health care reform september 18 th, 2013. individual marketplace o which individuals can purchase...
TRANSCRIPT
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Health Care Reform
September 18th, 2013
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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
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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.
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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
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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
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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
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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.
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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
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Actuarial Value
OCatastrophicO60% = BronzeO70% = SilverO80% = GoldO90% = Platinum
*Actuarial value is not affordability.
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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.
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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.
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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
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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
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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
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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
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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.
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Carriers outside the Marketplace
O Wellmark 14 Plans offered
O CoventryO AssurantO Federated
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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