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National Newspaper Association
127th Annual Convention & Trade Show
September 13, 2013
The Health Insurance Marketplace 101
• Community Resource
• California-Based
– Arizona, California, Hawaii, Nevada, and the U.S. Affiliated Pacific Islands
• Educate the public on the benefits of healthcare reform
-- Healthcare.gov
-- CuidadodeSalud.gov (Spanish)
Office of the Regional Director
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The Problem
• At least 51 million Americans without coverage • Fast rising health care costs, partially due to
uninsured
• Premiums had more than doubled over the last decade, while insurance company profits continued to rise
• Economic hardship for families, small businesses and the U.S. Economy
In March 2010, President Obama signed into law the
Affordable Care Act.
Affordable Care Act
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Three Aims of the Affordable
Care Act
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Better Care
Patient-Centered Care Coordination
Quality
Better Insurance
Accessibility Affordability
Staying Healthy
Prevention Public Health
• Protection from the worst insurance company
abuses
• Makes health care more affordable
• Better access to care
• Stronger Medicare
Affordable Care Act
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Affordable Care Act
• Young adults under the age of 26 can now stay on their parents’ health plans.
• It is now illegal for insurance companies to:
– Deny coverage to children because of a pre-existing condition like asthma or diabetes
– Put a lifetime cap on how much care they will pay for if you get sick
• Slowest sustained national health spending growth in 50 years
– Low growth continuing in 2012 for Medicare and Medicaid
• $2.1 billion returned to consumers in 2011 and 2012
– 80/20 rule: Plans must spend 80% now on healthcare
• Rate increases fell from 75% in 2010 to 14% so far in 2013
• $4.2 billion recovered in 2012 from anti-fraud efforts – a record high – for a total of nearly $15 billion over the last 4 years, double that of the previous 4 years
Affordable Care Act
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The Marketplace
• Place for individuals and small employers to directly compare private health insurance options
Qualified Health Plans (QHPs)
• Can directly compare on the basis of price, benefits, quality, and other factors
Include info re: open enrollment and coverage start date
Health Insurance Marketplace
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6. Prescription drugs
7. Rehabilitative and habilitative services and devices
8. Laboratory services
9. Preventive and wellness services and chronic disease management
10. Pediatric services, including oral and vision care
1. Ambulatory patient services
2. Emergency services
3. Hospitalization
4. Maternity and newborn care
5. Mental health and substance use disorder services, including behavioral health treatment
All Qualified Health Plans Will Cover These Essential Health Benefits
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A new way to get health insurance
• Enrollment starts October 1, 2013
• Coverage begins January 2014
About 25 million Americans will have access to quality health insurance
• Up to 20 million may qualify for help to make it more affordable
• Working families can get help through the Marketplace
The Health Insurance Marketplace
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Health Insurance Marketplaces:
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Health Insurance Marketplaces will be established in every state:
1) Federally Facilitated Marketplace (FFM)
2) State Partnership Marketplace (SPM)
3) State Based Marketplace (SBM)
Federally Facilitated Marketplace (FFM) Conditionally Approved
State Partnership
Marketplace (SPM)
Conditionally Approved State Based Marketplace (SBM)
Alabama Ohio Arkansas California
Alaska Oklahoma Delaware Colorado
Arizona Pennsylvania Illinois Connecticut
Florida South Carolina Iowa DC
Georgia South Dakota Michigan Hawaii
Indiana Tennessee New Hampshire Idaho
Kansas Texas West Virginia Kentucky
Louisiana Virginia Maryland
Maine Wisconsin Massachusetts
Mississippi Wyoming Minnesota
Missouri Nevada
Montana New Mexico
Nebraska New York
New Jersey Oregon
North Carolina Rhode Island
North Dakota Utah
Vermont
Washington
Total: 26 Total: 7 Total: 18
State-by-State Health Insurance Marketplace
Status
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1. It’s an easier way to shop for health insurance • Simplifies the search for health insurance
• All options in one place
• One application, one time, and an individual or family can explore every qualified insurance plan in the area
2. Most people will be able to get a break on costs • 90% of people who are currently uninsured will qualify for
discounted or free health insurance
3. Clear options with apples-to-apples comparisons • All health insurance plans present their price and benefit
information in plain language
Health Insurance Marketplace: Top-line
Messages
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Enhances competition in the health insurance market
Increases affordability through premium tax credits, cost sharing reductions, or public insurance programs
Ensures quality through QHPs that must meet basic standards, including quality standards, consumer protections, and access to an adequate range of clinicians
Makes costs clear by providing information about prices and benefits in simple terms consumers can understand, so they don’t have to guess about costs
Health Insurance Marketplace
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Based on family income and size • Premium discount
Family of four with annual income $23,550* – $94,200*
And not eligible for certain other insurance coverage like Medicaid
• Lower cost-sharing (like copays)
Family of 4 with annual income $58,875* or less (250% FPL)
*2013 amounts
Health Insurance Marketplace: Example
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Starting in 2014, you’ll have more choice and control over your health insurance spending through the Small Business Health Options Program (SHOP), a new program that simplifies the process of buying health coverage for your small business.
Small Business Health Options Plan (SHOP)
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Issues to offering health insurance to employees:
Difficulty comparison shopping between plans
Unpredictable rate increases
Higher rates for groups with: o Older workers
o Workers who have chronic conditions or high‐cost illnesses
O Women charged more than men
Waiting periods for coverage of pre‐existing conditions
The Situation for Small Employers Today
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The Small Business Health Care Tax Credit eligibility: With fewer than 25 “full‐time equivalent” employees Whose employees’ (not owner/employer) wages average less
than $50,000 per year Who contribute at least 50% of employees’ premium costs Who buy health insurance through the SHOP only, starting in
2014 Tax credits: Up to 35% of employer’s premium contribution (up to 25% for
tax‐exempt employers) now Up to 50% of employer’s premium contribution (up to 35% for
tax exempt employers) starting in 2014
Removing the Obstacles: Tax Credits
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Who’s eligible? 2014 /2015 - Upper limit of 100 FTEs. Some Marketplaces may opt to set
the upper limit at 50. 2016 – Marketplaces must accommodate 100 FTE and below. 2017 and Beyond – States can decide their upper limit.
When can businesses enroll? Starting October 1, 2013, for coverage beginning January 1, 2014
Thereafter, throughout the year
How can businesses enroll? Directly through the SHOP Through a broker registered with the SHOP
Small Business Health Options Plan: Who, When & How?
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Businesses with less than 50 full-time equivalent employees are exempt from any requirement.
96% of American businesses are less than 50 employees
There is no Shared Responsibility until 2015.
Employer Requirement (Shared Responsibility)
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The Health Insurance Marketplace is a new way to find and buy health insurance
Individuals and small businesses can shop for health insurance that fits their budget
There is financial help for working families and other people with limited income to obtain health insurance
There is assistance available to help consumers get the best coverage for their needs
Summary
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Marketplace Call Center (Consumers) - 24/7 – English and Spanish and 150 Languages
1-800-318-2596, 1-855-889-4325 (TTY)
SHOP Marketplace for Businesses
1-800-706-7893, 1-800-706-7915 (TTY)
Stay Connected
• Go to www.healthcare.gov / www.cuidadodesalud.gov
• Updates and resources for partner organizations are available at www.Marketplace.cms.gov
• Twitter@HealthCareGov
• facebook.com/Healthcare.gov
Want more information about the Marketplace?
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Steven Wiener
Regional Outreach Specialist, Region IX
(415) 437-8500 – Main Number
(415) 437-8518 – Direct Number
HHS Website: www.hhs.gov
Thank you!
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