Aca healthcare options for 2013 public by michael chapman 073113 slideshare

What You Need to Know NOW
& How to prepare for 2014
• What You Need to Know
• What You Need to Decide
• When You Need to Act
• Plus, How It Affects You, Your
Job, and Your Employer
What?
When?
Healthcare Options for 2013
And how to prepare for 2014
© 2013 Michael Chapman, GroupBenefitsAdvisors.com

Disclaimer:
• The information presented is subject to
change, and will likely change in the future.
• Subscribe to TheMedicalInsuranceExchange.com
newsletter or contact us for latestupdates.
• The information presented should not to be
construed as offering legal or tax advice; consult
with a lawyer or tax professional.
• Some state variations may occur, the information
presented is based on the laws of Texas.
What?
When?

My Qualifications:
• Former CEO
• Since 2003, Frequent Public Speaker on Healthcare and Insurance.
• Employee Benefits Broker for Companies and Individuals.
• Published Author, Blogger.
• Helpful, pro bono resource to thousands of individuals and companies in
DFW with benefits-related questions and concerns.
• Mike Chapman, mtchapman@endeavorgroup.net
• Linkedin.com/in/michaelchapman (14,000+)
• 214-764-6315 tel, 214-732-3691 cell

My Dilemma

Door # 2:
• Plunge head first
towards opportunities
created from PPACA
• Mike Chapman, mtchapman@endeavorgroup.net
• Linkedin.com/in/michaelchapman
• 214-764-6315 tel., 214-732-3691 cell

Best Healthcare Advice
for Anyone:

Best Healthcare Advice
for Anyone:
• Stay Healthy
• Don‟t Get Injured

2nd-Best Healthcare Advice for
Anyone:

2nd-Best Healthcare Advice for
Anyone:
• Die Quickly
• Die In Your Sleep!
• Over 80% of lifetime healthcare expenses
occur in last 18 months of life.
• Medical is Leading Cause of Bankruptcies

We Don‟t Get to
Choose
If, When, or
How
We Get
Sick, Injured or© 2013 Michael Chapman, GroupBenefitsAdvisors.com

The Choices We Make
Determines How Much We
Have to Spend
If and When We Get
Sick, Injured or Die

A Healthy, “Hazard-Free
„Lifestyle
Reduces How Much We‟ll
Eventually Pay When We Get
Sick, Injured and Die, and
Increases the Length and
Quality of Life

Insurance pools
the $$ Risk of
Sickness
Accident, and
Death

Healthcare is Expensive
• 30-35% of US GDP
• For many families, #1 or 2 budget
item.
• For many Businesses, #2 Overhead
item after salaries
• High, uncontrollable inflation.

Pre-2014 Options:
• COBRA
• Private Insurance
• “Risk Pool”
• VA/Tricare (Veterans/Active Duty)
• Medicare (65+)
• Medicaid/CHIP (Children)
• Self-Insure

Pre-2014 Options:
• COBRA/State Continuation
• Same plan, same $ as
employer
• 18 months/6 months
• No exclusion of health
conditions
• Must elect within 60 days

Pre-2014 Options:
• Private Insurance
• Can exclude
conditions, increase rates
based on health conditions
during underwriting.

Underwriting:
• Evaluation of Risk of claims
• Conditions
• Age
• Gender
• Residence

Pre-2014 Options:
• Group Insurance
• Guaranteed Issue
• Same cost for every employee
• Individual Insurance
• Individually Underwritten

Pre-2014 Options:
• Individually Underwritten
• Insuring a healthy, younger, male
with no health conditions is less
risk of a claim, so they will pay less
for insurance.
• Can reduce cost vs. COBRA by up
to 60%

Pre-2014 Options:
• Short term plans
• 0-6 months of coverage.
• Easy, short application.
• “Permanent” plans
• Stay in force as long as you pay
premium.
• Lengthy application/underwriting.
• Short term and permanent are both
major medical plans.

Pre-2014 Options:
• “Risk Pool”
• Option after COBRA and if either
spouse is not eligible for group plan.
• Covers individuals who are ineligible
or excluded individual insurance
because of health condition.

Pre-2014 Options:
• Medicare
• Guaranteed issue coverage at
age 65, can apply at 64 ½
• A+B+D plus medicare supplement
or Medicare Advantage (HMO)
plan in some areas.
• Limitation of healthcare
providers who accept.

Pre-2014 Options:
• Medicaid/CHIP (Children)
• Children 0-18
• Income/Asset qualify
• Waiting list
• HMO
• Affordable

Pre-2014 Options:
• Self-Insure
• You assume risk of sickness/injury
• Includes public health programs
such as Parkland and John Peter
Smith in DFW

Whether you yet know it or not…
…ACA Impacts EVERYTHING
• Every American faces healthcare decisions
Beginning 10/1/2013 for 2014.
• Every Business faces similar decisions in
2014
What? What?
When?

When Must I Make A Decision?
• Huge Advertising Campaign.
• Exchanges Open October 1, 2013
• ACA Coverage Begins January 1.
• Best Time To Make A Decision is NOW!
What?
When
?

The Obamacare Clock
Is Ticking..
…The Sooner You Know WHAT to
Do
…The Longer You‟ll Have to Adjust!

Change =
Opportunities
Use Knowledge of
Obamacare as Your
Secret Advantage.

Brief Overview of What it Is
• Coverage Differences
• How You Buy It
• What It Costs You
• Consequences to You and Employer
What?
When
?

Your Health Plan will be Different
2013 2014

98% of Today‟s
Health Plans Will
Be Replaced
Just Kidding!

Some of the Big Plan Differences:
• Different Deductibles –
• Max $2,000 Deductible.
• $3,500 Max Out of Pocket.
• “Guaranteed Issue,” Regardless of Your Health.
• More Coverage, Examples:
• Maternity Coverage, Dental Checkups to Age 6

More Big Plan Differences:
• Guaranteed issue, No “Rate Ups” for Risk or
Conditions
• Except May Charge 50% More for Smoking
• May Offer Discount for Wellness Plan Participation
• 3 vs. 6 Age Bands
• Community Rating.

Buzz Word: Essential Benefits
• Ambulatory patient services
• Emergency services
• Hospitalization
• Maternity and newborn care
• Mental health and substance use disorder
services, including behavioral health treatment
• Prescription drugs

Essential Benefits, continued:
• Rehabilitative and habilitative services and devices
• Laboratory services
• Preventive and wellness services; chronic disease
management
• Pediatric services, including oral and vision care

Essential Benefits, continued:
• Items or services that have an „A‟ or „B‟ rating
• Immunizations for routine use in children,
adolescents, & adults
• Evidence‐informed preventive care and
screenings
• No cost sharing for preventive care services
(in‐network)

Buzz Word: Actuarial Value
• Bronze plans = 60% of minimum of cost of healthcare
• Silver plans = 70% of minimum of cost of healthcare
• Gold plans = 80% of minimum of cost of healthcare
• Platinum plans = 90% of minimum of cost of healthcare

Your Premiums Will Be Different:
2013:
$$$
2014:
???

Anybody Want to
Guess the Biggest
Factor Whether You‟ll
Pay More or Less?

How Much You Earn!

Eligibility for Government Subsidy
Family of 4
Income Level
Percent of
Poverty Level
Individual Can Get
Coverage In:
Government
Subsidies
Above $88,200 Above 400% Federal or State Health
Ins Exchange
No
$88,200 400% Federal or State Health
Ins Exchange
Yes
$29,327
$22,050
$0
133%
100%
0%
Medicaid Yes

1. How Do Find Out if I Qualify for a
Subsidy for Obamacare?
2. Am I Sure I Really Want a Subsidy?
3. What‟s The Penalty If Uninsured?

Tax Credit or Subsidy
• Subsidies Only Available through Public and Private
Exchanges.
• Employee+ Dependents NOT ELIGIBLE for a Subsidy If:
• The employer offers at least the actuarial equivalent of
the Bronze Plan (60%)
• The employee cost share is not more than 9.5% of their
annual income (W‐2 Employee) (AGI)

Tax Credit or Subsidy
• If employer offers health insurance for employees,
employee cannot apply for subsidy for themselves or for
their dependents.
• This means employee must purchase high cost,
unsubsidized insurance for dependents or pay a tax
penalty if they are uninsured.

Subsidy
Calculator:

Go to:
http://TheMedicalInsuranceExchange.com/
obamacare-subsidy-calculator/
or http://goo.gl/LbldeU
For Subsidy Estimates

Go to:
http://themedicalinsuranceexchange.com/apply-
here-for-obamacare-subsidy-and-health-insurance/
or http://goo.gl/7QAx5y
For Final Draft Copy of ACA Paper
Applications

If your Adjusted Gross Income
ends up exceeding your
estimate, the IRS will
assess and take back
your subsidy.
The IRS Giveth and
Taketh Away:
Examples:
• Job Seekers
• Y.E. Bonus
• Unexpected Income

Where You‟ll Buy:
Employer
Exchange
• Employer
• Federal or State Exchanges
(Federal Only in TX)
• Private Exchanges
• 2015: SHOP for small biz (< 25)

Public Insurance Exchanges:
• State Run (23 states + DC)
• Federal Exchange (26 states, including Texas)

“Pre-2014” Health Insurance Transaction
When?
Healthcare Costs
You and/or
Your
Employer
Insurance
Company
Insurance
Policy
$$,
Health Information

2014 Exchange Transaction
What?
Healthcare Costs
You and/or
Your
Employer
Insurance
Company

2014 Exchange Transaction
What?
Healthcare Costs
You and/or
Your
Employer
Insurance
Company
$$ Premium Payment
Health Insurance Policy

Where:
Marketplace.CMS.Gov

Downside of Public Exchanges:
• Self-serve, with little to no
support
• Expect LONGGGGGG
Wait Times,
• WRONGGGGG Answers.

Downside of Public Exchanges:
• Inexperienced, minimally trained
“Navigators” and “Assistors”
• Navigator grant money awarded to
organizations favoring Administration

Downside of “Public Exchanges”
• Do you really want to
share your personal
health & tax information?

Downside of “Public Exchanges”
• No support or assistance
after purchase.

What is a “Private
Exchange”?• Multiple carrier venue for insurance policies
• Not just health insurance
• Run by Experienced, Trained, Licensed Agents

Example of
Private Exchange:
TheMedicalInsuranceExchange.com

• Out of pocket max greater than $3,500.
• You don‟t have guaranteed issue or maternity
coverage now.
• You‟re younger than age 35 (approx.)
• You live in an area with high healthcare utilization.
• Your employer decreases contribution or drops
group plan.
You May Pay More in Premiums If in 2013:

You May Pay Less in Premiums If in 2013:
• Out of pocket max now less than $3,500.
• You have guaranteed issue coverage (Risk Pool).
• You‟re older than age 50 (approx.)
• You live in an area with low healthcare utilization.
• Your employer maintains/increases health plan
contribution or improves health plan.

• 2014: $95 per Adult, $47.50 per Child up to $285 per family
or 1% of income.
Individual Tax Penalty If Uninsured:
• 2015: $325 per Adult, $162.50 per Child up to $975 per
family or 2% of income.
• 2016: $695 per Adult, $347.50 per Child up to $2085 per
family or 2.5% of income.

Your Choices:
COBRA
Private/Public Exchange Insurance
Short-term plan + Tax Penalty

Whatever You Choose, You‟ll Pay More:
Taxes
Goods & Services
New Federal Tax on Insurer Premiums, 3.8%
Tax on Unearned Income, dividend taxes.

Impact On Seniors:
• Harder to find doctors who
accept Medicare (25% pay cut)
• Gradual Closing of Donut Hole
• Reduction In Medicare Budget
• Likely: Medicare Premiums
Based on Assets and Income

Employer Impact

Employer Penalties (delayed):
• $2,000 per Employee over 30 FTEs if
Group Ins. or if no Essential Benefits
• $3,000 per Employee that does not enroll
in Employer‟s plan because it costs
employee more than 9.5% of income or
plan does not meet Bronze level.

Certain Industry Sectors Will Get Hammered:
• Staffing
• Seasonal
• Hospitality
• Retail

Employer Impact
• Increased cost, taxes and regulations/red tape
for all businesses.
• Employer tax penalties delayed until 2015 (50+
full time employees)
• Uncertainty impacting permanent, full-time
employment.

Employer Impact
• Increase in part-time employment.
• Fewer employers will offer health insurance as
an employee benefit.
• Fewer employees will want an employer to offer
health insurance so they can qualify for a
subsidy for their whole family.

In Many Cases, It Benefits Employer
to Drop Group Health Ins. Coverage
• Cost of Tax Penalty for 50+ Employees Is Less
than Health Insurance and is a Fixed Cost.

In Many Cases, It Benefits Employee
for Employer to Drop Group Health Ins.
Coverage
• Subsidized Cost of Health Insurance for
Employee + Dependents May Be Less for
Employee than Employee Cost of Health
Insurance for Employee Only

In Many Cases, It Benefits Employee
for Employer to Drop Group Health Ins.
Coverage
• For Lower Wage Employees, Its Like Getting
Dependents‟ Insurance for FREE!

At This Point, Which Are You?
Dazed & Confused Bored Zombie

My Unique Solutions:
• Education, Expertise, Year-Round Service.
• TheMedicalInsuranceExchange.com, a Private
Health Insurance Exchange
• Employer consultation
• Partially Self-Funded Plans for employers

The Obamacare Clock
Is Ticking..
• Advertising for Fed. Exchanges Has
Begun
• Open Enrollment begins October, go to
• You need to educate others what to do.

Decision-making Is
Like Constipation
Taxes, Penalties,
Higher Expenses, STRESS, Etc.
…The Longer You
Wait, the Worse It
Gets

How I Help Employers
• Consulting expertise
• Rapid assessment of options & impact
• Educate top management
• Develop plan of action
• Employee education is critical for success.

ACA Open Enrollment Preparation:
“Black Tuesday”: October 1st, 61 Days Away
• Schedule an appointment now for beginning October 1st.
• Write down your Family SS #s, Dates of Birth.
• If Insured, Make Copy of Your Insurance Card and Bill.
• Go to
http://TheMedicalInsuranceExchange.com/obamacare-
subsidy-calculator or http://goo.gl/LbldeU; Print out an
estimate of your subsidy.

ACA Open Enrollment Preparation:
• Subscribe to
http://www.TheMedicalInsuranceExchange.com for
updates and information as it becomes available.
• Find a good PCP ASAP!

If You‟re An Employer or Work for One:
• Whether or not your employer offers health
ins., An Employer Has An Obligation and
Opportunity to Communicate ACA to Employees.
• Schedule Me for an Employee Group Meeting
• Schedule Me to Visit with Owner/CFO/CEO

How You Can Help Me
• Refer me to companies that need
advice.
• What Business Leadership Groups
Could Use a Subject Matter Expert
Speaker?
• Bookmark/Share:
How You Can Help
Yourself & Your Company
• Share This Information ASAP
• ACT on This Information ASAP

Remember:
Use Your New Knowledge
of Obamacare as Your
Healthcare Advantage.
(Know enough to raise the
questions, then, “I know a
guy…”

Please Comment/Forward
Share/Like:
• http://TheMedicalInsuranceExchange.com
• Facebook:
• YouTube Channel: ObamacareInformation
• LinkedIn.com/in/michaelchapman
• Subscribe, Sign Up for Updates, Upcoming Presentation Schedule
and Webinars!

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