Qualified Health Plans

Report
Washington Health Benefit Exchange
Qualified Health Plans
SUMMER 2013
NAVIGATOR/IN-PERSON ASSISTER PROGRAM
Purpose
Purpose:
This presentation will provide a high level overview of
Qualified Health Plans (QHPs) available through the
Washington Healthplanfinder.
More in-depth information and procedures will be
included in the Healthplanfinder system training
module.
Course Summary
•
Program rules and guidelines related to Individual
Eligibility and Enrollment for Qualified Health Plan
(QHP) programs.
•
Application, eligibility results, QHP enrollment
and payment for individuals and households
applying for coverage.
•
Pediatric dental plans
3
Learning Objectives
Upon completing this module, you will
• Understand the different types of health care
coverage available through the Healthplanfinder
• Know program rules and guidelines related to
Qualified Health Plans for either an individual or for
an entire household
• Understand basis for eligibility results
• Know the steps to facilitate plan selection and
enrollment
Learning Objectives (Continued)
Upon completing this module, you will also
understand:
• The functions performed through the Federal Hub
in verifying applicant information
• Reasons for non-eligibility (incarceration,
citizenship, non-WA resident, etc.).
5
Exchange – A Single Doorway
Public Insurance
Private (commercial) Insurance
Medicaid (Apple Health)
Subsidized (tax credits)
<138% FPL
139-400% FPL
Unsubsidized
>400% FPL
Exchange
6
What is a Qualified Health Plan?
▪ A health insurance plan that has been certified by
The Office of Insurance Commissioner as meeting
all state rules and requirements.
▪ Approved by the HBE as meeting the requirements
of a Qualified Health Plan to be offered through the
Washington Healthplanfinder.
▪ A plan that provides comprehensive coverage by
meeting the standard of “10 Essential Benefits”
7
Qualified Health Plans
Key Point
▪ Commercial insurance plans offered through the
Healthplanfinder
▪ The same insurance carriers as outside the
Exchange (Group Health, Regence, Lifewise, etc.)
▪ Subject to open enrollment periods
▪ Regulated/certified by the Office of the Insurance
Commissioner
▪ Approved by the Health Benefit Exchange Board
8
In General…
▪ Plans with higher PREMIUMS have lower cost
sharing and/or richer coverage
Key Considerations
for Selecting a Plan
▪ Premium – monthly payment to be insured
▪ Cost sharing – you pay some, insurance pays some
▪ Deductible
▪ Co-insurance – a percentage
▪ Co-pay – a predetermined amount per visit
▪ Coverage – what services are part of the “package”?
▪ Providers – which ones participate in the plan?
10 Essential Benefits
Ambulatory Services
Laboratory Services
Emergency Services
Prescription Drug
Hospitalization
Rehabilitative/Habilitative
Maternity/Newborn Care
Preventive/Wellness
Mental Health and Substance
Abuse
Pediatric (including vision
and dental)
Key Point
11
Metal Tiers
Key Point
Bronze Level
Silver Level*
Gold Level
Platinum Level
Bronze plan
benefit coverage
is equivalent to:
Silver plan
benefit coverage
is equivalent to:
Gold plan
benefit coverage
is equivalent to:
Platinum plan
benefit coverage
is equivalent to:
60%
70%
80%
90%
* All plans are eligible for tax credits.
Actuarial Value: The amount (%) of the bill that the insurer pays
12
Health Insurance Premium Tax Credits
(HIPTC)
Key Point
▪ Designed to make premiums affordable for individuals
and families with lower incomes
▪ Only available to individuals and families with income
up to 400% Federal Poverty Level (FPL)
▪ Can be used to reduce monthly premiums
▪ Can be claimed as a credit on annual tax return
▪ Applications must be completed through Washington
Healthplanfinder
13
Premium Tax Credit and Cost Sharing Reductions
Key Point
Premium Tax Credits
Income Level
Up to 133% FPL
Cost Sharing Reductions
Premium as Percent of Income
Income Level
2% of income
133-150% FPL
3-4% of income
150-200% FPL
4-6% of income
200-250% FPL
6-8% of income
250-300% FPL
8-9% of income
300-400% FPL
9.5% of income
*Of the second lowest cost Silver plan
14
Reduction in Out-of-Pocket Liability
100-150% FPL
94% of the actuarial value*
150-200% FPL
87% of the actuarial value
200-250% FPL
73% of the actuarial value
Insurance Carriers in Exchange
as of September 4, 2013
▪
Community Health Plan of Washington
▪
Molina Health Care of Washington – King Pierce & Spokane
▪
Group Health Cooperative – Benton, Columbia, Franklin,
Island, King, Kitsap, Kittitas, Lewis, Mason, Pierce, San Juan,
Skagit, Snohomish, Spokane, Thurston, Walla Walla,
Whatcom, Whitman, and Yakima
▪
Lifewise – All 39 counties
▪
Premera Blue Cross – All counties except Clark
▪
Bridgespan – King, Kitsap, Pierce, Skagit, Snohomish,
Thurston, and Spokane
▪
Kaiser Foundation Health Plan – Clark and Cowlitz
15
Pediatric Dental Plan
Insurance Carriers in the Exchange
as of September 4, 2013
1) Delta Dental of Washington
2) Kaiser Foundation Health Plan
3) LifeWise
4) Premera Blue Cross
Health Insurance Programs and Benefits
Competitively Priced Qualified Health Plans (QHP)
• Individuals or families with income above 400% of the Federal
Poverty Level (FPL) can purchase a QHP at the insurance
carrier’s published premium cost
• QHPs are offered through commercial carriers such as Blue
Cross Blue Shield, Aetna, etc.
• Consumers choose a plan that best meets their health and
financial needs
• Families with children under 19 must enroll the children in a
pediatric dental plan
• Parents can cover children up to age 26 under a family plan
17
Health Insurance Programs and Benefits
Free and Low-Cost Opportunities
• Individuals or households with income below 400 % of the Federal
Poverty Level (FPL) are eligible for free or low-cost options.
• Based on household size and income, applicants can qualify for
either:
• Washington Apple Health (Medicaid) – no cost
• Health Insurance Premium Tax Credit (HIPTC) – reduced premium
rates (must get a Silver Plan to qualify)
• Additional reductions are available to those with the lowest incomes
(< 250% FPL) to reduce out of pocket expenses such as deductibles
and co-pays
18
Eligibility & Enrollment Flow - QHP
Account Creation
Application Data
Collection
Eligibility
Determination
Post Application
Shopping
QHP Enrollment &
Pediatric Dental
Enrollment
Payment
19
Primary Applicant
The primary applicant is an individual who creates an account on Washington
Healthplanfinder and initiates one of three types of applications types.
Individuals:
Household:
1. Myself
2. Myself and others
3. Other household members
20
Questions
21
Lesson 1
Application Type ‒ Individual
22
Account Creation
Account Creation
Application Data
Collection
Eligibility
Determination
Post Application
Shopping
QHP Enrollment &
Pediatric Dental
Enrollment
Payment
23
Account Creation
From the homepage there are two paths to creating an account:
Anonymous
Browsing
Projected Plan
Options
Qualified Health
Plan (QHP)
Free and LowCost Health
Insurance
Required to
Create and
Account
Not Required
to Create
Account
Create Account
Qualified Health
Plan (QHP)
Free and LowCost Health
Insurance
Required to
Create and
Account
Not Required
to Create
Account
24
Application Data Collection
Once an account is created – the first step in applying for
coverage is Application Data Collection.
The following data pages need to be completed:
1.
2.
3.
4.
5.
6.
About You
Contact Information
Additional Questions
Tribal Membership
Application Review
eSignature
25
Application Options
For Qualified Health Plan (QHP)
Programs, the Applicant would
select “No.”
For Free and Low Cost Health
Insurance programs, the Applicant
would select “Yes.”
26
Confidential Information
▪ Personal information must be disclosed throughout
the application process
▪ The primary applicant and all household members
who reside in the applicant’s household
▪ Income information and tax filing status
▪ Family composition and relationships, including
custody
27
Federal Hub Verification
The primary applicant’s social security number will be verified by the Federal
Hub.
Application Data
Collected:
Social Security
Number
Homeland
Security
Federal Hub
Response:
Verified
INS
IRS
Unverified
Federal Hub Data Verifications are stored in the Healthplanfinder and are not
visible to the consumer.
28
Conditional Eligibility
If any member of the household is
deemed conditionally eligible,
additional documentation will be
required as shown in these screens.
The primary applicant will have 90 days
to submit required documentation.
29
American Indians/Alaska Natives
▪ Special provisions
▪ Tribal members can be served by a non-tribal InPerson Assister or a Tribal Assister
▪ Training Module for serving AI/AN
30
Eligibility & Enrollment Flow (Qualified Health
Plan (QHP))
Account Creation
Application Data
Collection
Eligibility
Determination
Post Application
Shopping
QHP Enrollment &
Pediatric Dental
Enrollment
Payment
31
Eligibility Determination – Federal Hub
In order for an individual to be eligible for a Qualified Health Plan
(QHP) on Washington Healthplanfinder, he or she must be:
1. A U.S. citizen or lawfully present
Homeland
Security
2. Not incarcerated
INS
3. A resident of the State of Washington
IRS
When the Federal Hub verifies the individual’s SSN, it also looks for
Citizenship and Incarceration status associated with that SSN.
32
Eligibility Results
▪ Eligibility determined for each family member
▪ Coverage options displayed based on eligibility
▪ If eligible for Qualified Health Plan, the consumer will use
tools to compare and select a Plan
▪ Plan details can be viewed side by side
▪ Payment entry finalizes the transaction
33
Eligibility Rules
(what the system uses to “decide” eligibility)
Eligibility Determination
Business Rule
Eligible
• SSN verified
• Citizenship or lawful presence verified
• Resident of Washington
Conditionally Eligible
• SSN not verified or SSN is verified as “Match
for Death”
• Citizenship or lawful presence not verified
• Primary applicant has 90 days to provide
documentation
Denied
• Incarcerated – unless entered the disposition
question as “Yes”
• Not resident of Washington
34
Knowledge Check
What are the three different application types for
eligibility on Washington Healthplanfinder?
a. Myself
Myself and Others
b. _______________
Other Members of My Household
c. __________________________
35
Knowledge Check
Who creates an account on Washington
Healthplanfinder and initiates one of three types of
applications types?
a. Exchange Administrator (EA)
b. Primary Applicant
c. Household
d. Myself and Others
36
Knowledge Check
What organization verifies the social security number
of the primary applicant?
a. Federal Hub
b. eHealth
c. Eligibility Services
d. Washington Healthplanfinder
37
Knowledge Check
Which of the following it not true about Qualified
Health Plan (QHP) programs?
a. Households can claim children up to age 26 under
the parents' plan.
b. Consumer choice offered through plan selection
and metal levels.
c. Applicants eligible for QHPs only.
d. Applicants automatically enrolled in plans.
38
Questions
39
Lesson 2
Application Type – Household (All
Eligible Members)
40
Application Types
The primary applicant is an individual who creates an account on Washington
Healthplanfinder and initiates one of three types of applications types.
Individuals:
Household:
1. Myself
2. Myself and others
3. Other household members
41
QHP Eligibility & Enrollment Flow
Account Creation
Application Data
Collection
Eligibility
Determination
Post Application
Shopping
QHP Enrollment &
Pediatric Dental
Enrollment
Payment
42
Application Data Collection
When the primary applicant enters data for themselves and their
household, the data collected will be the same as for an individual.
The sections bolded below will be completed for both the primary
applicant and the other household members.
1.
2.
3.
4.
5.
6.
7.
About You
Contact Information
About Your Household*
Additional Questions*
Tribal Membership*
Application Review
eSignature
43
Household Composition Rules
To be considered part of the same household, the household
member must have one of the following relationships to the
primary applicant:
1. Legal Guardian
2. Child (up to age 26)
3. Spouse (including same sex marriage)
4. Spouse (including domestic partners)
Other family members living in the same home, such as
nieces/nephews, aunts/uncles, cousins, and grandmothers/
grandfathers would not be considered part of the household
application for eligibility determination.
44
Children Up to Age 26
▪ Children up to age 26 are eligible to be covered under
their parent’s plans.
• Common Examples:
 College Students
 Young Professionals
• Children do not need to live in the
same
household or location as the parents to qualify.
• For instance, a child away at college would still be
covered under his or her parent’s plan.
45
Eligibility Determination
Primary Applicant
Completes “About
You”
Primary Applicant
Enters Contact
Information
SSN Verification
HS
INS
Primary Applicant
Completes “About
Your Household”
IRS
SSN Verification
IRS
Primary Applicant
Completes
Additional
Questions
HS
Primary Applicant
Completes
Application Review
INS
IRS
Primary Applicant
Completes
eSignature
Eligibility Results
Displayed
46
Eligibility & Enrollment Flow (QHP)
Account Creation
Application Data
Collection
Eligibility
Determination
Post Application
Shopping
QHP Enrollment &
Pediatric Dental
Enrollment
Payment
47
QHP & Pediatric Dental Plan Enrollment
For household members over the age of 19:
• The primary applicant will enroll each eligible household
member in a QHP.
For household members under the age of 19:
• The primary applicant will enroll each child in a QHP and is
required to also enroll each child in a pediatric dental plan.
48
Knowledge Check
In order for an individual to be eligible for a Qualified
Health Plan (QHP) on Washington Healthplanfinder,
he or she must:
A. Live with the individual.
B. Not live with the individual.
C. Not be incarcerated.
D. Be employed.
49
Knowledge Check
To be considered part of the same household, the household
member must have one of the following relationships to the
primary applicant:
A. Niece
B. Aunt
C. Grandparent
D. Legal Guardian
50
Knowledge Check
The primary applicant will be required to select and
enroll their qualifying children (up to age 19) in…
A. A health insurance policy of their own.
B. A pediatric dental plan
C. Pediatric health care coverage
D. Summer school
51
Knowledge Check
In a Qualified Health Plan (QHP) scenario, which of the following
family members qualify as members of the primary applicant’s
household?
a. Spouse (including same-sex marriage)
b. Grandfather
c. Child (up to age 26)
d. Answers a and c
52
Knowledge Check
The primary applicant is required to enroll any children under 19
in a pediatric dental plan.
a. True
b. False
53
Knowledge Check
To be eligible for insurance coverage through Washington
Healthplanfinder, you must be:
a. U.S. Citizen or Lawfully Present
b. Not Incarcerated
c. Washington Resident
d. All of the Above
54
Agents-Brokers
• Key partners with IPAs
• Must complete Exchange training
• Must be registered with Exchange
• Listed on Exchange website
• Receive commission for QHP enrollments (paid by carrier)
• No charge to consumers
55
Questions
56
Congratulations! You have completed the
QHP Rules and Guidelines course!
Thank you!
58

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