Health Care Options 2014 BadgerCare Plus & The Marketplace Partner Training

1. Health Care Options 2014BadgerCare Plus & The MarketplacePartnerTraining Menasha, WINovember 7, 2013

2. Agenda • Outreach and Enrollment Timeline • BadgerCare Plus Policy Changes • MAGI (Modified Adjusted Gross Income) • Important Reminders • Partner Discussion • Additional Resources Protecting and promoting the health and safety of the people of Wisconsin

3. Outreach and Enrollment Timeline

4. Current BadgerCare Plus Enrollment and Benefits

5. New 2014 Healthcare Options

6. BadgerCare Plus Key Policy Changes • Income limit changes: • Income limit changes for parents/caretakers, childless adults and children • No income limit changes for pregnant women, Family Planning Only Services, or Elderly, Blind and Disabled (EBD) Medicaid • MAGI budgeting rules implemented Protecting and promoting the health and safety of the people of Wisconsin

7. BadgerCare Plus Policy Changes: Adults Parents and Caretakers: • Eligible at or below 100%FPL • Access to Standard Plan Benefits • No premiums • Nominal cost sharing for certain services Over 100% FPL will have access through the Marketplace Protecting and promoting the health and safety of the people of Wisconsin

8. BadgerCare Plus Policy Changes: Adults (continued) Childless Adults: • Eligible at or below 100% FPL • Standard Plan Benefits • No monthly premiums or annual enrollment fee • No mandatory Health Needs Assessment for eligibility • No Waitlist • Nominal cost sharing for certain services • No insurance access or coverage test • Over 100% FPLAccess through Marketplace Protecting and promoting the health and safety of the people of Wisconsin

9. BadgerCare Plus Policy Changes: Children • Eligible at or below 300% FPL • Premiums over 200% FPL • Over 300% FPLMarketplace Protecting and promoting the health and safety of the people of Wisconsin

10. Other Policy Changes • All BadgerCare Plus members will be enrolled in the BadgerCare Plus Standard Plan • 12-month certification periods • New Restrictive Re-enrollment Periods (RRPs) • Former Foster Care Youth age limit to 26 Protecting and promoting the health and safety of the people of Wisconsin

11. What is “MAGI”? • MAGI = Modified Adjusted Gross Income • Refers to new household composition and budgeting rules that will be applied for BadgerCare Plus and the Marketplace. • Members and applicants will be asked some different questions about their tax status, tax dependents, and tax deductions • Introduced by Patient Protection & Affordable Care Act to align BadgerCare Plus eligibility rules with tax rule-based policy in the Marketplace Protecting and promoting the health and safety of the people of Wisconsin

12. Who is Subject to MAGI Rules? BadgerCarePlus Members : • Children • Parents / caretakers • Pregnant women • Childless adults MAGI rules do not apply to: • Elderly, blind and disabled groups • EBD MA, LTC, SeniorCare • QMB, SLMB, SLMB+ • Categorically eligible populations • Former Foster Care Youth Protecting and promoting the health and safety of the people of Wisconsin

13. When will members be subject to MAGI Rules? • ACCESS changes • Updated November 18, 2013, and will be applied for those seeking coverage on for after January 1, 2014 • MAGI budgeting rules • New Applicants MAGI rules applied for coverage beginning on or after January 1, 2014 • Existing Members MAGI rules begin to be applied April 1, 2014 or at next renewal, whichever is later • Note: If a member reports a change before their renewal, they can also be subject to MAGI rules Protecting and promoting the health and safety of the people of Wisconsin

14. Reminder – Eligibility Determinations While it is important for everyone to know what questions will be asked of applicants, please remember that income maintenance (IM) workers determine eligibility.The information in this training will allow you to help applicants submit complete and accurate applications. Protecting and promoting the health and safety of the people of Wisconsin

15. Reminder – “Expect to…” • For MAGI questions, ACCESS will ask about what individuals are planning to do for the current tax year in which they are applying, not the previous year. • Example: If applying for benefits in March 2014, ACCESS will ask about the taxes that the individual expects tofile for income received in 2014. Protecting and promoting the health and safety of the people of Wisconsin

16. Reminder – Documents • Except for self-employed individuals, applicants will not be required to submit tax documents from previous years. • However, some previously filed tax documents, such as a Form 1040, may be helpful in figuring out how individuals plan to file for the current year. They could help figure out: • Whether spouses file jointly or are married filing separately, and • Who and when they have claimed tax dependents in the past. • Current pay stubs can also help someone find out what pre-tax deductions they have. • Note that pay stubs are generally required to verify income • It will be helpful for the applicant to have their pay stubs available, if applicable, when they complete their application Protecting and promoting the health and safety of the people of Wisconsin

17. Reminder – Important Information • It is important, but not required, that applicants have the name(s), date(s) of birth, and, where applicable, Social Security Number(s) for all individuals in the household. • Having this information allows Income Maintenance Agencies to utilize data exchanges to verify some information provided on the application and reduce the amount of information or proof that the individual is asked for on the verification checklist. Protecting and promoting the health and safety of the people of Wisconsin

18. Updates from the Field: Discussion with Partners, RENs • Marketplace Best Practices w/ Covering Kids & Families • REN & Community Updates Protecting and promoting the health and safety of the people of Wisconsin

19. Questions & Resources • To view archived trainings that go more in-depth into topics discussed today please go to http://www.dhs.wisconsin.gov/health-care • For questions that were not answered today, or that come up after this presentation, please send them to: • DHSHealthCare@dhs.wisconsin.gov • Note: Do not send personal health information or personally identifiable information to the inbox • For current, up to date information on BadgerCare Plus in 2014, please visit http://www.dhs.wisconsin.gov/health-care/ Protecting and promoting the health and safety of the people of Wisconsin

20. Additional Resources – Marketplace/Exchange • Marketplace Checklist and Employer Coverage Tool https://www.healthcare.gov/downloads/MarketplaceApp_Checklist_Generic.pdf • Kaiser Family Foundation – FAQs About ACA http://kff.org/health-reform/faq/health-reform-frequently-asked-questions/ • Kaiser Family Foundation – Fact Sheets http://kff.org/health-reform/fact-sheet/obamacare-and-you/ Protecting and promoting the health and safety of the people of Wisconsin

22. Marketplace Overview October 28, 2013 Covering Kids & Families - Wisconsin Updated October 24, 2013

23. Topics to be Covered • What is the Affordable Care Act (ACA)? • Individual Mandate • What is the Marketplace? • Essential Health Benefits • Coverage Tiers • Catastrophic Plans • What is the Cost of Coverage? • Financial Assistance • Premium Tax Credits • Cost-Sharing Subsidies • Out of Pocket Maximum • Household size • Modified Adjusted Gross Income (MAGI) • Enrollment Periods • Application and Enrollment Process • Marketplace Practice Tips and Troubleshooting Updated October 24, 2013

24. What is the ACA? • Also known as the Patient Protection and Affordable Care Act, ACA, ObamaCare and the Health Reform Law, it: • Provides new rules to improve the overall health care system • Improves coverage for those with health insurance • Provides coverage for people who are uninsured or looking for new coverage, beginning in 2014 Updated October 24, 2013

25. ACA – Current Provisions • Free preventive care for those with insurance, including Medicare • Financial assistance for seniors for prescription drugs • No lifetime limits on coverage of essential benefits • Young adults on parent’s private insurance plans until age 26 • Children cannot be denied coverage for having pre-existing conditions • Tax breaks for small businesses to provide coverage • Increased funding to community health centers and programs through Prevention and Public Health Fund Updated October 10, 2013

26. ACA – 2014 Provisions • Adults cannot be denied coverage for pre-existing conditions. • Annual limits on insurance coverage eliminated • Medicaid eligibility may change, based on each state’s decision • October 1, 2013 – Opening of the Health Insurance Marketplace/Exchange and the Small Health Options Program (SHOP) • Government will provide tax credits to purchase coverage for individuals within specific income ranges • Individual Mandate – most individuals are required to have insurance or pay a fee Updated October 10, 2013

27. Individual Mandate • Most individuals will be required to have insurance or pay a tax penalty/fee • 2014: $95 per adult or 1% of income • 2016: $695 per adult or 2.5% of income • Penalty also referred to as the “Shared Responsibility Payment” • Individuals may be uninsured for a period of up to three months before penalty would apply Updated October 10, 2013

28. Individual Mandate Exemptions • Some individuals may be exempt including: • Religious conscience; • Membership in a health care sharing ministry; • Member of an Indian tribe; • Taxable income below the threshold to pay taxes ($9,750 for individual in 2013 tax year) • Hardship (based on personal circumstance or a lack of affordable coverage); and • Ineligible for Medicaid based on a state’s decision not to expand (In WI - income between 100-133% FPL - $958-$1,245 per month for an individual). Updated October 24, 2013

29. Individual Mandate Exemptions • How do individuals apply for/claim exemptions? • Religious conscience and most hardship exemptions – apply for exemption certificate through the Marketplace • Member of an Indian tribe, members of health care sharing ministries and incarcerated individuals - apply for exemption certificate through the Marketplace certificate, or claim the exemption on federal income tax returns • Unaffordable coverage, short coverage gaps, certain hardships, and individuals who are not lawfully present can only claim the exemption on federal income tax returns • Individuals not required to file tax returns are automatically exempt, without further action Updated October 24, 2013

30. What is the Marketplace? • A website people can go to compare insurance plans, purchase healthcare coverage and apply for discounts (tax credits) on their premiums- www.healthcare.gov • Active October 1, 2013 • Marketplaces are managed either by the state or the federal government - Wisconsin’s is managed by the federal government • Call center available at 1-800-318-2596 Updated October 10, 2013

31. What is the Marketplace? • Citizens and people who are lawfully present who are not incarcerated can access the Marketplace • In the Marketplace, an individual or family can apply for: • Medicaid (BadgerCare+) • Private plans • Catastrophic plans • Those with income below 400% of the FPL can qualify for tax credits if they do not have access to affordable employer group insurance Updated October 10, 2013

32. Insurance Plans in the Marketplace • Insurance plans available through the Marketplace must be qualified and cover 10 essential health benefits • People can choose which plan works for them based on its value and cost, based on a standard summary of benefits and coverage • Plans are categorized as Platinum, Gold, Silver, or Bronze • Plans may choose to include dental coverage for adults (dental coverage for children is required) or to offer a stand alone dental plan for adults Updated October 24, 2013

33. Essential Health Benefits • Qualified Health Plans in the Marketplace must cover: Updated October 10, 2013

34. Coverage Tiers in the Marketplace • 4 levels with different actuarial value for each metal tier (percentage of cost for health services covered by the insurance plan): • Bronze – 60%, Silver – 70%, Gold – 80%, and • Platinum – 90% • Bronze plans will have the lowest premiums (besides catastrophic), but the highest cost sharing (deductibles, copays and coinsurance) Updated October 11, 2013

35. Coverage Tiers in the Marketplace • Platinum plans have the highest monthly premiums, but the lowest cost sharing (deductibles, co-pays and coinsurance) • Participating insurers must offer at least one plan at the “silver” level and one at the “gold” level of cost sharing Updated October 11, 2013

36. Catastrophic Plans • A high-deductible-low-premium plan for young adults under age 30or qualify for a hardship exemption; includes free preventive care; available inside or outside the Marketplace • Advantage: Beneficial for people who cannot afford traditional plan premiums or who are healthy and do not need routine care • Disadvantage: Costs for routine care before the deductible is met can accumulate rapidly, no premium assistance available Updated October 10, 2013

37. WI Insurers in the Marketplace Available Plans Vary by County Common Ground Healthcare CooperativeCompcare Health Services Insurance CorporationDean Health Plan, Inc.Group Health Cooperative of South Central WisconsinGundersen Health Plan, Inc.Health Tradition Health PlanMedica Health Plans of WisconsinMercyCare HMO, Inc.Molina Healthcare of Wisconsin, Inc.Physicians Plus Insurance CorporationSecurity Health Plan of Wisconsin, Inc.Unity Health Plans Insurance Corp.Arise (WPS Health Plan, Inc.) Updated October 10, 2013

38. WI Insurers in the Marketplace • Most areas in Wisconsin have between 1-4 insurance companies offering plans • Insurers may offer more than one plan at each metal tier • The plans are structured as Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs) or Point of Service plans (POSs) • For a list of participating insurance companies in each county go to: http://oci.wi.gov/pressrel/0913serviceareas.htm Updated October 24, 2013

39. What is the Cost of Coverage? • Premiums are influenced by: • geographic location • age • tobacco use (if the plan chooses to apply a tobacco surcharge) • The most an individual will pay for premiums is between 2-9.5% of their income • Go to the Kaiser Family Foundation Premium calculator for a cost estimate: http://kff.org/interactive/subsidy-calculator/ Updated October 10, 2013

40. What is the Cost of Coverage? • Total costs (premiums, deductibles, co-pays and co-insurance) will vary based on the plan and tier of coverage • All plans are subject to a maximum out-of-pocket limit in 2014 of $6,350 for an individual and $12,700 for a family (out of pocket limits are lower for those who qualify for cost-sharing reductions) • Out-of-pocket limits do not include premiums • All plans are required to provide free preventative services such as an annual exam, blood pressure and cancer screenings, and immunizations Updated October 25, 2013

41. Financial Assistance • Congressional Budget Office estimates that 7/8 people will qualify for financial assistance in the form of a premium tax credit or cost sharing subsidy • Premium Tax Credits (PTCs) are available for individuals with income between 100-400% FPL • $11,490-$45,960 for an individual • $23,550-$94,200 for a family of four • Cost-sharing assistance is available for individuals with income between 100-250% FPL (must purchase silver level plan!) • $28,725 for an individual • $58,875 for a family of four Updated October 11, 2013

42. Annual Income Categories: Federal Poverty Level (FPL), 2013 Updated October 10, 2013

43. Financial Assistance - Eligibility • Must not have access to “minimum essential coverage” from: • Medicare; • Medicaid; or • An offerof Employer-Sponsored Coverage that is “adequate” and “affordable” • What is “adequate and affordable” Employer-Sponsored Coverage? • Adequate – minimum value of at least 60% of total costs • Affordable – employee-only coverage costs less than 9.5% of household income Updated October 11, 2013

44. Financial Assistance - Eligibility • ALL family members who are offered adequate and afordable coverage through an employer sponsored group plan are ineligible for financial assistance in the Marketplace. • If employer offers individual coverage that meets the minimum essential coverage test but does not offer any family coverage, spouse and dependents are eligible for subsidies • If employer offers individual coverage that meets the minimum essential coverage test and offers employee and dependent coverage (not including spouse), employee and dependents are not eligible for subsidies but the spouse is Updated October 11, 2013

45. Premium Tax Credit • Amount of the PTC is based on the cost of second lowest cost silver plan in the individual’s geographic area and the amount the individual is expected to pay (sliding scale of 2%-9.5% of family income) • Eligibility determination and amount of PTC is made through the Marketplace • Full amount of the PTC can be used to purchase any plan sold on the Marketplace – if you buy a bronze level plan, the PTC will cover more of the premium, if you buy a platinum level plan, the PTC will cover less of the premium cost Updated October 11, 2013

46. Premium Tax Credit Source: Center on Budget and Policy Priorities http://www.cbpp.org/files/QA-on-Premium-Credits.pdf Updated October 30, 2013

47. Premium Tax Credit Source: Center on Budget and Policy Priorities http://www.cbpp.org/files/QA-on-Premium-Credits.pdf Updated October 30, 2013

48. Premium Tax Credit Example • John is 24 years old • His annual income is $22,980 = 200% FPL • Benchmark Silver plan for John = $5,000 annual premium • Expected contribution is 6.3% of income = $1,448 a year • John’s Premium Tax Credit = $3,552 ($5,000-$1,448) annually or $304 per month • John will pay $1,448 annually or $120.66 monthly for a silver plan • If John bought a Bronze plan that costs $3,000 a year, he would no premium because his annual credit is $3,552. Source: Center on Budget and Policy Prioritieshttp://www.cbpp.org/files/QA-on-Premium-Credits.pdf Updated October 11, 2013

49. Receiving Premium Tax Credits • PTCs are refundable, so individuals with little or no income can still benefit (like the Earned Income Tax Credit), however, taxes must be filed • PTCs can be paid “in advance,” directly to the insurance company • Advanced PTCs allow individuals to only pay their portion of the premium to the insurer • Don’t have to take PTCs in advance, or take full amount • Advance PTCs are subject to reconciliation upon tax filing • Reporting changes in income throughout the year • is critical Updated October 11, 2013

50. Cost-Sharing Assistance • The Cost-Sharing Reduction is designed to increase the actuarial value of the silver plans (70% without Cost-Sharing Assistance). • CAUTION: The consumer must purchase a silver level plan to receive the cost-sharing assistance. Updated October 30, 2013