This presentation provides an overview of eligibility for government financial assistance programs through Covered California and provides instructions for enrolling in a Covered California health plan.
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Covered California Enrollment
1.
2. Disclaimers and Copyright
This presentation is copyrighted by Brent Heurter and Healthy Halo Insurance Services, Inc. which is solely
responsible for its content. Affordable California, Brent Heurter and Healthy Halo Insurance Services are
not affiliated with Covered California, and Covered California bears no responsibility for the content of this
presentation. The email addresses and telephone number that appears throughout this presentation
belong to Brent Heurter and Healthy Halo Insurance Services, Inc. and cannot be used to contact Covered
California.
Copyright 2013-2014, Healthy Halo Insurance Services, Inc. All rights reserved. No duplication, in whole or
in part, permitted without expressed written consent. Health insurance provided by Healthy Halo
Insurance Services, Inc., CA License #: OF76504
3. Elea Sherrod, Enrollment Director
Affordable California™
Brent Heurter, Director of Education
Affordable California™
6. Introduction
• The Affordable Care Act and Obamacare are
the same
• Starting in 2014, most people are required to
have health insurance under Federal law
7. Introduction
• Financial assistance is available for those who
qualify
• Medi-Cal is being expanded to cover more
people and is based only on income
8. Reasons people
do not have
health insurance:
• Pre-existing conditions
• Not offered by their employer
• Unaffordable
9. Why get health insurance?
• Because life is unpredictable
• Because medical care is expensive
• Because health insurance protects you
financially
10. Why get health insurance?
• Because health insurance covers more than
just injury or illness
• Because health insurance is now affordable
• Because it’s the law!
11. Average costs
without insurance
• Average cost of broken arm is $14,911
• Average cost of pregnancy is $18,320
• Average cost of hospital stay is $33,079
13. Do any of the following
apply to you:
•Income is below the tax filing threshold
• Undocumented immigrant
• Insurance would cost more than 8% of your income
• Member of an Indian tribe
15. If No then:
Do you currently have health care coverage – or
expect to have it by January 1, 2014:
• Employer-sponsored healthcare
• Coverage purchased in the individual market
• Medicare
• Medi-Cal
• TRICARE or Veteran’s Health Program
16. If Yes then
The requirement to have
health insurance is satisfied
and no penalty is assessed
17. If No then
There is a penalty for being without
health insurance:
18. You must enroll no
later than
March 31, 2014 to
avoid a tax penalty
26. What is Medi-Cal?
• California’s version of Medicaid
• Government-run healthcare program for lowincome individuals and families that qualify
• Not private insurance
27. Am I eligible for Medi-Cal?
$15,856 or less
$21,403 or less
$26,961 or less
$32,499 or less
$38,046 or less
$43,594 or less
28. Are my children eligible
for Medi-Cal? (under age 18)
$30,563 or less
$41,256 or less
$51,949 or less
$62,643 or less
$73,336 or less
$84,029 or less
29. Med-Cal have access to
vs. Subsidized
What if I
Private Health Plan
affordable coverage?
• Ask your employer to not offer spousal and
dependent coverage
$$1.00
• Ask your employer to make your job
classification not eligible for benefits
in annual income can
• Consider working part-time
determine eligibility
30. What if I don’t want
Medi-Cal?
• Adults can purchase a private health plan, but
will not be eligible for subsidies
• Private health plans for children may be
purchased and the parents will still be eligible
for the maximum subsidy
• Health plans for children start at $96
34. Key Terms to Know
• Medical Deductible: how much you pay for medical services before the
health plan pays (example, $2,000)
• Brand Name Drug Deductible: how much you pay for brand-name
prescriptions before the health plan pays (example, $250)
• Co-Payment: fixed amount you pay for a service (example, $45)
• Co-insurance: a % of the plan’s negotiated rate that you pay for a
service (example, 20%)
• Maximum Out of Pocket: the most you pay in a year before the health
insurance pays 100% of costs. Think of it as your safety net.
35. Types of Health Plans
Plan Feature:
HMO EPO
PP
O
Designate a primary care
physician?
Need a referral to see a
specialist?
Out of network benefit?
Level of flexibility?
Yes
No
No
Yes
No
No
No
No
Yes
Minimal Moderate High
38. Enhanced Silver Benefits
based on Income
1 person = $15,857 to $28,725
2 people = $21,404 to $38,775
3 people = $26,953 to $48,825
4 people = $32,500 to $58,875
5 people = $38,047 to $68,925
6 people = $43,595 to $78,975
38
42. What is a Premium
Subsidy?
• Reduces your monthly premium
• Amount is based on your household’s
projected income for 2014
• Paid by the federal government
directly to the insurance company you
select
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45. Maximum Monthly
Premium
• Based on second most affordable Silver plan
• Maximum amount you will pay
• Based on percentage of income
• Your premiums cannot increase
• Buy less expensive Bronze plan or pay more for
Gold or Platinum
45
49. Income Includes:
• Wages, salaries, tips
• Business or self-employment income
• Rental income
• Interest received or accrued
• Capital gains
• Alimony
49
50. Deductions
• Self-employed expenses
• Student loan interest
• IRA and Health Savings Account deductions
• Moving expenses
• Penalty on early withdrawal of savings
• Alimony
50
51. Modified Adjusted
Gross Income (MAGI)
• Line 4 of Form 1040 EZ
• Line 21 of Form 1040A
• Line 37 of Form 1040
• Add in non-taxable Social Security Benefits
• Add in non-exempt interest
• Include any income earned by children if you claim them as dependents
• Spouses are required to file their income taxes jointly
51
52. Project I have access to
your income
What if
wisely… coverage?
affordable
• Ask your employer to not offer spousal and
dependent coverage
$$1.00
• Ask your employer to make your job
classification not eligible for benefits
• Consider working part-time
Can make a big
difference
53. What if I don’t qualify for
a subsidy?
Single
$45,961 or more
Family of Three
$62,041 or more
Family of Four
$78,121 or more
Family of Five
$94,201 or more
Family of Six
$126,361 or more
You can buy the same plans, have the same benefits and have more
choices from the private market
53
54. What am I eligible for?
Medi-Cal
Premium Assistance Premium Assistance
& Cost Sharing
Assistance
up to
$15,856
up to
$21,403
$21,404 to $38,775 $21,403 - $62,040 $62,041 or more
up to
$26,951
$26,952 to $48,825 $26,952 to $78,120 $78,121 or more
up to
$32,499
$32,500 to $58,875 $32,500 to $94,200 $94,201 or more
up to
$38,046
$38,047 to $68,925
up to
$43,594
$15,857 - $28,725
Affordable
Health
Insurance
$43,595 to $78,975
$15,857 - $45,960 $45,961 or more
$38,047 to
$110,280
$110,281 or
$43,595 to
$126,361 or
more
55. Eligibility for Medi-Cal
Premium Subsides
Not Eligible for
Subsidies
Eligible for
Subsidies
Eligible for
Enhanced
Benefits &
Subsidies
Eligible for
Medi-Cal
56. Eligibility for Medi-Cal
Premium Subsides
Not Eligible for
Subsidies
Eligible for
Subsidies
Eligible for
Enhanced
Benefits &
Subsidies
Eligible for
Medi-Cal
57. Eligibility for Medi-Cal
Premium Subsides
Not Eligible for
Subsidies
Eligible for
Subsidies
Eligible for
Enhanced
Benefits &
Subsidies
Eligible for
Medi-Cal
58. Eligibility for Medi-Cal
Premium Subsides
Not Eligible for
Subsidies
Eligible for
Subsidies
Eligible for
Enhanced
Benefits &
Subsidies
Eligible for
Medi-Cal
60. Open Enrollment
• You can only enroll during annual open enrollment
• Next open enrollment period starts November 15, 2014
for coverage effective January 1, 2015
• Exceptions are if you have a qualifying life event: loss of
employer-sponsored coverage, death of a spouse, birth of
a child
• You must enroll by March 31, 2014 to avoid a tax penalty
for 2014
60
62. How to Choose a Plan
• How many doctor visits, prescriptions and hospital
stays do I expect my family to use in the next year?
• What level of coverage do I want? Bronze, Silver,
Gold or Platinum?
• Do I qualify for an Enhanced Silver Plan?
• What type of network do I want?
PPO?
HMO, EPO or
64. We make it easy
•
We’ll determine your eligibility for subsidies
•
We’ll find the plans that have your doctors
•
We’ll show you plan choices and options
•
We’ll help you select the plan best suited for you
•
We’ll help you apply for government assistance
•
We’ll handle the enrollment process
•
We’ll help you with the appeals process if you get
turned down
64
65. Our commitment to
you
• We’ll help you figure out if you’re eligible for money from
the government or your employer, and we’ll help you get
that money
• We’ll help you choose the right health plan
• We’ll make sure you get the best deal possible
• We’ll help you with the paperwork to enroll or enroll for
you
• If you run into any roadblocks, get confused, have an
issue with your plan or a change in circumstance, we’ll
always here to help.
65
66. If You Enroll by:
Your Health plan must
receive first month’s
premium by:
For coverage effective:
January 15, 2014
January 28, 2014
February 1, 2014
February 15, 2014
February 25, 2014
March 1, 2014
March 15, 2014
March 26, 2014
April 1, 2014
March 31, 2014
April 25, 2014
May 1, 2013
67. Next Steps
• Complete enrollment form
• FAX with documentation to 1-800-297-6319 (no
emails, please) docs
• Call us at 1-800-788-2197 if you need help
• Pay the first month’s premium before the due
date
Bronze Plan: Most Affordable
Silver Plan: Second Most Affordable
Gold Plan: $0 Deductible & Lower Out of Pocket Costs
Platinum Plan: $0 Deductible and Lowest Out of Pocket Costs
6 health carriers in the Greater Los Angeles area and 27 plans to select from.
If you expect a lot of medical expenses, a plan that offers a higher level of coverage might be a better
choice. Premiums are higher, but your copays and deductible will be less, so overall it will be less expensive