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