Changes under the Healthcare Reform
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First there were two choices
 Under the Affordable Care
Act every individual must
have Minimum Essential
Health care Coverage or
Pay a Tax Penalty.
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Minimum Essential Coverage
 Minimum Essential Coverage is some form of major
medical healthcare coverage such as:
 Medicare
 TRICARE or VA Medical Benefits – Must be
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comprehensive, not limited in scope.
Medicaid
hawk-i
Employer based health insurance
Major medical health insurance purchased on the
individual market
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Tax Penalty
 If an individual does not
have Minimum Essential
Coverage they must pay the
greater of the two
penalties on their taxes.
 In years after 2016 the
penalty is indexed to the
rate of medical inflation.
 Parents are responsible for
their children too!
2014
2015
2016
Minimum
$95
$325
$695
Percent of
Income past
Filing
Threshold
1%
2%
2.5%
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There are a number of exceptions to the
requirement for Minimum Essential Coverage
 If a person is incarcerated
 If a person is an undocumented immigrant
 If a person is a member of an Indian Tribe
 If a person qualifies for a religious exemption
 If a person is a member of a healthcare sharing Ministry
 If premiums for health insurance would cost more than 8%
of your annual household income
 If your income is below the filing threshold for taxes
 If paying for health insurance would be a hardship for your
household
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Do I need to make any changes to
avoid the penalty?
 Are you uninsured? – Call the Marketplace
 Do you like your current health insurance?
 You can only qualify for tax credits on plans purchased on the
Health Insurance Marketplace.
 You may be able to keep your current plan.
 Or you can shop on the marketplace to see if there is a better
deal.
 Are you on Medicare? – No change needed
 Are you on Medicaid? – No change needed
 Are you on IowaCare? – IowaCare ends on December 31,
2013. All IowaCare members will receive instructions on
how to find new health care coverage.
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The Iowa Health Insurance
Marketplace
 Iowa is using the Federal Health Insurance
Marketplace.
 The Marketplace is a place for people to look for
affordable minimum essential coverage
 There is a single application process for Medicaid
(including the Iowa Health and Wellness Plan), hawk-i
Tax Credits, and Cost Sharing Subsidies.
 Applicants shopping for insurance on the Marketplace
will have the choice of multiple private insurers.
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Who can use the
Marketplace?
•Generally: Anyone can
use the Iowa Health
Insurance Marketplace.
•Only people who meet
certain income, and
health coverage
conditions can qualify
for government
programs and tax
credits.
•If you’re interested you
can apply and see if you
qualify for any help.
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Medicaid
 Medicaid provides low-cost or free health care coverage for low
income individuals, such as:
 Children
 Adults
 People with disabilities
 Elderly people
 Not available to non-citizens
 Medicaid provides comprehensive health care coverage, such as:
 Hospitals, physicians, prescriptions drugs, therapy, dental
 Covers long term care services
 Medicaid members can go to most Iowa health care providers.
 You may apply for Medicaid on the Marketplace.
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Income Level for an Individual
How Medicaid Fits with the
Health Insurance Marketplace
400% of the
Federal
Poverty Level
•
Medicaid provides
coverage to children with
family income up to 300%
of the Federal Poverty
Level
•
Medicaid provides
coverage to adults with
income up to 133% of the
Federal Poverty Level
•
Individuals whose income
is higher than Medicaid
allows may be eligible for
tax credits on the Health
Insurance Marketplace
Purchase Private Coverage from
Health Insurance Marketplace:
Not Eligible for Tax Credits
May Be Eligible
for Tax Credits to
Purchase Private
Coverage from
Health Insurance
Marketplace
Medicaid
Coverage for
Children
(0-18)
Medicaid
Coverage
for Adults
(19-64)
Population
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Iowa Health &Wellness Plan
 New plan beginning January 1, 2014.
 Available for adults age 19-64:
 Not eligible for other Medicaid or Medicare coverage.
 With income up to 133% of the Federal Poverty Level, or $15,282 per
year for a family of one.
 Created to provide comprehensive health care coverage for low-
income adults.
 Program will provide local access to doctors, hospitals, and other
providers.
 Will cover many services like hospitals, physicians, preventive care,
prescriptions drugs, therapy, dental
 Many members previously enrolled in IowaCare, may be eligible for
this program
 You may apply for the Iowa Health and Wellness Plan on the
Marketplace.
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hawk-i
 Provides health care coverage for uninsured children of working
families.
 Family income must be below 300% of the Federal Poverty Level
 No family pays more than $40 per month.
 Children are covered through commercial health care and dental
plans.
 To qualify, children must:
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Be under 19
Have no other health insurance
Live in Iowa
Be a U.S. citizen
Not qualify for Medicaid
Not be a dependent of a State of Iowa Employee
 You may apply for hawk-i on the Marketplace.
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What will insurance plans on the
Marketplace Look Like?
 Bronze - Lowest premium and highest out of pocket costs. Cost

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
sharing of 60% paid by insurer and 40% by the individual.
Silver - Lower premiums than gold and platinum, but with
higher out of pocket costs. Cost sharing of 70% paid by insurer
and 30% by the individual.
Gold - Lower premiums than platinum, but with higher out of
pocket costs. Cost sharing of 80% paid by the insurer, and 20%
by the individual.
Platinum - Highest premium with lowest out of pocket costs.
Cost sharing of 90% by insurer, and 10% by the individual.
Catastrophic Plans – Certain people up to the age of 30 may
select to purchase plans with very high deductibles and low
premiums.
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What will insurance plans on the
Marketplace Look Like?
 Benefits will include
 Prescription drugs
 Emergency services
 Hospitalization
 Maternity & newborn care
 Pediatric services
 Laboratory Services
 Ambulatory Patient Services
 Mental health & substance abuse services
 Rehabilitative & habilitative services and devices
 Preventative & wellness services and chronic disease
management
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Federal Poverty Level Guidelines
(FPL) 2013
If your income and household size fall within this chart you may get benefits.
Household
Size
100%
133%
150%
200%
300%
400%
1
$11,490
$15,282
$17,235
$22,980
$34,470
$45,960
2
$15,510
$20,628
$23,265
$31,020
$46,530
$62,040
3
$19,530
$25,975
$29,295
$39,060
$58,590
$78,120
4
$23,550
$31,322
$35,325
$47,100
$70,650
$94,200
5
$27,570
$36,668
$41,355
$55,140
$82,710
$110,280
6
$31,590
$42,015
$47,385
$63,180
$94,770
$126,360
7
$35,610
$47,361
$53,415
$71,220
$106,830
$142,440
8
$39,630
$52,708
$59,445
$79,260
$118,890
$158,520
Each
Additional
Person
$4,020
$5,347
$6,030
$8,040
$12,060
$16,080
* Based on Modified Adjusted Gross Income
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Modified Adjusted Gross Income?
 Modified Adjusted Gross Income is the amount of
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
gross income earned, with a few things added in and
deducted.
There are some deductions taken away, such as
business expenses.
There is some money that is normally non-taxed
added in, such as non-taxable interest.
The take away is that if you are near the income cut off,
you still might qualify for assistance.
The only way to find out is to apply.
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Health Premium Tax Credits
 Certain people may qualify for tax credits to help them purchase
insurance
 The tax credit can reduce what you owe in taxes OR what you
pay for health insurance premiums.
 They must:
 Have a household Modified Adjusted Gross Income between
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
100% and 400% of the federal poverty guidelines.
Not be eligible for Minimum Essential Coverage from some other
source, for example Medicaid.
Be lawfully present in the U.S., and may not be incarcerated.
Must purchase health insurance through the exchange.
A person might still qualify for tax credits if coverage from their
employer is not Affordable or does not provide Minimum Value.
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What is considered Affordable under
the law? What is Minimum Value?
 An Employer’s plan is
Affordable if the cost to
insure the employee only
is less than 9.5% of the
employee’s household
income.
 An Employer’s plan
provides Minimum
Value if it covers 60% of
the expected medical
expenses.
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How do I save with a Health
Premium Tax Credit?
 The tax credit can reduce what you owe in taxes OR
what you pay for health insurance premiums.
 Tax Credit = cost of the Silver benchmark plan – a
households required contribution.
 The Silver benchmark plan is the second least
expensive Silver plan in the marketplace.
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Required Contribution?
 A household’s required
contribution is a fixed
percentage of the household
income. This is a sliding scale
based upon the annual
income. (see table)
 The goal is to keep healthcare
spending to a limited portion
of a households income.
% of FPL
Low End
of Range
High End
of Range
100-133
2
2
133-150
3
4
150-200
4
6.3
200-250
6.3
8.05
250-300
8.05
9.5
300-400
9.5
9.5
 Go to
http://kff.org/interactive/sub
sidy-calculator/ to estimate
your tax credit!
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Things to Consider with Health
Premium Tax Credits
 The tax credit may be taken and applied towards any
of the plans available on the market place.
 The tax credit may be paid monthly to the insurance
company to reduce the monthly premium or taken at
the end of the year as a lump sum.
 The amount of the tax credit is capped at the cost of
the actual plan purchased.
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The Final Tax Credit is Figured at
the End of the Year
 If you overestimate your
income you may get a
refund at the end of the
year.
 If you underestimate your
income you may owe the
government money.
 The amount you need to
pay back is limited by
income and household
size. (see table*)
 If your income changes
during the year, let the
Marketplace know!
FPL %
Single
Family
Less than
200%
$300
$600
200%-300%
$750
$1,500
300%-400%
$1,250
$2,500
*26 CFR 1.36B-4(a)(3)
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Cost Sharing Subsidies
 If a consumer is enrolled on a Silver plan they may qualify for cost
sharing subsidies to decrease their share of costs.
 A Silver plan has coinsurance of 30% paid by the consumer and 70%
paid by the insurance company. With Cost Sharing Subsidies, the
coinsurance is instead reduced to the following:
Federal Poverty Level
Covered
Consumer Pays
200% to 250%
73%
27%
150% to 200%
87%
13%
100% to 150%
94%
6%
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You can enroll in the Marketplace at:
•Healthcare.gov
•1-800-318-2596
•With a paper
application
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When can I sign up?
 You can only enroll in an insurance plan during Open
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
Enrollment or Special Enrollment.
Open Enrollment for the first year is from October 1st
2013 till March 31st, 2014.
Open Enrollment for 2015 starts October 15th 2014,
through December 7th 2014.
If you don’t sign up during the open enrollment you
may only sign up during a Special Enrollment period.
Programs such as Medicaid and hawk-i, may be
enrolled in year round.
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Special Enrollment Period
 May enroll or change Qualified Health Plan
 Within 60 days in individual market and 30 days in small group market from
qualifying event
Special Enrollment Period Qualifying Events
Loss of minimum essential
coverage
Material contract violations by Qualified
Health Plans
Gaining or becoming a
dependent
Gaining or losing eligibility for premium
tax credits or cost sharing reductions
Gaining lawful presence
Relocation resulting in new or different
Qualified Health Plan selection
Enrollment errors of the Marketplace
Exceptional circumstances*
* May be granted on a case by case basis.
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What if I need help signing up?
Navigator
Certified Application
Counselor
 Funded by federal grants

to help people enroll in the
marketplace
 Cannot have a conflict of
interest

 Must provide information
in an impartial manner

 Must provide consumer
education and outreach
programs

 Must be trained and have
passing scores on
certification test

 May not charge a fee for
their services
Do not receive
funding to help
enroll people.
Must disclose any
potential conflicts of
interest to applicants
Must act in the best
interest of the
applicant
Must complete
trainings and receive
passing scores
May not charge for
consumer services
Insurance Agents and
Brokers
•Their job is to help
people select insurance
plans.
•Must be trained in
health insurance
•Must be licensed by the
state of Iowa
•Must act in the interest
of their clients.
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Other Sources of Help
 You can call the
marketplace, 1-800-3182596
 Or you can shop online
at healthcare.gov
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When can an Insurance Company
Cancel a Policy?
 If the consumer qualifies for Medicare
 If the consumer does not pay their monthly premiums
 If the consumer commits fraud on their application.
 If the policy is no longer offered or is removed from
the Marketplace.
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Watch out for Fraud
 If you are suspicious about a request for personal
information DO NOT GIVE IT OUT!
 The ONLY website for the Marketplace is
healthcare.gov
 If you get a suspicious phone call. DO NOT give out
your personal information.
 Call the Marketplace and let them know.
 1-800-318-2596
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Other Consumer Protections Under
the Healthcare Reform Coming in 2014
 Health Insurance
Companies cannot refuse
to cover you during open
enrollment.
 They can’t charge you
more because you have
chronic or pre-existing
conditions.
 They can’t charge more
for women than men.
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What Can Affect My Insurance
Rates?
 Insurance companies can now only vary their rates
based upon;
1.
2.
3.
4.
Age (limited ratio of 3 to 1)
Tobacco Use (limited ratio of 1.5 to 1)
Number of person on the policy
Where you live
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Additional Consumer Protections
 These Reforms are in Effect
 Plans must be presented in a uniform manner to make
easy “apple to apple” comparisons of coverage.
 Medical Loss Ratio Rebates
 Dependant coverage extended up to age 26.
 Insurers may only rescind policies in the case of fraud
 Insurance Companies can no longer set lifetime or yearly
spending limits.
 These Reforms are Coming in 2014
 The waiting period to get on group plans is limited to 90
days.
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Things to Remember?
 All individuals will face a tax penalty if they don’t have
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
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
minimum essential coverage and they don’t have an
exception.
Low and Middle income individuals may qualify for
government programs or tax credits to help them get
health insurance.
The change in laws may expand the benefits you receive on
new policies and it will change the way premiums are
calculated.
Open enrollment runs Oct.1, 2013 – March 31, 2014!!!!!!!
Individuals may select Marketplace policies on
healthcare.gov .
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Go to healthcare.gov to shop or enroll
Call 1-800-318–2596
Presented By:
State Interagency Team:
Iowa Insurance Division
Iowa Department of Human Services
Iowa Department of Public Health
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Tax Penalty Example 1
 Eric has the option to get affordable minimum
essential health insurance in 2014, and decides not to
get it. In 2014 Eric earned $14,000.
 Eric has a filing threshold of $12,000.
 Eric must pay the greater of;
 $95, the minimum flat amount or
 $20, 1% of his income past the tax filing threshold.

($14,000 - $12,000) = $2,000 * 1% = $20
 Eric must pay a tax penalty of $95
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Penalty Example 2
 In 2014 Jenny had the option to purchase affordable
health insurance, that provides minimum value, and
did not. She earned $120,000 in 2014.
 Jenny has a filing threshold of $12,000.
 She has to pay the greater of;
 $95, the minimum flat amount or
 $1,080, 1% of her income past the tax filing threshold.

($120,000 - $12,000) = $108,000 * 1% = $1,080
 Jenny must pay a $1,080 tax penalty.
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Silver Benchmark Example:
 Silver plans: A, B, C, and D.
 A costs $100 a month,
 B costs $110 a month,
 C costs $120 a month, and
 D costs $130 a month.
 B is the Silver benchmark.
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Example 1
 Household of 2 adults making $60,000 per year. Their
required contribution is 9.5% or $5,700 per year. The
Silver benchmark premium is $7,000 per year.
 Tax Credit = $7,000 (Silver Benchmark) - $5,700
(Required Contribution) = $1,300
 Tax Credit = $1,300
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Example 2
 Family of 4, two adults and two children making
$40,000 annually. The Silver benchmark premium is
$10,781, their required contribution is 5.89% or $2,650
per year.
 Tax Credit = $10,781 (Silver Benchmark) - $2,650
(Required Contribution) = $8,131
 Tax Credit = $8,131
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