Public Health-Seattle & King County/Access & Outreach
www.kingcounty.gov/health/ACCESS

Insurance companies could take advantage of you and
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.

And 50 million Americans had no insurance at all.
1.
Ends the worst insurance company abuses
2.
Makes health insurance more affordable
3.
Strengthens Medicare
4.
Provides better options for coverage
TODAY, it is illegal for insurance companies to:

Deny coverage to children because of a preexisting condition like asthma or diabetes.

Put a lifetime cap on how much care they will pay
for if you get sick.

Cancel your coverage when you get sick by finding
a mistake on your paperwork.

Cancer screenings such as mammograms & colonoscopies

Vaccinations such as flu, mumps & measles

Blood pressure screening

Cholesterol screening

Tobacco cessation counseling and interventions

Birth control

Depression screening

And more…
Visit www.healthcare.gov/prevention for a full list.
BEFORE, insurance companies spent as
much as 40¢ of every premium dollar on
overhead, marketing, and CEO salaries.
60% / 40%
TODAY, the new 80/20 rule says
insurance companies must spend at least
80¢ of your premium dollar on your health
care or improvements to care.
If they don’t, they must repay the money.
80% / 20%

Changes to private insurance, e.g.,
Kids can’t be denied health coverage if they are sick
 Young adults on parents’ policies to age 26
 Prohibit lifetime monetary caps
 Minimum medical loss ratio


Closes the Medicare prescription “doughnut
hole”
Expands coverage + imposes individual
mandate in 2014


Expands Medicaid to 138%* of FPL
Exchanges
1.
2.
3.
Most individuals will be required to have health coverage
or be penalized.
New affordable coverage options will be available:
 Medicaid coverage will be expanded to 138% FPL
 Health Benefit Exchange will provide individuals & small
businesses private health coverage options for purchase
 Apply for coverage through Washingtonhealthplan
finder.
 Subsidies and tax credits will be available to help
make coverage more affordable
Large employers (50+ employees) will be required to
provide coverage
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
January 1, 2014
Service
starts

October 1, 2013
Medicaid & Exchange
enrollment opens
October 15, 2014 – Dec 7, 2014
Exchange open enrollment for
individuals


March 31, 2014
Exchange enrollment
closes for individuals
Medicaid enrollment is continuous, but Exchange
enrollment is limited to an open enrollment period.
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Option 1: On their own
Option 2: With the help of a navigator
or enrollment specialist (individuals)
Healthplanfinder
Option 3: Through an agent or broker
(businesses)
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

New Medicaid coverage for about 80,000
uninsured King County residents
Affordable insurance options for over
100,000 uninsured individuals and about
68,000 small businesses through the
Exchange
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
Medicaid and Medicaid Expansion
populations

Adults (without children) up to 138% of FPL*

Parents 40% to 138% of FPL

Modified Adjusted Gross Income (MAGI)
* The ACA’s “133% of the FPL” is effectively 138% of the FPL because of a 5%
across-the-board income disregard
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Federal Poverty Level
Annual Income:
Individual
Annual Income:
Family of 3
100%
$11,496
$19,536
133%
$15,288
$25,980
138%
$15,864
$26,952
200%
$22,980
$39,060
300%
$34,476
$58,596
400%
$45,960
$78,120
Source: http://aspe.hhs.gov/poverty/13poverty.cfm
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There are 10 essential benefits that must be covered!
1. Ambulatory services
6. Prescription drugs
2. Emergency services
7. Rehabilitative and habilitative services and
devices
3. Hospitalization
8. Laboratory services
4. Maternity and newborn care
9. Preventive and wellness services and chronic
disease management
5. Mental health and substance use
disorder services, including behavioral
health treatment
10. Pediatric services, including oral and vision
care
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


The Exchange is the marketplace for people to buy insurance.
Designed to make premiums affordable for individuals and
families with lower incomes by providing subsidies to
purchase insurance.
Only available to individuals and families with income up to
400% Federal Poverty Level (FPL).

The subsidies can be used to reduce monthly premiums.

And it can be claimed as a credit on their annual tax return.
Premium Tax Credits:
Income Level
Up to 133% FPL
133-150% FPL
Cost Sharing Reductions:
Premium as Percent
of Income
Income Level
Reduction in Out-ofPocket Liability
2% of income
100-150% FPL
94% of the actuarial
value*
150-200% FPL
87% of the actuarial
value
200-250% FPL
73% of the actuarial
value
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
*Of the second lowest cost Silver plan
http://www.wahealthplanfinder.org/




Family of 3
Annual Income = 200% of FPL
Health Insurance Premium Tax Credit? YES
Cost Sharing Reduction?
YES
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



The ACA requires all states to create a new
marketplace website where consumers can go to
search, compare and enroll in an affordable health
coverage plan.
The one in our state is the:
Open enrollment is October 1, 2013 for coverage
effective January 1, 2014.
After answering a few questions including income,
consumers will be notified about their health care
coverage eligibility.
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20

Single portal for Medicaid, tax subsidies and
Qualified Health Plans

Use of electronic data to verify eligibility

Real-time eligibility determination

Interfaces to federal and state systems
21
2014: $95 per adult
2015: $325 per adult 2016: $695 per adult
and $47.50 per child
and $162.50 per child
and $347.50 per child
(up to $285 for a
(up to $975 for a
(up to $2,085 for a
family) or 1% of
family) or 2%,
family) or 2.5% of
income, whichever is
whichever is greater
family income,
greater
whichever is greater
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No
penalty
for being
without
health
insurance.
When any of the following apply:
 Religious objections
 Undocumented immigrant
 Incarcerated
 American Indians and Alaskan Natives
 Income below the tax filing threshold
 The lowest cost plan option exceeds 9.5
percent of an individual’s income
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You were insured for the whole year through a combination of
any of the following sources:







Medicare
TRICARE
The veteran’s health program
A plan offered by an employer
Medicaid or the Children’s Health Insurance Program (CHIP)
Insurance bought on your own that is at least at the Bronze
level
A grandfathered health plan in existence before the health
reform law was enacted
No Penalty. The
requirement to
have health
insurance is
satisfied
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


Large employers with over 50 FTE’s are required to offer a
minimum level of health insurance
Larger Employers offering non-qualifying coverage:
o May be assessed the lesser of up to $3,000 per year for
each FTE receiving income-based assistance, or, up to
$2,000 for every FTE.
Large Employers not offering minimum essential coverage:
o May be assessed $2,000 per FTE (first 30 full-time
employees excluded) if at least one full-time employee
receives income-based assistance to buy coverage in the
Exchange.
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



Up to 50 Employees (these employers are
exempt from the mandate)
Small Business Health Insurance Tax
credits available
Washington Healthplanfinder can be used
to manage employee health care benefits
Options are available
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
Confusion about what health reform is and how it
affects the community

Uninsured individuals will not necessarily take the
initiative to get coverage on their own

Education alone is not enough—some individuals,
especially the most vulnerable, will need extra
help with the enrollment process
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
Collaboration with community partners and
organizations that interact with those eligible

Build on effective outreach and enrollment
strategies by PHSKC’s Access & Outreach team
and create new methods

Build on federal and state efforts

Creation of a culturally and linguistically
competent, consumer-driven, multi-faceted
campaign
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We need your help…………
How can we enroll your uninsured participants?
Ideas…………
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Willie Allen
(253) 874-7642
Willie.Allen@kingcounty.gov
Educator Consultant II/Program Supervisor
Daphne Pie
(206) 263-8369
Daphne.Pie@kingcounty.gov
Program Manager
Callista Kennedy
(206) 263-8368
Callista.Kennedy@kingcounty
Outreach Specialist
Carmen Olvera
(206) 296-3948
Carmen.Olvera@kingcounty.gov
Outreach Specialist-Spanish
Brett Downey
(206) 263-8373
Brett.Downey@kingcounty.gov
Outreach Specialist-Spanish
Luis Salazar
(206) 263-8261
Luis.Salazar@kingcounty.gov
Outreach Specialist-Spanish
Penny Lara
(206) 263-8372
Penny.Lara@kingcounty.gov
Project Manager/Health Care Reform
Miguel Urquiza
(206) 296-9875
Miguel.Urquiza@kingcounty.gov
Education Consultant I
Cindy Mai
(206) 296-3949
Cindy.Mai@kingcounty.gov
Outreach Specialist-Vietnamese
Javier Amaya
(206) 263-8311
Javier.Amaya@kingcounty.gov
Education Consultant Ii
Carolina Marx
(206) 296-3943
Carolina.Marx@kingcounty.gov
Outreach Specialist
Carol Allen
(206) 263-8750
Carol.Allen@kingcounty.gov
Education Consultant I
www.kingcounty.gov/health/access
1-800-756-5437
7/12/2016
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