health care reform september 18 th, 2013. individual marketplace o which individuals can purchase...

Health Care Reform

September 18th, 2013

Individual Marketplace

O Which individuals can purchase insurance on the exchange? O Individuals who do not have access to

“minimum essential coverage” or “affordable coverage” through their employer

O Individuals who are eligible for either of the two types of financial assistance: O 1.Advance premium tax credits and/or O 2.Cost sharing reductions to out-of-pocket

maximums

Eligibility

Year

Enrollment

Timeframe

Time Period Effective Date Assigned

2013

Open Enrollment

10/1/2013 –3/31/2014

If applying between 10/1/13 – 12/15/13 = 1/1/14 If applying between 12/16/13 – 1/15/14 = 2/1/14 If applying between 1/16/14 – 2/15/14 = 3/1/14 If applying between 2/16/14 – 3/15/14 = 4/1/14 If applying between 3/16/14 – 3/31/14 = 5/1/14

Special Enrollment

Throughout the year

Next day effective date, if requested, or any other day up to 60 days of the event in the future.

2014

Open Enrollment

10/15/2014 -

12/7/20141/1/2015

Special Enrollment

Throughout the year

Next day effective date, if requested, or any other day up to 60 days of the event in the future.

Premium Tax Credits

Individual Market: O Premium assistance available to individuals who fall

between 100% to 400% of the Federal Poverty Level

O This premium assistance is only available to individuals who qualify and purchase through the marketplace.

O Credit amount is generally equal to the difference between the premium for the “benchmark plan” and the taxpayer’s “expected contribution.”

O Benchmark plan = the second-lowest-cost “silver” plan

Premium Tax Credits

Income Level Premium as a % of Income

Up to 133% of FPL 2% of Income

133 – 150% FPL 3 – 4% of Income

150 – 200% FPL 4 – 6.3% of Income

200 – 250% FPL 6.3 – 8.05% of Income

250 – 300% FPL 8.05 – 9.5% of Income

300 – 400% FPL 9.5% of Income

Calculating Premium Caps

Sample Single Household

Sample Family of 4

Annual Income

Monthly Premium Cap

Annual Income

Monthly Premium Cap

FPL Cap%

100% 2% $11,200 $19 $23,000 $39

200% 6.3% $22,300 $117 $46,100 $242

300% 9.5% $33,500 $265 $69,200 $548

400% 9.5% $44,700 $354 $92,200 $730

Cost-Sharing Reductions

Individual Market: O The expected contribution is a percentage of the

taxpayer’s household income based on a sliding scale (contribution increases as income increases)

O Cost-sharing reductions available to individuals below 250% of the Federal Poverty Level – these are reductions limiting the amount people must pay out-of-pocket

O This cost-sharing reduction is only available to individuals who qualify and purchase through the marketplace.

Cost-Sharing Reductions

Silver PlanActuarial Value

Consumer Max OOP Amount Limits

Applicable Population

94% $2,250 Single$4,500 Family

200 – 250% FPL

87% $2,250 Single$4,500 Family

150 – 200% FPL

73% $5,200 Single$10,400 Family

100 – 150% FPL

Individual Market - for a family of four in 2013: 100% of FPL = annual income of $23,052 250% of FPL = annual income of $57,636

Actuarial Value

OCatastrophicO60% = BronzeO70% = SilverO80% = GoldO90% = Platinum

*Actuarial value is not affordability.

Actuarial ValueMetallic Tier Member Pays Insurance Pay

Bronze 40% 60%

Silver 30% 70%

Gold 20% 80%

Platinum 10% 90%

You can check your plan at the CCIIO website using the AV Calculator.

Small Group

O Premiums are member level rated but capped at three dependents under the age of 21.

Once a child turns 21 they will count as another adult.

Small Group – Impacts to Premiums

Annual Health Insurer Fee

Reinsurance Fee

Premiums Will Increase to Account for

Fees+

=

We have heard from carriers that this will be between 4 & 6%.

Exchange User Fee

Small Group – Impacts to Premiums

Plan Design Changes

O Limit on out-of-pocket maximum (OPM) for Essential Health Benefits to HSA qualified amounts (2014) $6,350 single/$12,700 family

O Essential Health Benefit health and drug out-of-pocket payments include: Deductibles, Coinsurance, and Copayments

O Small Group deductible limits (2014) $2,000 single/$4,000 family

O Essential Health Benefits package effective for plan years on or after Jan. 1, 2014

Small Group – Impacts to Premiums

Pediatric Dental EHB Pediatric Vision EHB

Diagnostic & Preventative

Eye Exam

Basic Restorative Frames

Oral Surgery Lenses

Endodontics Contact Lenses

Periodontics

Major Restorative

Medically Necessary Orthodontia

Small Group – Impacts to Premiums

O Health and Gender No Longer a Factor!!!

O No Pre-Existing Conditions!!!O No waiting periods longer than

90 days!O 1st Plan Year following January 1st

2014O Wellmark is making all groups

change 1/1/14

Carriers In the Marketplace(aka Exchange)

O Sanford 4 Plan options

O Avera 10 Plan Options

O Dakotacare 2 Plan Options in the marketplace, Many more in the traditional market

Rates will be the same in and out of the marketplace.

Carriers outside the Marketplace

O Wellmark 14 Plans offered

O CoventryO AssurantO Federated

Small Employer Tax Credits

Available only inside the SHOP beginning in 2014.

So who’s eligible? Fewer than 25 full-time equivalent employee’s

Pay average annual wages below $50,000 per FTE

Contribute at least one half (50%) of the cost of each of their employee’s health insurance premium

Tax credit in 2014 for for-profit employers: 50% of premiums

Tax credit in 2014 for non-profit employers: 35% of premiums