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The Health Insurance Marketplace
- 1. Marjorie Petty, J.D., M.S. Regional Director The Health Insurance Marketplace
- 2. Insurance companies could turn away the 129 million Americans with pre-existing conditions Premiums had more than doubled over the last decade, while insurance company profits were soaring Tens of millions were underinsured, and many who had coverage were afraid of losing it 50 million Americans had no insurance at all The Problem 6/20/13 Health Insurance Marketplace 101 2
- 3. In March 2010, President Obama signed the Affordable Care Act into law The Health Care Law 6/20/13 Health Insurance Marketplace 101 3
- 4. 3.1 million young adults have gained insurance through their parents’ plans 6.1 million people with Medicare through 2012 received $5.7 billion in prescription drug discounts 34 million people with Medicare received a free preventive service 71 million privately insured people gained improved coverage for preventive services 105 million Americans have had lifetime limits removed from their insurance Affordable Care Act – Coverage Accomplishments 6/20/13 Health Insurance Marketplace 101 4
- 5. Slowest sustained national health spending growth in 50 years • Low growth continuing in 2012 for Medicare and Medicaid Rate increases fell from 75% in 2010 to 14% so far in 2013 $1 billion returned to consumers last summer • Plans now must spend 80% on healthcare $4.2 billion recovered in 2012 from anti-fraud efforts – a record high – for a total of nearly $15 billion over the last 4 years, double that of the previous 4 years Affordable Care Act – Cost Savings 6/20/13 Health Insurance Marketplace 101 5
- 6. Health Insurance Marketplace 1016/20/13 A new way to get health insurance • Enrollment starts October 1, 2013 • Coverage begins as early as January 1, 2014 About 25 million Americans will have access to quality health coverage • Up to 20 million may qualify for help to make it more affordable The Health Insurance Marketplace 6
- 7. 1. It’s an easier way to shop for health coverage • Simplifies the search • All options in one place • A streamlined application and an individual or family can explore every qualified insurance plan in the area 2. Most people will be able to get a break on costs • 90% of people who are currently uninsured will qualify for discounted or free health insurance 3. Clear options with apples-to-apples comparisons • All health insurance plans in the Marketplace present their price and benefit information in plain language 3 Things to Know about the Marketplace… 76/20/13 Health Insurance Marketplace 101
- 8. Each state can choose to • Create and run its own Marketplace • Partner with the Federal government to run some Marketplace functions • Have a Marketplace established and operated by the Federal government Marketplace Establishment 6/20/13 Health Insurance Marketplace 101 8
- 9. Region VI State Actions to Implement the Marketplace 6/20/13 Health Insurance Marketplace 101 9 Declining State Based Exchange Pursuing Partnership Exchange Pursuing State Based Exchange
- 10. 6/20/13 10 The SHOP is a Marketplace for small businesses and their employees (fewer than 100 FTE employees) • States may limit participation to those with 50 or fewer employees for the first 2 years • Employer will access the SHOP where its principal business office is located • Employer must offer coverage to all full-time employees • Sole proprietors may buy through the Marketplace rather than the SHOP Small Business Health Options Program (SHOP) - Employees
- 11. Eligible employers can • Define how much they’ll contribute toward their employees’ coverage • Have access to a small business tax credit • Benefit from new protections that help them get real value for consumer’s premium dollars Small Business Health Options Program (SHOP) - Employers
- 12. 12 Health Insurance Marketplace 101 6/20/13 Ambulatory patient services Prescription drugs Emergency services Rehabilitative and habilitative services and devices Hospitalization Laboratory services Maternity and newborn care Preventive and wellness services and chronic disease management Mental health and substance use disorder services, including behavioral health treatment Pediatric services, including oral and vision care (pediatric oral services may be provided by stand-alone plan) Qualified Health Plans cover Essential Health Benefits which include at least these 10 categories Essential Health Benefits
- 13. Undestanding the Marketplace Levels of Coverage Plan Pays On Average Enrollees Pay On Average* (In addition to the monthly plan premium) Bronze 60% 40% Silver 70% 30% Gold 80% 20% Platinum 90% 10% Plan Levels of Coverage *Based on the aggregate cost under the plan when benefits are provided to a standard population. This may not be the same for every (or any specific) enrolled person.
- 14. How the Marketplace Works hi 14Understanding the Marketplace6/20/13
- 15. 15 Health Insurance Marketplace 101 6/20/13 Submit streamlined application to the Marketplace Verify and determine eligibility Enroll Medicaid/CHIP Premium Tax Credit Cost-sharing Reduction Enroll in Marketplace Qualified Health Plan Eligible for Qualified Health Plan, Medicaid or CHIP Supported by Data Services Hub • Online • By Phone • By Mail • In Person Application and Eligibility
- 16. Health Insurance Marketplace 1016/20/13 Easy Convenient Streamlined In Person By Mail By Phone Online How to Apply 16
- 17. 17Health Insurance Marketplace 1016/20/13 1-800-318-2596 (TTY 1-855-889-4325) • Customer service representatives - 24/7 • English and Spanish Language line for 150 additional languages June – September • Provide general information to individuals in the Marketplace and employees of SHOP employers • SHOP call center for Employers – opens in August Starting October • Help with eligibility, enrollment and referrals National Marketplace Toll-Free Call Center for Federally Facilitated and State-Partnership Marketplaces
- 18. 18Health Insurance Marketplace 1016/20/13 CuidadoDeSalud.gov for Spanish The consumer site for info now, application and plan comparison in Oct Social media connections Responsive design Accessible for those with visual disabilities Starting October 1, 2013 you can apply through this site HealthCare.gov
- 19. Health Insurance Marketplace 1016/20/13 • Navigators • Other trained enrollment assisters Local community health centers, libraries, hospitals and other locations in local communities • Agents and brokers In Person Assistance 19 In person help will be available to help prepare electronic and paper applications to establish eligibility and to enroll in coverage through the Marketplace
- 20. Health Insurance Marketplace 1016/20/13 Get the latest resources to help people apply, enroll, and get coverage in 2014 Marketplace.cms.gov 20
- 21. The Marketplace is a new way to find and buy health insurance Qualified individuals and employers can shop for health insurance that fits their budget States have flexibility to establish their own Marketplace Individuals and families may be eligible for lower costs on their monthly premiums and out-of-pocket costs There is assistance available to help you get the best coverage for your needs Key Points to Remember 216/20/13 Health Insurance Marketplace 101
- 22. Health Insurance Marketplace 1016/20/13 Stay Connected • Sign up to get email and text alerts at HealthCare.gov/subscribe CuidadoDeSalud.gov for Spanish • Updates and resources for partner organizations are available at Marketplace.cms.gov • Twitter@HealthCareGov • Facebook.com/Healthcare.gov Want more information about the Marketplace? 22
Notas del editor
- The first question most people have is: Why did we need the health care law? The answer is that we had a health insurance market that worked very well for big insurance companies, but not so well for American families.The law has provided new coverage options for Americans with pre-existing conditions. Under the old system, no one got a worse deal than the 129 million Americans with pre-existing conditions. When they tried to buy coverage on their own, insurance companies could hike their rates, carve out needed benefits, or lock them out of the insurance market altogether. For people with potentially fatal conditions like cancer, this meant they often couldn’t afford life-saving treatments.The Health Care Law has given Americans who’ve been locked out of the market a new coverage option. As a result, more than 70,000 Americans with serious health conditions are now getting the health insurance they need.Premiums were skyrocketing even as insurers made record profits. Tens of millions were stuck with coverage that didn’t cover critical treatments and preventive care. And many of those who had insurance didn’t understand the basics of their plan – and were afraid of losing it if their employer dropped coverage or they switched jobs or retired.Fifty million Americans had no insurance at all. This left many Americans feeling like their health care choices were out of their hands.
- That’s why Congress passed and the President signed the Affordable Care Act in March 2010.
- Over the last three years, implementation of the law has built on what works in our health care system and has aimed to fix what’s broken.In creating new common sense rules of the road for insurance companies, we know that our insurance will be there when we need it the most. Most young people lost their family coverage when they graduated high school or college and it was often a few years before they got a job that offered good health insurance. That meant that if they had a car accident or an unexpected diagnosis while uninsured, they or their families could go broke trying to pay for the care they needed. Now, under the law, most young adults who can’t get coverage through their jobs can stay on their parents’ plans until age 26 – a change that has already helped 3.1million young adults get health coverage. 357,000 in TexasThere are 50 million Americans with Medicare who have access to new benefits like free preventive care and savings on prescription drugs when they hit the coverage gap known as the donut hole. There are an estimated 71 million Americans with private insurance who can now get recommended preventive care without paying any copay or deductible. In 2012, more than 206,000 Texans saved over $140 million or an average of $680 per beneficiary on prescription drugs. For those that hit the donut hole this year, the law has afforded them an average of over $1100 in savings—dollars back in their pockets. And in just a few months, women will no longer be charged more just because they are women. And they won’t be able to be turned away because of a pre-existing condition like having had a C-section or even, being a domestic violence survivor. The law also removed lifetime limits. As a result, 105 million Americans no longer have to worry about lifetime limits.
- The Health Care Law also gives consumers greater control over their health care dollars. Over the last couple of decades, we have seen insurance premiums grow at a rate three times faster than wages—families just couldn’t keep up. Now, insurance companies cannot raise the costs of premiums more than 10% without giving a reasonable explanation.And we have seen a difference made. Premiums are continuing to go up but at a slower rate and in some states they are even going down. We have seen a decline in double-digit premium increases filed: from 75% in 2010 to 14% in 2013.Insurance companies can no longer spend almost half your premium on overhead or marketing instead of actual health care services. They must spend 80% on health care and no more than 20% can go to profits or administrative costs. As a result, this past summer, 12.8 million people received $1B in rebates from insurers not meeting their medical loss ratio requirements. The Department of Justice and the Department of Health and Human Services have reported that $4.2 billion was recovered in 2012 from anti-fraud efforts – a record high – for a total of nearly $15 billion over the last 4 years, double that of the previous 4 years.
- When key parts of the health care law take effect, there’ll be a new way to buy health insurance: the Health Insurance Marketplace.The Marketplace is for qualified individuals and employers to directly compare certain competitive private health insurance options, known as Qualified Health Plans, on the basis of price, quality, and other factors. This presentation focuses mainly on coverage for qualified individuals and not on small businesses. Enrollment in the Marketplace begins October 1, 2013. Coverage can begin as early as January 1, 2014.The Marketplace will help enhance competition in the health insurance market, improve choice of affordable health insurance, and give small businesses similar advantages as large businesses.
- When you shop at the Marketplace, everything you need is laid out for you. All your costs are stated up front, so you’ll get a clear picture of what you’re paying and what you’re getting before you make a choice.About 90% of the people who currently don’t have insurance will qualify to get a break on their costs. This includes coverage by Medicaid, the Children’s Health Insurance Program (CHIP), and cost savings in the Marketplace. Thanks to new rules and expanded programs, even working families will be able to get help through the Health Insurance Marketplace. There will be new, expanded programs available, and more people than ever before will qualify for free or low-cost health insurance programs.Even if you think your income is too high to get help you should apply. A streamlined application let’s you see all the programs you qualify for.
- A state has substantial flexibility in establishing a Marketplace that meets the needs of its citizens. States across the country have received grants to establish new Marketplaces. States may create and operate their own Marketplace. The Federal government will establish and operate a Marketplace in those states that do not establish their own. In states where the Federal government is operating a Marketplace, the state can opt to partner with the Federal government. A Partnership Marketplace allows states to make recommendations for key decisions and help tailor a Marketplace to local needs and market conditions. States may also choose to run a SHOP.States that decided to operate their own Marketplace submitted a letter of intent and an application to HHS. States applied to participate in a State Partnership Marketplace with the Federal government by February 15, 2013. A state may apply at any time to run its own Marketplace in future years. U.S. territories can decide whether to create their own Marketplace or expand Medicaid coverage. Residents of a U.S. territory aren’t eligible to apply for health insurance using the federal or state Marketplace; you must be a resident of the state in which a Marketplace is operating to be eligible to enroll in coverage through the Marketplace. Check with your territory’s government offices to learn about these options.
- Today, small employers have a tough time finding and affording coverage that meets the needs of their employees. Small employers must have 100 FTE or fewer employees to be eligible to participate in the SHOP, although states may define a small employer eligible to participate in SHOP as one with 50 or fewer employees until 2016. Then all states will use the 100 employee limit.SHOP gives power similar to what large businesses have to get better choices and lower prices. A qualified employer will access the SHOP where its principal business office is located. They must offer coverage to all full-time employees. Sole proprietors may buy through the individual Marketplace rather than the SHOP.Last week, HHS announced it is coordinating with U.S. Small Business Administration (SBA), the Small Business Majority, Main Street Alliance, Business Forward, and the U.S. Hispanic Chamber of Commerce, the campaign will help small employers learn more about how to take advantage of the Small Business Health Option Program (SHOP).SBA and HHS will also offer a new schedule of educational webinars tailored to educate small business owners across the country about what the SHOP offers, and how it works. HHS has trained more than 40,000 agents and brokers, who will continue their traditional role of helping small businesses enroll in coverage, both inside and outside the SHOP Marketplace.
- Small employers will choose the level of coverage they’ll offer, and define how much they’ll contribute towards their employees’ coverage. They’ll also have access to an expanded Small Business Healthcare Tax Credit. This tax credit covers as much as 50% of the employer contribution toward premium costs for eligible employers who have low- to moderate-wage workers.When you get insurance through the SHOP, it makes it easy for you to take advantage of other tax breaks too including the chance for you and your employees to use pre-tax dollars to make your premium payments.Small employers and their employees will also benefit from new protections that help them get real value for their premium dollars. There are new limits on the higher premiums insurers can charge businesses with older employees, and an employee with high health care costs no longer increases your group’s premium. There are also new limits on the share of premiums going to insurers’ profits and administrative costs.SHOP will be fully interactive on Nov. 1. Can go online to view information and work with agents and brokers until then.
- The Health Care Law provides for the establishment of an Essential Health Benefit (EHB) package that includes coverage of EHBs (as defined by the Secretary of the Department of Health and Human Services (the Secretary)). The law directs that EHBs be equal in scope to the benefits covered by a typical employer plan and cover at least the following 10 general categories:Ambulatory patient services (outpatient care you get without being admitted to a hospital)Emergency servicesHospitalizationMaternity and newborn care (care before and after your baby is born)Mental health and substance use disorder services, including behavioral health treatment (this includes counseling and psychotherapy)Prescription drugsRehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills)Laboratory servicesPreventive and wellness services and chronic disease managementPediatric services, including oral and vision care (pediatric oral services may be provided by stand-alone plan)
- The Health Care Law requires that plans meet certain levels of coverage referred to as “metal tiers.” The levels of coverage are as follows: Bronze level - is a health plan that has an AV of 60%. Silver level - is a health plan that has an AV of 70%. The second lowest cost silver plan is used for figuring the reductions in cost sharing and premium tax credits for eligible individuals.Gold level - is a health plan that has an AV of 80%. Platinum level - is a health plan that has an AV of 90%. Plan Rates:Texas consumers will be able to choose from an average of 54 health plans in the Marketplace. Nationally, the vast majority of consumers will have a choice of at least 2 different health insurance companies - usually more. In Texas, the average premium for the lowest-cost silver plan will be $287 and for the lowest cost bronze plan it will be $211. The average premium nationally for the second lowest cost silver plan will be $328 before tax credits, or 16 percent below projections based off of Congressional Budget Office estimates. About 95 percent of uninsured people eligible for the Marketplace live in a state where their average premium is lower than projections. For example, in Houston-Brazoria, TX, a 27-year old who makes $25,000 per year will pay $81 per month for the lowest cost bronze plan and $145 per month for the second lowest cost silver plan, taking into account tax credits. For a family of four in Houston-Brazoria, TX with an income of $50,000 per year, the lowest bronze plan would cost only $52 per month. And Houston-Brazoria consumers will be able to choose from among 46 qualified health plans.
- There are four steps to using the Marketplace. Create an account. You’ll provide some basic information to get started, like your name, address, and email address. Sign up for Marketplace emails now at HealthCare.gov/subscribe and we’ll let you know when you can set up a Marketplace account. We’ll also keep you up-to-date on other key information. Apply. Starting October 1, 2013, you’ll provide information about you and your family, like income, household size, current health coverage information, and more. This will help the Marketplace find options that meet your needs. You’ll be able to see all the options you qualify for, including Qualified Health Plans and free and low-cost coverage through Medicaid and the Children’s Health Insurance Program (CHIP). The Marketplace will tell you if you qualify for lower costs on your monthly premiums and out-of-pocket costs on deductibles, copayments, and coinsurance. You’ll see details on costs and benefits before you choose a plan. Enroll. After you choose a plan, you can enroll online and decide how you pay your premiums to your insurance company. If you or a member of your family qualify for Medicaid or CHIP, a representative will contact you to enroll.If you have any questions, there’s plenty of live and online help along the way.
- There are a number of ways you will be able to submit a streamlined application to the Marketplace. You can apply online, by phone, via mail or in person.Then your application is verified (supported by a data services Hub between SSA, the IRS, Homeland Security, and other approved data sources for verification. You may be determined eligible for the Marketplace (to purchase and enroll in a Qualified Health Plan through the Marketplace), Medicaid, or the Children’s Health Insurance Program (CHIP). If you are eligible to enroll in a Qualified Health Plan in the Marketplace, you also find out if you are eligible for the Premium Tax Credit and the cost-sharing reduction.You then enroll in the program you are eligible for.
- You can apply for coverage in the Marketplace online, by phone, by mail or in person.When you complete the application, information will be verified including: residency; that you live in the service area of that Marketplace; your incarceration status; Indian status; household income; household size; and eligibility for other essential coverage including employer coverage or government programs like Medicare, Medicaid, CHIP, VA, and TRICARE. This information is checked electronically against the data of Social Security, the IRS, DoD, Homeland Security, and other approved electronic data sources for verification. Someone submitting an incomplete application will receive a notice and have 90 days to provide the needed information. The paper application is available on Marketplace.cms.gov.Applying for insurance affordability programs is optional. If you choose to apply only for eligibility to purchase a Qualified Health Plan through the Marketplace, you will be required to provide only limited information on residency, immigration status, and incarceration status, and no household income information will be required.NOTE: There is a question about foster care on the application. This only needs to be answered for those age 18-25 as it relates to a new Medicaid category for people aging out of foster care.
- A toll-free call center is now live. The number for this National Health Insurance Marketplace Call Center is 1-800-318-2596. TTY users should call 1-855-889-4325.Customer Service Representatives will be available 24 hours a day, 7 days a week, including New Year's Day. The call center is closed on Thanksgiving, Christmas, Labor Day, Memorial Day, and the Fourth of July.The call center will provide objective information in English and in Spanish. It will also use language lines for 150 additional languages.From June through September, callers can get general information about the Marketplace. Once Open Enrollment begins on October 1, 2013, the Customer Service Representatives will be able to help consumers go through the eligibility and enrollment process, and refer them to local in-person help.When you call, you will be asked what state you live in. If you live in a state operating a State-Based Marketplace, you will be provided with the number to that state’s Marketplace call center.
- HealthCare.gov can help you identify your options for health insurance. The website is also available in Spanish at CuidadoDeSalud.gov. It is in responsive design and can be used on smart phones and tablets. This website is also accessible for those with visual disabilities. CuidadodeSalud will be fully interactive Oct. 15.
- Navigators will provide assistance in every state regardless of the type of Marketplace. Navigators have a vital role in helping consumers prepare electronic and paper applications to establish eligibility and to enroll in coverage through the Marketplace. They will be required to go through a training and certification program. Every Marketplace will have at least two types of entities serving as Navigators, and at least one will be a community and consumer-focused nonprofit organization. You will hear from Stephen Williams who is part of the largest Navigator grant in Texas. United Way of Metropolitan Tarrant CountyMigrant Health Promotion, Inc. National Hispanic Council on AgingChange Happens United Way of El Paso County Southern United Neighborhoods East Texas Behavioral Healthcare Network National Urban LeagueOther types of assisters may include certified application counselors. Organizations will be designated by the Marketplace to certify individuals to perform many of the same functions as Navigators and in-person assistance personnel—including educating consumers and helping them complete an application for coverage. They would also be required to complete comprehensive training, and they will likely integrate consumer assistance into their existing programs, for example at community health centers or hospitals. Finally, agents and brokers will continue to play an important role in the individual and small group markets and will be able to enroll consumers into coverage in the Marketplace. Both consumers and small businesses can use their agent or broker to complete the application and enroll.
- You can get up to date information to help you counsel people who may benefit from the Heath Insurance Marketplace at Marketplace.cms.gov. There is access to consumer materials, training materials, research and more. You can sign up for updates as well.
- Here are some key points to remember:The Marketplace is a new way to find and buy health insuranceIndividuals and small businesses can shop for health insurance that fits their budgetStates have flexibility to establish their own Marketplace Individuals and families may be eligible for lower costs on their monthly premiums and out-of-pocket costsThere is assistance available to help you get the best coverage for your needs
- Need more information about the Health Insurance Marketplace?Sign up to get email and text alerts at HealthCare.gov/subscribe (CuidadoDeSalud.gov provides the HealthCare.gov information in Spanish)Updates and resources for partner organizations are available at Marketplace.cms.govLike us on Facebook and follow us on Twitter!