Local: (208) 651-6208
Toll Free: (877) 817-1406
1424 Sherman Ave. #400
Coeur d’Alene, ID 83814
info@landersins.com

Your Health Idaho

The Idaho Health Insurance Exchange is coming weather you are ready or not.

(also known as the Affordable Care Act, Obama Care, and the Idaho Health Insurance Marketplace)

 

Open enrollment for the 2014 Idaho Health Insurance Exchange will start on October 1st 2013 and end March 31st 2014.

You can sign up for the Idaho Health Insurance Exchange through the quote box above or at or office located at 1424 Sherman Ave. #400, Coeur d'Alene, ID 83814. We can walk you through all the new coverages, make sure you get all the subsidies you deserve, help you pick out the best plan for you and your family, and answer any questions you might have.

Primary Goal of Obama Care

The primary objective of the Idaho Health Insurance Exchange is to help millions of Americans obtain health insurance coverage. To achieve that goal, the Idaho Health Insurance Exchange provides new coverage options, gives consumers the tools they need to make informed choices about their health care coverage, and puts in place strong consumer protections.

Health Law Changes in the Affordable Care Act

The health law changes include:

  • Creation of Marketplaces, through which individuals who do not have access to public assistance programs or affordable employer-sponsored coverage may compare and purchase plans. Some individuals will be eligible for financial assistance through premium tax credits and/or cost-sharing reductions
  • Expansion of Medicaid in some states to cover individuals under age 65 whose household incomes are less than 138% of the Federal Poverty Level (FPL)
  • Introduction of a requirement that requires individuals to maintain minimum essential coverage, qualify for an exemption from coverage, or make a payment when filing their federal income tax returns

Major Consumer Protections in the Affordable Care Act

The Affordable Care Act included many provisions designed to help ensure that you have access to effective health care coverage, and to limit your costs:

  • Extension of health insurance coverage to children up to age 26
  • Expansion of the "guaranteed issue" requirement to ensure that health insurance issuers offer group and individual market policies to any eligible individual in a state, regardless of health status
  • Prohibition on charging consumers a higher premium based on health status or gender
  • Elimination of annual and lifetime coverage limits
  • Prohibition on coverage limitations or exclusions based on pre-existing conditions
  • Prohibition on precluding a qualified individual's participation in an approved clinical trial, or discriminating against that individual based on such participation
  • Introduction of an 80/20 MLR rule to ensure that at least 80 percent of the premium dollars paid to a health insurance issuer are spent on providing health care

All of these provisions are explained in further detail later in this course.

The Idaho health Insurance Exchange will offer only health insurance plans that are certified as qualified health plans, or QHPs. These QHPs must be licensed and accredited, and must meet certain requirements for transparency. To become certified, a QHP must meet a minimum set of criteria, including the following:

  • Coverage, at a minimum, of a comprehensive package of benefits, known as essential health benefits, or EHB
  • Benefit design standards, including non-discrimination requirements and limits on cost-sharing
  • Network adequacy standards

Five Levels of Coverage

In addition to covering EHB and limiting cost sharing (including out-of-pocket costs), QHPs in The Idaho health Insurance Exchange must also provide coverage that meets one of five levels of generosity.

The five levels of generosity are called catastrophic, bronze, silver, gold, and platinum in ascending order of generosity. These levels sometimes referred to as "metal levels" provide several benefits:

  • Help in comparing coverage options to determine which plans best fit the consumers' needs
  • Help consumers understand their benefits and the cost of services once they enroll
  • Facilitate consumer choice based on specific value comparisons

Catastrophic Plans

Catastrophic plans are offered in the Individual Marketplace and cover EHB. They provide affordable coverage options for young adults and people for whom coverage would otherwise be unaffordable.

Catastrophic plan enrollees pay higher deductibles than enrollees in bronze, silver, gold, or platinum plans. However, catastrophic plans have several benefits:

  • Lower premiums on average than bronze, silver, gold, or platinum plans
  • Protection against out-of-pocket costs above $6,350 for an individual and $12,700 for a family
  • Coverage of recommended preventive services without cost sharing

Eligibility for catastrophic plans is limited to:

  • Individuals under age 30
  • Individuals who otherwise do not have an affordable coverage option, or who otherwise qualify for a hardship exemption to the minimum essential coverage rule

Out-of-Pocket Limits and Minimum Essential Coverage

The Affordable Care Act requires QHPs to provide certain recommended preventive health services without cost sharing or deductible requirements.

All QHPs must limit cost sharing for enrolled individuals in the following ways:

  • Deductibles and copays cannot be applied to preventive services.
  • Deductibles for small group plans cannot exceed $2,000 for self-only coverage or $4,000 for any other coverage (adjusted annually), except to the extent that a higher deductible is necessary to create a reasonable bronze or silver plan.
  • Annual cost-sharing limits cannot exceed the limits for certain high deductible health plans including catastrophic plans. (For 2014 the limits are $6,350 for an individual and $12,700 for families enrolled in individual market plans.)

No annual or lifetime dollar limits are allowed on EHB beginning January 1, 2014.

Minimum Essential Coverage

Beginning January 1, 2014, individuals not eligible for an exemption are required to demonstrate that they maintain minimum essential coverage or make a payment when filing their federal income tax return. Coverage purchased in the individual market including a Federally-facilitated Marketplace, as well as coverage under government programs such as Medicare, Medicaid, CHIP, and TRICARE, and coverage under an employer-sponsored plan, meet the requirements.

Premium Tax Credits

Individuals enrolling in a QHP through an Individual Marketplace may be eligible for premium tax credits which reduce the cost of premiums for themselves and for any tax dependents. An individual may choose to apply the tax credit towards QHP premium costs on an advance basis – with reconciliation at the end of the year – or to receive the credit on his or her federal tax return filed for the coverage year. Advance payments are paid directly to QHP issuers on a monthly basis.

Individuals eligible for a premium tax credit who do not receive an advance payment of the premium tax credit may claim the credit on their income tax return filed for the coverage year. Individuals who are married at the end of the coverage year are required to file a joint return to receive a premium tax credit.

A tax filer on whose behalf advance payments are made is required to file a tax return for the coverage year to reconcile any advance payments of the premium tax credit with the premium tax credit allowed on the return. Thus, if the premium tax credit allowed on the return is more than the amount of the advance payment of the premium tax credit, the individual may receive the excess amount as a tax return. On the other hand, if the premium tax credit allowed on the return is less than the amount of the advance payment of the premium tax credit, the individual will repay the excess amount via the tax return, subject to statutory caps.

The Marketplaces will provide documentation to the tax filer and to the IRS that will support the reconciliation process, in the same way that an employer or bank provides a Form W-2 or Form 1099.

Eligibility for Premium Tax Credits

Eligibility for the premium tax credit is based on the household income and access to minimum essential coverage. The following summarizes the key eligibility standards for premium tax credits (tax credits that reduce the cost of insurance premiums).

Individuals must meet the following eligibility criteria to be eligible for a premium tax credit:

  • Not be eligible for minimum essential coverage — including employer-sponsored coverage, Medicaid, CHIP, Medicare, and other forms of coverage — other than through the individual insurance market, unless their employer-sponsored coverage is not affordable or does not provide minimum value
  • Have an annual household income that is between 100% and 400% of the Federal Poverty Level (FPL) (or below 100% of FPL for lawfully present non-citizens who are ineligible for Medicaid by reason of immigration status)
  • Be a part of a tax household that will file a tax return for the coverage year and, if the tax household includes a married couple, that files a joint return
  • Be eligible for coverage through a QHP

Cost-sharing Reductions

Cost-sharing reductions limit the out-of-pocket costs for EHB covered by QHPs.

To be eligible for cost-sharing reductions, individuals must:

  • Meet the eligibility requirements for enrollment in a QHP
  • Meet the criteria for eligibility for a premium tax credit
  • Have annual household income at or below 250% of FPL, except for members of federally-recognized Indian tribes, who have special standards
  • Be enrolled in a silver-level QHP, except for members of federally-recognized Indian tribes who have special standards

There are several categories of cost-sharing reductions that are based on annual household income and family size. Each QHP issuer will implement these differently, based on their specific plan design. When an individual is determined eligible for a category of cost-sharing reduction, the plan comparison pages will reflect adjusted cost-sharing requirements of each plan.

Medicaid and CHIP Eligibility

It is important to understand the basic elements of Medicaid and CHIP, in case an applicant or their family members are assessed or determined to be eligible for Medicaid or CHIP, and ask questions about these programs. The following information may help you in these circumstances.

  • Medicaid and CHIP provide free or low-cost health insurance coverage.
  • Medicaid is administered by states to provide health coverage for low-income people, families and children, the elderly and people with disabilities. Beginning in 2014, individuals with incomes of about $15,000 or less will qualify for Medicaid in about half of all states. The Medicaid program is designed to be very affordable for every participant and cost sharing is extremely limited.
  • CHIP is administered by states to provide no-cost or low-cost health insurance coverage for children in families who earn too much to qualify for Medicaid coverage but cannot afford to purchase private health insurance. CHIP also covers pregnant women in some states.

Small Business Health Options Program Features

Under the Affordable Care Act, during the first year of operation, small businesses that qualify for coverage through a SHOP will be able to offer their employees a single QHP option. SHOPs will offer qualified small groups access to QHPs in each state, and will provide flexibility in the amount that members of the small group contribute towards the total premium.

To qualify for SHOP coverage, a business must:

  • Be located in a SHOP's service area (generally a state)
  • Offer coverage to all full-time employees (those working an average of 30 or more hours per week)
  • Have at least one eligible employee on payroll
  • Have 50 or fewer full-time equivalent (FTE) employees on payroll in 2014
    • This methodology includes part-time employees, but not seasonal employees (those working fewer than 120 days per year)
    • While the Federally-facilitated SHOPs (FF-SHOP) must determine eligibility using the definitions above, State-based SHOP Marketplaces have flexibility in their counting approaches in 2014

The premium tax credits and cost-sharing reductions described earlier are not available to employers and families covered through a SHOP. However, employers meeting certain size and average wage requirements may receive a small business tax credit on their tax returns of up to 50% of the employer's contribution to the premium. This credit is only available for coverage provided through a SHOP

Minimum Essential Coverage

The Affordable Care Act requires individuals who are ineligible for an exemption to have minimum essential coverage for themselves and their dependents. Minimum essential coverage is the type of health care coverage an individual needs to have in order to meet the individual responsibility requirement under the Affordable Care Act. Coverage purchased in the individual market including through a Federally-facilitated Marketplace, as well as coverage under government programs such as Medicare, Medicaid, CHIP and TRICARE, and coverage under an employer-sponsored plan, meet this requirement.

Individuals who are ineligible for an exemption and do not have coverage by 2014 may be required to pay a fee. The fee is $95 for plan year 2014.

As an agent or broker, you can assist consumers in meeting this requirement by helping them receive an eligibility determination, apply for financial assistance programs, and choose and enroll in a qualified health plan (QHP).

Allowable Basis for Premium Variations

Under the Affordable Care Act, premiums can only vary based on the following factors: age, family composition, geographic area, and tobacco use.

Special Enrollment Periods

Under certain circumstances, individuals may change QHPs outside of the annual open enrollment period. These SEPs are based on certain triggering events or exceptional circumstances.

Events that permit a SEP include, but are not limited to:

  • Gaining or becoming a dependent
  • Gaining status as a citizen, national, or lawfully present individual
  • Loss of minimum essential coverage (e.g., loss of Medicaid eligibility, termination of a QHP), except if enrollment is terminated based on failure to pay premiums
  • Loss of affordable employer-sponsored coverage
  • Determination that an individual is newly eligible or ineligible for premium tax credits or a change in eligibility for cost-sharing reductions
  • Permanent move to an area where different QHPs are available
  • Other exceptional circumstances identified by the Marketplace

In most cases, SEPs will extend for 60 days from the date of the triggering event. Under certain circumstances, such as the pending loss of minimum essential coverage due to the termination of a QHP, a SEP may begin before the triggering event takes place.

Special Enrollment Period for Marriage

As mentioned in triggering events, a SEP exists for marriage. This means that, if a qualified individual gets married, he or she has the chance to either enroll in a QHP for the first time, or add a spouse to the plan without waiting for the annual open enrollment period.

  • If a marriage occurs and the Individual Marketplace is notified before the last day of the month when the marriage occurred, coverage will begin the 1st of the following month.
  • If a marriage occurs and the Individual Marketplace is notified after the end of the month when the marriage occurred, coverage will begin the 1st of the month following the notification.

The Individual Marketplace would need to be notified within 60 days of a marriage for a spouse to be covered. If the 60-day deadline is missed, the spouse cannot enroll until the plan's annual open enrollment period.

Special Enrollment Period for Birth or Adoption

Another important SEP exists for the birth or adoption of a child.

The effective date of coverage can be the date of the birth or the official date of adoption as long as the Individual Marketplace is notified in a timely manner.

The Individual Marketplace would need to be notified within 60 days of a birth or adoption for dependents to be covered. If the 60-day deadline is missed, the dependents cannot be enrolled until the plan's annual open enrollment period.

Premiums would be pro-rated for the month, based on when the child was added to the policy.

Enrollment Termination

Enrollees may terminate QHP coverage on their own accord at any time of the year, including as the result of obtaining other minimum essential coverage (e.g., Medicaid, employer-sponsored insurance coverage), after giving appropriate notice to the Marketplace.

Marketplaces and QHPs may terminate an enrollee's coverage if the individual:

  • Is no longer eligible for coverage in a QHP through the Marketplace
  • Fails to pay premiums, consistent with the three-month minimum grace period requirement
  • Is enrolled in a QHP that is being terminated or decertified and does not select a different QHP during an applicable enrollment period
  • Has obtained coverage based on fraud or an intentional misrepresentation of material fact

When an individual selects a different QHP during an applicable enrollment period, coverage under the previous QHP will end automatically on the date that coverage under the new QHP takes effect

Small Business Health Options

The Idaho Health Insurance Exchange is a great way for small businesses to compare different carrier plans and pick the coverage that best suits their business. Starting in 2014, there is a new tax credit for small businesses who have fewer the 50 employees. The tax credit is up to 50 percent of premiums paid by small business employers.

To qualify for SHOP coverage, a business must:

  • Be located in the state of Idaho
  • Offer coverage to all full-time employees (those working an average of 30 or more hours per week)
  • Have at least one eligible employee on payroll
  • Have 50 or fewer full-time equivalent (FTE) employees on payroll in 2014
  • This methodology includes part-time employees, but not seasonal employees (those working fewer than 120 days per year)
  • While the Federally-facilitated SHOPs (FF-SHOP) must determine eligibility using the definitions above, State-based SHOP Marketplaces have flexibility in their counting approaches in 2014

The premium tax credits and cost-sharing reductions described earlier are not available to employers and families covered through a SHOP. However, employers meeting certain size and average wage requirements may receive a small business tax credit on their tax returns of up to 50% of the employer's contribution to the premium. This credit is only available for coverage provided through a SHOP.