Nebraska Health Insurance Exchange Update

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1 Nebraska Health Insurance Exchange Update State of Nebraska s Health Insurance Exchange A Presentation to Advocacy Groups August 2012

2 TODAY'S AGENDA Section 1: Overview of Health Insurance Exchanges Section 2: Exchange Requirements Section 3: Proposed Navigator Program Approach Section 4: Nebraska s Exchange Progress Update Section 5: Nebraska s Next Steps

3 OVERVIEW OF HEALTH INSURANCE EXCHANGES

4 THE PATIENT PROTECTION & AFFORDABLE CARE ACT (PPACA) Among its basic provisions, the federal law:» Requires Americans to have health insurance ( individual mandate )» The Patient Protection and Affordable Care Act has been ruled to be constitutional because the United States Supreme Court determined that the penalty for not being in compliance with the individual mandate is actually a tax and not a penalty» Expands Medicaid to all persons with income below 133% of the Federal Poverty Level» However, the recent United States Supreme Court Decision held that this expansion is a new program which is unconstitutional unless the expansion is elected at the option of each state.» Imposes new regulations on all health plans sold in the newly created Exchanges and in the individual and small group markets» Creates exchanges through which individuals and small businesses can purchase private coverage Page 4

5 WHAT IS AN EXCHANGE? A State-based insurance Exchange is a newly created marketplace that will facilitate the comparison and purchasing of health insurance for individuals and small business employers. The Exchange will certify state-licensed health plans to be able to sell their commercial insurance products through the Exchange. Page 5

6 EXCHANGE FUNCTIONS» Exchanges must perform a variety of functions, including: Operating an Exchange website to facilitate comparing, selecting and purchasing health insurance coverage for eligible individuals and small employers Certifying health plans as qualified health plans to be offered in the Exchange Determining eligibility of consumers for enrollment into Qualified Health Plans and for insurance affordability programs (e.g., premium tax credits, and Medicaid/SCHIP; this subject requires more analysis as a result of the Supreme Court Decision Facilitating the enrollment process of individuals and employees into Qualified Health Plans Operating a toll-free hotline for consumer support, providing grant funding to Navigators for consumer assistance, and conducting outreach and education to consumers regarding Exchanges Page 6

7 EXCHANGE IMPLEMENTATION TIMELINE January 1, 2014: Exchanges must be fully operational October 1, 2013: Exchanges must begin enrolling participants January 1, 2013: Exchange progress in each state will be certified by US Dept. of Health & Human Services November 16, 2012: Blueprint application for certification : Establishment Grants awarded (Level I and Level II) July 11, 2011: US Dept. of Health & Human Services released proposed rules governing implementation of Exchanges; more to follow September 30, 2010: State of Nebraska awarded $1 million Planning Grants for planning research March 23, 2010: Patient Protection and Affordable Care Act (PPACA) signed into law January 1, 2015: Exchanges must be financially self-sustaining and no further federal funds Page 7

8 HOW WILL EXCHANGES WORK? Individuals contact Exchange (via website or call center) Medicaid Exchange Qualified Health Plans Co-op Multistate Plan Small Employers (<50 employees) Small Business Health Options Program (SHOP) Exchanges will serve the individual and small employer markets differently Page 8

9 WHO CAN USE THE EXCHANGE?» The Nebraska Exchange will become a marketplace for qualified individuals and small employers to purchase health insurance: Individuals are qualified to use the Exchange if they meet certain criteria including no access to other affordable insurance; and lawfully residing in Nebraska Individuals that meet certain income guidelines will become eligible for federal insurance premium assistance (tax credits) providing they purchase a Qualified Health Plan offered through the Exchange Small business employers are qualified if they employ up to 50 fulltime employees Small employers that meet certain criteria will become eligible for a tax credit if they join/contract with the Exchange» Nebraska estimates the potential Exchange enrollment to be: Approximately 100,000 individuals Small business employers with approximately 20,000 employees (by 2016)

10 EXCHANGE REQUIREMENTS

11 EXCHANGE REQUIREMENTS» Standardized application process» Standardized way to compare health plans» Essential benefits that all Exchange health plans are required to offer» Qualified Health Plans will be held to specific requirements» Consumer assistance programs Toll free telephone line Website Navigator program» Provider quality data and health plan rating information will be available to assist in consumer decision-making process Page 11

12 ESSENTIAL HEALTH BENEFITS» All Exchange Qualified Health Plans must include the follow health benefit categories: Ambulatory patient services Emergency services Hospitalizations Maternity and newborn care Mental health and substance use disorder services, including behavioral health Prescription drugs Rehabilitative and habilitative services and devices Laboratory services Preventive and wellness services and chronic disease management Pediatric services, including oral and vision care Page 12

13 WHAT IS A QUALIFIED HEALTH PLAN?» A Qualified Health Plan is certified by the Exchange before it can sell insurance products through the Exchange. The Patient Protection & Affordable Care Act (PPACA) provides criteria for which qualified health plans must comply in order to become certified and these include: Meet state regulatory requirements for licensing and solvency Meet specific marketing requirements Ensure a sufficient choice of providers with adequate network provisions Provide information to enrollees and prospective enrollees of in-network and out-of-network providers Include within health insurance plan networks those essential community providers, where available, that serve predominantly low income, medically underserved individuals Obtain accreditation on clinical quality measures Implement a quality improvement strategy Disclose plan performance measures Page 13

14 CONSUMER ASSISTANCE PROGRAMS» Toll-free telephone line General health insurance coverage information Eligibility and enrollment (application intake and questions) Tax credit premiums, cost sharing, enrollment cards, provider network, billing,etc. Appeals and grievances guidance SHOP questions from employers and employees Case updates (income changes, insurance status changes, address changes)» Website Compare, select and purchase health coverage Access educational material regarding health insurance and health issues» Navigator program Page 14

15 PROPOSED NAVIGATOR PROGRAM APPROACH

16 WHAT IS A NAVIGATOR?» At a minimum, the Patient Protection & Affordable Care Act (PPACA) requires that Navigators perform the following duties: Conduct public education activities to raise awareness of health coverage available through the Exchange by Qualified Health Plans Distribute fair and impartial information about enrollment in Qualified Health Plans and the availability of premium tax credits and cost-sharing assistance in the Exchange Facilitate enrollment in Qualified Health Plans Provide referrals to consumer assistance programs or any other appropriate State agencies to Exchange enrollees with grievances, complaints, or questions regarding their Qualified Health Plan, their coverage, or a determination made under such plan or coverage Provide information in a manner that is culturally and linguistically appropriate to the needs of the populations being served by the Exchange Page 16

17 WHO CAN BE A NAVIGATOR?» Regulations specify that the Exchange must select entities from at least two of the following categories to serve as Navigators: A community and consumer focused nonprofit group A trade, industry, and professional association A commercial fishing industry organization, ranching and farming organization Chambers of commerce Unions Resource partners of the Small Business Administration Licensed agents and brokers Other public or private entities or individuals that meet the requirements, such as Indian tribes, tribal organizations, urban Indian organizations, and State or local human service organizations The Federal Government has promised more guidance on this program in the future Page 17

18 PROPOSED NAVIGATOR PROGRAM APPROACH» Navigators are funded and accountable to the Exchange but are not directly employed by the Exchange» Licensed brokers/producers that want to become Navigators can use their existing license as their certification ; however, they will be precluded to receive commissions from Qualified Health Plans» Navigators will be trained and qualified to perform Navigator functions and there will be no different tier or category levels» Navigators will assist with the application process and facilitate the enrollment process (not offer input regarding which health plan an individual should select)» The Exchange will develop and provide some of the outreach materials for Navigators» Navigators will have access to a web portal designed exclusively for them to use and Navigators will also have a distinct telephone number when contacting the Service/Call Center Page 18

19 ASSISTORS» New Concept from the Federal Government» Assistors are not Navigators and may have different rules and roles that have yet to be fully defined by the federal government. Page 19

20 NEBRASKA S EXCHANGE PROGRESS UPDATE

21 NEBRASKA S EXCHANGE DESIGN PROGRESS» Drafting the Exchange Information Technology system strategy and architectural diagram» Drafting the business model flows of Exchange functions to determine business and technical requirements. The business flows are the method in which the business plans drive the technology and create the back office procedures.» Drafting the Request for Proposal (RFP) to solicit proposals and select the most beneficial solution(s) for the Nebraska Exchange» Examined whether or not the state should conduct the reinsurance, risk adjustment and risk corridor programs» Contracted with Mercer to conduct a study regarding the Essential Health Benefits: Evaluate the largest three small group plans, the largest HMO, the largest state employee plan and the federal employees health insurance plan Page 21

22 NEBRASKA EXCHANGE POLICY ASSUMPTIONS Exchange will be operated within the Nebraska Department of Insurance There will be a single Exchange that serves both the individual and small employer markets All Exchange certified health plans will be able to sell within the Nebraska Exchange. The Exchange will not limit the number of qualified health plans Exchange Service & Call Center will be located and staffed in Nebraska Page 22

23 NEBRASKA S NEXT STEPS

24 FEDERAL RULES STATES ARE STILL WAITING FOR» New rules after Supreme Court of the United States ruling Is No wrong door still valid? What is the definition of Medicaid expansion and what effect does that definition have on the operations of the Exchange?» Risk Adjustment, Risk Corridors, and Reinsurance» Regulation on Essential Health Benefit Only a bulletin has been issued to date» Final guidance regarding Federal Exchange» Over 200 mentions of forthcoming guidance Appeals Process Page 24

25 NEXT STEPS Moving forward with design of State-based Exchange Continued Study» Scope of Supreme Court decision unclear» Still need federal regulations» We continue to welcome input from all parties Continued Banking Committee Briefings & Public Information Sessions Page 25

26 NEBRASKA S NEXT STEPS Develop a procurement/acquisition strategy (e.g., multiple vendors, service contract, hosted technology, etc.) Conduct Phase II Stakeholder meetings Develop a Marketing and Outreach Strategy Issue the Request for Proposal and receive proposals from solutions vendors and select a vendor Gate Review with Centers for Medicare and Medicaid Services (CMS) and complete the Blueprint application Develop a funding strategy and submit grant for additional funding Await further guidance from CMS for many areas Page 26

27 QUESTIONS / DISCUSSION

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