Qualified Health Plans Company Code 42 ID card starts with 42 and 8 Off Exchange= Members who have enrolled into a Healthfirst Leaf Plan through Healthfirst will be considered Off-Exchange and not eligible for any subsidies On-Exchange= Enrolled at NYSOH and MarketPlace Binder Payment= Initial payment Premium Payment= Full Payment Common QHP Term: Binder Payment: The first payment that a member will need to submit to begin coverage. All prospect must make their first payment (binder payment) in full to be effectuated. The binder payment is due before or by the 1st of month they want coverage for.(Member has a 10-day grace period to submit binder payment.) / Non-Effectuated Members Applicants= Members who have not Paid their Binder payment. / Effectuated Members= Members who are active because they have paid their binder patment / Pre-Effectuated= Members need to pay Their Binder payment before they can Activate their Premium Plan Fully Subsidies= 100% Tax Credit or Financial Assistant from NYSOH Parcial Subsidies= Receives only Partial Financial Assistance or Tax Credit Non-Subsidies= Non Eligible for any Financial Assistance Tax Credit, they need to Pay in Full Amount 1. What are Qualified Health Plan?= . Certified by the state for consumer . Provides essential Health Benefits . Follows established limits on cost sharing Examples deductibles, co-payments, co-ensurance, and out of pocket maximum amounts . Allows eligible consumers to enroll in the QHP, during the annual Open Enrollment Period (OEP) or spacial enrollment period (SEP) 2. When can eligible customers enroll in a Qualified Health Plan? . Open Enrollment Period = The open Enrollment Period is a limited time in the year when consumers can enroll in a Qualified Health Plan. It usually spans from November through January. If the consumer does not enroll during this time, and does not have a Special Enrollment Period throughout the year, they must wait until the following OEP to enroll. When consumers enroll by December 15th, their health insurance plan becomes effective on January 1st. Those enrolled by January 15th will start on February 1st. and those enrolled by February 15th will start on March 1st. . Special Enrollment Period = A Special Enrollment Period is when someone has a Qualifying Life Event that allows them to enroll in or change their coverage through a Qualified Health Plan outside of the Open Enrollment Period. Consumers mest report the Qualifying Life Event to New York State of Health within 60 days of the change. New York State of Health may request proof of the event. 3. What is SEP?= Special Enrollment Period 4. What is the MArketplace and what would members use this for? . The appordable Care Act created state run health insurance Marketplace's Where consumer can compare health plans by their Quality and cost. Some state do not offer their own marketplace's Residence of this places can use the healthcare.gov website. The new york state of health, Eligible consumer can get coverage through the marketplace for themselves and their families 5. How do subsidies help members?= To lower the cost of healthcare and minimize its impact on individuals and families, the Affordable Care Act offers its enrollees subsidies towards monthly premiums and/or cost sharing. 6. What two types of subsidies are available to QHP customers/Members?= 1. Advance Premium Tax Credit (APTC), 2. Cost Sharing Reduction (CSR) 7. How can a member pay their premium? 4 Ways, 1. Online = 2. Healthfirst Community Office = 3. Mail = 4. Member Services = 8. What is a Binder Payment?= The binder payment is their commitment to become a Healthfirst Member. Until the full binder payment is made, the consu,er is not an active member and cannot recieve Healthfirst coverage for treatment. 9. What is the service area for Qualified Health Plans?= NYC, The Bronx, Brooklyn, Manhatan, Queens, Kings, Staten Island, Nassau, Suffolk, Weschester counties 10.What are the 5 Qualified Health PLan categories?= 1. Catastrophic 2. Bronze 3. Silver 4. Gold 5. Platinum 11.How often must a member renew his/her plan?= Healthfirst Qualified Health Plan Members are required to renew their coverage every year during the Open Enrollment Period. To ensure their coverage is re-certified for January 1st, members must demonstrate their status to the NY State of Health by Decmber 15th. Members may be asked to share their immigration status and estimated income level for the upcoming year. ================================================================================================== Child Health Plus & Essential Plans COmpany Code 20 ID number starts at 9 1. Child Health Plus and Essential Plans are offered through which entry? = NYC 2. What is Child Health Plus? . The affordable Care Act, or Obamacare, is a health care reform law enacted in 2010 that went into effect in 2014. It includes insurance reforms design to improve fairness, assure transparency of prices and quality, and make health coverage more accesible and affordable. A key purpose of the ACA was to foster competition, improving quality and reducing cost, and to reduce discrimination in the health insurance market. Increased competition among health plans was intende to lower the cost of care rather thatn selecting best risk or shifting cost. This has improved care delivery and health outcomes. . FOstering competition . Improving Quality . Reducing Cost . Reducing Discrimination 3. What are the eligibilty requirements? . Families eligible for Child ?Health Plus can enroll at any time. They do not need to wait for the Open Enrollment Period. . to be covered by Child Health Plus, a child must have no other health insurance coverage, including thier parents employer-sponsored health coverage. Child Health Plus is available to children regardless of their immigration status. The only children who may not be eligible are those on visistors visas or other short-term visas, because they are not residents of New York State. 4. Family income determines what for a CHP member? 5. The premium applies to how many children in the household? . Max of 3 Child per Family 6. How often do income guidlines get released? .Every year, New York State releases income guidlines to determine premium responsibility. For the latest NYS Income Guidelines for Child Health Plus, we recommend you visit the NYS Deppartment of Health website. 7. Will CHP plans be different of how much they pay? 8. What are the four ways they can pay their premium? . Online . Healthfirst Community Office . Mail . Member Services 9. Do CHP member have any cost sharing responsibilities? . Child health Plus members do not have any cost sharing responsibility for services covered by Healthfirst . That means $0 to visit the primary care physician, for specially care, urgent or emergency care, and much more! 10. To enroll in a essential Plan prospects must: . A prospect will be eligible for essential plan 200-250, and Essential Plan 1 & 2 if thay have an income greater than 138% FPL and less than or equal to 250% FPL. . Ages 19 through 64 . Lawfully Present . New York State Resident . Not eligible for Medicaied or Child Health Plus . Not eligible for Affordable Minimum Essential Coverage (MEC) . Have an annual income at or below 250% of the Federal Poverty level, with a maximum income of $36,450 for a household of one . Meet immigration status requirements . Live in NYS within our service area . Be 19 to 64 years old . Like Child Health Plus, the essential Plan is available to individuals whose income is high enough to disqualify them for Medicaid. The difference is that Essential Plans are for eligible adults ages 19-64. . The essential Plan offers access to health benefits like doctor visit, lab test, prescription drugs, urgrnt and emergency care, dental and vision, and more. 11. How may EP variations are there, and what are they based off?= 5 Essential Plan= EP 200-250, EP1, EP2, EP3, EP4, 12. How often will CHP and EP need ot renew? every year Alt 164-165= ñ Ñ