Affordable Care Act
Marketplace Implementation Briefing
PA Refugee Resettlement Program
Annual Meeting
June 11, 2013
Aryanna Abouzari, Esq.
Executive Officer
U.S. Department of Health & Human
Services, Region III
Pennsylvania, Delaware, District of Columbia,
Maryland, Virginia, West Virginia
Critical Need for Health Reform
48.6 million uninsured Americans
$3 trillion spent annually on healthcare
17.9 % of our economic output tied up
in the health care system
Without reform, by 2040, 1/3 of
economic output tied up in health care
Affordable Care Act Overview
Creates Consumer Protections
Prevents denials of coverage for pre-existing
Make health insurance more affordable for
middle class families and small businesses
with tax credits
Expands access to care through Marketplaces
and Medicaid expansion
Health Insurance Marketplace
Sometimes called “Exchanges,” the Marketplace
is required by the ACA to be created by January
1, 2014
New “marketplace” where small businesses and
individuals can select and enroll in a private
health insurance plan
Consumers will have
• the same level of benefits and coverage
available to members of Congress
• more choice and selection in health plans
Marketplace Implementation
Three models available
 State-Based
 Federal-State Partnership
 Federally-Facilitated
States can apply for Marketplace
establishment funding at any time and be
awarded grants through 2014
HHS to operate marketplaces for States
that have not elected to do so
Health Insurance Marketplace
Regional Snapshot
• PA – No enabling legislation; Federally-facilitated
• DE – No enabling legislation; Federal-State Partnership
• MD – Passed enabling legislation; State-based
• DC – Passed enabling legislation; State-based
• WV – Passed enabling legislation; Federal-State
• VA – No enabling legislation; Federally-facilitated
Marketplace Eligibility
Marketplace eligibility requires
• You live in the service area,
• Are a U.S. citizen or national, or
• Are a non-citizen who is lawfully
present in the U.S. for the entire
period for which enrollment is sought
• Are not incarcerated
Financial Assistance
Premium tax credits
• Will reduce the premium amount the consumer
owes each month
• Available to eligible consumers with household
incomes between 100% and 400% of the FPL
($44,680 for an individual and $92,200 for a family
of 4 in 2012), and who don’t qualify for other
health insurance coverage
• Based on household income and family size for the
taxable year
• Paid each month to the insurer
Financial Assistance
Cost-sharing reductions:
 Reduce out-of-pocket costs (deductibles,
coinsurance, copayments)
• Generally available to those with income 250%
FPL or below ($27,925 for an individual and
$57,625 for a family of 4 in 2012)
• Based on household income and family size for
the taxable year
Quality Insurance
The ACA requires plans inside the Marketplace
to meet particular actuarial value (AV) targets
• Bronze = 60% AV
• Silver = 70% AV
• Gold = 80% AV
• Platinum = 90% AV
“Metal Levels” will enable consumers to
compare plans with similar levels of coverage,
promote competition on premiums, and allow
plans flexibility to design cost sharing
Quality Insurance
Essential Health Benefits
Ambulatory patient services
Emergency services
Maternity and newborn care
Mental health and substance use disorder
services, including behavioral health treatment
Prescription drugs
Rehabilitative and habilitative services/devices
Laboratory services
Preventive and wellness services and chronic
disease management
Pediatric services, including oral and vision
Marketplace for Small Business
Starting in 2014, a Small Business Health
Options Program (SHOP) will be available in
each state
To enroll, employers must
• have fewer than 100 employees; a state SHOP
may limit eligibility to employers with 50 or
less employees for the first two years
• have an office within the service area of the
• offer SHOP coverage to all full-time employees
Sole proprietors must purchase through the
Marketplace, not through SHOP
Tax Credits for Small Business
Tax credits to small employers with up to 25
employees and average annual wages less
than $50k that provide health insurance for
their employees
• Currently, 35% for profit; 25% non-profit
• In 2014, 50% for companies that
participate in SHOP
• Visit for Form 8941 and
calculator tool to help determine whether
you are eligible to claim the credit
Enrollment Process
Consumer submits application to the marketplace
In Person
The marketplace verifies and determines
eligibility for
• enrollment in a Qualified Health Plan (QHP)
• tax credits and cost-sharing reductions
• Medicaid or CHIP
Consumer enrolls in a QHP or Medicaid/CHIP
• Online plan comparison tool available to inform health plan
• Tax credit is sent to insurer (if eligible) to reduce consumer
premium owed
Enrollment Assistance
Help available in each Marketplace
Toll-free call center
Navigator program
Certified Application Counselors
In-Person Assistors
Community-based organizations
Agents and brokers
Marketplace Call Center
A single 1-800 number for the call center
A single TTY number for hearing impaired
Services will be available in English and
• A separate language line will be available for
translation services (over 150 additional languages
A special “assistor” phone line to support
Navigators, IPAs, and Medicaid Offices
June – September 2013:
• The call center will launch in conjunction with
the re-launch of
Initial Open Enrollment Period
October 1, 2013 – March 31, 2014
Enroll during the Initial
Open Enrollment Period
Your coverage is
On or before December 15,
January 1, 2014
Between the 1st and 15th day
of January – March
First day of the following
Between the 16th and the last
day of December – March
First day of second following
Special Enrollment Period
Consumers may enroll or change QHP:
• Within 60 days in individual market and 30 days in small group
market from qualifying event
Special Enrollment Period Qualifying Events
Loss of minimum
essential coverage
Material contract violations by Qualified
Health Plans
Gaining or becoming a
Gaining or losing eligibility for premium
tax credits or cost sharing reductions
Gaining lawful presence
Relocation resulting in new or different
Qualified Health Plan selection
Enrollment errors of the
Exceptional circumstances
Medicaid Expansion
Medicaid Expansion in PA
 650,000 Pennsylvanians will be
eligible for health insurance if
Medicaid is expanded
 Federal Government pays 100% of
costs 2014 thru 2016; 90% from
2020 onwards
 PA will receive $17 billion in federal
funding in first six years
Affordable Care Act website –
Health Insurance Marketplace –
Center for Consumer Information & Insurance
Oversight website –
Affordable Care Act Spanish
website –
Thank you!

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