Insurance Options under the Affordable Care Act
Brendan Riley
NC Community Health Center Association
January 23, 2014
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As of October 1, 2013, you can enroll in new
health coverage options
Insurance options based on eligibility:
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Employer-sponsored coverage
Medicaid & CHIP
Medicare
Individual/non-group coverage you buy yourself
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Medical bills leading cause of bankruptcy
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Premium costs rising faster than wages
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No protections for people with pre-existing
conditions
Insurance companies can deny coverage to
sick people, even children
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Can’t be denied coverage because of a preexisting condition
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No lifetime limits or annual caps on coverage
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Limits on out-of-pocket costs for consumers
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Companies can’t charge women more money for
same coverage
Companies can’t cancel your policy because of an
illness
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Plans must cover “essential health benefits”
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Plans must provide easy-to-read summaries
of benefits and covered services
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Children can stay on parents’ plan ‘til age 26
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Preventive services with no cost-sharing
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Tax credits for small businesses that provide
coverage
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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
subsidies
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Medicare
◦ No eligibility changes
◦ Strengthens program with new benefits
 Free preventive services
 Closes doughnut hole on Rx drug costs
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Medicare Advantage
◦ Premium dollars must go toward improving care per
80/20 rule
 Keeps seniors’ costs down & makes plans more
efficient
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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
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Benefit from consumer protections, such as
caps on lifetime limits, protections for preexisting conditions, etc.
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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
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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
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Amount of tax credit depends varies on sliding
scale
◦ Tax credit at 200% FPL will be larger than 300% FPL
credit
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How do premium tax credits work?
◦ Used to purchase qualified health plan on
Marketplace
◦ 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
month
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Eligibility for Premium Tax Credits
Family Size
Eligible for Subsidies in
Marketplace (100-400% FPL)
1
$11,490 -$45,960
2
$15,510 - $62,040
3
$19,530 - $78,120
4
$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.
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Caps on out-of-pocket expenses
◦ Deductible, co-pays, coinsurance
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Eligible if household at or below 250% FPL
(~$28,750/household of one)
Must select silver tier plan
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CHIP
◦ Public program that covers children in families up to
200% FPL (~$47k for family of four)
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Medicaid
◦ 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
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12 month eligibility period — can enroll anytime
in the year
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ACA provides full
federal funding for
expansion for first
three years
Tapers down to 90%
in 2020 and years
beyond
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Marketplace Open Enrollment Period: October
1, 2013-March 31, 2014;
Full year enrollment period for Medicaid &
CHIP
www.HealthCare.gov
www.CuidadoDeSalud.gov
1-800-318-2596
(TTY 1-855-889-4325)
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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
◦ www.ncdoi.com/Smart/
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NCDOI can also help you file complaints or
appeals with your insurance company
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Brendan Riley
Outreach & Enrollment Coordinator
North Carolina Community Health Care Association
rileyb@ncchca.org
http://www.ncchca.org/