Kit Wagar: Outreach Specialist, US Department of Health and Human Services Missouri Health Policy Summit 2013

1. The Affordable Care Act
A new age in health care:
Insurance that works,
Navigators to show the way
Kit Wagar
Affordable Care Act Specialist
U.S. Department of Health and Human Services
Region 7 – Missouri, Kansas, Iowa, Nebraska
1

2. Enrollment is a marathon, not a sprint

Enrollment schedule:
 The first enrollment period began Oct. 1, and ends on March 31,
2014
 We are in only the fourth week of a six-month enrollment period
 Coverage through the Marketplaces begins as early as Jan. 1,
2014
 Must be enrolled by Dec. 15, 2013, for coverage to begin in January
 In subsequent years, enrollment runs from October 15 to December 7

3. Moving ahead

Two benchmarks from the first three weeks:
 Nearly 20 million unique visitors have checked out Healthcare.gov
 Nearly 700,000 people have completed online applications nationwide
 But the health reform law is not just a website:
 It’s a new approach that makes health insurance more affordable and
health care more accessible to everyone

4. Marketplaces – A fairer system
 In 2014, private insurers will no longer deny coverage or charge a
higher price based on a person’s medical history
 Prices for individuals will vary based only on four criteria:
 Age –
a maximum of 3 times the price of younger applicants
 Tobacco use –
a maximum of 50 percent higher than non-smokers
 Location
states can establish rating areas
–
 Family size
 Ending gender discrimination
 Women will no longer be charged more than
men the same age
 Currently, 22-year-old women are often charged 50
percent more than men their age simply because
women bear children

5. A fairer market – Essential Health Benefits
 Currently, many plans offered in the individual market leave out
major categories of coverage
 Consumers often don’t realize the omission until they need the coverage
 62 percent don’t have maternity benefits
 34 percent don’t cover substance abuse
 18 percent don’t provide mental health coverage
 9 percent don’t cover prescription medication
In 2014, all health insurance plans must cover the following services:

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
Ambulatory patient services
Emergency Services
Hospitalization
Maternity and newborn care
Mental health and substance abuse
services, including behavioral health
treatment
 Prescription drugs
 Rehabilitative and habilitative
services and devices
 Laboratory services
 Preventive and wellness services
and chronic disease management
 Pediatric services, including oral and
vision care

6. Key requirements of a Marketplace

Marketing of policies
These functions include:
 Toll-free phone number
 Website
 Presenting benefits in a standardized format
 Single application for Medicaid/CHIP/private insurance
 Providing electronic calculator to determine actual cost of policy
 Includes premium subsidies for less than 400% of poverty level
 Cost-sharing reductions for households at less than 250% of poverty
 Determining eligibility for Medicaid and CHIP
 Certifying people too poor to make personal responsibility payments

Review insurance plans for eligibility in the marketplace
 In Kansas & Missouri, insurers had to file their proposed plans and rates by May 3
 They were reviewed last summer and approved in September

7. Making insurance affordable

8. Help for the middle class
Beginning in 2014:

Workers without health benefits receive tax credits to help buy
insurance through the marketplaces
 Credits will be available up to 400 percent of the poverty level
 Maximum income of:
 $45,960 for 1 person
 $94,200 for family of 4

The IRS estimates the average credit will be more than $5,000
These credits:
 allow family farmers and the self-employed to obtain health insurance as
if they had an employer helping them buy it
 help small business owners that can’t afford health insurance to compete
for employees with large companies that provide generous benefits

9. Affordable Health Plans
 Expected contribution to insurance premiums, silver-level plan
 For an individual:
Annual Income
% of FPL
 $13,788
120*
 $16,200
141
 $20,107
Expected
Contribution
2% of income
Maximum
Monthly Premium
Reduction in
Out-of-Pocket
Maximum
Consumer’s
Portion of
Total costs
$23
2/3
6%
3.5%
$47
2/3
6%
175
5.15%
$86
2/3
13%
 $25,852
225
7.18%
$155
1/2
27%
 $31,597
275
8.78%
$231
0
30%
 $40,215
350
9.5%
$318
0
30%
 Incomes below 250% of the poverty level qualify for lower co-pays and
deductibles
* This level of income would be eligible for Medicaid in states that expand their programs in accordance with
the Affordable Care Act

10. Affordable Health Plans
 Expected contribution to insurance premiums, silver-level plan
 For a family of 4:
Annual Income
% of FPL
 $28,260
120*
 $33,205
141
 $41,212
Expected
Contribution
2% of income
Maximum
Monthly Premium
Reduction in
Out-of-Pocket
Maximum
Consumer’s
Portion of
Total costs
$47
2/3
6%
3.5%
$97
2/3
6%
175
5.15%
$177
2/3
13%
 $52,987
225
7.18%
$317
1/2
27%
 $64,762
275
8.78%
$474
0
30%
 $82,425
350
9.5%
$653
0
30%
 Incomes below 250% of the poverty level qualify for lower co-pays and
deductibles
* This level of income would be eligible for Medicaid in states that expand their programs in accordance with
the Affordable Care Act

11. Actual prices in the Missouri Marketplace
Individual policies, lowest-priced plan in each category:
Age
27
27
27
27
County
Boone
Boone
Boone
Boone
Annual
income
$20,107
$20,107
$25,852
$25,852
27
27
27
27
St. Louis
St. Louis
St. Louis
St. Louis
$20,107
$20,107
$25,852
$25,852
Plan
Monthly
level premium
Silver
$242
Bronze $195
Silver
$242
Bronze $195
Silver
Bronze
Silver
Bronze
$196
$147
$196
$147
Actual
payment
$76
$29
$145
$98
$66
$17
$135
$86
Size of
Discount
$166
$166
$97
$97
$130
$130
$61
$61
Many rural areas, which traditionally have higher insurance prices than urban areas, get
bigger discounts to even out the costs

12. Actual prices in the Missouri Marketplace
Family of 4, lowest-priced plan in each category:
County
Boone
Boone
Boone
Boone
Annual
Income
$41,212
$41,212
$52,987
$52,987
Plan
Monthly
level premium
Silver
$816
Bronze $659
Silver
$816
Bronze $659
St. Louis
St. Louis
St. Louis
St. Louis
$41,212
$41,212
$52,987
$52,987
Silver
Bronze
Silver
Bronze
$663
$496
$663
$496
Actual
payment
$141
$0
$281
$124
Size of
Discount
$675
$675*
$535
$535
$110
$0
$250
$83
$553
$553**
$413
$413
* In Boone County, 1 plan would produce a $0 monthly premium; 1 plan would produce a monthly
premium of $5.
**In St. Louis County, 2 bronze plans would produce a $0 monthly premium

13. Calculating your income
 When you apply for lower costs in the Marketplace, you’ll need to
estimate your household income for 2014
 Most people can use their household’s adjusted gross income for this estimate
 If you know your 2013 adjusted gross income, use that and take into account any
changes you expect in 2014
 You could also add up the following items for everyone in your household,
based on what you think they’ll receive in 2014:
 Wages
 Salaries
 Tips
 Net income from any self-employment or business
 Unemployment compensation
 Social Security payments
 Other kinds of income to include when estimating your 2014 income are:
 rental income, interest, dividends, capital gains, annuities, alimony, and some retirement
and pensions.

14. Individual responsibility

Beginning in 2014, individuals can choose to:
 carry health insurance, or
 pay a fee to offset the cost of treating the uninsured
 Qualifying coverage: Medicare, Medicaid, Veterans’ coverage , Tricare, employer
coverage, private insurance

The fee is the greater of:
 $95 per person in the household or 1% of your income that exceeds
the tax filing threshold in 2014
 $325 per person or 2 percent of income in 2015
 $695 per person or 2.5% of income in 2016 and thereafter
 Maximum per household is the income percentage or 3 times the flat fee
 The flat fee for each child is half the adult amount

15. Consumer assistance

16. No wrong door to enrollment

17. Healthcare.gov (aka “The Culprit”)
 Links to key questions consumers
have about health insurance,
eligibility & enrollment
 Offers Web chat capability to answer
users’ questions
 Directs users to appropriate
destination based on geography
 Footer contains links for nonconsumer users to find information
 You can create an account*
 You provide family and income
information to qualify for discounts*
 You peruse the health plan options*
 You enroll in the plan best for you*
*We’re working out the kinks

18. Marketplace Call Center
Call Center launched in June
1-800-318-2596
TTY/TDD line for hearing-impaired callers:

Helps with wide range of questions, including:

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Health insurance and how it works
Premium assistance and health care affordability programs
Steps to take now to get ready for open enrollment beginning Oct. 1
General inquiries, such as “I have insurance. How will I be affected?”
After Oct. 1, the call center will help with:
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1-855-889-4325
Filling out the application
Plan selection
Assistance is Available 24/7 in English and Spanish

Help in 150 other languages is available

19. Help for small employers
Small Business Health Options Program – “The SHOP”
 SHOP Call Center launched in August
TTY/TDD line for hearing-impaired callers:
1-800-706-7893
1-800-706-7915
Hours: 8 a.m. to 4 p.m. (central time)
Beginning Oct. 1: 8 a.m. to 6 p.m. (central)
 Information on tax credits that cover up to 50 percent of the cost of
employee health insurance for two years at eligible small employers
 New, more competitive pricing for health insurance policies
 Plans grouped by “metal level” to let employers compare plans with truly similar benefits
 Metal levels – bronze, silver, gold, platinum – reflect the generosity of the plan’s coverage
 SBA Fact Sheets, Training Materials and insurance finder tool:
 http://www.sba.gov/content/affordable-care-act-training-materials
 Information based on your business location, size, and whether you now offer insurance
 SHOP enrollment expected to begin in November

20. Finding the right health plan
 Once an account is created, the
website offers:
 A comparison tool to evaluate policies
 A calculator to estimate each plan’s:
 premiums
 co-payments
 deductibles
 maximum out-of-pocket costs
 Filtering options to let the user narrow
the choices based on specific criteria
 The most relevant plans are presented
first, based on the applicant’s answers
 Key data listed with links to plan details

21. In-person assistance

22. Sources of enrollment help
 Navigators
 Navigators received grants from Marketplace funds
 They must provide community outreach and education programs
 They are agencies or individuals trained to work with the uninsured and the
underinsured and with employers buying health benefits for employees
 Key groups that Navigators will work with include:
 Young people who may never have had health insurance
 The self-employed, many of whom previously could never afford insurance
 Vulnerable populations, including
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Low-income groups
Non-English-speaking populations
People with disabilities
Workers between jobs
 To ensure that their advice is impartial, Navigators cannot accept compensation
directly or indirectly from any health insurer
 Navigators will be listed on the Marketplace website under “Find Local Help”

23. Missouri Navigators
Navigator funding was announced Aug. 15:
Missouri received $1.8 million for navigator organizations
 Primaris Healthcare Business Solutions
$1,045,624
 Primaris
will lead a coalition of 11 community partners to provide free and
unbiased information about insurance plans offered on the Marketplace
 Primaris already works with health care providers to improve quality of care
 Primaris also operates the Medicare CLAIM program, which provides counseling
to help people choose the most appropriate Medicare Advantage plan
 Missouri Alliance of Area Agencies on Aging
 These agencies have an extensive
$ 750,000
network of contacts and experience
dealing with vulnerable populations
 They will provide navigators in most of Missouri, outside Kansas City

24. Sources of enrollment help
 Application Counselors
 They receive similar, but less extensive, training than Navigators. They
must pass a similar, though less comprehensive test
 Training is available online at http://marketplace.cms.gov/training/get-training.html
 Counselors are certified by the organization they work or volunteer for
 Individuals can take the training and provide assistance, but they will not be listed on the
Marketplace website as certified application counselors
 No funding is attached to becoming an application counselor
 Most counselors are likely to be staff and volunteers of organizations
with a business interest or a social mission to get people insured
 Clinics, hospitals, health care providers, social agencies are encouraged to become
designated to certify their staff members as application counselors
 Counselors must show applicants all insurance options available
 To ensure unbiased advice, counselors cannot accept compensation in
connection with enrollment and must disclose any potential conflict

25. Becoming a CAC agency
 To apply to be designated as a certified application counselor
agency, go to:
 http://marketplace.cms.gov/help-us/cac.html
 Agencies designated as certified
application counselors will be listed on
the www.healthcare.gov website under
“Find local help”
 Questions about becoming a certified
application counselor or agency can be
sent to CACQuestions@cms.hhs.gov

26. Sources of enrollment help
 Licensed health Insurance agents and brokers
 To enroll individuals, must undergo training on:
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website enrollment
Marketplace affordability programs
Medicaid options
security of personal information
 Paid by insurers
 Brokers and agents represent certain insurance companies and
are not required to show applicants all insurance options
 Broker training in the federally run Marketplaces is available at:
 http://www.cms.gov/CCIIO/programs-and-initiatives/health-insurancemarketplaces/a-b-resources.html

27. Security of personal information
 Navigators and application counselors must:
 comply with the Marketplace privacy policies
 follow Marketplace rules on security of personal information
 Information entered on paper applications should not be retained
 Information in electronic applications is secure within applicant’s online account
 Designated application counselor organizations must:
 screen staff and volunteers to ensure they protect personal information
 confirm in writing that its workers will comply with privacy and security rules
 All certified application counselors must:
 obtain authorization from each consumer before obtaining personal information
 maintain a record of the authorization
 The consumer can revoke the authorization at any time
 Organizations or individuals who violate privacy and security
standards are subject to monetary penalties
 Fraudulent activity will be investigated and addressed under federal law

28. Steps to take now
 Learn about different types of health coverage
 The Marketplace lets you choose a health plan with the right balance of costs and
coverage. You’ll be better prepared if you understand different types of coverage
 Make sure you understand how coverage works, including things such as premiums,
deductibles, out-of-pocket maximums, copayments, and coinsurance. You'll want to
consider these details while you're looking for health insurance
 Gather basic information about your household income
 Most people using the Marketplace will qualify for discounts on monthly premiums or
out-of-pocket costs. To find out your savings, you'll need income information from
documents such as your W-2 form, current pay stubs, or your tax return.
 Set your budget
Different types of health plans meet different
needs and budgets. You'll need to figure out
how much you want to spend on premiums
each month.

29. A final thought
“Opportunity is missed by most people because it
is dressed in overalls and looks like work.“
----Thomas Edison