1. January 29, 2014

2. Purpose

3. Agenda
 Definition
 Operation
 Key Functions
 Individual Marketplace
 Qualified Health Plans
 Tax Credits and Cost
Sharing Reductions
 Resources and Questions

4. Definition

5. Key Functions of the Marketplace
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6. Operation of the Marketplace
• Federally-
Facilitated
Marketplace
• Federal
government
manages all
Marketplace
functions
• Marketplace
website is
healthcare.gov
• National Call
Center at 1-800-
318-2596
• State
Partnership
Marketplace
• Type of FFM
• State partners
with federal
government
• Federal
government runs
some functions
• State can
manage plans or
consumer
assistance or
combination of
both
• State Based
Marketplace
• State manages
all Marketplace
functions
• Operate own
Marketplace
website
• Monitor own
consumer
assistance
programs
• State Hybrid
Marketplace
• 3 States:
• MS
• NM
• UT
• State Based
SHOPs
• Federally
facilitated
individual
marketplaces that
use
healthcare.gov
• Monitor own
consumer
assistance
programs

7. Where States Stand on Exchanges
Map updated 12/9/13
https://www.statereforum.org/where-states-stand-on-exchanges

8. Annual Changes
States applied in late 2013
to make changes for the 2015 plan year.
The answer to this
question can change
every year.
States can decide to
change their
Marketplace type –
FFM, SPM, SBM, or
Hybrid – on a yearly
basis.

9. Where is the Marketplace?
Healthcare.gov or the
National Call Center at
1-800-318-2596
For these Marketplaces:
• Federally-Facilitated
• State Partnership
• State Hybrid

10. Where is
the Marketplace?
State Portals
For State Based Marketplaces
• KY: Kynect
• CACs are “Kynectors”
• NM: Be Well NM
• CACs are “Health Care
Guides”
• OR: Cover Oregon
• WA: Washington
Healthplanfinder

11. Healthcare.gov and StateReforum.org
If you’re not sure whether the online Marketplace for a state is at
healthcare.gov or a state portal, check one of these two resources.
https://www.healthcare.gov → Apply Now → Choose Your State

12. Healthcare.gov and StateReforum.org
If you’re not sure whether the online Marketplace for a state is at
healthcare.gov or a state portal, check one of these two resources.
https://www.statereforum.org/state-exchange-websites

13. Example of a Hybrid:
New Mexico
 SBM operating as hybrid
 SHOPs use
http://bewellnm.com/
 Individuals use
https://www.healthcare.gov/

14. Information Provided
in the Marketplace:
Eligibility and
How to Enroll
in Qualified
Health Plans
(QHPs)
https://www.healthcare.gov/find-premium-estimates/

15. Information Provided
in the Marketplace:
Eligibility and
How to Enroll
in Medicaid/CHIP
https://www.healthcare.gov/find-premium-estimates/

16. Information Provided
in the Marketplace:
Ways to Save –
Kaiser Family
Foundation
Subsidy
Calculator
https://www.healthcare.gov/how-can-i-get-an-estimate-of-costs-and-savings-on-
marketplace-health-insurance/
http://kff.org/interactive/subsidy-calculator/

17. Information Provided
in the Marketplace:
Ways to Save –
Quick Check Chart
https://www.healthcare.gov/how-can-i-save-money-on-marketplace-coverage/

18. Federal Data Services Hub (FDSH)
• Routing tool to securely send
information from various
trusted government databases
through secure networks
• Verifies accuracy of specific
information entered in the
application
• Does not retain or store data
1. Create an
Application
2. Verification of FDSH
3. Compare Options,
Pick a Plan
Agency Information Verified
SSA SSN & Citizenship
VA, Medicaid, Medicare If already have insurance
IRS Income (if seeking financial assistance)
Dept. of Homeland Security Citizen or Legal Resident

19. The Role of ESS CACs
• Educators
• Subject Matter Experts
• Objective Assisters – to help
consumers make informed
decisions without offering
recommendations and without
making eligibility or enrollment
determinations

20. Marketplace
and Risk Pools
• Open to consumers regardless of:
• medical history
• pre-existing conditions
• Risk pool
• Group of consumers whose estimated medical costs are
combined in order to calculate health insurance premiums
• Needs both high-risk and low-risk consumers
• People who have greater healthcare needs are more likely to
buy the insurance, but, if only those people were included in
the risk pool, it would not be affordable
• Penalty causes more and healthier people to buy coverage,
which balances out the risk

21. Premium Variations
• Makeup of risk pool directly affects cost of premiums
• Premiums for the same QHP can vary significantly
• Within established limits:
• Age – 3:1 ratio
• Family composition – 3:1 ratio
• Geographic area – 3:1 ratio
• Tobacco use – 1.5:1 ratio
• Cannot charge more than 3x more for the same plan based on
differences in the first 3
• Cannot charge more than 1.5x more for the same plan based on
tobacco use
• Factors NOT considered:
• Gender
• Ex: charging higher premiums for mothers
or men with heart disease
• Medical history or pre-existing condition

22. Eligibility Requirements
• Live in the Marketplace
geographical area (state)
• Based on the state of
residency claimed on
taxes
• U.S. citizen or national or
lawfully present
• Cannot be currently
incarcerated

23. Qualified Health Plans
aka QHPs
Definition:
An insurance plan* that:
 is certified by the Health Insurance Marketplace
 provides essential health benefits
 follows established limits on cost-sharing between
the insurance company and consumers through
copays, deductibles, and out-of-pocket maximum
amounts
 follows any additional state requirements
A qualified health plan will have a certification
by each Marketplace in which it is sold.
* Under the Affordable Care Act
* Starting in 2014
https://www.healthcare.gov/glossary/qualified-health-plan/
QHPs
● Accept subsidies
● Only found inside
Marketplace
● Renewed yearly

24. QHPs
• “Certified” by the Marketplace:
• Sold by licensed insurance companies
• Offers at least one Silver and one Gold plan
• Includes at least minimum Essential Health Benefits
• Meet requirements for non-discrimination and provider network
adequacy
• Premium is same whether sold inside or outside the Marketplace
• Can only receive financial assistance if purchased inside the Marketplace
https://www.healthcare.gov/what-does-marketplace-health-insurance-cover/

25. 10 Essential Health Benefits
• Comprehensive
package of items
and services
required by the
ACA
• Required for plans
sold both inside
and outside of the
Marketplace
• Required for all
Medicaid plans

26. 10 Essential Health Benefits
Ten categories of items and services that must be provided:
1. Ambulatory patient services (e.g., outpatient care you get without being
admitted to a hospital, such as doctor visits and clinics)
2. Emergency services (e.g., ambulance, first aid services, and rescue squad)
3. Hospitalization (such as surgery)
4. Maternity and newborn care (care before and after your baby is born)
5. Mental health and substance use disorder services, including behavioral
health treatment (such as counseling and psychotherapy)
6. Prescription drugs
7. Rehabilitative and habilitative services and devices (services and devices -
such as therapy sessions, wheelchairs, and oxygen - that help people with
injuries, disabilities, or chronic conditions gain or recover mental and physical
skills)
8. Laboratory services (X-rays, blood work, etc.)
9. Preventive and wellness services and chronic disease management (e.g.,
blood pressure screening, immunizations)
10. Pediatric services for children, including dental and vision care

27. Health Plan Categories
• 5 Levels
• 4 Metal Levels
• Catastrophic (not for everyone)
• People under 30
• People with hardship exemptions
https://www.healthcare.gov/can-i-buy-a-catastrophic-plan/
• Do not refer to the quality or amount of care, just
how much of the cost the plan will pay for (aka Actuarial Value)
• Percentages are just an average
• Amounts vary depending on actual health care needs
• Same category can have several plans offered by different companies

28. Consumer Responsibility
• Can be spread across 3 different areas
• Deductibles
• Amount you owe before insurance pays
• Example: $1,000
• Copays
• Fixed amount you owe for service up front
• Example: $15
• Coinsurance
• Percentage you owe of total costs
• Example: 20% after deductible
• Can be front-loaded
• Copays and deductibles
• Can be back-loaded
• Coinsurance
Level Plan Pays Consumer
Pays
Catastrophic < 60% > 40%
Bronze 60% 40%
Silver 70% 30%
Gold 80% 20%
Platinum 90% 10%

29. Dental Coverage
• Can be offered as part of a QHP
or as a stand-alone plan
• Children 18 and under:
• Dental is an EHB
• All Marketplace QHPs must offer pediatric dental plans
• Adults:
• Not considered EHB
• Do not need to have dental coverage to avoid the penalty
• Can choose:
• One premium via a QHP that includes dental
OR
• Two premiums via a stand-alone dental plan
https://www.healthcare.gov/can-i-get-dental-coverage-in-the-marketplace/

30. Prescription Drug Coverage
• Very significant concern
for many consumers!
• Does the QHP they choose cover the
prescription drugs they need?
• Formularies and drug tiers can vary
for each QHP
• PDF: “What Consumers Should Know
About Getting Prescriptions”

31. How Tax Credits Work
• AKA “Subsidy,” “Advanced Premium Tax Credit,” or “APTC”
• Eligible if income is 100-400% of Federal Poverty Level (FPL)
• Based on INCOME
• Tax credit is the SAME regardless of what plan level you choose
• Marketplace will give consumers a dollar amount they can apply toward
their premiums in the form of a tax credit
• Consumers choose how much of this amount they want to apply toward
monthly premiums
• Must be reconciled when they file taxes for the year
• Refund if you used less tax credit than qualified for
• Owe taxes if used more tax credit than qualified for
• No financial assistance if not at least 100% FPL
https://www.healthcare.gov/glossary/premium-tax-credit/

32. How Tax Credits Are Calculated
Based on:
1. Cost of premium for the
Second Lowest Cost Silver
Plan (SLCSP)
2. Premium Cap (limit on %
of income premium is
allowed to cost based on
FPL)
• Ex: If 100% FPL, premium
cannot cost more than
2% of income http://obamacarefacts.com/costof-obamacare.php
OOP = Out of Pocket
Tax Credit = Premium for SLCSP – Premium Cap

33. Tax Credit Example
• HH Size: 4
• Income: 200% FPL or $47,000
• Cost of SLCSP (Second Lowest Cost Silver Plan): $1,000/month
• Premium Cap for 200% FPL = 6.3% of Income
• Premium Cap = $47,000 x .063 = $2961 per year or $247/month
• Tax Credit = $1,000 Premium - $247 Premium Cap = $753
• Amount is the same regardless of what plan
or plan level actually chosen
• Based solely on a) income and
b) premium for SLCSP
• Consumer then chooses a plan
and decides how much of the tax credit to use

34. How Cost Sharing Reductions (CSR) Work
• “Cost sharing” is between consumer
and insurance company
• CSR available for:
• Consumers 100-250% FPL
• Who choose Silver Plans Only
• Cost sharing is reduced so that the insurer pays more of total cost
• Consumers pay less for copays, deductibles, and/or coinsurance
• Actuarial Value (AV) of Silver Plan increases
• Actuarial Value (AV) = percentage of
total average costs for covered benefits
that a plan will cover
• Remainder is consumer out of pocket costs
• Ex: If AV = 70% on average (Silver),
consumer pays 30% of total costs
https://www.healthcare.gov/glossary/actuarial-value/

35. How Cost Sharing Reductions Work
• Those between 100% and 250% FPL who choose a Silver Plan can get more costs
covered for the Silver price.
• Those between 100% and 200% FPL who choose a Silver Plan can get higher than Gold
or Platinum costs covered for the Silver price.
http://obamacarefacts.com/costof-obamacare.php
OOP = Out of Pocket

36. Moral of the Story:
Choose Silver!
• Pay attention to income
• If between 100-250% FPL, consumers can receive both:
• Tax Credits
• Cost Sharing Reductions
• If so, Silver is by far the best option
• More for your money
• There is no advantage to choosing Gold or Platinum if:
• Between 100-250% FPL
• Choosing Silver Plan
• Educate consumers about the difference.
• But be careful not to influence them.

37. More Resources
 See what plans are offered in your area – and exactly
what they cover – before you apply
 Customer Service phone numbers for the national QHPs
 Official CAC training module
 ESS Intranet → Education → CAC Training
 Navigator SOP Manual
 Pages 32-33 for tax credits and cost sharing reductions

38. Questions?
Please submit via the “Ask a Question” feature!
Thank You!