1. The Affordable Care Act and You
How to Navigate the New Healthcare Landscape

2. Presented by Jean S. Twombly
Member Academy Health
Consulting Partner with PCResourcesVT.com
Sponsored by SMARTvt and

3. How do I get better health coverage?
A
C
A
Can I get a subsidy?
My employer’s plan costs
too much. I need a break.
When is open enrollment?
Will I pay a penalty if I don’t buy coverage?

4. ACA Fast Facts

5. ACA Fast Facts

The ACA is short for the Patient Protection and Affordable Care Act

It was passed into law on March 23, 2010.

Many people who purchased healthcare plans after that date are affected by the PPACA Individual
Mandate and will need to enroll in an ACA – Compliant insurance plan in 2014.

Many individuals and families
with incomes between 133400% of the Federal Poverty
Level qualify for a subsidy to help
pay for health insurance.

Subsidies can only be obtained
by enrolling On Exchange.

States are mandated to furnish
residents access to an Exchange,
a health insurance marketplace.

Open Enrollment for ACA health
plans begins October 1, 2013.
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6. ACA Ten Essential Benefits
All new ACA – compliant plans are mandated to furnish the following ten essential benefits.
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Prescription Drug Coverage
Hospitalization
Emergency Care
Laboratory Services
Ambulatory Patient Services
Mental Health and Substance Abuse Benefits
Pediatric Dental and Vision Services
Maternity Services
Wellness and Preventive Care
Habilitative and Rehabilitative Benefits
Insurance carriers have reworked both plans and rates to comply
with the mandate. The State and Federal healthcare marketplaces
are designed to foster competition among plans and to facilitate
comparison between plans which are similarly priced.
ACA Plans are ranked by actuarial value and are grouped by
metal level: Platinum, Gold, Silver, and Bronze.
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7. ACA Plan Metal Levels
Plans with higher monthly premiums offer the benefit of lower coinsurance when care is
received. Plans with lower monthly premiums have higher deductibles, coinsurance,
copays and out-of-pocket maximums.
The insured can choose a plan which fits the anticipated use of the healthcare system.
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8. ACA Plan Actuarial Values
Each ACA plan must meet the following actuarial values with a variance of +/- 2%.
Platinum = 90% AV
Gold = 80% AV
Silver = 70% AV
Bronze = 60% AV
This means that a plan with
70% AV pays approximately
70% of the cost of healthcare.
The insured will be responsible
for the 30% remainder.
Actuarial values are based on standard EHB costs and population measurements.
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9. Healthcare Plan Subsidies

10. Exchange Subsidy Overview

The Individual Mandate also requires the Federal government to provide subsidies to make health
insurance affordable for low and middle income individuals and families.

A new Federal Data Hub will determine subsidy eligibility based on income as % of Federal Poverty
Level (FPL).

Beginning in 2014, applicants seeking coverage on-exchange may qualify for two types of subsidies:
– Advance Premium Tax Credit (APTC)
• Applicants who qualify for the APTC will owe a reduced premium.
• The Federal Government will advance the difference in premium amounts
to the carriers monthly.
– Cost-Sharing Reductions (CSR)
•
•
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Applicants who qualify for CSR will be enrolled in a specific plan with
reduced cost-sharing.
Federal Government will advance an estimated cost-sharing reduction
monthly. e Premium Tax Credit.
Individuals and families with incomes between 100-250% of the FPL qualify for BOTH the
Cost-Sharing Reduction subsidy and the Advance Premium Tax Credit.
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11. Income Guidelines for Subsidies

The amount of subsidy depends on family size and income level. In general, applicants at the
following income levels will qualify to save in 2014*. The lower the income, the greater the
savings.
Family of
Income level
Family of
Income Level
1
$110,280
$62,040
6
$126,360
3
$78,120
7
$142,440
4
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5
2
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$45,960
$94,200
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$158,520
If the expected 2014 income you report is too high, you might not get the correct amount of
savings.
If you make more money than predicted, you might have to repay some or all of the subsidy
amount on the next tax return.
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12. Subsidy Calculator
 The Kaiser Family Foundation
subsidy calculator prompts
individuals to enter the
following information:
o
Income
o
Whether employer
coverage is available
o
Family size
o
Ages of applicants
 Applicants then receive an
estimate of the subsidies they
are eligible for and expected
health insurance costs.
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13. APTC – Premium Subsidy Details
Availability:

Available to individuals/families with incomes between 133% and 400% of FPL .

Vermont has expanded Medicaid up to 133% of federal poverty level.

The APTC subsidy is calculated as a premium cap based on income level.
Income Level
Premium Cap as % of Income
Income Level
Premium Cap as % of Income
< 133% of FPL
Medicaid
201-250% FPL
6.3-8.05% of income
133% -150% FPL
3-4% of income
251-300% FPL
8.05-9.5% of income
151-200% FPL
4-6.3% of income
301-400% FPL
9.5% of income
Eligibility:
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No employer coverage or
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Employer coverage either
– Does not have an actuarial value of 60% or more
– The cost of the coverage would exceed 9.5% of income.
Note: In 2013 the Federal Poverty Limit is $11,490 for an individual and $23,550 for a family of four.
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14. APTC Computation Example
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The subsidy is tied to the premium of the “average” of plan choices – the Silver Plan.
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The subsidy calculator on the Exchange computes the APTC, applying a premium cap as a % of
household income.
For Example:
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John is an individual with household
income at 275% FPL.
Premium cap for a taxpayer at 275% FPL
is 8.775% (halfway between 8.05% and
9.5%)
In our example, a 275% FPL equals a
monthly income of $2,560 for a
household of one
Income Level
Premium Cap as a % of Income
< 133% FPL*
Medicaid
133%-150% FPL
3-4% of income
151-200% FPL
4-6.3% of income
201-250% FPL
6.3-8.05% of income
251-300% FPL
8.05-9.5% of income
301-400% FPL
9.5% of income
> 400% FPL
No subsidies
Note: The FPL is updated annually, and will likely be different in 2014. The chart for 2013 can be found at
http://www.familiesusa.org/resources/tools-for-advocates/guides/federal-poverty-guidelines.html
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15. APTC Computation Example

continued
If the Silver Plan costs $384/month and John has a monthly income of $2,560 :
– His premium subsidy equals the difference between plan cost and $224.64 [8.775% x $2,560
monthly income]
Tax credit: $384 minus $224.64 = $159.36/month
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Individuals may select any plan and still receive the tax credit.
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The amount of the tax credit may not exceed the plan premium. Since John is eligible for a
$159.36/month tax credit:
– If he selects a less expensive plan with a cost of $150/month, John can only receive a tax credit of
$150/month
– If he selects a more expensive plan with a cost of $500/month, he will owe $340.64 monthly:
His plan cost: $500 minus $159.36 = $340.64/month
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16. CSR – Cost Sharing Reductions

Available to families and individuals
o With incomes up to 250% FPL AND
o Enrolled in a Silver plan on the Exchange
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Cost-sharing reductions include lowered deductibles, coinsurance and copayments.
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Carriers must create three variations of the basic silver metal plan – essentially increasing the
actuarial value by decreasing cost sharing – to accommodate the cost sharing bands by FPL.
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There are three CSR bands:
o
Medicaid-eligible to 150% of FPL
o
151 to 200% of FPL
o
201 to 250% of FPL
 If FPL changes during the year, cost sharing reductions must be updated.
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17. Example of a Silver Metal Base Plan
Silver Base Plan (.70 AV)
Deductible: $1,300
OOP Max: $6,350
Copay: $30 PCP / $40 Specialist after deductible
Coinsurance: 20% after deductible
Rx: Integrated Medical/Drug Deductible.
All Generics: 20% after deductible.
Preferred Brand: 30% after deductible.
Non-Preferred Brand: 50% after deductible.
Specialty: 50% after deductible
MVP
Healthcare
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18. Silver Plan Cost Sharing
Silver Base Plan (.70 AV)
Deductible: $1,300
OOP Max: $6,350
Copay: $30 PCP / $40 Specialist after deductible
Coinsurance: 20% after deductible
Rx: Integrated Medical/Drug Deductible. All Generics: 20% after deductible. Preferred
Brand: 30% after deductible. Non-Preferred Brand: 50% after deductible. Specialty: 50%
after deductible
100%-150% FPL (.94 AV)
151%-200% FPL (.87 AV)
201%-250% FPL (.73 AV)
Deductible: $0
Deductible: $0
Deductible: $900
OOP Max: $2,250
OOP Max: $2,250
OOP Max: $5,200
Copay: $0 PCP / $10 Specialist
copay
Copay: $5 PCP /
$ 25 Specialist copay
Coinsurance: 10%
Coinsurance: 20%
Rx: All Generics: No charge
Preferred Brand: 10% coinsurance
Non-Preferred Brand: 20%
coinsurance
Specialty: 20% coinsurance
Rx: All Generics: 10% coinsurance
Preferred Brand: 30% coinsurance
Non-Preferred Brand: 50% coins
Specialty: 50% coinsurance
Copay: $30 PCP /
$40 Specialist after deductible
Coinsurance: 20% after deductible
Rx: Integrated Medical/Drug Deductible
All Generics: 20% after deductible
Preferred Brand: 30% after deductible
Non-Preferred Brand: 50% after deductible
Specialty: 50% after deductible
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19. The Federal Data Hub and
Penalties for the Uninsured

20. The Federal Data Hub
SSA
Treasury
CMS
HHS
Homeland
Security
IRS
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21. Who Manages Subsidies and the Hub?

The IRS and Treasury will manage the Advance Premium Tax Credit Subsidy which will be based on
the applicant’s Modified Adjusted Gross Income (MAGI).
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The APTC Subsidy will be sent by the U.S. Treasury Department to insurance carriers to fulfill
premium payments each month.
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Any changes in income will be reconciled with the insured when filing the following year’s taxes.
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Health and Human Services (HHS) will manage the Federal Data Hub and the Federally Facilitated
Exchange (FFE).
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HHS will also manage the Cost-Sharing Reducation
Subsidy. Once a member has enrolled in a new
plan and is eligible for a subsidy, the insurance
carrier will be sent a monthly subsidy amount.
 Note that Vermont has expanded Medicaid to
133% of Federal Poverty Level through federal
funding.
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22. Overview of ACA Uninsured Penalties

The ACA requires most Americans to have or obtain health coverage starting in 2014 or pay a
penalty fee.
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The fee increases every year.
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The fee in 2014 is 1% of yearly income or $95 per person for the year, whichever is higher.
Family maximum is $285.
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In 2016 the penalty fee is 2.5% of income or $695 per person, whichever is higher. The family
maximum has now risen to $2,085
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23. Exemptions from the Penalty
Uninsured individuals and families will not have to pay the penalty fee if they:
 Are uninsured for less than 3 months of the year
 Are determined to have very low income and coverage is considered
unaffordable
 Are not required to file a tax return because their income is too low
 Would qualify under the new income limits for medicaid, but their state
has chosen not to expand medicaid eligibility
 Are a member of a recognized religious sect with religious objections to
health insurance
 Are a member of a federally recognized indian tribe
 Participate in a health care sharing ministry
These individuals are automatically exempt if low income.
Otherwise, they may file with an exchange for an exemption.
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24. Vermont Health Connect
http://healthconnect.vermont.gov/
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Vermonters may only enroll On Exchange. No Off Exchange business.
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Subsidies are only available On Exchange.
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Open Enrollment: October 1, 2013 through March 31, 2014. Outside these dates you will not
be able to buy health insurance either on or Off Exchange without a “life event” such as
moving, loss of employer coverage, or certain changes in family status.
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25. Connecting Organizations at the County Level
Chittenden County Organizations of Vermont Health Connect
Association of Africans Living in Vermont
(802) 985-3106
20 Allen St., Burlington, VT 05401
Vermont Businesses for Social Responsibility
(802) 324-1920 or (802) 989-4844
255 South Champlain St., Burlington, VT 05401
Champlain Valley Office of Economic Opportunity Fletcher Allen Health Assistance Program
(802) 860-1417 x115
(802) 847-6984
255 S. Champlain St. #9, Burlington, VT 05401
128 Lakeside Ave., Suite 106, Burlington, VT 05401
Community Health Centers of Burlington
(802) 264-8124
617 Riverside Ave., Burlington, VT 05401
Lake Champlain Lifelong Learning Fund
(Chamber of Commerce)
(802) 863-3489 ext. 208
60 Main St., Suite 100, Burlington, VT 05401
Planned Parenthood of Northern New England
1-866-476-1321
128 Lakeside Ave., Suite 301, Burlington, VT 05401
Vermont Family Network
1 800 800-4005 or (802) 876-5315
600 Blair Park Rd., Suite 240, Williston, VT 05495
Vermont Campaign for Health Care Security
Donna Sutton Fay
879-8604
donnasuttonfay@gmail.com
Blueprint Community Health Team –
Burlington Hospital Service Area,
Community Health Improvement Fletcher Allen Health Care
(802) 847-1601
Spectrum Youth & Family Services
(802) 864-7423 ext. 222
31 Elmwood Ave., Burlington, VT 05401
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26. On-Exchange Consumer Assistance

27. Overview of Consumer Assistance

Consumers will have assistance as they apply for new insurance options through
o Navigators
o In Person Assisters
o Certified Application Counselors.
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The ACA governs who may provide consumer assistance and
What approval, registration, and/or training is required
o What activities each may perform
o What funds may be used to pay for these activities
o Provides that state law cannot impede Title I of the ACA (such as require Navigators
to be licensed agents or brokers, or carry errors and omissions coverage)
o
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HHS has final rules and has announced funding opportunities to guide these efforts.
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Activities and funding depend on whether ACA assistors are working with a State-based
Marketplace, State Partnership Marketplace, or Federally Facilitated Exchange (FFE).
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28. Description of Consumer Assistors
Entities
Description
Navigators
Employees of the Exchange
In-Person Assistors
Employees of the Exchange
Non-Licensed “Customer Service
Representatives”
Employees of the Exchange
Certified Application Counselors and
Health Center Assistors
“Trusted community-based organizations, providers, or other
organizations with expertise in social service programs”
Employees of a Federally Qualified Health Center (FQHC)
Application Filers/Authorized Representatives
Individuals who are permitted to assist persons with disabilities
in making informed decisions
Agents/Brokers
Work with all issuers in a marketplace
These efforts do not include the volunteer ground game being organized by
 Health and Human Services
 Centers for Medicare and Medicaid
 Enroll America,
 and other partners to drive people to consumer assistance and facilitate enrollment.
For example, the Obama administration is looking to partner with professional sports organizations like the
NFL to get the word out.
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