1. NAVIGATING AFFORDABLE HEALTH CARE
Personal Assistance Within Reach
Thursday, October 31, 13

2. Mountain Projects Inc.
Graham County Presentation
October 29, 2013
6-7:30 pm
Graham and Swain County
Navigator: Julia Buckner
Thursday, October 31, 13

3. Today’s Topics
Mountain Project's Role
The MarketPlace
Personalized assistance
Privacy and Protection
Eligibility and Enrollment
Preparing for an Appointment
Contact Information
Thursday, October 31, 13

4. Mountain Projects Inc.
A Community Action Agency
MPI awarded a grant to implement a Navigator program in the
seven counties in WNC
Counties:
Clay, Cherokee, Haywood, Graham, Jackson, Swain, Macon
Local and personal assistance
Community education and partnership agencies
5.5 employees- covering the 7 counties of WNC-Navigators
Volunteers trained and more needed
Thursday, October 31, 13

5. FINDING A CERTIFIED NAVIGATOR?
Far -Western North Carolina
Thursday, October 31, 13

6. FINDING A CERTIFIED NAVIGATOR?
Far -Western North Carolina
Jan Plummer: Project Coordinator &
Haywood
Julia Buckner:
Graham & Swain
Patti DeRidder
and Claire
Tiernan:
Cherokee & Clay
Thursday, October 31, 13
Jane Harrison:
Haywood &
Jackson
Rebecca Mathis:
Jackson
Cindy Solesbee:
Macon
Personal Assistance
Within Reach
www.mountainprojects.org

7. How do Mountain Projects’
Navigators Assist You?
Certified to assist through
enrollment
Explain insurance
terminology; choices;
implications
Unbiased, impartial, and free
Privacy/Confidentiality
Thursday, October 31, 13
No rush, no pressure, no
affiliation
Resource for questions
May complete on-line or
paper applications

8. Navigator Assistance
Unbiased, free, impartial
Individuals or Small Employers
Assigned to Counties
Block Times at partner
Agencies, i.e. DSS, Mountain
Projects
Thursday, October 31, 13
Community Events
Can not go door to door
Refer to state agencies if
appropriate
Appointments available

9. Provisions of the ACA
GOAL: Affordable health care for millions
TOOLS: The Marketplace/An Insurance Exchange
Shop, compare and purchase insurance based on income and
household size.
Medicaid Expansion: NC did not expand
Individual Mandate beginning 2014/Exemption
Employer Shared Responsibility:
Must offer a plan that meets ACA minimum essential
benefits or pay a fee (ESRP)
Thursday, October 31, 13

10. Affordable Care Act
Protections
Prohibits higher premiums due
to health/gender
Extend coverage for
dependents up to age 26
Prohibits discrimination against
consumers seeking coverage
with pre-existing conditions
Eliminated Insurance Annual
Coverage Limits
Thursday, October 31, 13

11. Marketplace Consumers
Individuals
Need health insurance
Have health insurance they
can't afford
Have dependents or a spouse
that make insurance
unaffordable
Employed by a small
employer getting health
insurance through the
Marketplace
Thursday, October 31, 13
Small Businesses
Investigate coverage for
employees
Explore options via the
Marketplace
Questions about exemptions
and penalties
Have 50 FTE's or equivalent

12. MARKETPLACE DETAILS
Insurance Affordability
Transparency, Competition, and Choice
APTC
Advanced
Premium
Tax Credits
Thursday, October 31, 13
CSR
MEDICAID
CHIP
Cost
Sharing
Reductions
Medicaid
Children’s
Health
Insurance
Program

13. MARKETPLACE DETAILS
Insurance Affordability Programs
Transparency, Competition, and Choice
APTC
NEW federal program that uses tax credits to
reduce premium costs for QHP enrollees.
For people who meet financial criteria and don’t
have access to other coverage.
Advanced
Premium
Tax Credits
Thursday, October 31, 13
Can be paid in “advance” to provide immediate
help in paying premiums.
IRS reconciles over/under payments of advance
premium tax credits when people file taxes.

14. MARKETPLACE DETAILS
Insurance Affordability Programs
Transparency, Competition, and Choice
NEW federal program
CSR
Cost
Sharing
Reductions
Thursday, October 31, 13
Helps reduce out-of-pocket costs for enrollees in
QHPs.
Payments are made directly to issuers to reduce
deductibles, co-insurance, and/or copayments
(out-of-pocket) costs.

15. MARKETPLACE DETAILS
Insurance Affordability Programs
Transparency, Competition, and Choice
MEDICAID
Existing federal-state health insurance program for
low income people.
Expanded to more low-income adults by the ACA.
States can opt out of expansion.
Medicaid
Thursday, October 31, 13
Provides comprehensive health care benefits.
Minimal out-of-pocket costs.

16. MARKETPLACE DETAILS
Insurance Affordability Programs
Transparency, Competition, and Choice
CHIP
Existing federal-state health insurance program for
low- and moderate-income children.
Provides comprehensive health care benefits.
Children’s
Health
Insurance
Program
Thursday, October 31, 13
Modest out-of-pocket costs.

17. Eligibility and Enrollment
Started October 1, 2013
Enroll by December
15,2013 coverage begins
January 1, 2014
Premium by Dec. 15
Ends March 31, 2014
Special Enrollment Periods
Coverage by Jan. 1
Thursday, October 31, 13

18. How to Prepare
Individuals
Employer
SSN for Household/
Birthdates
Expected enrollment
Pay Stubs/W2 Tax
Information for 2013/
estimate2014
Age of Spouse
Employer insurance
information (handout)
Additional HH income
information
Thursday, October 31, 13
Existing health coverage?
Dependent information
Agent may help enroll/
explore

19. Qualified Health Plans
Minimum Essential Benefits
Ambulatory Patient Services
Emergency Services
Hospitalization
Maternity and Newborn Care
Mental Health/Substance
Abuse/Behavioral Health
Treatment
Prescription Drugs
Thursday, October 31, 13
Rehabilitation: physical or
mental
Labs
Wellness/Chronic Disease
Management (Asthma,
diabetes)
Pediatric Services including
dental

20. Health Plan Categories
BRONZE: Minimum Essential Benefits/Insurance
pays 60% of covered expenses
SILVER: Minimum Essential Benefits/Insurance
pays 70% of covered expenses
GOLD: Minimum Essential Benefits/Insurance pays
80% of covered expenses
PLATINUM: Minimum Essential Benefits/
Insurance pays 90% of covered expenses
CATASTROPHIC: Meet all QHP requirements but
only cover 3 primary care visits annually until
deductible is met. Must be under 30 or receive a
hardship exemption.
Thursday, October 31, 13
Silver
30%
you
70%
insurance

21. Health Plan Categories
BRONZE: Minimum Essential Benefits/
Insurance pays 60% of covered expenses
SILVER: Minimum Essential Benefits/
Insurance pays 70% of covered expenses
GOLD: Minimum Essential Benefits/
Insurance pays 80% of covered expenses
Premiums
increase
Thursday, October 31, 13
PLATINUM: Minimum Essential
Benefits/Insurance pays 90% of covered
expenses
Out of
Pocket
increase

22. Options to Lower Costs
Premium Tax Credits
Lower monthly premiums/HH income, size, cost of
available plans
Cost Sharing Reductions
Limits out-of-pocket costs (deductibles and co-pays)/
HH income/size
MAY REQUIRE SILVER PLAN SELECTION
Competition in the Marketplace: Blue Cross & CoventryOne
Thursday, October 31, 13

23. Exemptions to Individual
Responsibility Requirement
Investigate first
Hardships: Homelessness, eviction, foreclosure, utility shut-off,
domestic violence victim, death of close family member, recent
bankruptcy, unexpected caretaker expenses, eligibility denials,
coverage exceeding 8% of projected annual income, ineligible
for Medicaid/no state expansion
Navigators can not assist with the exemption application. (IRS)
Incarceration Past months
Indian Status Past and Future
Religious Conscience Complete IRS Form 4029
Health Care Sharing Ministry Past months
Thursday, October 31, 13

24. HOW THE MARKETPLACE
WORKS
Thursday, October 31, 13

25. WWW.HEALTHCARE.GOV
Thursday, October 31, 13

26. Window Shopping
www.healthcare.gov
Look at Plans
Kaiser Health Calculator
BCBS Site: http://
www.bcbsnc.com/content/
providersearch/index.htm
Coventry Site: http://
nc.coventryproviders.com
Thursday, October 31, 13

27. KAISER SUBSIDY
CALCULATOR
Thursday, October 31, 13

28. Thursday, October 31, 13

29. FEDERAL POVERTY LEVELS
Thursday, October 31, 13

30. OPTIONS TO LOWER COSTS
Thursday, October 31, 13

31. NC Medicaid Eligibility
NC Medicaid covers only 30% of adults in
poverty
100
Medicaid for Families** & Medicaid
for Aged, Blind, Disabled
75
50
21-64: nondisabled, no child,
25
No Medicaid
0
Medicaid Eligibility
The Affordable Care Act, as written,
expands Medicaid eligibility to all US
citizens under 138% of the Federal
Poverty Line (FPL).
Because ACA assumed Medicaid
expansion, those under 100% of FPL do
not qualify for APTC.
COVERAGE GAPS
Thursday, October 31, 13

32. NC Medicaid Expansion
Many more can get Medicaid/
CHIP, due to higher income
limits, income exclusions,
choices re claiming
dependents.
A few will LOSE Medicaid/
CHIP due to changes. First
recertification after 3/31/14.
e.g. stepparent with income,
sibling with taxable income,
separated but file jointly.
Thursday, October 31, 13
Often child will be enrolled in
Medicaid or CHIP while parent
is enrolled in private insurance.
This will lead to different
provider networks, different
coverage, and different copays/
deductibles (which are very low
for Medicaid and CHIP) for
parent vs. child.

33. NC Coverage Gaps
Consumers not eligible for Medicaid/
Chip will not receive tax credits unless
their projected 2014 income is higher
than 100% of FPL.
There is no risk (and significant benefit) to
honestly, reasonably projecting 2014
income over 100% of FPL.
IRS will waive overpayment if actual 2014
income turns out to be under 100% of
FPL.
Federal Poverty Levels
Thursday, October 31, 13

34. TAX CREDITS
How much will this cost?
Thursday, October 31, 13

35. EXPECTED FAMILY $$
How much will this cost?
Thursday, October 31, 13

36. BENCHMARK PLANS
How much will this cost?
REMEMBER: The size of the tax
credit equals the silver benchmark
plan minus a family’s expected
contribution.
The higher the cost of the benchmark
plan, the larger the APTC.
Benchmark plan costs will change
based on where the family lives, the
ages of the family members seeking
coverage,and the number of
household members enrolled in QHP.
Even when the benchmark plan
changes, the family’s expected
contribution amount remains the
same.
Thursday, October 31, 13

37. FINDING A CERTIFIED NAVIGATOR?
Far -Western North Carolina
Personal Assistance
Within Reach
www.mountainprojects.org
828-452-1447, ext. 115
1-800-627-1548
All NC Counties: 1-855-733-3711
Health Insurance Marketplace:
1-800-318-2596
Thursday, October 31, 13

38. MOUNTAIN PROJECTS
Serving the Community since 1965
Thursday, October 31, 13