Health Reform and You

Insurance Options under the Affordable Care Act
Brendan Riley
NC Community Health Center Association
January 23, 2014
As of October 1, 2013, you can enroll in new
health coverage options
Insurance options based on eligibility:
Employer-sponsored coverage
Medicaid & CHIP
Individual/non-group coverage you buy yourself
Medical bills leading cause of bankruptcy
Premium costs rising faster than wages
No protections for people with pre-existing
Insurance companies can deny coverage to
sick people, even children
Can’t be denied coverage because of a preexisting condition
No lifetime limits or annual caps on coverage
Limits on out-of-pocket costs for consumers
Companies can’t charge women more money for
same coverage
Companies can’t cancel your policy because of an
Plans must cover “essential health benefits”
Plans must provide easy-to-read summaries
of benefits and covered services
Children can stay on parents’ plan ‘til age 26
Preventive services with no cost-sharing
Tax credits for small businesses that provide
Single, streamlined application
Determine eligibility for and enroll in nearly
all types of coverage
Application and enrollment assistance
◦ Certified in-person assisters
◦ 24-hour call center
◦ Online chat helpers
Step 1: Person can apply in
person, by phone, or online
Step 4: Compare plans
and enroll
Step 2: Marketplace verifies income,
citizenship, and immigration status
thru online data from federal and
state agencies
Step 3: Marketplace determines
eligibility for public or private
insurance coverage and
◦ No eligibility changes
◦ Strengthens program with new benefits
 Free preventive services
 Closes doughnut hole on Rx drug costs
Medicare Advantage
◦ Premium dollars must go toward improving care per
80/20 rule
 Keeps seniors’ costs down & makes plans more
Job-based coverage
◦ >50% of non-elderly North Carolinians
◦ Most will continue on this coverage in 2014
 Don’t have to apply, but can shop around to see if
better coverage or better costs
Benefit from consumer protections, such as
caps on lifetime limits, protections for preexisting conditions, etc.
Pre-ACA, very difficult and costly to purchase
health insurance on individual market
ACA creates Health Insurance Marketplace
◦ Like Expedia or Priceline — consumers can shop for
and compare insurance plans and levels of coverage
in online Marketplace
 www.HealthCare.Gov
◦ Plans must provide essential health benefits
Financial help for many to purchase health
insurance through Health Insurance Marketplace
Eligible for Premium Tax Credits if:
◦ Between 100% and 400% of Federal Poverty Level
◦ No access to affordable employer-based coverage
◦ Ineligible for Medicaid, CHIP, or Medicare
Amount of tax credit depends varies on sliding
◦ Tax credit at 200% FPL will be larger than 300% FPL
How do premium tax credits work?
◦ Used to purchase qualified health plan on
◦ Eligibility determined by household size and income
◦ Can be claimed fully in advance, in part in advance,
or at end of year
◦ Paid directly by the Marketplace to the insurer
◦ Consumer is responsible for the difference each
Eligibility for Premium Tax Credits
Family Size
Eligible for Subsidies in
Marketplace (100-400% FPL)
$11,490 -$45,960
$15,510 - $62,040
$19,530 - $78,120
$23,550 - $94,200
Each additional person
$4,020 - $16,080
Note: This example is based on the 2013 Federal Poverty Levels (FPL). These
income limits will be increased by 2014.
Caps on out-of-pocket expenses
◦ Deductible, co-pays, coinsurance
Eligible if household at or below 250% FPL
(~$28,750/household of one)
Must select silver tier plan
◦ Public program that covers children in families up to
200% FPL (~$47k for family of four)
◦ Public program that covers some individuals & families
◦ Provides funding to states to expand eligibility for all
individuals up to 138% FPL
 Supreme Court rendered expansion voluntary for states
12 month eligibility period — can enroll anytime
in the year
ACA provides full
federal funding for
expansion for first
three years
Tapers down to 90%
in 2020 and years
Marketplace Open Enrollment Period: October
1, 2013-March 31, 2014;
Full year enrollment period for Medicaid &
(TTY 1-855-889-4325)
The North Carolina Department of
Insurance (NCDOI) consumer information
office can help you with questions about
your insurance coverage
◦ Health Insurance Smart NC
◦ 1-877-885-0231
NCDOI can also help you file complaints or
appeals with your insurance company
Brendan Riley
Outreach & Enrollment Coordinator
North Carolina Community Health Care Association
[email protected]