EVERY DANCER INSURED: NAVIGATING THE ACA

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
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Social Services
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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?
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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?
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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?
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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?
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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?
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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?
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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?
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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?
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Outpatient services (such as 
office visits)
emergency services
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hospitalization
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maternity and newborn
care
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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?
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Hospitalization
Office visits (PCP &
Specialist)
Emergency Room
Ambulance
Mental Health treatment
Substance Abuse
treatment
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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?
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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?
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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?
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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?
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You are ESTIMATING YOUR 2014 INCOME
Use your HOUSEHOLD modified adjusted gross income:
 Adjusted Gross Income (guideline: line 37 of Form 1040)
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 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?
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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?
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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?
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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)
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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
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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
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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