The SHOP Marketplace

Report
The Affordable Care Act:
Illinois Health Insurance
Marketplace
GIOVANNI GOMEZ
REGIONAL COORDINATOR OF OUTREACH
What is the Affordable Care Act?
 Signed into law on March 23, 2010 by President
Obama.
 Includes provision for states to create Health
Insurance Marketplaces for individuals, families,
and small employers to purchase affordable plans
Consumers can sign up starting Oct. 1, 2013
 Coverage starts Jan. 1, 2014

What does the ACA do now?
 Extend dependent eligibility to age 26
 Children with pre-existing conditions cannot be
denied coverage
 Elimination of lifetime limits on coverage
 Preventive care covered
 Implementation of 80/20 rule that requires
insurance companies spend at least 80% of
premiums on health care
What does the ACA do in 2014?
 Equal premium rates for men and women
 No one can be denied because of a pre-existing
condition
 The extension of Medicaid
 The establishment of the Marketplace

You may qualify for assistance to help with health care
premiums and lower your out-of-pocket costs
What is the Marketplace?
 A place where you can review your options and apply
for health insurance coverage, knowing the
premiums, deductibles, and co-pays ahead of time!
 You can apply at the online marketplace, by phone,
or by mail
 Assistance will be available in-person and over the
phone if you need it.
How will it work?
 One Application Process
 The Marketplace and ABE
Eligibility for Individuals
 U.S. Citizen;
 U.S. National;
 Or otherwise lawfully present during the intended
enrollment period.
 Not incarcerated
 Resident of Illinois
Who is Eligible for Tax Credits?
 Individuals and families with income between 100%
to 400% FPL


Must be US citizens or lawfully present in the US
Must not be eligible for other “minimum essential coverage”

If your offered insurance at work and it fills all the requirements
 Lawfully residing immigrants with incomes below
100% FPL who are not eligible for Medicaid because
of their immigration status
Who is Eligible for Tax Credits?
FPL
Unsubsidized
400%
300%
300%
Marketplace
Subsidized
Premiums on
sliding scale.
200%
200%
133%
100%
Children
(All Kids)
Pregnant
Women
Parents
People w/
Disabilities
Adults w/o
Children
Marketplace Plans
 Must include Essential Health Benefits:
 Ambulatory patient services
 Emergency services
 Hospitalization
 Maternity and newborn care
 Mental health and substance use disorder services
 Prescription drugs
 Rehabilitative and habilitative services and devices
 Laboratory services
 Preventive and wellness services including chronic disease
management
 Pediatric services including oral and vision care
Marketplace Plans
 Medaled plans:
 Medal level signifies actuarial value, not content, of plan
Platinum
 Gold
 Silver  Benchmark Plan
 Bronze

 Catastrophic coverage will be available to people under 30 and those
who qualify for the individual exemption.
Example: Single Individual
 John
 24 years old
 Income of $22, 980 (200%FPL)
 Expected Contribution: 6.3% or $1,448
 Plans Covering John
 Gold: $5,200
 Silver Plan: $5,000
 Bronze: $4,800
 Benchmark Plan
 Premium Credits
 $5,000 - $1,448= $3,552
*These are not official prices*
$3,552
$3,552
$3,552
$3,552
$1,848
$1,648
$1,448
$1,248
Eligibility for Individuals
 You could get a break on costs:

Consumers between 100% and 400% FPL are eligible for tax
subsidies that are applied to premiums.

Consumers between 100%-250% FPL can receive cost-sharing
reductions.
 Must be enrolled in a silver plan from the marketplace
 Must be eligible for the tax credit
Both are on a sliding scale.
 Consumers also receive a cap on out-of-pocket spending.

Eligibility for Individuals
 Those who receive employer-provided insurance that
meets ACA standards of value and affordability can
apply for coverage on the Marketplace, but they are
not eligible for tax subsidies.
Who Can Help You Through The Process?
 The IL Assistor Program
 The In-person Counselor program (IPCs) & Navigators
 No Wrong Door Policy
 Certified Application Counselors (CACs)
 They will help you every step of the way.
Questions?
 Contact Information
 Giovanni Gomez
 Email: [email protected]

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