Healthcare Financial Management Association Stonewall Resorts May 16, 2013

1. Healthcare Financial Management AssociationStonewall ResortsMay 16, 2013

2. The ACA Signed into Law March 23, 2010

3. Four Goals of the ACA • Strong emphasis on prevention • New regulations of the insurance industry • Cost containment • Expand access to virtually every American

4. Expanding Coverage • Expand Medicaid up to 138 percent of the federal poverty level (FPL) • Establish the Health Insurance Marketplace where private insurance plans are offered

5. Medicaid Expansion Income Eligibility for a Family of Three

6. Medicaid Expansion • Now that Governor Tomblinhas approved the Medicaid expansion, 120,000 low-income West Virginians become eligible • Enroll begins October 1, 2013 and coverage begins January 1, 2014

7. Medicaid Expansion • Federal government pays 100% of the expansion costs the first three years • The federal share gradually reduces but never drops below 90% • Medicaid is exempt from sequestration

8. Examples of FPL for Medicaid

9. Medicaid Eligibility • Medicaid eligibility is determined by: • Income • Family size • US citizenship • State Residency • Under age 65 Federal Poverty Level

10. Changes in CHIP • With the increase in Medicaid eligibility, many children currently enrolled in CHIP will become Medicaid eligible and cannot remain on CHIP: • 10,800 kids transfer to Medicaid • 2,800 kids picked up under the new MAGI eligibility rules

11. Beyond Medicaid • If an applicant earns too much to qualify for MAGI Medicaid, and does not qualify for traditional Medicaid, they will be screened for eligibility for a qualified health plan • Enrollment in a qualified health plan is more complex than Medicaid and requires consumers to make additional decisions

12. Health Insurance Marketplace

13. Health Insurance Marketplace • Offers private insurance policies: Blue Cross Blue Shield, The Health Plan, Carelink, etc. • Who is eligible? People who do not have access to employer sponsored plans or qualify for government plans (Medicaid, Medicare, Tricare, VA, etc.)

14. Qualified Health Plans (QHPs) • Eligibility for a QHP include: • Be a US citizen or lawfully present in the US • State resident • Not being incarcerated

15. Premium Subsidies • In order to qualify for premium tax credits, an applicant must meet the qualifications for QHPs plus: • Have projected income between 100% and 400% of the FPL in 2014 • Not have access to other insurance coverage (there are two exceptions for ESI) • Are expected to file income tax at the end of the coverage year

16. Health Insurance Marketplace • An estimated 99,000 West Virginians will qualify for premium tax credits in the Marketplace by 2016.

17. An Example of the Subsidies • Family of four with annual income of $55,000. They pay $345 a month in premiums and the tax credits equal $840 a month. • Additional assist with deductibles and copayments plus out-of-pocket maximum protection.

18. Subsidies for Cost Sharing Expenses • Individuals and families earning less than 250% of the FPL, and • Select a silver plan (to be discussed later), then • They receive subsidies to reduce the costs of deductibles, copayments and co-insurances

19. FPL for Cost Sharing Subsidies and Premium Subsidies 250% of the FPL level is the eligibility threshold for cost sharing reductions and 400% of the FPL is the threshold for premium assistance

20. Levels of Plan Options for QHPs • Four “metal levels” of plans may be offered in the Marketplace and vary based on their actuarial value • The actuarial value is what percentage of claims for essential health benefits the insurance company pays and what percentage on average consumers pay

21. Levels of Plan Options for QHPs • In a platinum plan, the insurance company pays 90% of claims and consumers on average pay 10% of the claims • Gold plans are split 80/20 between the insurance company and consumers • Siler is a 70/30 split, and • Bronze is a 60/40 split

22. Premiums in the Various Metal Levels • Premiums in a platinum plan would be higher, while deductibles and copayments would be lower • Conversely, the premiums in a bronze plan will be lower, while the cost sharing would be higher

23. Selecting a QHP • Unlike Medicaid, which is a two step process (eligibility and then enrollment), the Marketplace can determine eligibility and provide options for an individual or family to select an insurance plan and enroll in a plan.

24. Selecting a QHP • The Marketplace will have a calculator showing an individual or family their premium, deductibles, copayments or co-insurances for each insurance company

25. Summary of Benefits and Coverage • The Marketplace will allow have an 8-page summary of benefits and coverage: • What’s covered, what’s not • Costs for a typical Type II diabetic • Costs for a normal delivery • All written in plain English

26. Selecting a QHP • The Marketplace will also have links to insurance company’s web site • Consumers can check to see if their doctor or hospital are in the company’s network • Consumers can check to see if the drug(s) they are taking are on the company’s formulary

27. Selecting a QHP • In future years, the Marketplace will have the results of consumer satisfaction surveys for each insurance company • And a rating system for insurance companies

28. SHOP Marketplace • Eligibility for the Small Business Health Insurance Option Program (SHOP) is 50 or fewer employees, about 42,000 West Virginia businesses employing 280,000 people • Only 16,000 employees projected to be enroll in SHOP Marketplace by 2016

29. Who are the uninsured? • 48% Healthy and Young • Take health for granted • Tech savvy • Low motivation to enroll • 29% Sick, Active and Worried • Generation X and Baby Boomers • 15% Passive and Unengaged • 49 and older • Live for today • Don’t understand health insurance Source: HHS Marketing Survey, March 2013

30. Personal Assistance Needed • 83% of people who will qualify for assistance in the future know nothing about it • Skeptical and interest framed by past negative experience • 75% want personal assistance

31. How Do We Enroll All These People? • Web site and call center operated by HHS • A number of entities will provide personal assistance

32. Personal Assistance • Insurance agents and brokers • Navigators • In-person Assisters • Certified Application Counselors • DHHR Employees • Community Assisters

33. The Enrollment Process • Single, Streamline Application for Medicaid, CHIP and qualified health plans (QHPs) in the Health Insurance Marketplace • There is no asset test for any of theses three insurance policies

34. Take Aways • The uninsured can enroll where ever there is a lap top or iPad with internet connection. They can also use a toll-free call center or personal assistance.

35. Take Aways • For the most part, the system will be paperless and will rely on electronic databases or self-attestation to determine eligibility for Medicaid or the QHPs

36. Take Aways • The numbers are staggering: • 120,000 eligible for Medicaid • 99,000 eligible for premium assistance • 16,000 eligible for the SHOP Marketplace

37. Opportunity • We have a once-in-a-lifetime opportunity to improve the lives of thousands of our friends and neighbors. I hope you will join WVAHC in this journey • We need…

39. Contact Information Perry Bryant West Virginians for Affordable Health Care 1544 Lee Street, East Charleston, West Virginia 25311 304-344-1673 perrybryant@suddenlink.net www.wvahc.org