EVERY DANCER INSURED: NAVIGATING THE ACA Artists Health Insurance Resource Center A program of The Actors Fund Renata Marinaro, Eastern Region Health Svcs Director 917-281-5975, [email protected] What is The Actors Fund? The Actors Fund is a nationwide human services organization that helps all professionals in performing arts and entertainment. The Fund is a safety net, providing programs and services for those who are in need, crisis or transition. www.actorsfund.org Our services  Social Services     The Dancers Resource Center Housing Employment and Training Services Health Services Words to know Co-pay Co-insurance Deductible Premium Out-of-pocket maximum HMO & POS/PPO Federal Poverty Level Marketplace/Exchange Advanced Premium Tax Credit (aka subsidy) What has health care reform done for me so far?    Children under age 19 with pre-existing conditions can’t be denied coverage. Young adults up to age 26 (in NY, through age 29) can stay on or enroll in their parents’ coverage. Note: special rules apply for coverage from age 26-29. Insurers can’t retroactively cancel the policies of people who get sick. What has health care reform done for me so far?   All new plans must cover certain preventive services for free. These include: certain breast, colon and cervical cancer screenings; blood pressure, diabetes and cholesterol tests; vaccines, immunizations, and flu shots; and HIV & STD testing. Insurers can’t impose annual or lifetime dollar limits on medical benefits. What happened January 1, 2014?    Insurers can’t refuse coverage to anyone, or exclude preexisting conditions Most people are mandated to have coverage or pay a penalty. In 2014, the penalty is $95 or 1% of your income, whichever is greater. Exceptions include: Native Americans, those w/religious objections, undocumented immigrants, those who don’t meet tax filing threshold (approx $10,000 single), people who’ve been uninsured for less than 3 mo. What happened January 1, 2014?    Medicaid eligibility in roughly half the states has been expanded to people with incomes up to 138% of FPL (approx $15,856/yr or $1,322 per month) New insurance marketplaces, called Exchanges or Marketplaces, offer insurance to those who don’t get it through their employer or Medicare. Subsidies are available to people who buy insurance through an exchange with income less than 400% of the Federal Poverty Level. ($45,960 single, $62,040 for a couple, $78,120 for a family of 3) When can I enroll? The initial open enrollment period for plans on the Marketplace is October 1, 2013 - March 31, 2014. If you apply between 1st-15th of the month, coverage begins the first of the following month If you apply between the 16th and last day of month, coverage begins the first of the second following month Are there special enrollment situations? In an open enrollment period, you’re free to sign up for a plan or switch plans. Only in limited circumstances will you be able to enroll in or switch plans outside of this period. Circumstances that would trigger a “special enrollment period” include: losing job-based insurance, losing Medicaid coverage because of an increase in income, marriage, divorce, and the birth or adoption of a child. Where do I enroll?    In New York, the Marketplace is called New York State of Health. Visit http://www.nystateofhealth.ny.gov/ or call 1855-355-5777. In California, the Marketplace is called Covered California. Visit http://www.coveredca.com/ or call 1-800-300-1506 In all other states, visit www.healthcare.gov or call 1-800318-2596 to be directed to the Marketplace in your state. This website and phone number will also direct you to local Navigators and In Person Assistors who can help you apply. Yikes - I need help enrolling! The Actors Fund team of Navigators will dedicate January 13 and 14th to helping dancers enroll! If you haven’t signed up already, visit: http://www.danceusa.org/2014dance-forum To find a Navigator or broker: In New York, go here: http://info.nystateofhealth.ny.gov/IPANavigatorSiteLocations In all other states, go here: https://localhelp.healthcare.gov/ Does an employee have to accept an employer’s insurance?    If you choose to opt out of your employer’s coverage, you will still have to be insured or pay a penalty. Employees who are offered coverage and choose not to take it will not be eligible for subsidies to pay for coverage through the Marketplace, unless the employer’s plan fails to meet certain benefit guidelines. Guidelines: Policy must cover at least 60% of medical costs and cannot cost more than 9.5% of employee’s income I’m self-employed. How will this affect me?   You can buy insurance as an individual on the Marketplace, without having to worry about being turned down for preexisting conditions, or paying more because of your medical history or gender. This increases your options and will reduce premiums for those with lower to middle incomes. You may qualify for Medicaid if your income is under $15,856 (single). Considerations when picking a plan Cost of Care • Premium • Deductible • Out of Pocket Max • Do you qualify for APTC? • Do you qualify for Cost Sharing Reductions? Access to Care • Network • HMO or PPO? • Doctors • Hospitals • Benefits • Consider your health status/needs! Quality of Care • Independent ratings • Opinions from family and friends • Feedback from doctors/providers • Personal experience What are the federally mandated essential benefits for every state?       Outpatient services (such as  office visits) emergency services  hospitalization  maternity and newborn care  mental health and substance abuse services  prescription drugs rehabilitative services and devices laboratory services preventive and wellness services chronic disease management pediatric services, including oral and vision care What do the federally-run Exchange plans look like? Tier % of costs covered by insurer Deductible Consumer’s max out of pockets costs Bronze 60% varies $6,350 Silver 70% varies varies Gold 80% varies varies Platinum 90% varies varies Catastrophic 100% after deductible $6,350 $6,350 Note that the catastrophic plan is only available to those who are under age 30 or whose policies were cancelled What are the benefits on the New York Marketplace?       Hospitalization Office visits (PCP & Specialist) Emergency Room Ambulance Mental Health treatment Substance Abuse treatment       Medications Diagnostic and lab work Preventive Screenings (free) Maternity care Chiropraxis Gym reimbursement! What do the plans look like in NY? Tier % of costs covered by insurer Deductible Consumer’s max out of pockets costs Bronze 60% $3,000 $6,350 Silver 70% $2,000 $5,500 Gold 80% $600 $4,000 Platinum 90% $0 $2,000 Catastrophic 100% after deductible $6,350 $6,350 What about family coverage?    If a company offers coverage to an employee, the company must also offer coverage to children (but not spouses). The employer must make insurance “affordable” to the employee (definition: less than 9.5% of household income) but does not have to offer affordable family coverage. If the employer-offered coverage for the employee is “affordable”, then no matter what the employer charges to cover the employee’s dependents, those dependents will not be eligible for government-subsidized coverage on the Marketplace. What about family coverage?   All states have the Children’s Health Insurance Program, which covers kids up to age 18. However, eligibility guidelines vary by state. All children in New York – regardless of parents income - are eligible for Child Health Plus (CHIP). The Marketplace website will determine whether your child qualifies for your state program. Dependents (incl. spouses) who decline employer-provided coverage that they cannot afford will not be penalized under the Individual Mandate if the cost of the family coverage exceeds 8% of modified adjusted gross income. Are there special programs for people under 30?   Under age 30: high-deductible plan option. Deductible is $6,350. Prevention benefits and 3 primary care visits are exempt from deductible. Under age 26: can stay on/enroll in parents’ plan, regardless of living situation, marital status, student status, or financial dependence. In NY, adults age 26-29 can stay on their parents coverage, but special rules apply: you must be unmarried, live or work in NY, and have a policy that was issued in NY. How do I calculate my income?   You are ESTIMATING YOUR 2014 INCOME Use your HOUSEHOLD modified adjusted gross income:  Adjusted Gross Income (guideline: line 37 of Form 1040) +  Non-taxable social security benefits  Tax Exempt Interest  Foreign Earned income For Medicaid eligibility, you can exclude from your income: scholarships, awards and grants (for education only), and certain lump sum one-time payments I’m broke. How Will I Afford Insurance?   If your income is $15,856 (single), you will be eligible for Medicaid. Household Size Income Limit 1 2 3 4 $15,856 $21,404 $26,951 $32,499 Medicaid is a joint federal-state program that provides comprehensive health insurance at no cost to patients. There are no premiums or deductibles, and very small co-pays. Which states expanded Medicaid? Arizona Michigan (April 2014) Arkansas Minnesota California Nevada Colorado New Jersey Connecticut New Mexico Delaware New York DC North Dakota Hawaii Ohio Illinois Oregon Iowa Rhode Island Kentucky Vermont Maryland Washington Massachusetts West Virginia Indiana and Pennsylvania are considering expanding Medicaid post2014; Wisconsin will expand Medicaid to 100%FPL What does it mean if my state didn’t expand Medicaid? Many adults with incomes below 100% of the FPL will fall into a gap. Their incomes are too high to get Medicaid under their state’s current rules, but are too low to qualify for federal help buying coverage in the Marketplace. What does it mean if my state didn’t expand Medicaid?    If your income is more than 100% of FPL -- about $11,500 a year as a single person or about $23,500 for a family of 4 -- you will be able to buy on the Marketplace and receive a subsidy. If you make less than that, you may not qualify for a subsidy. Even if your state doesn’t expand Medicaid coverage, you should still apply. You may qualify under your state’s existing rules. What will it cost to buy coverage on the Exchange/Marketplace?   Costs vary by county and in most states by age. Insurers can no longer charge you more based on your gender or medical history. If your household income is below 400% of the Federal Poverty Level, you’ll receive a subsidy (APTC) to lower the cost of your premiums on the Marketplace. You can apply that amount to whatever level plan you choose. People whose income is below 250% FPL will also qualify for cost-sharing reductions (CSR), which lower the cost of deductibles and co-pays. The CSR applies to Silver Level plans only. Premium subsidies (APTC)    You can take the premium subsidy in advance, or as a tax credit when you file your taxes. Advance payments are made directly to the insurer. If you choose to wait until you file taxes, the credit will be applied to what you owe, or refunded to you. If the advance subsidy payments exceed the amount of credit for which you’re eligible, a portion of the overpayment must be repaid. Subsidy Chart Income as % of Federal Poverty Level Income range for 1 Max % of your person at this level income you will spend on premiums 133-150% 150-200% 200-250% 250-300% 300-400% $15,282-$17,235 $17,235-$22,980 $22,980-$28,725 $28,725-$34,470 $34,470-$45,960 3-4% 4-6.3% 6.3-8.05% 8.05-9.5% 9.5% Example  Example: Susan is single and makes $22,000/yr. At that income level, Susan receives both APTC and CSR. She will have her premiums capped at 6.3% of her income (approx $130/mo for a silver level plan) and her annual out-of-pocket medical costs will be limited to under $4000/yr (excluding premiums). How to Calculate Your Subsidy     New York: calculate your potential subsidy here: http://www.healthbenefitexchange.ny.gov/PremiumEstim ator All other states: calculate your potential subsidy here: http://kff.org/interactive/subsidy-calculator/ For more information visit www.ahirc.org