The ABCs of the
Affordable Care Act
For Students
Topics to Cover
ABCs of the ACA for Students
Heathcare.gov
What do you have access to, as a Student
Options offered by AHP
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Student Coverage and ACA
What is more beneficial?
Student health insurance or dependent coverage under
their parents’ plans, or the Health Insurance Marketplace?
 How does ACA relate to Students?
 What are the 2014 ACA changes?
 What are the Essential Health Benefits?
 What is Minimum Essential Coverage?
 How will the Marketplace affect us?
 What are the key dates?
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Definition of Student Health
Insurance Coverage: A type of
individual health insurance coverage.
ABCs of Reform
Institution of Higher Learning
Health Insurance Issuer
Written Agreement
Must meet the following conditions:
• Must be enrolled as a student (or a dependent of a student) in the institution.
Offering dependent coverage is determined by the university
• Does not condition eligibility for the health insurance coverage on any health status
• Meets any additional requirements that may be imposed under state law
• Eligibility decisions that determine student status under student health insurance
plan coverage is up to the university and or the insurer
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ABCs of Reform
Student Plans under ACA: A type of Individual
Coverage
ACA-compliant
student plans
can satisfy the
individual
mandate
requirements
Student plans
are not on the
Marketplace
Unique
pooling for
student plans
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ABCs of Reform
Minimum Essential
Health Coverage
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ABCs of Reform
Tax Penalty
• When filing 2014 taxes in 2015, individuals must indicate on
their returns if they have health insurance coverage and, if not,
pay a fine.
• The individual penalty is the greater of $95 or 1 percent of
income, rising to the greater of $695 or 2.5 percent of income,
in 2016. The Congressional Budget Office estimates that less
than 2 percent of Americans who don’t have health insurance
will pay the fine.
Rising
Greater
Greater
1% of
Income
2.5% of
Income
$95
$695
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ABCs of Reform
“Mandate Exemptions”
Included in individual coverage
mandate but exempt from paying
the penalty
Excluded from individual coverage
mandate
•
•
Individuals who are not lawfully in the
United States;
•
Individuals who are incarcerated;
•
Religious conscience objectors; or
•
Members of a health care sharing
ministry.
•
Individuals who have “unaffordable
coverage” (based on household
income and required contributions
for coverage);
Individuals who have income below
the threshold for filing a tax return;
•
Individuals who are members of an
Indian tribe;
•
An individual whose first coverage
gap experience of a calendar year
lasts less than 3 months; or
•
Individuals who apply for and receive
a hardship exemption from HHS.
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ABCs of Reform
Major ACA Changes
in 2014
• Essential Health Benefits (EHB) will be included in every
insurance plan
• Prevention comes with no out-of-pocket cost (for in-network
providers only)
• There are no annual or lifetime limits
• Simplified coverage descriptions will be available – summary of
benefits and coverage (SBC) must be provided to students
• Pre-existing conditions will be covered
• ACA fees and taxes apply
Effective upon renewal in 2014
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What are the
Essential Health
Benefits?
ABCs of Reform
ACA lists 10 categories of essential health benefits (EHBs) that must be covered by
non-grandfathered individual and small group plans in 2014. Each state benchmark
plan sets the standard for EHBs in the state. In Illinois, Oklahoma and Texas, the
state benchmark plan is a BCBS plan.
1.
Ambulatory patient services;
Plans that DO have to cover EHBs in 2014:
2.
Emergency services;
1.
Plans on the exchange
3.
Hospitalization;
4.
Maternity and newborn care;
2.
5.
Mental health and substance use
disorder services, including behavioral
health treatment;
Non-grandfathered, individual health care
plans (Student Plans are considered
individual for ACA purposes)
3.
Non-grandfathered, fully insured small
group health plans
6.
Prescription drugs;
7.
Rehabilitative and habilitative services
and devices;
Plans that DO NOT have to cover EHBs in
2014:
8.
Laboratory services;
1.
Self-insured/ASO health plans
9.
Preventive and wellness services and
chronic disease management; and
2.
Grandfathered health plans
3.
Large group health plans
10. Pediatric services, including oral and
vision care.
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ABCs of Reform
What Are Marketplace
Qualified Health Plans?
1. Provide essential health benefits package
2. Offered by licensed insurer
3. Certified by the exchange as “qualified health plans”
No one is required to purchase health insurance through the
Marketplace
Premium tax credits and subsidies or cost-sharing assistance are
only available to those that qualify and purchase on the
Marketplace and may apply to select plans
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Marketplace Coverage
(Metallic Levels)
ABCs of Reform
Individual and insured small group plans, sold on and off the
Marketplace, will have to meet one of four metallic levels that
correspond to plan actuarial value (AV). Student plans are sold
off exchange.
Bronze
Silver
Gold
60% Actuarial
Value
70% Actuarial
Value
80% Actuarial
Value
Platinum
90% Actuarial
Value
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ABCs of Reform
Summary of Benefits
Coverage Requirements
Under the Affordable Care Act, all health insurers and group health plans are required
to provide consumers with a Summary of Benefits and Coverage (SBC). The SBC is a
summary of the benefits and health coverage offered by a particular plan. The SBC is
intended to provide clear, consistent, easy-to-understand descriptions that may make
it easier for people to understand their health insurance coverage and for consumers
to shop for and compare insurance plans.
•
The SBC is completed using a government-designed template, so the SBC will be
consistent across all health insurance plans and will include:
–
–
–
–
–
What is covered by the plan
What is not covered by the plan
Cost-sharing provisions and exclusions
Coverage examples
A website and phone number for customer service and obtaining more information
•
The items in the SBC represent an overview of coverage; they are not an
exhaustive list of what is covered or excluded. The full terms of coverage are
located in the insurance policy.
•
SBC is listed on the AHP website at ahpcare.com/mwsu
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ABCs of Reform
•
•
•
•
ACA Toolkit
FAQ
Postcard
Today’s Webinar
Bcbstx.com/Reformandyou
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Summary: Student Health Plans
Effective upon renewal in 2014
• Individual mandate
• Essential Health Benefits Required
• No Pre-existing conditions exclusions for anyone
• Unlimited lifetime maximums
• Annual fee on health insurers, tax changes
Federal Marketplace
 The Federal Health Insurance Marketplace is a new way
to find quality health coverage. It can help if you don’t
have coverage now or if you have it but want to look at
other options.
 With one Marketplace application, you can learn if you
can get lower costs based on your income, compare
your coverage options side-by-side, and enroll.
 www.healthcare.gov
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Student Health Insurance options as a student at
Texas Woman’s University
 The TWU Student Health Insurance Plan (SHIP) is
underwritten by Blue Cross and Blue Shield of Texas and
administered by Academic Health Plans
https://www.academichealthplans.com/twu/2013-2014/
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Advantages of Student Health




Covers Health Center at 100%
Includes Broad PPO Network
Includes Global Emergency Services
Has nurse line and additional features geared for
students
 Lower cost than most Exchange Plans
 Easy enrollment procedure
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Questions?
Who Can Apply for
Assistance?
Appendix
(Student Plans Not Eligible)
•
•
•
Must file an annual tax return and must purchase coverage on the Marketplace
Citizens and legal residents may be eligible for premium tax credit to reduce the cost
of coverage and/or cost-sharing subsidies based on income and family size.
Incomes between 100% and 400% of federal poverty level (FPL) are eligible for a
premium tax credit to reduce the cost of coverage on the Marketplace. 2013
individual FPL is $11,490.
Marketplaces are required to tell enrollees about their
eligibility for subsidies at the time they enroll.
Cost-sharing subsidies* protect lower income people from
high out-of-pocket costs at the point of service.**
For example
Up to 400% of FPL in 2013
•
Up to $45,960 for individuals
•
Up to $62,040 for a family of 2
•
Up to $78,120 for a family of 3
•
Up to $94,200 for a family of 4
If a person’s income:
• Is 100-150% ($11,490-17,235) the AV must be 94%
• Is 150-200% ($17,235-$22,980) AV must be 87%
• Is 200-250% ($22,980-$28,725) AV is 73%
*Based on the second lowest-cost silver plan in their area for up to 250% of FPL
** Out-of-pocket cost savings only apply to Silver plans.
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Appendix
Health Plan
Comparison
Student Health Plans
• More affordable
• Easy enrollment
• 100% coverage of eligible benefits through student health centers
• Supports financial viability of Health Center
• Broader network for all student metal level plans
• Same EHB benefits as ACA & Marketplace options
• University endorsed/supported
Marketplace Health Plans
• May be eligible for premium tax credit and cost-sharing assistance
• More Selections
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