2. 2
Understanding the Marketplace
6/20/13
The Health Insurance Marketplace – a new way to buy
health insurance
• Enrollment begins October 1, 2013; coverage begins
January 1, 2014
Provides:
• Access to affordable coverage options and financial
assistance
• Ability to buy certain private health insurance
• Access to health insurance information
Allows apples-to-apples comparison
of Qualified Health Plans
Health Insurance Marketplace
3. Coverage to fit individual needs
Marketplace affordability
• May be able to get lower costs on premiums and out-
of-pocket costs
Unbiased help and customer support provided
Quality health coverage though “Qualified
Health Plans” at different levels
Easy to use
How the Marketplace Works
6/20/13 Understanding the Marketplace 3
4. A Qualified Health Plan
• Is offered by a private health insurance issuer
• Covers Essential Health Benefits
• Is at one of the levels of coverage – bronze, silver,
gold, or platinum
• Is offered by an issuer that agrees to charge the same
premium rate whether offered directly through the
Marketplace or outside the Marketplace
Qualified Health Plans
6/20/13 Understanding the Marketplace 4
5. 5
Understanding the Marketplace
6/20/13
Ambulatory patient services Prescription drugs
Emergency services Rehabilitative and habilitative
services and devices
Hospitalization Laboratory services
Maternity and newborn care Preventive and wellness services
and chronic disease management
Mental health and substance use
disorder services, including
behavioral health treatment
Pediatric services, including oral
and vision care (pediatric oral
services may be provided by
stand-alone plan)
Qualified Health Plans cover Essential Health
Benefits which include at least these 10 categories
Essential Health Benefits
6. Marketplace eligibility requires you to
• Live in its service area, and
• Be a U.S. citizen or national, or
• Be a non-citizen who is lawfully present in the U.S. for
the entire period for which enrollment is sought
• Not be incarcerated
Can apply if pending disposition of charge
Can apply for Medicaid/CHIP at any time
Marketplace enrollment starts October 1, 2013
and ends March 31, 2014
Enrolling in the Marketplace
6/20/13 Understanding the Marketplace 6
7. Financial help available for working families
includes
– A new refundable or Advanced Premium Tax Credit (APTC) that lowers
the cost of Qualified Health Plans
• Eligibility is based on household income, and family size
• Income between 100% to 400% of the Federal Poverty Level (FPL)
($23,550 – $94,200 for a family of four in 2013)
– Reduced cost sharing to lower out-of-pocket spending for
health care
Marketplace Affordability
6/20/13 Understanding the Marketplace 7
8. Medicaid and the Children’s Health Insurance
Program (CHIP)
• Creates new opportunities for states to expand Medicaid
eligibility
Adults ages 19 – 64 with incomes up to 133% of the Federal Poverty
Level ($15,282/year for an individual, $31,322/year for a family of 4)
Simplifies eligibility in all states
Coordinated with the Marketplace
• Single, streamlined application with “no wrong door”
Medicaid and CHIP
6/20/13 Understanding the Marketplace 8
9. One process to determine eligibility for
• Qualified Health Plans through the Marketplace
• New tax credits to lower premiums
• Reduced cost sharing
• Medicaid
• Children’s Health Insurance Program (CHIP)
Streamlined Application
6/20/13 Understanding the Marketplace 9
10. Help available in Marketplaces
• The Marketplace Toll-Free Call Center: 1-800-318-2596
(TTY 1-855-889-4325)
Customer service representatives - 24/7
English and Spanish
Language line for 150 additional languages
• Certified Assisters
Navigators program
Non-Navigator in-person assisters
• Agents and brokers
• HealthCare.gov and state Marketplace websites
Enrollment Assistance
6/20/13 Understanding the Marketplace 10
12. The Marketplace is a new way to find and buy health
insurance
Qualified individuals and employers can shop for
health insurance that fits their budget
Individuals and families may be eligible for lower
costs on their monthly premiums and out-of-
pocket costs
There is assistance available to help you get the
best coverage for your needs
Key Points to Remember
6/20/13
Understanding the Marketplace
12
I’m Christen Linke Young, Director of Coverage PolicyI’ve had the great privilege of working on a law that brings health insurance consumer protections to millions of Americans that already have health insurance, and that will bring access to coverage for the uninsured. Today, I want to spend the bulk of my time talking about changes that are coming in just a few weeks that will help the uninsured get covered.But before I do that, will step back for a second. 85% of Americans already have health insurance, and the Affordable Care Act doesn’t change that. For that 85%, what the law did is put in place some new consumer protections that made our coverage stronger. For example:-Banned lifetime caps on their coverage – which used to mean we could “run out” of health insurance in the middle of the second round of chemotherapy or right before a surgery for our daughter’s life-threatening heart condition.-Free preventive care, so you can get your mammograms and colon cancer screening at no extra costs-Young adults can stay on their parents plan until they turn 26.-80/20 rule - Insurance companies have to spend at least 80% of the premium money they take in on actually providing care, not on CEO salaries and marketing-Closing the Medicare “doughnut hole” so millions of seniors are getting lower cost prescription drugs.
But what about the 15% that don’t have health insurance? The pieces of the law set to take effect in the next few weeks are about making sure millions of people locked out or priced out can get coverage. So, starting on October 1, 2013 – 26 days (not that I’m counting) – there’s a new way to buy health insurance. The Health Insurance Marketplace.Through the Marketplace – choice of private health plans, access to financial assistance (90% of currently uninsured get help, thousands of dollars a year.) Millions of Americans will pay less than $100 a month for coverage. Also makes shopping easier – can compare plans, no one charged more because of a pre-ex.
The marketplace is a single website – called HealthCare.gov where people can see a variety of private health plans – like Expedia or Orbitz-Plans are called QUALIFIED health plans – that means they all meet certain standards-Meaningful financial protection in the event of illness or injury, cover comprehensive benefits-But they are different to fit individual needs-Can’t say this enough – tons of financial assistance
So what does it mean to be one of these “qualified” plans.Has to cover all Essential Health Benefits, which means it’s a real comprehensive plan. Gone are the days when I as a 30 year old woman couldn’t buy a policy that covers maternity care – every plan has to cover maternity services so I know my health insurance is there when I need it. There are 10 essential health benefits, and they cover things like doctors visits, hospitalizations, prescription drugs, preventive care, mental health services.But plans are in different tiers based on how generous they are – higher premiums and lower copays, or lower premiums and higher copays. All that’s within limits – and so it’s guaranteed that I won’t go bankrupt from getting sick.
So, if I want to get one of these plans… there are some basic eligibility rules:Live in the state, be residing in the country legally, not be currently in jail – and apply between October 1 and March 31
I’ve mentioned affordability a few times. New tax credit that is paid in advance directly to the health insurance issuer. -up to 400% FPL-some families also get reduced cost-sharing
Lower income individuals and families can get Medicaid-All states have the option to expand Medicaid to EVERYONE with income under about $15K for an individual or %30K for a family.-Federal government will cover nearly all the costs – millions of dollars for hospitals and health care providers in Wisconsin-Wisconsin hasn’t done this yet, but it’s an option whenever they want to.
People who want to get coverage through a QHP or Medicaid have a simple streamlined process. Won’t ask them about pre-ex, if they have a history of acne or sleep apnea. Just one app. Take about 8 minutes for a single person to fill out, 20-30 minutes for a family.Determines eligibility for everything – Medicaid, CHIP, purchasing a QHP in the Marketplace, and the financial assistance in the Marketplace.The application is at HealthCare.gov, or you can fill it out in person or over the phone.
Quickly mention assistance-Call center, and super awesome online chat function that can walk through an app with you-Community-based – CAC, Navigators, others-Agents and brokers
So, what do you need to do? If you have insurance today – from Medicare or your employer – you don’t need to do anything. Sit back and enjoy the consumer protections – no lifetime limits, and free preventive care.But, if you want to get ready to apply for this coverage:First, go to HealthCare.gov. There, you can create an account that will be ready for you in a couple weeks when the application opens.Second, on October 1, come back and complete the application. It’ll ask you some basic questions, and if you want lower premiums – which lots of people qualify for! – you’ll provide some information about your household income. Then, right away, it’ll determine how big a tax credit you qualify for.Third, pick a health plan from all the different options available to you. Compare, choose the one that’s best for you and your family.Finally, enroll in that plan – and your coverage will start January 1.
HC.gov – where consumers apply. Can learn and create account now.Marketplace.CMS.gov – infor for partners. Fact sheets, brochures, leave behinds, etc, etc.
