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Affordable Care Act Community Forum


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Title: Affordable Care Act Community Forum

Affordable Care Act Community Forum September 2013
David Evans Chief Executive Officer
Affordable Care Act (ACA) Marketplace 101
  • Introduction to the ACA and the Health Insurance
  • Eligibility
  • Application Process
  • Coverage
  • Affordability
  • Responsibility for Coverage
  • Key Points to Remember
  • Local Resources

What is the ACA?
  • The Patient Protection and Affordable Care Act,
  • More commonly known as
  • The Affordable Care Act (ACA) is the national
    health reform law passed by Congress and signed
    by the President in March 2010.

What is the goal of the ACA?
  • Increase the rate of healthcare coverage for
    Americans while addressing overall healthcare
  • Establishing consumer rights and protections
  • Increasing insurance options
  • Providing assistance for healthcare costs

What is the Health Insurance Marketplace?
  • Also known as the Exchange, the Health
    Insurance Marketplace is a new way to purchase
    health insurance.
  • The Marketplace will provide a way for
    consumers to
  • Look for and compare health plan options
  • Complete one application for multiple plans
  • Determine eligibility for tax credits cost
    sharing subsidies
  • Enroll in health insurance plan

Who Manages the Marketplace?
  • Each State can choose to
  • Create and manage their own marketplace
  • Partner with the federal government to manage
    their marketplace jointly
  • Have the federal government manage the
    marketplace for their State

Who is Eligible to Participate?
  • Individuals and Small Businesses with up to 100
    employees can purchase health insurance through
    the Marketplace.
  • Eligibility requirements
  • Must live in the U.S. within service area
  • Must be a U.S. citizen or national, or
  • Be lawfully present in U.S.
  • Cannot be currently incarcerated

Application Process
  • One streamlined process to determine potential
    eligibility for
  • Medicaid
  • Children's Health Insurance Program (CHIP)
  • Private health insurance offered by Qualified
    Health Plans (possible tax credits and cost
    sharing subsidies)
  • Can apply
  • On-line
  • Phone
  • Mail
  • In person -receive personal assistance

Qualified Health Plans
  • Private insurance companies certified by the
    Marketplace in each respective State, who
  • Have adequate provider networks
  • Provide Essential Health Benefits
  • Offer at least one plan at the Silver level and
    one plan at the Gold level
  • Agree to charge the same premium rates whether
    offered through the Marketplace or outside of the

Coverage Essential Health Benefits
  • Qualified Health Plans participating in the
    Marketplace will be required to offer benefits
    that meet a minimum set of standards called
    Essential Health Benefits.
  • Ambulatory services
  • Emergency services 
  • Hospitalization
  • Maternity and newborn care
  • Mental health and substance use disorder
    services, including behavioral health treatment
  • Prescription drugs
  • Rehabilitative and habilitative services and
  • Laboratory services
  • Preventive and wellness services and chronic
    disease management
  • Pediatric services, including oral and vision

Coverage Plan Levels
Levels of Coverage Plan Pays on Average Consumer Pays on Average (In addition to the monthly premium)
Bronze 60 40
Silver 70 30
Gold 80 20
Platinum 90 10
Based on average cost of an individual under the
plan may not be the same for every enrolled
Coverage Catastrophic Plans
  • Who is Eligible?
  • Young adults under age 30
  • Those who cannot afford coverage and obtain a
    hardship waiver from the Marketplace
  • What is Catastrophic Coverage?
  • Plans with high deductibles and low premiums
  • Includes coverage of 3 primary care visits and
    preventive services at no cost
  • Protects consumers from high out-of-pocket costs

Coverage Enrollment
  • Initial Enrollment Period (1st year only)
    October 1, 2013 March 31,

If you enroll Your coverage will begin
October 1 December 15 January 1, 2014
December 16 January 15 February 1, 2014
January 16 February 15 March 1, 2014
February 16 March 15 April 1, 2014
March 16 March 31 May 1, 2014
  • Beginning October 2014 - Annual Enrollment Period
    October 15th December 7th

Coverage Qualifying Events
  • Certain qualifying events will allow individuals
    to enroll during the year

Examples of Qualifying Events Examples of Qualifying Events
Birth/Death Loss of Minimum Essential Coverage
Adoption Gain of a dependent or becoming a dependent through marriage
Legal separation or divorce Error in enrollment
Becoming a U.S. citizen, national, or lawfully present individual Financial change impacting eligibility for tax credit
Move out of service area Exceptional circumstances such as a natural disaster
Affordability Advanced Premium Tax Credits
  • Advanced Premium Tax Credit is a new kind of tax
    credit that can be used to lower monthly health
    plan premiums
  • Through the Marketplace individuals can apply for
    advance payment of this tax credit
  • Advance payments will be sent directly to the
    insurance company and applied towards monthly

Affordability Advanced Premium Tax Credits
  • Monthly amounts owed by individuals can be
  • Example
  • Monthly premium 300
  • Advance payment 240 a month
  • Monthly amount owed by individual 60

Affordability Advanced Premium Tax Credits
  • The Marketplace will estimate the amount of
    advance payments based on projected income
  • Report income changes immediately to avoid
  • Advance payments will be reconciled at tax time
    against the actual Premium Tax Credit amount
    individuals are eligible for based upon actual

Affordability Advanced Premium Tax Credits
  • Option to pay total monthly premiums and claim
    tax credit on income tax return
  • Example
  • Monthly premium 300
  • Projected advance payment 240 month
  • Individual can choose to pay 300 monthly and
    receive 2,880 refund (240 x 12) instead of
    advance payments

Affordability Advanced Premium Tax Credits
  • Who is Eligible?
  • Individuals/Families with household incomes
    between 100-400 of Federal Poverty Level (FPL)
    who do not have access to public health benefits
    or affordable employer coverage. 
  • Affordable employer coverage exists as long as
    the lowest cost "individual" plan offered by an
    employer does not exceed 9.5 of the employee's
    household income

Affordability Cost-Sharing Subsidies
  • Cost Sharing Subsidies
  • A provision of the ACA requires that individuals
    with lower income levels have their cost sharing
    amounts reduced
  • Health plans will be responsible to pay a greater
    share of the covered benefits for qualifying
  • Who is Eligible?
  • Individuals/Families with household incomes
    between 100 - 250 of FPL
  • Who enroll in a Silver-Level plan

Affordability Cost-Sharing Subsidies
  • Qualifying subsidies will be automatically
    reflected in individual cost sharing amounts
  • Example
  • (Silver Plan)
  • Co-pays for households at 250 FPL may be 10 for
    Dr. Visit, 7 for prescriptions
  • Co-pays for households at 100 FPL may be 5 for
    Dr. Visit, 3 for prescriptions

Responsibility for Coverage
  • A provision of the ACA requires that all
    individuals have health insurance beginning in
  • Exceptions may be given for
  • Financial hardships
  • Religious objections
  • Qualifying Indian tribes
  • Those for whom the lowest cost health plan
    exceeds 8 of their household income
  • Those whose income is below the tax filing
  • Those who do not qualify for an exception and do
    not have qualifying coverage will be required to
    pay an annual financial penalty. 

Responsibility for Coverage Penalties
Penalty amounts will be phased in and will
gradually increase from 2014 to 2016
Key Points to Remember
  • There will be multiple options for health care
  • Public Programs Medicare, Medicaid, CHIP
  • Health insurance plans offered thru Employers
  • Health insurance plans offered outside of the
  • Health insurance plans offered by Qualified
    Health Plans through the Marketplace
  • Tax Credits and Cost-Sharing Subsidies available
    through the Marketplace

2013 Federal Poverty Guidelines
Persons in family/household 100 250 400
1 11,490 28,725 45,960
2 15,510 38,775 62,040
3 19,530 48,825 78,120
4 23,550 58,875 94,200
5 27,570 68,925 110,280
6 31,590 78,975 126,360
7 35,610 89,025 142,440
8 39,630 99,075 158,520
For family units of more than 8 members, add
4,020 for each additional member Sources and FamiliesUSA
Application Assistance Available to General
Public Travis County
Organization Address City Zip Code
1 CommUnityCare North Central 1210 W. Braker Lane Austin 78758
2 CommUnityCare Pflugerville 15822 Foothill Farms Loop Pflugerville 78660
3 CommUnityCare Rundberg 825 E. Rundberg, Suite B1 Austin 78753
4 CommUnityCare UT Family Wellness 2901 N. IH-35, Suite 101 Austin 78722
5 CommUnityCare Hancock 1000 E. 41st Street, Suite 925 Austin 78751
6 CommUnityCare Manor 600 W. Carrie-Manor Street Manor 78653
7 CommUnityCare East Austin 211 Comal Street Austin 78702
8 CommUnityCare Rosewood-Zaragosa 2802 Webberville Road Austin 78702
9 CommUnityCare South Austin 2529 S. 1st Street Austin 78704
10 CommUnityCare UT Childrens Wellness 5301 Ross Road, Suite H Del Valle 78617
11 CommUnityCare Oak Hill 8656-A Hwy 71 West, Suite C Austin 78735
12 CommUnityCare William Cannon 6801 S. IH-35, Suite 1-E Austin 78744
13 LoneStar Circle of Care Seton Northwest 11111 Research Blvd., Suite 230 Austin 78759
14 LoneStar Circle of Care Ben White 1221 W. Ben White Blvd. Suite B200 Austin 78704
15 Foundation Communities North Highland Mall 6001 Airport Blvd Austin 78752
16 Foundation Communities Southwest 2600 W. Stassney Lane Austin 78745
CommUnityCare 512.978.9015 ? LoneStar Circle
of Care 1.877.800.5722 ? Foundation
Communities 2-1-1
Application Assistance to Existing Client Base
  • Central Health Eligibility Services
  • Seton Community Clinics
  • Austin Travis County Integral Care (ATCIC)
  • Peoples Community Clinic

Education and Referrals for Existing
Client Base
  • Child Inc./HeadStart Program
  • Easter Seals
  • Project Access
  • WIC Program
  • SIMS HAAM Foundations

Additional Services
  • Central Health has committed to fund additional
    outreach education efforts
  • These efforts will
  • Compliment services provided by Enroll America
  • Coordinated culturally competent, community based
  • Data driven activities, directed at targeted
    populations and underserved areas of county
  • Allow for assistance in non-traditional settings
    such as schools, community events or even
    personal residents

Additional Services
  • Central resource for local information
  • United Way for Greater Austin
  • Manages the local 2-1-1 Center
  • 10 County Central Texas region
  • Central Health Healthcare Navigation Center

United Way 2-1-1 Center
  • Available to provide
  • General information and referrals to Health
    Insurance Marketplace Call Center
  • Information and warm transfers to
  • Each of the local Marketplace resources
  • Central Health Healthcare Navigation Center
  • Prescreen individuals for potentially eligibility
  • Medical Access Program (MAP)
  • Medicaid
  • CHIP/CHIP Perinatal
  • Health Insurance Marketplace

  • Coordinated, systematic approach
  • Prevent confusion avoid duplication of efforts
  • Maximize use of existing resources
  • Locally
  • Enhanced outreach education efforts
  • In person application assistance general
  • Application assistance for existing clients of
    multiple organizations
  • Education referrals from numerous organizations
  • Central resource for local information - United
    Way 2-1-1 Center


Enrollment and Outreach for Integral Care
ACA and Integral Care
  • Champion for Coverage and Certified Application
    Counselor Organization
  • Training staff and volunteers to assist with
  • Consumer Benefits Office will enroll eligible
    people using Integral Care services
  • Additional Open Enrollment for the public
  • 1631 East 2nd Street
  • 1702 South Lamar, Large Training Rm
  • 5225 North Lamar Professional Building
  • Dove Springs

Enrollment Information for People Currently Using
  • Approximately 1,200 People are Eligible
  • Provide Technical Assistance
  • Begin October 1st March 31st
  • Currently Recruiting Volunteers for Enrollment
    Assistance for the Public (Limited Space)
  • Offering Extended Hours

Additional Outreach Efforts
  • Working with partner organizations for referrals
    to enrollment sites
  • Traditional marketing and social media activities
  • Online information and resources
  • Participation in fairs and community events
  • Binational Health Week fair
  • Community Connections Health Fairs

Mental Health Substance Use Parity
  • Parity means insurance companies can not
    discriminate against mental health and substance
    use treatment in coverage decisions
  • ACA designates mental health coverage as an
    essential health benefit
  • All plans offered in the Marketplace must offer
    coverage and you cannot be denied due to a
    preexisting condition

Prevention, Wellness Chronic Disease Management
  • Essential Health Benefit
  • Profound disparity in life expectancy for persons
    with serious mental illness
  • Persons with a serious mental illness are more
    than twice as likely to smoke cigarettes
  • People with major depressive disorder are at
    higher risk for cardiovascular disease and stroke
  • Includes smoking cessation and other programs to
    help people get and stay healthy

Q A Session
David Evans Chief Executive Officer
Closing Remarks