Navigating the Federal Marketplace
AFFORDABLE CARE
Learning Objectives
I. Highlight the basics of the Affordable Care Act (ACA).
II. Explain common health insurance terms and concepts.
III. Identify approaches for assisting consumers with
Marketplace applications.
IV. Highlight best practices for outreach and enrollment
strategies in health centers and other consumer
assistance entities.
V. Identify strategies for assisting consumers with
maintaining health coverage and avoiding the individual
shared responsibility payment.
VI. Emphasize the Navigator’s responsibilities
post-open enrollment season
Basics of the Affordable Care Act (ACA)
• The Patient Protection and Affordable Care Act (ACA) was
passed on March 23, 2010 under the Obama
administration
• This created:
– A new avenue to purchase health insurance coverage—
Marketplace, or Exchange
• Accessed through www.healthcare.gov
• Managed by the U.S. Centers for Medicare & Medicaid Service (CMS)
– Tax subsidies to help individuals afford coverage
– Tax penalties associated with not having health insurance
– Restricted period of the year when coverage is available for
purchase
Basics of the Affordable Care Act (ACA)
• Eliminated the ability for insurers
to deny coverage based on health status
• Coverage is guaranteed
available and renewable
• Changed requirements
around cost-sharing and
the comprehensiveness
of offered benefits
Types of Assisters
Indiana Navigator
• Certified by the Indiana •
Department of
Insurance (IDOI)
• Certified to assist with
federal Marketplace and •
Indiana Health
Coverage Programs
applications
•
• All Medicaid enrollment
staff must be certified
as Indiana Navigators
Federal Navigator
Recipients of the
federal Navigator grant
are required to serve
as a federal Navigators
Selected and funded
by the federal
government
Also required to
become Indiana
Navigators in Indiana
Certified Application
Counselor (CAC)
•
•
•
Certified by the
Centers for Medicare
and Medicaid (CMS)
Recipients of HRSA
grant money are
required to complete
this training
Not required to do
outreach & education
The Navigator’s Responsibilities
To be an efficient Navigator, one must
understand certain health insurance concepts and
have the ability to explain terms to consumers.
Health Insurance Markets
TYPE
DEFINITION
Individual Market
 Policies cover an individual or family
Small Group Market
 Issued to employers with 50 or fewer eligible
employees (30 hours or more per week; met
waiting requirement)
 At employer’s option to include
families/dependents
Large Group Market
 Issued to employers with over 50 eligible
employees
 At employer’s option to include
families/dependents
Self-insure
Employer is responsible for paying health cost
of enrollees up to a capped amount (stop loss
insurance)
Health Insurance Cost
TERM
Premium
Deductible
Coinsurance
DEFINITION
 Monthly fee to maintain enrollment in coverage regardless of
service use
 Base amount that a member pays for services prior to their
health insurance paying for coverage
 Reset each year
 Percentage of the cost of the service the health care provider
will expect to have paid at the time of the visit
Copayment
 Specific dollar amount that an individual will pay for a particular
service, regardless of the total cost of service
Out-of-pocket
maximums
 Maximum amount the enrollee can expect to pay for services in
any plan year
 $6,350 for an individual plan on individual market ($6,600 in
2015)
 $12,700 for family plan on individual market ($13,200 in 2015)
Health Insurance Cost
Out-of-pocket Maximum Increases for 2015
Individual Market
Small Group
Market
Individuals
$6,600
$2,050
(previously $6,350) (previously $2,000)
Families
$13,200
$4,100
(previously
(previously $4,000)
$12,700)
Test Your Knowledge
The ___________________is the maximum
amount the enrollee can expect to pay for services
in any given year, while the
__________________is the base amount that a
member pays for services prior to their health
insurance paying for their coverage.
Test Your Knowledge
The ___________________is
out-of-pocket maximum the maximum
amount the enrollee can expect to pay for services
in any given year, while the
deductible
__________________is
the base amount that a
member pays for services prior to their health
insurance paying for their coverage.
Rating Rules
• The ACA limits the factors
that major medical plans can
base the price of their plan
on to age, location and
tobacco use
• Rating for Age
– Limited to a 3 to 1 ratio—Older
adults may be charged no more
than 3 times the premium as
younger adults
Rating Rules
• Rating for Location
– The ACA allows insurers to adjust
their premiums depending on
enrollee’s location
– There are 17 rating areas in Indiana
• Rating for tobacco
– Up to 1.5 times the premium for
individuals that use tobacco
– Tobacco use defined as use of any
tobacco product on average four or
more times per week over the past 6
months
– At no point may a rate increase for
tobacco based on age contradict the 3
to 1 rating limit
Help Paying for Health Insurance
Two programs to help qualified individuals afford health insurance
and cost-sharing for health services:
1. Premium Tax Credit (PTC)
•
•
•
•
Lowers the monthly premium amount
Can be used to purchase any plan on the federal Marketplace
Can be paid directly to insurer (Advanced Payment)
Available to consumers 100-400% of the Federal Poverty Level
(FPL)
2. Cost-Sharing Reduction Program (CSR)
•
•
•
Reduces out-of-pocket costs for consumers
Increases the Actuarial Value (AV) of health coverage plans for
low-income consumers (below 250% FPL)
Consumer must select at least a Silver plan
Who is eligible for the PTC and CSR?




Individual must be a citizen, national or legal resident of the U.S.
Not currently incarcerated
Meet income requirements
Meet tax-based requirements
• Plan to file a federal tax return
• If married, plan to file jointly
• Not eligible to be claimed as a dependent on someone else’s tax
return
 Lack access to Minimum Essential Coverage (MEC) OR
Have MEC available, but the premium amount is ≥ 9.5% of
household income or does not provide minimum value (at
least 60% actuarial value)
How to get Help Paying for Health Insurance
1
Apply for
health
insurance on
the
Marketplace
6
File Taxes
- If married,
must file
jointly
2
5
Provide
information
about income,
household size,
access to
coverage, etc.
3
Marketplace
determines
eligibility for
Financial
Assistance
Report any
changes
throughout
the year (e.g.
lose job or
have baby)
4
Choose a
health plan
Premium Tax Credit (PTC)
1. Full Advanced
Payment
 Reduces monthly
premium cost
 Paid in full to
insurance carrier
 If income increases
during the year,
consumer may owe
some or all of the
PTC back at tax filing
2. Partial Advanced
Payment


Reduces
premium costs &
likelihood of PTC
overpayment
Consumer bears
more of the
premium cost
immediately than
if full
advancement
payment is taken
3. Claim Later


Ensures that
PTC is not
overpaid and
that consumer
will not owe at
tax filing
Consumer
bears the full
cost of the
premium
immediately
Claim Later
Partial Advanced Payment
Full Advanced Payment
Premium Tax Credit (PTC)
If an individual or family falls between 100-400% of the Federal Poverty Level
(FPL), then they will generally qualify for a PTC.
Family Size
100% FPL
400% FPL
1
$11,670
$46,680
2
$15,730
$62,920
3
$19,790
$79,160
4
$23,850
$95,400
5
$27,910
$111,640
6
$31,970
$127,880
7
$36,030
$144,120
8
$40,090
$160,360
(Based on the 2014 FPL)
How is the Premium Tax Credit Calculated?
Advanced Premium
Tax Credit
“Fills the gap”
between what a
family is expected to
contribute to health
insurance and the
cost of a benchmark
plan.
Cost of a
Benchmark Plan
Expected Family
Contribution
The cost of the
second lowest cost
Silver plan adjusted
to reflect selected
characteristics of the
family, such as age
and size.
Set on a sliding scale
based on income;
varies from 2% of
income at 100% FPL
to 9.5% at 400% FPL.
Premium Tax Credit (PTC) Required Premium
Contribution
FPL
2014 Estimated Annual
Income (Individual)
Required %
of Income
Contribution
2014 Estimated Annual
Contribution (Individual)*
100-133%
$11,670-$15,521
2%
$233-$311
133-150%
$15,521-$17,505
3-4%
$465-$701
150-200%
$17,505-$23,340
4-6.3%
$701-$1471
200-250%
$23,240-$29,175
6.3-8.05%
$1,471-$2,349
250-300%
$29,175-$35,010
8.05-9.5%
$2,349-$3,326
300-400%
$35,010-$46,680
9.5%
$3,326-$4,435
*This estimated contribution is for the second lowest-cost Silver plan available on the
federal Marketplace; estimated annual contribution could change based on plan metal
tier selected
Premium Tax Credit (PTC) Calculation
Example
In Marion County, IN, the estimated annual premium for a 35-year old nonsmoker’s second-lowest Silver plan is $3,912 annually* for 2014. The PTC
amount is calculated by taking this total premium cost and subtracting the
required contribution.
FPL
2014 Estimated SecondLowest Silver Plan
Premium
Required
Contribution
PTC Amount
100%
$3,912
$233
$3,679
150%
$3,912
$701
$3,211
200%
$3,912
$1,471
$2,441
250%
$3,912
$2,349
$1,563
300%
$3,912
$3,326
$586
400%
$3,912
$4,435
$0
*Source: Indiana Department of Insurance
Cost-Sharing Reductions (CSR)
Who is eligible?
• Individuals who meet all requirements for the PTC
AND
• Have household income between 100% to 250% of the
Federal Poverty Level (FPL)
AND
• Enroll in a Silver plan (70% Actuarial Value) on the
federal Marketplace
Cost-Sharing Reductions (CSR)
Benefits:
- Increase the Actuarial Value (AV) of health coverage plans
for low-income consumers
- Reduce out-of-pocket costs for consumers
- Offered in addition to PTC
- Qualifying individuals do not have to apply for CSR
separately
Cost-Sharing Reductions (CSR)
2014 FPL
Estimated Annual
Income
(Individual)
AV of Silver plan
after CSR
(originally 70%)
Individual Annual
Out-of-Pocket
Maximum (2014)
100-133%
$11,670 - $15,521
94%
$2,250
133-150%
$15,521 - $17,505
94%
$2,250
150-200%
$17,505 - $24,340
87%
$5,200
200-250%
$23,340 - $29,175
73%
$6,350
Based on 2014 FPL
Test Your Knowledge
To be considered for cost-sharing reductions, an
individual must enroll in a _______________ plan.
The ________________ is an insurance
affordability program that can be applied to any
plan on the Marketplace to lower a monthly
premium.
Test Your Knowledge
To be considered for cost-sharing reductions, an
Silver
individual must enroll in a _______________
plan.
The ________________
Premium Tax Credit is an insurance
affordability program that can be applied to any
plan on the Marketplace to lower a monthly
premium.
HEALTH INSURANCE PLANS
What’s Offered on the Marketplace?
 The Marketplace offers four categories of Qualified Health
Plans (QHPs), known as “Metal Levels”
• Distinguished by the share of health care costs QHP are expected
to cover
 Actuarial Value (AV) The percentage that insurance
companies will pay on average for the health services
consumers use
 Other Plan Options
• Catastrophic plans
o APTC cannot be applied
• Stand-alone plans such as dental
Actuarial Value and Metal Tiers
Lower
Premiums
Higher
Premiums
Higher Consumer Cost-Sharing
Lower Consumer Cost-Sharing
BRONZE
SILVER
GOLD
60%
70%
80%
PLATINUM
Percent of Total Cost of Care Covered
90%
Actuarial Value and Metal Tiers
Actuarial Value and Metal Tiers
Test Your Knowledge
1. A plan in the ____________tier will have the
lowest premium amount and ___________costsharing amount.
2. A plan in the ____________tier will have the
_____________ premium amount and the
lowest cost-sharing amount.
Test Your Knowledge
1. A plan in the ____________tier
bronze
will have the
highest
lowest premium amount and ___________costsharing amount.
platinum
2. A plan in the ____________tier
will have the
highest
_____________
premium amount and the
lowest cost-sharing amount.
The Individual Mandate
 Also called the Individual Shared
Responsibility Requirement– Affordable
Care Act (ACA) condition requiring
individuals to maintain health coverage for
themselves and their dependents
• Health coverage must be considered
Minimum Essential Coverage (MEC) as
determined by the federal government
• All Qualified Health Plans (QHPs) on the
Marketplace must cover certain benefits
• There are 10 Essential Health Benefits
(EHBs) set for 2014 and 2015 which must be
offered by health plans
• Will change in 2016
Minimum Essential Coverage (MEC)
• Coverage that is considered comprehensive health insurance under
the ACA
 Coverage for one day in the month is considered to be coverage for the entire month
TYPES OF MINIMUM ESSENTIAL COVERAGE
Coverage under a government sponsored program including:
 The Medicare Program
 The Medicaid Program
 The Children’s Health Insurance Program (CHIP)
 Veteran’s Administration programs including TriCare and CHAMP VA
 Coverage for Peace Corps Volunteers
 Coverage under an employer-sponsored health plan
 Coverage under a health plan offered in the individual market within a State
 Coverage under a grandfathered health plan
 Additional coverage as specified such as Refugee medical assistance and
Medicare advantage plans
Minimum Essential Coverage (MEC)
NOT CONSIDERED MINIMUM ESSENTIAL COVERAGE
Policies that cover only a specified disease or illness
Medi-gap policies
Accidental death and dismemberment coverage
Disability insurance
Workers’ compensation
Coverage for employer-provided on-site medical clinics
Limited-scope dental or vision benefits
Long-term care benefits
Essential Health Benefits (EHBs)
Ambulatory
Patient
Services
Mental
Health
Services
Emergency
Services
Hospitalization
Prescription
Rehabilitative
Services
Drugs
Preventive
&
Wellness
Care
Pediatric
Services
Maternity
&
Newborn
Care
Laboratory
Services
Qualified Health Plans (QHPs)
 Plans sold on the Marketplace must be
certified as QHPs
 QHPs sold on the Marketplace must
• Provide Minimum Essential Coverage
(MEC)
• Cover Essential Health Benefits (EHBs)
• Meet Actuarial Value (AV)
• Meet provider network standards
 QHPs are the only plans that an
individual can purchase that are
eligible for the Premium Tax Credit
(PTC) or Cost-Sharing Reductions
(CSRs)
Catastrophic Coverage
• What is catastrophic coverage?
– Plans with high deductibles and lower premiums
– Consumer pays all medical costs up to a certain amount
– Includes 3 primary care visits per year and preventative services
with no out-of-pocket costs
– Protects from high out-of-pocket costs
• Who is eligible?
– Young adults under 30
– Those who qualify for a hardship exemption
– Those whose plan was cancelled and believe Marketplace plans
are unaffordable
NOTE: People who enroll in catastrophic health plans are not
eligible for PTC
Grandfathered Plans
• Health plans in existence prior to the passage of the ACA
and do not have to comply with some provisions related to:
–
–
–
–
Benefits
Cost-sharing
Pre-existing condition exclusions
Annual maximum
• Plans may only maintain grandfathered if they do no make
substantial changes to their policies
• Individuals offered grandfathered coverage through an
employer may choose to not accept the coverage and
purchase coverage that meets ACA requirements instead
Excepted Benefit Plans
• Plans that cover a specific service or condition and do not provide
comprehensive health coverage
• Not subject to many of the ACA market reforms
• Most common is stand-alone vision
• Stand-alone dental plans are the only excepted benefit plans
offered on the Marketplace
• Not offered in the metal tier levels of QHP
• Subject to a $700 maximum out of pocket amount for a single
individual and $1,400 for family
• May be purchased using the APTC
• Not eligible for cost-sharing reductions
Shared-Responsibility Payment
• Those who do not have
MEC or an exemption
will be required to pay a
shared-responsibility
payment to the IRS upon
tax filing
Test Your Knowledge
Stand-alone ________ plans are the only excepted
benefit plans available on the Marketplace, while
the most common is stand-alone __________
plans.
Test Your Knowledge
dental plans are the only excepted
Stand-alone ________
benefit plans available on the Marketplace, while
vision
the most common is stand-alone __________
plans.
Screening Consumers
• Introduce yourself as a Navigator
– Explain your role and how you can help
– Reveal any potential conflicts of interest
• Assess their knowledge
– Are they familiar with the Affordable Care Act? Individual Mandate?
Premium Tax Credits?
• Ask about
– Household income
– Household size
– Plans to file taxes
• Answer any questions
− Direct them to additional
resources if necessary
Screening Consumers
To purchase coverage on the Marketplace, individuals must:
• Be a United States citizen or legal resident
• Reside in the state they are applying in
• Not be incarcerated
 You can help individuals compare
plans based on:
•
•
•
•
Quality
Covered benefits
Covered providers
Expected cost-sharing level
Create an
account
Apply
Enter information
First obtain some
about the
basic information.
consumer and
Then help the
consumer’s
consumer choose family, including
a username,
household size,
password, and
income and
security questions
more.
for added
protection.
Pick a Plan
Enroll
See all the plans
Help the
and programs
consumer choose
and compare
a plan that meets
them side-bytheir needs and
side. Find out if
enroll. Instruct
the consumer
them to pay their
can get PTC
first premium!
and/or CSR.
Marketplace Functions
 Gives individuals an avenue to compare and purchase
health insurance
 Assesses eligibility for:
• Medicaid, Premium Tax Credits (PTCs) Cost-Sharing
Reductions (CSRs), Individual Mandate Exemptions
 Manages eligibility appeals
 Facilitates enrollment in Qualified Health Plans (QHPs)
 Ensures appropriate PTC and CSR payments to health
insurance plans
 Collects and publishes quality data on health plans
 Operates consumer assistance call center
 Starting in 2015: Collects premiums for small
businesses
Application Basics: Reporting Household
Size
Include
Do NOT Include
Consumer
Unmarried partner who does not need
health coverage
Consumer’s spouse
Unmarried partner’s children, if they are
not consumer’s dependents
Children who live with the consumer,
even if they make enough money to file
a tax return themselves
Parents living with the consumer, but
file their own tax return and are not
consumer’s dependents
Unmarried partner needing health
coverage
Other relatives who file their own tax
return and are not the consumer’s
dependents
Anyone claimed as a dependent on tax
return, even if they don’t live with the
consumer
Anyone else under 21 who consumer
lives with and takes care of
Application Basics: Estimating Income
Include
Do NOT Include
Consumer’s and their spouse’s gross
income, if they are married and will file
a joint tax return
Child support
Any dependent’s gross income who is
required to file a tax return
Gifts
Wages
Supplemental Security Income (SSI)
Salaries
Veterans’ disability payments
Tips
Workers’ compensation
Net income from any self-employment
or business
Proceeds from loans (like student
loans, home equity loans or bank loans)
Unemployment compensation
Social security payments, including
disability payments—but not SSI
Alimony
Modified Adjusted Gross Income (MAGI)
• Modified Adjusted Gross Income, or MAGI is the figure
used to determine eligibility for lower costs in the
Marketplace and for Medicaid and CHIP.
• Generally, modified adjusted gross income is your adjusted
gross income plus any tax-exempt Social Security, interest,
or foreign income you have.
• When filling out the Marketplace application, MAGI is
automatically calculated through the system.
Modified Adjusted Gross Income (MAGI)
 APTC and CSR (as well as Medicaid) rely on the measure
of income known as MAGI
Adjusted
Gross
Income (AGI)
Any social
security
benefits (not
included in
AGI)
Add up the income of all
household members who
must file taxes
Tax Exempt
Interest or
Foreign
Earned
Income
MAGI
Modified Adjusted Gross Income (MAGI)
IMPACTS
New applicants:
 Adults
 Parents and Caretaker
relatives
 Children
 Pregnant Women
DOES NOT IMPACT
Aged
Blind
Disabled
Those needing longterm care
Former foster children
under age 26
Deemed newborns
Determining Application Method
Household Size
Family Income (Projected 2014 Gross Household Income)
1
$12,254 or less
$12,179.01 - $45,960
$45,960.01 or more
2
$16,517 or less
$16,441.01 - $62,040
$62,040.01 or more
3
$20,780 or less
$20,702.01 - $78,120
$78,120.01 or more
4
$25,043 or less
$24,963.01 - $94,200
$94,200.01 or more
5
$29,306 or less
$29,224.01 - $110,280
$110,280.01 or more
6
$33,569 or less
$33,485.01 - $126,360
$126,360.01 or more
7
$37,832 or less
$37,747.01 - $142,440
$142,440.01 or more
8
$42,095 or less
$42,008.01 - $158,520
$158,520.01 or more
Apply for Indiana’s Health Coverage Programs
Apply on federal Marketplace
Apply on federal Marketplace or commercial health
insurance market
Test Your Knowledge
Modified Adjusted Gross Income (MAGI) is your
adjusted gross income plus any _____-_______
__________ ___________, _________, or
________ income you have.
Test Your Knowledge
Modified Adjusted Gross Income (MAGI) is your
tax exempt
adjusted gross income plus any _____-_______
Social
Security
interest or
__________
___________,
_________,
________
foreign income you have.
Completing the Application: Disability Questions
• The consumer should answer “yes” to the Marketplace
disability question if he or she and/or
other household members:
Activities of daily living
• Is blind, dead, or hard of hearing
Bending
Eating
• Receives SSDI or SSI
Hearing
Lifting
• Has physical, intellectual or mental Thinking
Breathing
health condition causing:
Sleeping
Standing
• Serious difficult completing
Seeing
Walking
activities of daily living
• Difficulty doing errands
• Serious difficulty concentrating, remembering or making
decisions
• Difficulty walking or climbing stairs
Completing the Application: Employer-Sponsored
Coverage
• The Marketplace may require consumers who are currently
employed with access to employer-sponsored coverage to
enter additional information about
• Who (with employer) to contact about employee health
coverage (usually HR)
• Amount employee pays for premium cost
• Any known changes in future employer coverage
• Whether employer-sponsored coverage meets minimum
value (whether the policy covers at least 60% of
healthcare costs for the covered pool, on average, after
premiums)
Assisting Immigrants
There are two categories of immigrants for federal benefits eligibility
purposes:








Qualified
Not Qualified
Lawfully Permanent Residents
 Undocumented
Refugees, Asylees ,Conditional entrants
immigrants
Cuban and Haitian entrants
Parolees (in U.S. for more than 1 year)
Certain American Indians
Persons granted withholding of
deportation/removal
Lawfully present individuals (e.g.
nonimmigrant visa holders; i.e. students or
temporary workers)
For Medicaid: Individuals who have met the
5 year waiting period (post-August 22,
1996 with some exceptions)
Assisting Immigrants
Eligibility Rules
- Undocumented immigrants are ineligible to purchase QHPs
and are exempt from the penalty
- May be eligible for Medicaid payment of package E–
Emergency Services or services through FQHCs or other
health centers
- Immigrants must be in a status recognized by HHS as
lawfully present
- Status can be pending
Assisting Immigrants: Unique Challenges
-
-
Mixed-status families are less likely to enroll because eligibility
rules divide them
The Marketplace can’t require applicants to provide information about
citizenship or immigration status of any household members who are not
applying for coverage
Inform consumers that information obtained on the Marketplace
application cannot be used by the Immigration and Customs
Enforcement (ICE) Department of Homeland Security (DHS) for
immigration enforcement purposes
- Agencies can collect, use and disclose only the information strictly necessary
for enrollment in health coverage
- Medicaid and Marketplace subsidies are not considered in screening green
card applicants for public charge
-
The Call Center can connect language lines for immediate
interpretation into 150 languages
What do American Indians and Alaskan Natives
need to know about the Marketplace?
• A member of a federally recognized tribe can:
– Buy private insurance in the Health Insurance Marketplace without
paying out-of-pocket costs if income is up to $70,650 for a family of 4
– Enroll in Marketplace health insurance any month and change their
plan up to once a month
• American Indian or Alaska Native otherwise eligible for
services from the Indian Health Service, tribal program, or
urban Indian health program:
– Have special cost and eligibility rules for Medicaid and the Children’s
Health Insurance Program (CHIP) that make it easier to qualify for
these programs
– Don’t have to pay the penalty for not having Minimum Essential
Coverage (MEC)
Coverage Start Dates
 The start date for federal Marketplace coverage:
• Based on the date a consumer completes enrollment in a QHP
• A consumer is not considered enrolled in a QHP until they pay their
portion of the first months premium
 In general:
• Coverage purchased before the 15th of the month is effective the 1st of
the next month
• Coverage purchased after the 15th is effective the 1st of the following
month
2014/2015
Enrollment Date
November 15thDecember 15th
December 16thJanuary 15th
January 16thFebruary 15th
Effective Coverage
Date
January 1, 2015
February 1, 2015
March 1, 2015
Test Your Knowledge
A member of a federally-recognized tribe can
change their health plan on the Marketplace up to
____ times a year.
Test Your Knowledge
A member of a federally-recognized tribe can
change their health plan on the Marketplace up to
____
12 times a year.
Best Practices
• Offer services for extended hours, including nights and weekends
• Monitor wait times
• Coordinate consumers’ appointments so they
align with other appointments at your
organization
• Establish a follow-up process to ensure that
consumers receive health insurance
• Ensure that staff and volunteers are familiar with
your organization’s policies regarding outreach,
in-reach and using personally identifiable
information (PII)
• Set up an organizational reminder system that notifies people about
their appointments by texting, emailing, or calling them
the day before
Best Practices
• Build trust with consumer by greeting them warmly, smiling and
listening carefully throughout the appointment
• Be patient, detail-oriented and take your time
• Ensure appropriate accommodations are available for consumers
with disabilities
• Have the appointment in a space that is
private and free from distractions
• Assist consumers in a culturally sensitive
manner
• Check with the consumer frequently to
make sure that he or she understands the
information
Best Practices
Provide consumers with a “next steps document” that includes the
following:
– Information about the process consumers
will need to follow in order to report any life
changes throughout the year
– Information about what to do prior to and
during the next open enrollment period
(renewals)
– Guidance on how to use their health
insurance
– Culturally appropriate resources to help
them identify primary care physicians in
their network, and information on how to
setup a first appointment
Navigator’s Responsibility
• There are many reasons adults and children lose
coverage despite their eligibility
– Administrative barriers
– Cost
– Not knowing how to navigate the health coverage system
• Consumers are learning to navigate a new coverage
system with new rules
• As a Navigator, you should help consumers understand
the rules under the Affordable Care Act (ACA) and
become aware of their responsibilities as insured
Navigator’s Responsibility
Help consumers:
• Understand how and when to report specific life changes
to the appropriate agency
– How changes may affect premium tax credits
– How changes may affect type of coverage they are eligible to
receive
• How and when to pay premiums (if applicable)
• The annual redetermination and open enrollment process
Paying Premiums
• If consumers do not pay their premiums, qualified health
plans (QHPs) can cancel their coverage
• Consumers receiving the advanced premium tax credit
(APTC) have a three-month grace period before their
coverage can be cancelled (as long as they have paid
their premiums for at least one month)
– Consumer must repay all outstanding premiums by end of grace
period, or QHP may cancel the coverage
– Consumer may have to pay for all health care services received
during the second and third months of the grace period
Reporting Life Changes
Once a consumer has Marketplace coverage, they are
responsible for reporting certain life changes which may change
the coverage or savings they’re eligible for.
 Marriage or divorce
 Having or adopting a child or placing
child for adoption
 Change in income
 Getting health coverage through
employment or Medicare/Medicaid
 Changing place of residence
 Change in disability status
 Gain or lose a dependent
 Becoming pregnant
 Other changes affecting income or
household size
 Change in tax filing status
 Change in citizenship or
immigration status
 Incarceration or release
 Change in status as an
American Indiana/Alaska
Native or tribal status
 Correction to name, date of
birth, or Social Security number
Reporting Life Changes
• Consumers should report changes as soon as possible, which
may activate a special enrollment period (SEP)
• SEPs generally last 60 days from the life event
• Reporting a change can occur through two methods:
1. Online
2. By phone
• Log-in to account. Select the
application, then select “Report a
life change”
• A new eligibility notice will be
generated that will explain
eligibility for a SEP and eligibility
or ineligibility for lower costs, or
different savings (e.g. Medicaid)
• Contact the Marketplace Call
Center
• A representative will authorize the
SEP
Special Enrollment Periods
• Other types of special enrollment periods:
– Material contract violations by qualified health plan
– Gaining or Losing eligibility for PTC or change in eligibility for costsharing reductions
– Enrollment Errors of the Marketplace
• Consumer chose plan, but enrollment wasn’t processed on time, or
insurance carrier doesn’t have record of enrollment
– Exceptional circumstances
• Serious medical emergencies—unexpected hospitalization or cognitive
incapacitation or disability
– Misrepresentation
• Misconduct or misinformation by person(s) providing enrollment assistance
and/or failure to enroll
– e.g. enrolled in wrong plan or found ineligible for
PTC or CSR due to error
Special Enrollment Periods
SEP Event
Loss of coverage
QHP Effective Date
If loss of coverage is in the past, 1st of the month
following QHP selection. If loss is in the future, 1st of
the month following loss of coverage
Marriage
Denial of Medicaid or CHIP
1st of the next month following plan selection
Birth, Adoption, Foster Care
Date of birth, adoption, placement of adoption or
placement in foster care
Gaining lawfully present
status
Newly eligible or ineligible for
APTC, change in CSRs
Moving & Incarceration
Release
Native American status
Within first 15 days of the month: 1st of the following
month
On or after the 16th of the month: 1st of the month
after next
The Annual Enrollment Period
Annual Redeterminations
 Insurer will send information prior to November 15th about updated
premiums and benefits
• If consumer is happy with current plan—and income or household
size HAVE NOT changed—s/he doesn’t need to do anything.
o The Marketplace will auto-enroll the consumer in the same plan
for 2015
• If income or household size HAVE changed, the consumer will
need to report it to the Marketplace to get the correct PTC amount
o If information is not updated, the PTC from 2014
will be used
2014-2015 OPEN ENROLLMENT PERIOD:
NOVEMBER 15—FEBRUARY 15
Where does Indiana stand?
• During the first open enrollment period, 132,423 Hoosiers
selected a plan on the Marketplace
• 56% female and 44% male
• 33% under age 35
• 26% between ages of 18 and 34
• 67% selected a Silver plan
• 89% selected a plan with financial
assistance
• An estimated 880,000 to 909,636
individuals are still uninsured, and
181,930 are in the coverage gap.
Source: HHS and KFF
Test Your Knowledge
Today is September 8th, and Lilly is applying on the
Marketplace because she is losing her health
coverage through her employer on September 30th.
She is eligible for a Special Enrollment period and
selects a plan. When will her new Marketplace
coverage begin?
Test Your Knowledge
Today is September 8th, and Lilly is applying on the
Marketplace because she is losing her health
coverage through her employer on September 30th.
She is eligible for a Special Enrollment period and
selects a plan. When will her new Marketplace
coverage begin?
October 1st (if she pays her first premium)
Exemptions
• Individuals seeking an exemption from
the individual shared responsibility
requirement may apply for one or more
of the exemption types
• Exemptions can be categorical,
based on income, or related to
other circumstances
• To be eligible for an exemption in any month, the
individual must meet the criteria for the exemption for at
least one day in that month.
Exemptions
 Uninsured for < 3 months
of the year (short coverage
gap)
 Lowest-priced coverage
available costs more than
8% of household income
 Income below tax filing
limit
 Member of a federal
recognized tribe or eligible
for services through an
Indian Health Services
Provider
 Member of a recognized
religious sect with
religious objects to
insurance
 Incarcerated and not
awaiting disposition of
charges
 Now lawfully present
 Suffer from a hardship
(discussed on next slide)
Hardship Exemptions
1. Evicted within past 6 months
or facing eviction or
foreclosure
2. Received utility shut-off notice
3. Experienced death of a close
family member
4. Experienced flood, fire, or
other natural or humancaused disaster that caused
substantial damage to
property
5. Determined ineligible for
Medicaid because state did not
expand
6. Individual insurance plan was
canceled and other
Marketplace plans are
unaffordable
7. Eligible for enrollment in QHP
through the Marketplace, CSR,
or APTC for a time period when
not enrolled in a QHP through
Marketplace
Hardship Exemptions
8. Homeless
9. Filed for bankruptcy within
last 6 months
10.Domestic violence victim
11.Unable to pay medical
expenses within last 24
months
12.Experienced unexpected
increases in necessary
expenses due to caring for an
ill, disabled or aging family
member
13. Expect to claim a child as a
tax dependent who’s been
denied coverage in
Medicaid and CHIP, and
another person is required
by court order to give
medical support to the child
14. Another hardship in
obtaining health insurance
Exemptions
Tips for helping consumers with an exemption application
1.Read each type of exemption to find best fit for consumer
2.Submit supporting documents with application
3.Do not leave questions blank—this may cause delays
4.Make a copy of the Step 2 page for each adult in the
household, even if the adult doesn’t want an exemption
• Include tax-filing information for every adult
5.Consumer should keep a copy of their completed application
Appeals
Consumers may challenge a federal Marketplace decision
in the following circumstances:
1. He or she disagrees with a federal Marketplace eligibility
decision regarding enrollment in a QHP, PTC or CSR
2. He or she disagrees with the amount of PTC or CSR
determined by the Marketplace
• Information on how to appeal will be included on most
notices, and the consumer should file the instructions or
call the Marketplace call center
The Navigator’s Role After
Open Enrollment
Indiana Navigator Responsibilities
• Expect to continue to educate consumers about the
benefits of the ACA in preparation for the 2015 Enrollment
Cycle, including
– Building trust in your communities
– Building and strengthening community partnerships and local
coalitions
– Reflecting on what worked and what didn’t work
– Collaborate, brainstorm and plan for the next enrollment period
– Recruit volunteers and bilingual staff
– Assign a lead Navigator
– Involve entire health center staff in ACA awareness and in-reach
strategies
Indiana Navigator Responsibilities
• Expect to continue and enhance efforts to help
consumers navigate the health insurance and health care
system, including helping consumers to:
–
–
–
–
Understand and use their health care coverage
Understand their rights as health care consumers
Appeal eligibility and coverage decisions
Report a change in circumstance and navigate subsequent
eligibility redeterminations
Helpful Resources and Tools for Assisters
• CMS Assister Resources
Page
• Families USA Enrollment
Assister Resource Center
• In The Loop: Connecting
the Enrollment
Community
• Indiana Family and Social
Services Administration
(FSSA)
• Indiana Department of
Insurance: Navigator
Certification
• Enroll America Easy
Premium Calculator
• Cover Indiana
• Get Covered America
• InsureKidsNow.gov
• ACA Tax Penalty Calculator
• Enroll America In-Person
Assistance Page
• Kaiser Family Foundation
Descargar

Presentation Prepared For: