HEALTH INSURANCE MARKETPLACE
& MEDICAID TRANSITION
KEVIN R. HAYDEN
Chief Executive Officer
Group Health Cooperative of South Central Wisconsin
CHANGING LANDSCAPE
In 2014, there will be three main ways for
Americans to get insurance coverage.
Through:
 an employer (roughly 85% of Americans today)
 government programs (Medicaid/Medicare)
 the Health Insurance Marketplace (for individual
consumers & small businesses)
Individual Mandate & Expanded Coverage:
 everyone who can have insurance must have
insurance or receive a tax penalty
 more opportunities for people to gain coverage
The US House
voted 219-212
to pass health
care reform. Four
votes the other
way, and we
wouldn’t be here
today.
IMPACT ON WISCONSIN
Most Wisconsinites are insured through work:
 Employees of large group businesses (51+ full time
workers) won’t see major changes in 2014
 These employee plans must now cover preventive
service at 100% (without a copay, deductible, etc.)
Examples: screenings for blood pressure, colorectal cancer,
depression, and others
Remaining Wisconsinites face bigger
changes:




Changes to individual policy plans
State didn’t accept funding for Medicaid expansion
State didn't create a state-run exchange
The Health Insurance Marketplace will be a new
CURRENT WI COVERAGE
Groups in bold face the most changes heading
into 2014:
Medicare
15%
Uninsured
10%
Medicaid
(BadgerCare)
16%
Individual
6%
Employer
54%
The actual
universe of potential
health insurance
buyers in
Wisconsin is at
least 638,000.
WISCONSIN CHANGES IN
MEDICAID ELIGIBILITY
CURRENT
COVERAGE
ELIGIBILITY
BASED ON
INCOME
Pregnant
Women
Children
Parents and
Caretakers
Childless
Adults
0-100%
FPL
100-200%
FPL
200-250%
FPL
250-300%
FPL
300-400%
FPL
400% +
FPL
Does Not Qualify for
BadgerCare
FUTURE
COVERAGE
ELIGIBILITY
BASED ON
INCOME
Pregnant
Women
Children
Parents and
Caretakers
Childless
Adults
0-100%
FPL
100-200%
FPL
200-250%
FPL
Marketplace
Eligible for tax credit and
cost-sharing subsidies
250-300%
FPL
300-400%
FPL
400% +
FPL
Marketplace
Eligible for tax credit subsidy
Marketplace
Not eligible for subsidies
HEALTH INSURANCE
MARKETPLACE
22 DAYS
Until open enrollment!
NOW OPEN
For Enrollment!
WELL, KIND OF…
There are significant technical issues with the Marketplace
website due to overwhelming demand. We anticipate these
issues will be resolved in the coming weeks. In the meantime,
there are other ways to access the Marketplace.
MARKETPLACE GOALS
Offer insurance coverage to individual
consumers, folks transitioning off BadgerCare
(92,000), and small group businesses
 Provide the best coverage at an affordable price
 Help qualifying individuals pay for coverage
 Guarantee Issue: prohibit insurance carriers from
denying coverage to sick individuals.
Create a competitive environment among health
insurance companies to lower cost trends.
Due to technical
issues with the
website, the
Individual
Mandate may be
postponed by six
weeks.
WHAT WE KNOW TODAY
Available online at healthcare.gov, by phone,
and in-person.
User keys in their personal information about
household and income, then the website
determines eligibility results. At this point:
 subsidies (financial help paying for coverage)
is determined
 eligibility for Medicaid and other governmental
programs is determined
December 15, 2013: Deadline to enroll for coverage
beginning January 1, 2014
The Marketplace
website is
comparable to
online tax service,
Turbo Tax. The
user is guided
through multiple
steps to customize
the shopping
expereince.
WHAT'S IN THE
HEALTH INSURANCE
MARKETPLACE?
See our Health Insurance
Marketplace handout for
additional details.
ESSENTIAL HEALTH BENEFITS
METAL PLANS
Monthly Premium
Platinum
90%
Gold
80%
Silver
70%
Bronze
60%
Catastrophic
Plan
Out-of-Pocket Expense
WHAT’S IN A PLAN?
Platinum
90%
Gold
Difference between plans not based on benefit
offerings; difference based on cost sharing
between insurance company and consumer
80%
Silver
70%
Bronze
60%
Catastrophic
Plan
Almost all plans offered in the Marketplace
cover the 10 Essential Health Benefits
Most plans have deductibles and
may have office visit copays
PLAN EXAMPLES
Individual
PLATINUM
Plan
Individual
GOLD
Plan
Individual
SILVER
Plan
Individual
SILVER
Plan
without
cost-sharing
with
cost-sharing
Individual
BRONZE
Plan
Deductibles
$500 member
$1000 family
$1500 member
$3000 family
$2000 member
$4000 family
$0
$2000 member
$4000 family
Maximum
Out-ofpocket
$1500 member
$3000 family
$3000 member
$6000 family
$6350 member
$12700 family
$2115 member
$4320 family
$6350 member
$12700 family
Primary
Care Visits
$20 copay
$30 copay
$40 copay
$40 copay
$80 copay
Specialty
Care Visits
$20 copay
$60 copay
$80 copay
$80 copay
$150 copay
ER Visits
$100 copay
$500 copay
$500 copay
$0 copay
$1000 copay
$0 Tier 1
$30 Tier 2
$60 Tier 3
$100 Tier 4
$0 Tier 1
$40 Tier 2
$80 Tier 3
$150 Tier 4
$20 Tier 1
$40 Tier 2
$80 Tier 3
$150 Tier 4
$0 Tier 1
$40 Tier 2
$40 Tier 3
$40 Tier 4
$50 Tier 1
$120 Tier 2
$200 Tier 3
30% with Max
of $300 Tier 4
Rx
Please note these
plans are for
example only
and are subject
to change.
SUBSIDIES
Consumers can get financial help paying for
insurance coverage in two ways:
 advanced premium tax credits
• helps reduce monthly premiums
• for individuals between 100-400% of FPL
• examples: single person making approx. $46,000/year or a
family of four making approx. $95,000/year
 cost-sharing reduction
• helps pay out-of-pocket costs for: copays, deductibles,
coinsurance, etc.
• for individuals between 100-250% of FPL
• examples: single person making approx. $29,000/year or a
family of four making approx. $59,000/year
Subsidies are only
available through
the Marketplace.
An individual may
qualify for one or
both kinds of
subsidies.
HEALTH CONNECT
In Dane County, individuals at 100-133% FPL
are eligible to apply for:
https://www.unitedwaydanecounty.org/healthconnect/
Financial assistance
to help pay for
insurance
premiums with
plans purchased
through the
Marketplace.
PARTNERING FOR SUCCESS
Success depends on insurance providers
playing an active role
 Consumer education
 Consumer enrollment outreach
Impetus for GHC Better Together Project
 A public service of Group Health Cooperative
 We’re on a mission to inform you about what health
care reform means, without spin or politics
The government
will have to partner
with health care
systems throughout
the country to
make this program
successful. Effective
outreach and
enrollment efforts
are key.