Marketplace 3.0
What’s up next for the Health
Insurance Marketplace
Kit Wagar
Affordable Care Act Specialist
U.S. Department of Health and Human Services
Region 7 – Missouri, Kansas, Iowa, Nebraska
1
Enrollment results: The first two years
For 2014:
For 2015:
 8,019,763 people signed up
through the new Health
Insurance Marketplaces
 11,688,074 signed up for insurance,
up 46 percent from the previous year
 6,050,059 new participants in
Medicaid (As of April 2014)
 13,334,460 new participants in
Medicaid
(As of April 2015)
 5,237,673 in the 26 states &
DC where Medicaid expanded
 11,246,255 in the 28 states & DC
that had expanded by April 2015*
 812,386 in the 24 states that
 2,088,205 in the 22 states that had
not expanded*
did not expand Medicaid
* Two states – Montana and Alaska – are in the process of
expanding their Medicaid programs
Iowa enrollment vs. nearby states
2015
2014
29,163 people signed up for
insurance through Iowa’s Health
Insurance Marketplace
45,162 people enrolled in insurance
through the Marketplace, up 55 percent
from the previous year
90,304 new participants in
Medicaid, up 18 percent from third
quarter 2013 (As of April 2014)
99,422 new participants in Medicaid, up
10 percent from previous year (As of April
Nearby states:
Nearby states:
Marketplace Medicaid
enrollment enrollment




2015)
Missouri:
152,335
Kansas:
57,013
Nebraska:
42,975
Minnesota: 48,495
(39,445)
28,371
(8,388)
131,603
Marketplace
enrollment Incr
 Missouri:
253,430
 Kansas:
96,197
 Nebraska:
74,152
 Minnesota:
59,704
66%
69%
73%
23%
Medicaid
enrollment
62,158
29,367
(7,747)
153,366
2015 Marketplace enrollment
300,000
250,000
200,000
150,000
100,000
50,000
0
2014
Market
place
enroll
ment
2015
Market
place
enroll
ment
Pctg increase in
enrollment, year 2
80%
70%
60%
50%
40%
30%
20%
10%
0%
Change in Medicaid coverage
200,000
150,000
100,000
50,000
0
-50,000
2014 change in
Medicaid from
2013
2015 change in
Medicaid from
2013
2015 paid enrollments
Pctge of total signups
90.0%
Effectuated Enrollment
88.0%
86.0%
250,000
84.0%
200,000
82.0%
IA
MO
KS
NE
MN
State
Effectuated
Enrollment
IA
39,090
86.6%
MO
219,953
86.8%
KS
85,490
88.9%
NE
63,380
85.5%
MN
52,169
87.4%
US
10,187,197
Pctge of total
signups
87.2%
150,000
100,000
50,000
0
IA MO KS NE MN
A few demographics
State
Total Paid-up
Enrollment
Advanced
Premium Tax
Credit
Enrollment
Pctge with
APTC
IA
39,090
34,172
87.40%
49.50%
$371
$111
MO
219,953
197,663
89.90%
58.60%
$363
$82
KS
85,490
69,979
81.90%
56.00%
$301
$90
NE
63,380
56,910
89.80%
50.90%
$354
$104
85.00%
57.40%
$364
$101
US
10,187,197 8,656,210
Pctge with Avg premium Avg premium
Cost-Sharing
in plan
after premium
Reductions
selected
tax credit
$400
$300
Avg premium in plan
selected
$200
Avg premium after
premium tax credit
$100
$0
IA
MO
KS
NE
US
Plan types purchased by Iowa residents
Pctge of sales in Iowa
11%
0% 0%
31%
Catastrophic
Bronze
Silver
Gold
Platinum
58%
Pctge of sales nationally
7%
3% 1%
21%
Catastrophic
Bronze
Silver
68%
Gold
Platinum
Iowa Marketplace consumers’ income
Iowa Marketplace Consumers’ Income
543
4,200
479
6,974
< 100% of FPL
2,414
≥ 100% to ≤ 150%
4,794
> 150% to ≤ 200%
> 200% to ≤ 250%
15,485
> 250% to ≤ 300%
> 300% to ≤ 400%
> 400%
9,072
Unknown
Premium affordability, after tax credits
50%
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
46%
40%
38%
34%
27%
29%
27%
23%
25%
25%
Premium of $50 or less
Premium of $51 to $100
* 36 states & DC
A few reasons for enrollment jump
 Enrollment ran much smoother
 Healthcare.gov performed well most of the time
 The Marketplaces and Call Centers had figured out most weird situations
 The minimum penalty for not having insurance more than tripled
 In most places, new insurers boosted competition
 The world did not end
 Consumers learned no death panels, no embedded chips. Just a way to buy insurance
 Word of mouth
 Consumers are hearing that this is a good deal – average discount of 70%
 This is especially true in rural areas, where enrollment more than doubled in
more than 20 percent of all zip codes in the four states in this region
 The work of agents & brokers
 You are the traditional sales network for health insurers
 In zip code 50310, 72 local organizations that offer free help are listed
 When agents and brokers are added, 433 organization come up -- 83% agents
 In my zip code in midtown Kansas City, 138 organizations balloon to 1,151
 Nearly 90 percent of organizations enrolling people are agents and brokers
Current issues
Examples of HHS activity this summer
 Special enrollment periods
 SEPs are becoming the routine bridge between eligibility for job-based coverage
 Final regulation issued providing a 60-day SEP for victims of domestic violence or
spousal abandonment
 Applicants married to their abuser allowed to select unmarried on FFM applications
 Final rule issued on contents of Summary of Benefits and Coverage
 Developing the Marketplace Learning Management System to handle all
Marketplace training requirements
 Improving health literacy among consumers
 The Coverage to Care initiative from CMS
 Fact sheets available:






What to Know About Getting Your Prescriptions
What You Should Know About Provider Networks
What You Should Know About Seeing Your Doctor
Getting Emergency Care
Contacting Your Health Plan’s Customer Service Center
I Signed Up, but Don’t Have Health Coverage
Data matching issues
 Many consumers ignore notices that they have a data matching
issue:
 They receive an eligibility notice, giving them 90 days to resolve the issue
 They are sent a 60-day notice, a 30-day notice, and receive a reminder
phone call from the Marketplace 14 days before their deadline
 Early summer 2015, the Marketplace sent notices to consumers
receiving financial help who may have access to other coverage
 This can include:
 Private insurance through an employer
 Medicaid
 Medicare
 Veterans Administration coverage
 Peace Corps coverage
 Failure to resolve these issues can cause them to lose Advanced Premium
Tax Credits and CSRs as early as September 1
Consumer issues – income matching
 People should attach explanations to their documentation
 Example: Consumer making $72,000 a year in salary and $15,000 in
interest and dividends in 2013 and 2014.
 He retires at the end of October 2015. If he tells the Marketplace that
his income in 2016 will be $16,000 the Marketplace is going to say it
needs documentation
 If he sends in only his W-2 form for 2015, it will say he was paid $60,000
(10 months at $6,000 a month)
 The W-2, by itself, will not be accepted as documentation for an income
of $16,000. Indeed, the W-2 actually documents a much higher income
 Rather, he should send in his W-2 and some document from his
employer stating that he has left employment
 He should also attach an explanation saying that he is retired and stating
the source of ALL $16,000 in income that he is reporting to the
Marketplace
 Do not send in one brokerage statement showing $6,000 in dividends
Consumer issues – Income matching
TIPS FOR RESOLVING INCOME INCONSISTENCIES
 Documents used to support your estimate of annual income:
https://www.healthcare.gov/help/how-do-i-resolve-an-inconsistency/
 This Web page has lists of documents that can be used to resolve a wide
variety of issues regarding eligibility for Marketplace assistance
 Scroll down to the “Income” heading. If applicable, use the items under the
“Self-employment” and “Unearned income” headings as well
 Other links that you may find useful:
 Reporting changes in income:
 https://www.healthcare.gov/reporting-changes/how-to-report-changes/
 How to upload a document:
 https://www.healthcare.gov/help/how-to-upload-documents/
Consumer issues – tax issues
 Consumers must have filed a tax return to get tax credits
 The reason doesn’t matter: No tax credits in 2016 if didn’t file a
2014 tax return
If requested an extension, get the return filed now
 Consumers must have reconciled their tax credits with
actual 2014 income
 They must include Form 8962 using information on their Form 1095-A
 Form 8962 compares actual tax credits with tax credits paid to the
insurance company during the year
 Consumers who qualify for tax credits should file an amended return
immediately if they did not calculate their actual tax credit or they lose
advance credits in 2016
 Their Form 1095-A can be obtained in their HealthCare.gov account
 The Marketplace Call Center (1-800-318-2596) also can help
consumers find their Form 1095-A online
What’s ahead?
18
Iowa’s Marketplace will have new players
7 insurers applied to offer Marketplace health plans in 2016
Individual Marketplace:
Coventry Health Care:
Medica Insurance Co.
United Healthcare
Avera Health Plans
Gundersen Health Plan
Statewide
Statewide
76 counties
9 counties
5 counties
Small-Business Health Options Program (SHOP)
United Healthcare
Sanford Health Plan
Avera Health Plans
Gundersen Health Plan
Statewide
10 counties
9 counties
5 counties
Open enrollment lasts from Nov. 1 to Jan. 31, 2016
Shared responsibility payment
 A huge motivator to buy insurance – and it’s getting bigger
 2014: 1% of income, minimum $95 per adult
 2015: 2% of income, minimum of $325 per adult
 2016: 2.5% of income, minimum of $695 per adult
 For 2014, 7.5 million Americans paid all or part of this
penalty for not carrying health insurance
 The average penalty was about $200
 About 40 percent of these taxpayers paid less than $100
 Preliminary IRS figures, as of July, show that:
 About 1.6 million returns – half the returns that claimed a tax credit
– underestimated their income and had to pay money back
 The average repayment was about $800
 About an equal number of returns had no change or bigger refund
Shared responsibility payment
 In context of the price that people pay in Iowa:
 27% of consumers obtained insurance for $50 or less
 29% obtained insurance for $100 or less
 The average premium, after tax credits was $111
 In 2016, the minimum penalty will be $58 a month
 This means:
At least 27% of Iowa consumers could get coverage for less than
the minimum penalty
56% of Iowa consumers could get insurance for a net cost of $42
a month or less
The average consumer with tax credits could get coverage for
only $53 a month more than the penalty
Getting ready for 2016
Resources for agents and brokers:
 http://www.cms.gov/CCIIO/programs-and-initiatives/health-insurancemarketplaces/a-b-resources.html
 Marketplace Call Center open 24 hours a day
1-800-318-2596
 To sell policies through the Marketplace, agents and brokers must
register and complete training each year
 Create an Account on Marketplace Learning Management System
 This was formerly know as the Medicare Learning Network
 Execute Agreements with the Marketplace
 Create a user account and complete identity proofing
 Complete the FFM Training and Testing
 Training in use of the SHOP Marketplace is recommended but not
required
Marketplace training
 The procedures this year have changed
 3 webinars were scheduled; two have already been held
 The one remaining:
Wednesday, August 19, 2015, from Noon – 1:30 PM CT
 Registration closes 24 hours before the webinar begins
To register, go to https://www.regtap.info (detailed instructions
are on main page)
 Training will also be available for a fee from CMSapproved vendors
 The list of approved vendors will be available soon
SHOP
aka Small-Business Health Options
Program
The Small-business Health Options Program

For employers, the Insurance Marketplace allows small
businesses with up to 50 employees to pool their risk
Insurers are required pool risks
across the small group market, both
inside and outside the Marketplace
 This larger pool reduces the impact
of one worker with high medical costs
on individual employers’ rates
 In 2014, sales in the federally run
SHOPs were through agents and
brokers or directly through carrier
 SHOP plans are now sold through the Healthcare.gov website
 An agent/broker portal will allow agents to manage the account
online once approval has been received from the employer
The SHOP Marketplace
 The big advantage for SHOP plans is two years of tax credits for
employers with fewer than 25 full-time equivalent workers
 Employers with 10 or fewer workers can receive credits covering up to half
their heath insurance costs
 Credits decrease as number of workers and average wage rise
 SHOP enrollment dates and the plan
year are set by the employer
 Iowa requires a minimum participation
rate of 75 percent of eligible employees,
except:
 Most states have no minimum
participation rate for companies who enroll
employees from Nov. 15 through Dec. 15
Selling through the SHOP
If you plan to sell small-group plans through the Marketplace,
you must:
 Complete the SHOP Privacy and Security Agreement
 Create a User ID and go through Identity Proofing
 Log in to the SHOP Agent & Broker Portal
 https://healthcare.gov/marketplace/small-businesses/agent
 This is how you manage the account, update employee lists and check
account status
 Create your SHOP profile
 This allows clients to search for an agent or broker based on specific skills
 Profiles can contain:
 Contact information, such as phone, address, email
 Languages spoken in your office
Corporate responsibility
In 2016:

Large employers – 50 or more full-time equivalent workers –
can choose either to:
 provide health insurance benefits to their employees, or
 make shared responsibility payments to cover the cost of the tax
credits that help employees buy private insurance
 $2,000 per employee (excluding the first 30 employees)
More than 96 percent of firms with at least 50 workers already offer
health insurance to their employees
 Small employers – those with fewer than 50 full-time workers – are
exempt from any shared responsibility payments
Corporate responsibility
Employer-provided insurance must be adequate and affordable
 Adequate is defined as having an actuarial value of at least 60 percent
 This is equivalent to the bronze plans offered through the Marketplace
 Affordable is when the employee’s share of employee-only coverage is
no more than 9.56 percent of the employee’s household income
 Employers can use 9.56% of the employee’s wages as a proxy for household income
 If the employer coverage meets both these requirements, then the
employee is not eligible for tax credits to buy Marketplace coverage
 If employer coverage is either inadequate or unaffordable, then the
employee can receive tax credits to buy insurance on the Marketplace
 For each employee who receives tax credits to help pay for insurance through
the marketplace, the employer will be assessed a penalty of $3,000
New rules taking effect in 2016
 In 2016:
 Employers with 50 to 99 FTE employees are no longer exempt
from the shared responsibility fee
 This applies to any plan year that begins in 2016
 Employer-provided health plans are required to offer
coverage to dependents, but not spouses
 However, dependent coverage is not required to be subsidized and is
not factored into the affordability calculation
 Employers must offer coverage to at least 95 percent of their fulltime employees
Employee choice
 Employers in every state will be allowed to offer their
employees a choice of Marketplace health plans in 2016
 Employee choice means employers choose a level of coverage
and a standard contribution per employee
 Employees choose a plan and apply the employer contribution
to any health plan within that level of coverage
 The employer makes one payment to the Marketplace
 The Marketplace parcels out the payment to the insurers on
behalf of each employee
Tools available to employers

SHOP tax credit estimator:
 https://www.healthcare.gov/small-business-tax-credit-calculator/
 This tool provides an estimate of the value of a Small Business Health Care
Tax Credit based on the employer’s actual workforce

Full-time Equivalent Employee Calculator:
 https://www.healthcare.gov/fte-calculator/
 This tool helps employers count their “full-time equivalent” employees and
determine eligibility for the SHOP health plan
 Minimum value calculator
 http://www.cms.gov/cciio/resources/regulations-and-guidance/index.html
 This tool will calculate the actuarial value of an employer’s health plan
 Small business coverage page
 https://www.healthcare.gov/small-businesses/
 This tool has links to:
 browse health plans and prices
 learn about coverage for the self-employed
The SHOP call center & other resources
 SHOP Call Center
1-800-706-7893
 SHOP Call Center is open:
 Monday through Friday
 8 a.m. to 6 p.m. CT
 SBA Fact Sheets, Training Materials and insurance finder tool:
 http://www.sba.gov/content/affordable-care-act-training-materials
 Information based on your business location, size, and whether you now
offer insurance
 Affordable Care Act Fact Sheet for Small Business (June 2015)
 This is one of the best summaries that I’ve seen!
State-based Marketplaces
The law requires Marketplaces to be self-sustaining by 2015
 Question: How will States fund Exchanges once the federal funding
goes away?
 Answer: The law gives states great flexibility on how to fund Health
Insurance Exchanges
 They can be funded through:
 assessments on insurers
 state general fund appropriations
 provider taxes
 other funding as long as it does not violate the law
Let’s Go…..
Questions?