
•  Depending on your income, you may qualify for
financial help
•  Has an ‘open enrollment’ window: November 15-
February 15
•  Special enrollment periods available to people who
have certain life changes (stay tuned for more
info!)
Medicaid:
•  Medicaid provides free or low cost health coverage
•  Visit your state’s Medicaid website to see if you are
eligible
•  If eligible, you can enroll today!
Visit Getcoveredamerica.org

Enrollment Timeline
Annual open enrollment
period
à
Nov 15, 2014 –
Feb 15, 2015
Medicaid & CHIP à year-round
Special enrollment period
because of a life-change
à year-round

Post-Open Enrollment:
Three Types of Situations
Already
enrolled in some
form of coverage
Eligible to
enroll between
April and
November
Uninsured but
not eligible to
enroll until
November

Eligible to
Enroll between
April and November
2014

Medicaid and CHIP
Medicaid and CHIP
enrollment is open
year-round!

Life Changes that May Trigger a
Special Enrollment Period
I had
a(nother)
baby!
I’m a new
citizen! I turned 26
I got
married!
I got
out of
prison
Resource:
https://www.healthcare.gov/how-can-i-get-coverage-outside-of-open-enrollment/#part=2

Experience a
life change
Report the life
change to the
marketplace/
complete the
application
Enroll and pick
a plan
Report the change as soon and possible.
Individuals have 60 days from the date of the event to
complete this process.
Reporting a Life Change to the
Marketplace

•  Individuals may also be able to get a
special enrollment period after
experiencing other limited
circumstances related to system or
display errors.
•  Consumers should work with local
help for further information regarding
their specific situation.
•  To get a special enrollment period in
these cases, the consumer or
assister needs to call the Marketplace
Call Center (1-800-318-2596).
Additional resource:
http://www.cms.gov/cciio/Resources/Regulations-and-Guidance/Downloads/complex-cases-
SEP-3-26-2014.pdf
Special Enrollment Periods in
Complex Cases

Enrollment Assistance
Who Can Provide Help?

Already
enrolled in some
form of coverage

14
Keeping Coverage
Marketplace
Pay premiums. Pay them
on time.
Report life changes
In October or November,
individuals will get a
renewal notice. They may
need to send information
back to the Marketplace
to stay covered.
Medicaid
Pay premiums. Pay
them on time.
Report life changes
Every 12 months,
individuals will get a
renewal notice. They
may need to send
information back to
the Medicaid office to
stay covered.

Experience a
life change
Report the
event/Complete
the application
process
Change
Marketplace
plans (or enroll
in Medicaid)
Report the change as soon and possible.
You have 60 days from the date of the event to
complete this process.
Reporting Changes to the
Marketplace

Uninsured but not
eligible to enroll until
November

Consequences for Individuals
Without Coverage
Individuals
who had
affordable
options but
did not
enroll
Individuals
without
access to
affordable
coverage
Individuals
who lose
coverage
during the
year

•  You most likely will pay a
fine at tax time in 2015.
•  Fine is $95 or 1% of annual
income, whichever is
greater.
Uninsured Individuals with
Affordable Options

Individuals Without Affordable
Options
•  If you’re in the “Medicaid gap”, you should
apply for coverage through the
Marketplace. You will automatically get an
exemption that protects you from the fine.
You will also have access to a special
enrollment period if your income increases
later in the year.
•  You can also apply for an affordability
exemption through the Marketplace or
when filing taxes.

Individuals Who Lose Coverage
During the Year
•  Report the loss to the Marketplace and
apply for coverage. You may get a special
enrollment period.

Summary
1.  Seek In-Person Help
•  For questions or help applying
2.  Already Covered / Stay Covered
•  Pay your premiums
•  Look for communication from the Medicaid
office
•  Report life and income changes
3.  Uninsured Looking to Be Insured:
•  Life changing events may qualify you to get
insured before next open enrollment period.
•  If in the “Medicaid gap” apply for coverage
through the Marketplace to get an exemption
from the fine and access to coverage later in
the year if your income increases

Health Insurance 101 : Understanding
Your Health Plan
Lauren Birchfield Kennedy
Senior Health Policy
Counsel
22

About us
The National Partnership for Women & Families is a nonprofit,
nonpartisan advocacy group dedicated to promoting fairness in the
workplace, access to quality health care, and policies that help women
and men meet the dual demands
of work and family.
More information is available at
www.NationalPartnership.org.
23

  Keeping Your Coverage: Monthly Premiums
  Cost-Sharing & Out-of-Pocket Expenses
  Finding a Provider
  Understanding Your Benefits
  Health Care Services
  Pharmacy Services (Prescription Drugs)
Just the Basics: Health Insurance 101
24

  What is a premium?
  How do I pay my premium?
  What happens if I miss a premium payment?
  What does it mean to be eligible for financial help or
premium assistance?
Keeping Your Coverage:
Premium Payments
25

Eligibility for premium assistance depends on income and family
size:
  If your income falls within the following ranges you'll likely
qualify for a premium tax credit. The lower your income is within
these ranges, the larger your credit.
  $11,490 to $45,960 for individuals
  $15,510 to $62,040 for a family of 2
  $19,530 to $78,120 for a family of 3
  $23,550 to $94,200 for a family of 4
  $27,570 to $110,280 for a family of 5
  $31,590 to $126,360 for a family of 6
  $35,610 to $142,440 for a family of 7
  $39,630 to $158,520 for a family of 8
Source: Healthcare.gov
Premium Assistance
26

  Insurance plans often require you to cover part of the cost of
a covered health care service out-of-pocket. Examples of
cost-sharing include co-pays, co-insurance, or a deductible.
  Co-Pays
  Co-Insurance
  Deductible
  What does it mean to be eligible for cost-sharing assistance?
  How can I learn more about a health plan’s cost-sharing
requirements?
  Are there limits on out-of-pocket expenses?
Cost-Sharing &
Out-of-Pocket Expenses
27

  Co-Pay: A fixed amount (for example, $15) you pay for a covered
health care service, usually when you get the service. The
amount can vary by the type of covered health care service.
  Co-Insurance: Your share of the costs of a covered health care
service, calculated as a percent (for example, 20%) of the
allowed amount for the service.
  Deductible: The amount you owe for covered health care
services before your health plan begins to pay. For example, if
your deductible is $1,000, your plan won’t pay anything until
you’ve met your $1,000 deductible for covered health care
services subject to the deductible. The deductible may not apply
to all services, like preventive care.
Cost-Sharing
28

  If your income falls within the following ranges you'll likely
qualify for cost-sharing assistance if you purchase a silver-
level plan. The lower your income within these ranges, the
more you’ll save on out-of-pocket costs.
  $11,490 to $28,725 for individuals
  $15,510 to $38,775 for a family of 2
  $19,530 to $48,825 for a family of 3
  $23,550 to $58,875 for a family of 4
  $27,570 to $68,925 for a family of 5
  $31,590 to $78,975 for a family of 6
  $35,610 to $89,025 for a family of 7
  $39,630 to $99,075 for a family of 8
Cost-Sharing Assistance
29

  Plans in the Marketplace are primarily separated into four
health plan categories. The plan category you choose affects
the total amount you'll likely spend for covered health
benefits during the year.
  Bronze (60%)
  Silver (70%)
  Gold (80%)
  Platinum (90%)
What to Expect: Cost-Sharing
Requirements
30

Requirements
31

Requirements
32

  Out-of-Pocket Costs: Your expenses for medical care that aren't
reimbursed by insurance. Out-of-pocket costs include
deductibles, coinsurance, and copayments for covered services
plus all costs for services that aren't covered.
  Limit on Out-of-Pocket Expenses: The most you pay during a
policy period (usually one year) before your health insurance or
plan starts to pay 100% for covered essential health benefits.
  The maximum out-of-pocket cost limit for any individual Marketplace
plan for 2014 can be no more than $6,350 for an individual plan and
$12,700 for a family plan.
  Check with your insurer to find out what expenses count towards your out-of-
pocket limit and what expenses are not included.
Limits on Out-of-Pocket Expenses
33

  To find a doctor covered by your plan, review your plan’s
provider directory. This directory should be posted on your
health plan’s website.
Finding a Provider
34

  In-Network
  Insurance companies contract with specific providers to accept their enrollees as covered
patients. Providers that have contracted with your health plan are considered “in-
network.” Your health plan is responsible for providing you with a list of in-network
providers.
  Out-of-Network
  Providers that do not have a contract with your health plan are likely to be considered
“out-of-network.” Unless it’s an emergency, if you access care outside of your plan’s
network, you likely will pay more than if you had accessed the same care in-network.
Provider Network
35

Seeing a Specialist
36
  Some plans require that you first get a referral from your
primary care doctor before you see a specialist. If you don’t
get the required referral, your plan may not pay for the services
you receive from the specialist.
  Contact your plan to find out if you need a referral to see a
specialist.
  You do not need a referral to see your OB-GYN. You don’t
need to get a referral from a primary care provider before you can
get obstetrical or gynecological (OB-GYN) care from a specialist.

What Health Services Does
My Plan Cover?
37
  All Qualified Health Plans cover essential health benefits, like maternity care.
  All Qualified Health Plans cover key preventive care services with no cost-sharing
requirements.
  For questions about coverage of specific health care services, contact your insurer.

  Formulary: A list of
prescription drugs
covered by a
prescription drug plan
or another insurance
plan offering
prescription drug
benefits. Also called a
“drug list.”
Does My Plan Cover
My Prescription?
38

  Does Your Deductible Apply to Your Prescription?
  What tier is your prescription drug?
How Much Will My
Prescription Cost?
39

  What Tier or Level Is Your Prescription?
How Much Will My
Prescription Cost?
40

How Much Will My
Prescription Cost?
41

  “Accessing Care 101”
  NationalPartnership.org/Enroll
  Healthcare.gov
  Marketplace.cms.gov
Resources
42

For more information
Find us:
www.NationalPartnership.org
Follow us:
www.facebook.com/nationalpartnership
www.twitter.com/npwf
43

Karen
Davenport
and
Mara
Gandal-‐Powers

National
Women’s
Law
Center

May
6,
2014

*  In
general,
ACA
guarantees
coverage
for:

*  Maternity

*  Mental
Health/Substance
Use
Disorder
Services

*  Preventive
Services

*  Prescription
Drugs

*  Coverage
may
diﬀer
for
individuals
with
Medicaid

coverage
through
traditional
pathways
(e.g.,
children,

parents,
individuals
with
disabilities).

ACA-‐Guaranteed
Beneﬁts

Important
to
Women

*  No
common
deﬁnition;

typically
health
services

related
to
prenatal,
labor
and
delivery
and
postnatal

care.

Can
include:

*  Prenatal
outpatient
obstetrical
visits

*  Prenatal
laboratory
and
diagnostic
tests

*  Inpatient
care
for
delivery

*  Newborn
care

*  Mix
of
preventive
and
non-‐preventive
services,
which

drives
what
you
should
expect
to
pay

Maternity
Coverage

*  New
required
beneﬁt
for
individual,
small
group

markets

*  Plans
must
oﬀer
to
same
extent
as
other
health

services
–
e.g.,
at
parity

*  But
parity
requirements
are
phasing-‐in
for
some

services,
will
be
fully
implemented
for
Marketplace

plans
in
2015

Mental
Health
and
Substance
Use

Disorder
Services

A
sampling
of
covered
services
includes:

*  Cervical
cancer
screening
every
3
years

*  Mammography
after
age
40

*  Depression
screening
in
adults
and
adolescents

*  Well-‐woman
visits

*  Counseling
and
screening
for
HIV

*  Screening
for
gestational
diabetes

*  Breastfeeding
support,
supplies,
and
counseling

*  Screening
and
counseling
for
interpersonal
and
domestic
violence

*  All
FDA-‐approved
contraceptive
methods,
sterilization
procedures,
and

patient
education
and
counseling
for
women
with
reproductive
capacity

HHS
list
of
preventive
beneﬁts
for
women

Preventive
Services

*  The
law
draws
a
distinction
between
preventive
services

and
diagnostic
services

*  Preventive
care
may
head-‐oﬀ
a
disease
or
condition,
such
as

medication

for
women
with
particular
risks

*  Folic
acid,
tamoxifen
or
aspirin

*  Preventive
screenings
look

for
disease
or
symptoms
of

disease,
such
as
a
lump
seen
on
a
screening
mammogram

*  Diagnostic
services
follow-‐up
on
ﬁndings
from
screenings,

such
as
a
diagnostic
mammogram
or
biopsy

*  You
should
not
be
charged
cost-‐sharing
for
preventive

services,
but
will
likely
pay
cost-‐sharing
for
diagnostic
services

Using
Preventive
Services

*  Oﬃce
visits,
covered
without
cost-‐sharing,
that:

*  Provide
an
opportunity
for
women
to
receive

recommended
preventive
services

*  Enable
women
and
their
health
care
professionals
to

talk
about
health
concerns

*  May
be
more
than
one
visit
per
year

*  Do
not
include
visits
for
current
illnesses
or
to

diagnose
symptoms

Well-‐Woman
Visits

*  Adult
immunizations
covered
without
cost-‐sharing
for

those
who
meet
age
requirements
and
have
not
been

previously
vaccinated
or
infected:

*  Flu
shots

*  Tetanus/tetanus
boosters

*  Chicken
pox

*  HPV

*  Measles/Mumps/Rubella

*  Zoster
(regardless
of
previous
infection)

Immunizations

*  New
beneﬁt
–
not
previously
covered
by
health

insurance

*  Includes
lactation
consultant
services,
breast
pumps

and
other
breastfeeding
supplies

*  Insurance
plans
and
breastfeeding
community

are

still
getting
up
to
speed
–
some
problems
with
in-‐
network
coverage
of
pumps
and
lactation

consultants,
consumer
information,
coverage

limitations

Breast-‐Feeding
Supports

and
Counseling

*  Covered
as
a
preventive
service

without
cost-‐sharing

every
10
years,
beginning
at
age
50

*  Removal
of
polyps,
if
found,
covered
without
cost-‐
sharing
for
a
preventive
colonoscopy

*  If
you
have
a
colonoscopy
more
frequently
than
every

10
years,
or
after
a
ﬁnding
of
pre-‐cancerous
or

cancerous
tissue,
you
will
need
to
pay
cost-‐sharing

Colonoscopy

*  Covered
once
per
year
beginning
at
age
40

*  Coverage
without
cost-‐sharing
does
not
include

diagnostic
mammograms

*  Preventive
coverage
does
not
include
other
breast

imaging,
such
as
ultrasound
or
MRI

Mammograms

*  “All
FDA-‐approved
contraceptive
methods,
sterilization

procedures,
and
patient
education
and
counseling”

*  FDA
Birth
Control
Guide:

http://www.fda.gov/downloads/ForConsumers/ByAudience/
ForWomen/FreePublications/UCM356451.pdf

Birth
Control

*  Sterilization
surgery
for

women

*  Sterilization
surgical
implant

for
women

*  Implantable
rod

*  IUD
Copper

*  IUD
with
Progestin

*  Shot/Injection

*  Patch

*  Vaginal
Contraceptive
Ring

*  Oral
Contraceptives

(Combined
Pill)

Birth
Control
Methods
that
Must
Be

Covered
without
Out-‐of-‐Pocket
Costs

•  Oral
Contraceptives
(Progestin

only)

•  Oral
Contraceptives
Extended/
Continuous
Use

•  Diaphragm
with
Spermicide

•  Sponge
with
Spermicide

•  Cervical
Cap
with
Spermicide

•  Female
Condom

•  Plan
B/Plan
B
One
Step/Next

Choice

•  Ella

Examples:

*  IUD
insertion,
ultrasound
to
confirm
placement,
and

removal

*  Sterilization
anesthesia,
confirmation
tests

Plans
are
required
to
cover
“services
related
to
follow-‐
up
and
management
of
side
effects,
counseling
for

continued
adherence,
and
device
removal”
without

cost-‐sharing

Plans
Must
Cover
Services
Associated

with
Birth
Control

*  Plans
must
cover
all
of
the
FDA-‐approved
methods

*  Very
limited
times
that
they
can
charge.

Examples:

*  Brand-‐name
drugs
when
there
is
a
generic

*  When
you
go
out-‐of-‐network

*  If
you
don’t
have
a
prescription
for
an
over-‐the-‐counter

method
(like
emergency
contraception)

*  The
“Waiver
Process”

*  Allows
women
to
access
medically
appropriate
method

without
cost-‐sharing
if
plan
typically
imposes
cost-‐sharing

*  Typically
involves
providers
completing
paperwork

on
why
method
is
medically
appropriate

Are
there
times
it
is
OK
for
my
plan
to

charge
for
my
birth
control?

*  www.nwlc.org/preventiveservices

*  FAQs
about
the
health
care
law’s
preventive
services

requirements

*  What
plans
are
and
are
not
allowed
to
do
around
cost-‐
sharing

*  Appeal
letters
for
insurance
companies:
instructions
and

sample
letters

*  Hotline
for
help
with
women’s
preventive
services:

1-‐866-‐PILL4US

pill4us@nwlc.org

What
if
I
have
a
problem
with

my
coverage?

QUESTIONS

Tools at
getcoveredamerica.org
•  Calculator
•  Find Help
•  What Plan is Right for Me?
•  Frequently Asked Questions
Resources

THANK YOU!

Women and ACA: How to Use Your New Health Coverage (Like a Pro)

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