PNA COMPANY Presents Healthcare Reform for Individuals

Report
PNA COMPANY
Presents
Healthcare Reform for
Individuals/Families
This PowerPoint contains
information we have gathered from
state and federal communications.
Although largely accurate, the
governing bodies “CAN” and “MAY”
change some of what you hear today.
Bottom Line: This is what we know
TODAY.
Exchange Timeline
HEALTHCARE REFORM
Patient Protection & Affordable Care Act (PPACA)
Also-Known-As (AKA) - “OBAMACARE”
1.
2.
March 23, 2010 - Healthcare law enacted.
3.
4.
5.
6.
July 11, 2011 - HHS issued first set of proposed rules
August 2010 - HHS (Health and Human Services Dept.) started issuing
planning grants to states.
June 28, 2012 - Supreme Court approves PPACA
October 1, 2013 - Open enrollment begins
January 1, 2014 - Mandatory Exchange coverage begins
PPACA Annual Open Enrollment period (AOE)
• October 1, 2013 till March 31, 2014
• October 15, 2014 till December 7, 2014
• October 15, 2015 till December 7, 2015
• October 15, 2016 till December 7, 2016
NO UNDERWRITING/GUARANTEED ISSUE
Penalties for Individuals under PPACA:
• 2014 – The Greater of $95 or 1% of taxable income
• 2015 – The Greater of $325 or 2% of taxable income
• 2016 – The Greater of $695 or 2.5% of taxable income
• 2017 and beyond - Annual adjustments
In California, ACA will subsidize at 100% of
the premium up to 138% of the Federal
Poverty Level (FPL). Once you have
identified eligibility based on the client’s
Modified Adjusted Gross Income (MAGI)
found on the first page of your 1040, other
factors decide the final subsidy.
Modified Adjusted Gross Income (MAGI)
• The Modified Adjusted Gross Income (MAGI) is calculated by adding back
certain items to your Adjusted Gross Income. Your Adjusted Gross Income
(AGI) can be found on line 38 of your Form 1040; line 22 of your Form 1040A;
or line 36 of your Form 1040NR. IF YOU HAVE NOT FILED A PRIOR YEAR TAX
RETURN, NO SUBSIDY WILL BE GIVEN!
• The following items must be added to your Adjusted Gross Income (AGI) to
calculate your Modified Adjusted Gross Income (MAGI):
 Traditional IRA contributions that were deducted.
 Student loan interest amounts deducted.
 Tuition and fees deducted.
 Domestic production activities deducted.
 Foreign income or housing costs excluded on Form 2555.
 Foreign housing deduction taken on Form 2555.
 Savings bond interest excluded on Form 8815.
 Adoption benefits from an employer excluded on Form 8839.
2013 Federal Poverty Level
Household
Size
100%
138%
150%
200%
300%
400%
1
$11,490
$15,856
$17,235
$22,980
$34,470
$45,960
2
$15,510
$21,403
$23,265
$31,020
$46,530
62,040
3
$19,530
$26,951
$29,295
$39,060
$58,590
$78,120
4
$23,550
32,499
$35,325
$47,100
$70,650
$94,200
5
$27,570
$38,046
$41,355
$55,140
$82,710
$110,280
6
$31,590
$43,594
$47,385
$63,180
$94,770
$126,360
7
$35,610
$49,141
$53,415
$71,220
$106,830
$142,440
8
$39,630
$54,689
$59,445
$79,260
$118,890
$158,520
Each
extra
Person
$4,020
$5,547
$6,030
$8,040
$12,060
$16,080
Healthcare Providers in CA
2.6 Million are eligible for Premium Subsidies and 2.7 are uninsured in CA, 5.3 total
58 COUNTIES
HOSPITAL
PHYSICIANS
Anthem Blue Cross
All regions
300
30,000
Blue Shield of CA
All regions
223
22,040
Healthnet
13 counties
204
44,000
Kaiser
All Regions
(except 9)
35
14,219
12
10
9
31,000
5,000
315
6
176
HMO
LA Care H.P.
Valley Health Plan
6 (Alameda)
5 (Contra Costa)
4 (SF) San Mateo
12 (San Luis Obispo,
Ventura)
15 & 16 (LA)
7 (Santa Clara)
NETWORK
PPO
EPO (SF 4)
HMO (Santa Clara 7)
PPO
EPO (Monterey)
2,4,5,7,8,9,10,14,
15,16,17,18,19
PPO/HMO (LA)
HMO Santa Cruz,
Monterey,
San Bernito
HMO
HMO
HMO
35
4
1,005
993
HMO
HMO
Molina Health Care
3 (Sacto), 15,16,17,19
29
4,508
HMO
2,3
15
3,000
HMO
19
7
2,600
HMO
Alameda Alliance
Contra Costa H.P.
Chinese Community H.P.
Ventura County H.C.P.
Western Health
Advantage
Sharp Health Care
Standard benefits for Individuals
KE Y B E N E F IT S
S ilve r 70 / 3 0
B ro nz e 6 0 / 4 0
Go ld 8 0 / 2 0
P l a t i num 9 0 / 10
Ded uct ib le (if any)
$2 0 0 0 M ed ical Ded uct ib le
$5,0 0 0 Ded uct ib le fo r
M ed ical and Drug s
No Ded uct ib le
No Ded uct ib le
Prevent at ive C are
No C o s t
at leas t 1 yearly vis it
No C o s t
at leas t 1 yearly vis it
No C o s t
at leas t 1 yearly vis it
No C o s t
at leas t 1 yearly vis it
Primary C are Vis it
$4 5
$6 0 - 3 vis it s p er year
$3 0
$2 0
Sp ecialt y C are Vis it
$6 5
$70
$50
$4 0
Urg ent C are Vis it
$6 0
$12 0
$9 0
$4 0
Generic M ed icat io n
$2 5
$2 5
$2 0
$5
Lab Tes t ing
$4 5
30%
$3 0
$2 0
X-R ay
465
30%
$50
$4 0
Emerg ency R o o m
$2 50
$3 0 0
$2 50
$150
3 0 % o f yo ur p lan's
neg o t iat ed rat e
HM O
Out p at ient Surg ery $6 0 0
Ho s p it al - $6 0 0 / d ay up
t o 5 d ays
PPO - 2 0 %
HM O
Out p at ient Surg ery $2 50
His p it al - $2 50 / d ay up t o
5 d ays
PPO - 10 %
$2 50
$150
$50 -$75 aft er meet ing
d ed uct ib le
No Ded uct ib le
No Ded ucct inle
Hig h co s t and infreq uent
s ervices like His p it al C are
and Out p at ient Surg ery
$2 50
Imag ing
(M R I, C T, PET Scans )
$2 50
B rand M ed icat io ns may
b e s ub ject t o Annual
Drug Ded uct ib le b efo re
yo u p ay t he co p ay
$2 50 d ed uct ib le t hen p ay
t he co p ay amo unt
40%
Preferred b rand co p ay
aft er Drug Ded uct ib le
(if any)
$50
$50
$50
$15
M AXIM UM OUT-OFPOC KET FOR ONE
$6 ,4 0 0
$6 ,4 0 0
$6 ,4 0 0
$4 ,0 0 0
M AXIM UM OUT-OFPOC KET FOR FAM ILY
$12 ,0 0 0
$12 ,8 0 0
$12 ,8 0 0
$8 ,0 0 0
Sliding Scale for Silver Plan
A nnua l Inc o me - - >
$15,8 56 -$17,2 3 5
$17,2 3 5-$2 2 ,9 8 0
$2 2 ,9 8 0 -$2 8 ,72 5
$2 8 ,72 5-$4 5,9 6 0
KE Y B E N E F IT S
$19 -$57
$57-12 1
$12 1-$19 3
$19 3 -3 6 4
Ded uct ib le (if any)
No Ded uct ib le
$50 0
Prevent at ive C are
No C o s t
No C o s t
No C o s t
No C o s t
1 Annual Vis it
$1,50 0 M ed ical Ded uct ib le $2 ,0 0 0 M ed ical Ded uct ib le
Primary C are Vis it
$3
$15
$4 0
$4 5
Sp ecialt y C are Vis it
$5
$2 0
$50
$6 5
Urg ent C are Vis it
$6
$3 0
$8 0
$9 0
Generic M ed icat io n
$3
$15
$4 0
$4 5
Lab Tes t ing
$5
$2 0
$50
$6 5
X-R ay
$3
$5
$2 0
$2 5
Emerg ency R o o m
$2 5
$75
$2 50
$2 50
2 0 % o f yo ur p lan's
neg o t iat ed rat e
2 0 % o f yo ur p lan's
neg o t iat ed rat e
Hig h co s t and infreq uent
s ervices like His p it al C are
and Out p at ient Surg ery
10 %
15%
Imag ing
(M R I, C T, PET Scans )
B rand M ed icat io ns may
b e s ub ject t o Annual
Drug Ded uct ib le b efo re
yo u p ay t he co p ay
No Ded uct ib le
$50 t hen p ay
t he co p ay amo unt
$2 50 t hen p ay
t he co p ay amo unt
$2 50 t hen p ay
t he co p ay amo unt
Preferred b rand co p ay
aft er Drug Ded uct ib le
(if any)
$5
$15
$3 0
$50
M AXIM UM OUT-OFPOC KET FOR ONE
$2 ,2 50
$2 ,2 50
$5,2 0 0
$6 ,4 0 0
M AXIM UM OUT-OFPOC KET FOR FAM ILY
$4 ,50 0
$4 ,50 0
$10 ,4 0 0
$12 ,8 0 0
A blog post (July 11, 2013) created by Marilyn Tavenner, the Administrator of the
Centers for Medicare and Medicaid Services (CMS), clarifies concerns
surrounding Exchange operability after last week’s release of new Affordable Care
Act (ACA) regulations. In the post, Tavenner proclaimed that the Exchanges will
be fully operational by the October 1st enrollment deadline. Of chief import,
Tavenner responded to concerns about whether or not the Exchanges will verify
an applicant’s submitted income information and if there are safeguards in place
to prevent applicants from fraudulently receiving subsidies. Tavenner responded
in the affirmative to both, stating that an applicant’s income will be compared
against tax filings, social security data, and income reports. Tavenner found that
individuals who falsely apply for subsidies will run the risk of receiving a penalty
for perjury, and that the Internal Revenue Services (IRS) already has mechanisms
in place to recollect subsidies that were overpaid or provide subsidies to those
that did not initially receive the correct amount.
Thank you.
www.pnacompany.com
Enrollment
Product type: Health
Product name: OBAMACARE
Comments: Income, Household size, etc.
Kenny Phan (800)810-4762
Email: [email protected]

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