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Open Enrollment 2016:Guide for LA HAP assisters

Call-in information Toll Free: 1-888-398-2342

Access code: 5018903Please MUTE your phone line upon joining the call. Thank

you!

Open Enrollment 101

2016 Marketplace• All 2015 Marketplace plans end December 31st, 2015• OE2016 runs from November 1st, 2015 – January 31st, 2016• Health and dental plans (dental plans may only be purchased if you

are also purchasing health insurance)

Metal level

Premium

Deductible

Limitations

Bronze $ $$$$ LA HAP will NOT cover Bronze premiums

Silver $$ $$$ ---

Gold $$$ $$ No cost-sharing reductions available

Platinum $$$$ $ No cost-sharing reductions available

Full plan name Individual yearly deductible

In-network/out-of-network portion covered

What’s different?• Clients who did not authorize Marketplace to request

tax information or did not file taxes and reconcile APTCs will be identified by Marketplace and be ineligible for tax credits• Louisiana Health Cooperative is no longer in business

(existing plans will terminate December 31st, 2015)• Far fewer platinum plans offered

R I P

Tax CreditsTax credits available to those between 100%-400% FPL

• Anyone who took a premium tax credit in 2015 MUST FILE TAXES in 2016.

• Tax credit can be taken in advance or at tax time LA HAP clients requesting premium assistance MUST TAKE THE CREDIT IN ADVANCE

Tax credit “reconciliation” on federal tax forms:

• Overpayment must be returned to LA HAP• All clients consent to this when signing their LA HAP

application.• LA HAP is currently creating policy for

underpayment reconciliation assistance– stand by!

To avoid a difficult tax

reconciliation, report income and household changes to the

Marketplace throughout the year. Notify LA

HAP of any premium changes.

Marketplace & Medicare• It is illegal for someone who knows you have Medicare to sell you a Marketplace plan.• Includes having Part A only: “minimum essential

coverage”• POSSIBLE exception if you are employed and employer

offers job-based coverage through Marketplace

•What happens if you drop Medicare and get a Marketplace plan instead?• If you have premium-free Part A:

• When you drop Medicare, you will lose your Social Security Benefits and have to pay back all SSA & Medicare benefits you’ve received to date.

Marketplace and Medicare• If you have a Marketplace plan and then become eligible for Medicare:• You should sign up for Medicare in your Initial Enrollment

Period• If you keep your Marketplace plan instead:

• You will lose premium tax credits and cost-sharing reductions

• You will lose Social Security Benefits if you receive them• You will have to pay a lifetime monthly penalty for Part

B if you opt for Medicare after the IEP• LA HAP will NOT cover both a Marketplace plan and

Medicare

Marketplace and employer plans

Can you have a Marketplace plan AND an employer-based plan?

--Yes, but you aren’t eligible for tax credits/cost-sharing reductions

--LA HAP will NOT pay for a client to have both a Marketplace and an employer-based plan

Marketplace & LA HAP

Important dates

If you enroll…

Insurance add/change

form due to LA HAP…

Your coverage starts…

November 1st - December 15th 2015

December 18th 2016

January 1st 2016

December 16th - January 15th 2015

January 18th 2016 February 1st 2016

January 16th - January 31st 2015

February 16th 2016

March 1st 2016

Client enrollment4 Marketplace scenarios:• Client is uninsured, enrolling for

first time• 2015 plan still being offered in

2016 • Ex: HMO Louisiana, Inc. Blue

POS copay 80/60 $1000• 2015 plan terminating, similar

plan being offered in 2016• Ex: Blue Cross Blue Shield

Platinum 80/60 $250• 2015 plan terminating, no similar

plan being offered in 2016• Ex: All LAHC plans

Look for correspondence from:• MARKETPLACE on basic Open

Enrollment information• INSURANCE COMPANY on what

is happening to existing plan

No Insurance: enrolling for first time

1) Create account online at 2) Gather: ID card, tax forms, pay stubs, Social Security card, piece of mail with current address3) Enter information, browse plans• Providers: in-network?• Medications: on formulary?• Medical conditions: covered?• Health Care Reform Passport tool

4) Select plan, save invoice/screen printout5) Submit Insurance Add Change form to LA HAP

2015 PLAN STILL BEING OFFERED IN 2016

Re-evaluate needs and update expected

household/income info on healthcare.gov

Keep plan

SEND 2016 INVOICE TO HIP

Switch plans

SEND INSURANCE ADD/CHANGE FORM TO

LAHAP

If you do nothing:

• You will be auto-reenrolled into same plan

• If premium amount changes and HIP isn’t informed, you risk insurance termination

Act by December 15th

2015 PLAN TERMINATING, SIMILAR PLAN BEING OFFERED IN 2016

Re-evaluate needs and update expected

household/income info on healthcare.gov

Opt for auto-mapping

SEND INSURANCE ADD/CHANGE FORM

TO LA HAP

Switch plans

If you do nothing:

• You will be auto-mapped into new plan

• You risk insurance termination if LA HAP/HIP is not informed about new plan/premium amount

Act by December 15th

2015 PLAN TERMINATING, NO SIMILAR PLAN BEING OFFERED IN 2016

Re-evaluate needs and update expected household/income info

on healthcare.gov

Switch plans

SEND INSURANCE ADD/CHANGE FORM

TO LA HAP

If you do nothing:

• Your insurance coverage will terminate January 1st

• Then, you still have option to select new plan by January 31st

Act by December 15th

LA HAP recertification

• Separate process from insurance enrollment• 6-week

recertification period• Full application for

insured services does NOT replace Insurance Add/Change form

LA HAP Eligibility

expiring: LA HAP

APPLICATION

Adding/changing

Insurance: INSURANCE

ADD/CHANGE FORM

Send LA HAP application AND Insurance Add/Change form if LA HAP eligibility is expiring AND insurance is changing

Smooth processing of paperwork• New Insurance Add/Change forms• ONE PER MARKETPLACE PLAN- choose the correct one

• Send one fax transmittal per client• Submit recertification paperwork well in advance• Fill out forms completely• Include proper documentation• Priority Approval Request forms are NOT necessary• LA HAP reserves the right to return any application where insurance or other necessary information is left blank

Maintaining coverageHow did LA HAP clients lose coverage this year?• Nonpayment of premiums: LA HAP/HIP end• Nonpayment of premiums: client end

• Make sure premium assistance is requested on application

• Acceptance of premiums: insurance carrier end• Limited by staffing/high volume of requests for processing

• Failing to provide follow-up information to Marketplace• Failing to recertify for LA HAP• Misunderstandings between client, Marketplace, LA HAP,

HIP, Insurance Company • Active coverage erroneously reported to LA HAP as “terminated”

Communication

LA HAP (New

Orleans)

HIP (Baton Rouge)

Insurance

Company

Case Manager(

s)

Market-place

Client

Broker(s)

Provider

Medicare

HIP Reminders

Payment Information Reminders

Premium Information

• Medicare • Part D-Open Enrollment• LIS• 2016 Invoice

• Cobra• Enrollment Information• Cannot pay for family• Usually last for 18 months

• Group • Human Resources Form

(lahap.org)• Employer does not have to

accept HIP payments

• Marketplace• Forward All correspondence to

HIP regarding payments

Co-Payments and Deductibles

• HCFA Claim form from provider with the matching EOB

• Bill from client with the matching EOB

• Claims received within 90 days of service=Approved

• Claims received > 90 days but claim paid by insurer with in 90 days of receipt=Approved

• If EOB received within 90 days but the service is > 6 months=Denied

CDAP Claims Decision Tree

Did Client's primary insurance pay

claim?

Is EOB attached?

Is the claim for Inpatient services?

NO Forward to HIP Designee for EOB Needed Letter

YES Forward to HIP Designee for Denial

Letter

No, claim is GREATER than 90 days of service, ANDpayment by insurer is

greater than 90 days. Forward to HIP Designee for Denial Letter

RECEIVE CLAIM&

EVALUATE CLAIM DOCUMENTATION

NO Forward to HIP Designee for Denial

Letter

90 DAY/6 MONTH

Is claim 6 months or greater?

YES Forward to HIP Designee for Denial

Letter

Is claim from a HIP Client? AND is/was

client eligible at time of service?

YES, claim is WITHIN 90 days OR, claim is GREATER

than 90 days of service, BUT date of payment by insurer is LESS than 90 days of receipt.

Process for payment

Is claim WITHIN 90 days of

NO proceed to 90 day/6 month

YES proceed to 90 day/6 month

CDAP Denial Data

Community Affairs CoordinatorKatie Dearman 225-424-1799

Fax 225-927-1267

Resources & next steps

Community ResourcesEnrollment• Navigators

• Southwest Louisiana Area Health Education Center (SWLAHEC)- statewide• Family Road of Greater Baton Rouge- Ascension, East and West Baton

Rouge, Iberville, East and West Feliciana, Livingston, and Pointe Coupee parishes

• Certified Application Counselors- statewide• Search by zip code at healthcare.gov

Using Insurance• Coverage to Care- CMS (located on lahap.org)• LA HAP-specific resources

Tax preparation• IRS Volunteer Income Tax Assistance Program (VITA)

All FREE!

LA HAP updates• Comprehensive dental & vision services• Remember: LA HAP coverage limitations, reimbursement

policies

• New program income limit: 300 400% FPL• LA HAP.org • Open Enrollment tab• Updated forms & policies• Slides from this webinar• Resuming application tracking

What’s next?• Agency-specific data on client insurance enrollment• Medicare & LA HAP webinar• Ryan White Part B case management conference:

February/March

Questions?