Welcome Broker Community Ready to Serve You Altius ACA Sales Training

Transcription

1 Welcome Broker Community Ready to Serve You Altius ACA Sales Training Presented by: Stan Rogers (VP Sales and Marketing) & Jamie Larson (Director, Sales) September

2 Agenda Health Insurance Marketplace & PPACA Overview Altius 2014 Products (On/Off-Exchange) Customer Service Organization (CSO) Readiness Broker Partnership with Altius 2

3 Overview Health Insurance Marketplace & PPACA Overview Key ACA Changes Essential Health Benefits What is New? Benchmark plans Rate Shock, Taxes and Fees Small Group Qualified Plan Metal Levels AltiusOne Qualified Plan Metal Levels & Catastrophic Premium Subsidy Cost Sharing and AV Subsidy 3

4 Health Insurance Marketplace also known as Exchange or HIX (Public & Private) Public Exchanges ACA (Affordable Care Act) dictates the creation of two distinct types of Public Exchanges Individuals and businesses (SHOP) can shop and compare plans Individual Managed by federal or state government. Travelocity - style shopping experience Provides access to tax credits and subsidies to promote affordability wpcontent/uploads/hbe_ EB_121018_Presentatio n_consumer_interface.p df Small Group (SHOP) Managed by federal or state government Small businesses shop for insurance for their employees Target groups with up to 100 lives; states can opt to limit up to 50 lives until 2016 States will decide on the degree of choice and contribution models offered to employees Altius is not participating in the SHOP 4

5 Individual Public Exchange Individual Who is Eligible? US citizen or legal alien Not incarcerated Resident of the state in which exchange is based Available Assistance Access to premium tax credits and cost-sharing subsidies 5

6 Health Insurance Marketplace Three ways to develop and operate these exchanges: FFE (Federally-facilitated exchange) where the state has no role in operation or management Wyoming Partnership Model federal government builds infrastructure but states retain authority (network adequacy, licensure, etc.) Utah & Idaho State-based exchange -- the state creates, operationalizes, and maintains their own exchange Nevada 6

7 Health Insurance Marketplace On-exchange and off-exchange what is the difference? Subsidy only on-exchange: Premium subsidy on all Metal products Silver Variations: Actuarial Value and Cost Share Subsidy American Indian Plans: Zero Cost Share & Limited Cost Share Products must qualify as QHP (Qualified Health Plan) on-exchange Must allow applicant to purchase an onexchange product outside the exchange Off-Exchanges: Small Group and COA (CoventryOne Online Assistant) for Brokers 8

8 Areas of Expected Impact All Individual and Small Group plans on and off Exchange must meet Essential Health Benefit standards, while all Qualified Health Plans must also meet Network Adequacy requirements Beginning in 2014, the Individual Mandate requires all Americans, with some exceptions, to maintain a minimum level of health insurance or face a penalty There will be increases in the reporting requirements in the coming years Dramatic premium increases in 2014, primarily driven by the rising underlying cost of health care services 9

9 Opportunity Driven by Public Population Individual market is expected to grow by 16M lives due to guaranteed issue, financial subsidies, penalties and employer opt-outs. Small Group market is projected to decline due to employer opt-outs Uninsured will decline as subsidies and penalties drive people to buy insurance. Significant Long-Term Opportunity to Grow Commercial Business 10

10 Individual Mandate Individuals are now required to obtain minimum essential coverage through their employer, government or exchange or pay a financial penalty. There are two types of penalties: 1. greater of a dollar penalty or 2. a percentage of household income penalty The penalty is less for dependents: ½ of the dollar amount listed above for each uninsured dependent under the age of 18 Total penalty for a family is capped at 300% of the normal penalty 11

11 EHB Requirements Health insurance plans must cover a list of 10 Essential Health Benefits (EHB) as part of core package of benefits and services. All member cost share goes to meet MOOP including deductibles, copays, coinsurance, any admit fees, MH/SA, pediatric dental and vision. 1. Ambulatory Services 2. Emergency Services 3. Hospitalization 4. Maternity / Newborn Care*. 5. Mental / Behavioral Health* 6. Prescription Drugs 7. Rehabilitative / Habilitative Services 8. Laboratory Services 9. Preventive / Wellness Services 10.Pediatric Services* *New ACA Requirements Many consumers will pay more because they will get more 12

12 Benchmark Plans The ACA did not define the specific benefits to be covered under each service category. That task fell to the U.S. Department of Health and Human Services (HHS). HHS is allowing states to define the benefits in the EHB packages for their exchanges by tying it to one of four potential benchmarks: 1. Any of the three largest small group plans in the state 2. One of the three largest state employee health benefits plans 3. One of the three largest national plans offered to federal employees 4. The largest commercial health maintenance organization (HMO) plan in the state. If a benefit is included in the Benchmark, it is considered an EHB for that state with exception of adult vision and dental benefits. No dollar limits, annual or lifetime Can have other limits (# of visits, waiting periods), but have to be at least as generous as benchmark plan limits 13

13 Metal Level The ACA requires that the EHB package is offered at four levels of coverage: Platinum: Actuarial value of 88%-92% Gold: Actuarial value of 78%-82% Silver: Actuarial value of 68%-72% Bronze: Actuarial value of 58%-62% For example, a plan with an actuarial value of 70% would be a silver plan. This means that on average the plan will pay 70% of enrollee health care expenses while enrollees will pay 30% through some combination of deductibles, co-pays and coinsurance. Issuers must offer at least one plan in the silver and one plan in the gold levels of coverage. HHS will establish a system for rating exchange plans based on quality and price, also on enrollee satisfaction. 14

14 Pediatric Dental and Vision For members up to age 19 Vision must be both on and off exchange On-Exchange: Qualified Dental Plan can be sold Stand Alone (SADP) on-exchange only If at least one carrier offers SADP in state on-exchange, we are not required to embed it into our products Coventry chose not to embed pediatric dental into on-exchange products Aetna chose to embed pediatric dental into on-exchange products Off-Exchange: Dental can be sold off-exchange but is not required to meet ACA standards, in order to offer a compliant product off-exchange, we have to include pediatric dental 15

15 Rate Shock, Taxes and Fees Four Factors Driving 2014 Rate Increases Increasing Medical Cost Trend Essential Health Benefit (EHB) Requirements 1 Health insurance premiums in the past decade have increased faster than the rate of inflation and wage increases 2 Health plans are required to cover a government-issued list of essential health benefits and services Rating Changes Taxes and Fees 3 Under the new rating bands, the difference in what older consumers pay vs. younger will be limited to a range of 3:1 4 The ACA contains new tax and fee provisions that will add to the cost of coverage as they are implemented 16

16 Four Factors Driving 2014 Rate Increases Under the new rating rules, health plans will only be allowed to vary rates based on the following criteria: Age Rating Area Family Composition Tobacco Use The difference in what consumers pay will be limited to a range of 3:1 Each state must establish one or more rating areas Depends whether the plan covers an individual or family Insurers can now rate for tobacco use; however rates cannot vary by more than 1.5:1 17

17 Individual Subsidies There are three types of subsidies for individuals with coverage through an Exchange: 1. Premium limits 2. Cost-sharing limits (i.e. limits on deductibles, copays, and co-insurance) 3. Out-of-pocket spending Subsidy amount is dependent on income with respect to Federal Poverty Level (FPL) For , 400% of the FPL is $44,680 for a single individual and $92,200 for a family of four Income level (in terms of FPL) Max % of income paid toward health care premium Up to 133% 2% % 3-4% % 4-6.3% % % % % % 9.5% Income level (in terms of FPL) Cost sharing limit % 6% % 13% % 27% % 30% Income level (in terms of FPL) Out-of-pocket spending limits % $2,016 (I) / $4,033 (F) % $3,025 (I) / $6,050 (F) % $4,033 (I) / $8,067 (F) 18

18 Taxes and Fees Aetna estimates the combination of the first two fees will add about % to health coverage costs Health Insurer Fee Transitional Reinsurance Contribution Program Patient-Centered Outcomes Research Fee 19

19 Catastrophic Product No premium or cost share subsidy available. Under the Exchange regulation, the following individuals are eligible for catastrophic plans on-exchange: (i) individuals who have not attained the age of 30 prior to the first day of the contract year or (ii) individuals who have received a certificate of exemption for the reasons identified in section 1302(e)(2)(B)(i) or (ii) of PPACA. All benefits are subject to the deductible other than three office visits and preventive care. Our product has a family deductible (umbrella deductible) no benefits are paid for any one family member until the family deductible has been met other than the three office visits and preventive care. 20

20 Overview Altius 2014 Products (On/Off-Exchange) Exchanges and Current Business Small Group Metal Level Products (Off Exchange) AltiusOne Metal Level Products (On/Off Exchange) New RX Benefit for AltiusOne HSA Vendor Coventry Online Quoting Tool (COA) 21

21 Exchanges and Current Business Any Small Group or Individual Product sold after Dec. 31, 2013 must be ACA compliant. Members can keep their existing products until 2014 renewal. Current Products: are not considered off-exchange ; will no longer be administered after Dec. 31, Grandfathered plans will no longer be administered after Dec. 31, all existing members will be offered either early renewal or mapped to ACA compliant product at renewal. 22

22 Altius Metal Level Products Altius Small Group Products for Off-Exchange Only 8 Peak Preference HMO (HPN) Options (2 Gold, 4 Silver, 2 Bronze) 9 Peak POS Options (1 Platinum, 4 Gold, 3 Silver, 1 Bronze) AltiusOne Products for On-Exchange 1 Gold (80% AV) 1 Silver (70% AV) + 3 variations due to AV and cost sharing subsidies 2 Bronze (60% AV) One of these Bronze products is HSA eligible Catastrophic (below 60% AV) no premium subsidy American and Canadian Indian - No Cost Share and Limited Cost Share Identical Products for Off-Exchange except: No Silver variations or Indian Plans offered off exchange Pediatric Dental embedded for off exchange only 23

23 Product Benefit Grid Refer to the benefit grids. 24

24 New Rx Benefits for AltiusOne Prescription Drugs Pharmacy Separate $1,000 Rx Deductible Tier 1A Lower Cost Preferred Generic Drugs Preferred Pharmacy $5 / Non Preferred Pharmacy $20 / Mail Order $10 Tier 1 Preferred Generic Drugs Preferred Pharmacy $15 / Non Preferred Pharmacy $20 / Mail Order $20 Tier 2 Preferred Brand Drugs Tier 3 Non Preferred Brand/ Generic Drugs Preferred Pharmacy Deductible + $45 / Non Preferred Pharmacy Deductible + $55 / Mail Order Deductible + $ Preferred Pharmacy Deductible + $75 / Non Preferred Pharmacy Deductible + $85 / Mail Order Deductible + $225 Tier 4 Preferred Specialty Drugs Preferred Pharmacy Deductible + 30% Coinsurance Tier 5 Non Preferred Specialty Drugs Preferred Pharmacy Deductible + 40% Coinsurance 25

25 Health Savings Account Coventry will continue to use HealthEquity for our member s HSA accounts. Specialists are available 24- hours a day, 365 days a year by calling Free HSA Product! No setup or monthly administration fees. The member website provides a single location for account holders to estimate out of pocket expenses, compare prescription prices, manage claims and much more. 26

26 OFF-HIX Products for Individual Business CoventryOne Online Assistant (COA) Brokers will have the same functionality with the existing 2013 products and the 2014 Off-Exchange products as they do today: Managing Clients Creating/Sending Proposals Starting/Sending Applications Tracking Applications & Proposals 27

27 ON-HIX Products CoventryOne Online Assistant (COA) working toward a Direct Enrollment broker solution for ON-HIX products by early 2014 Create proposals with comparison of products showing subsidy from FFM Assist clients with the application process to enroll with the FFM Track proposals and submissions through the COA 28

28 Overview Customer Service Organization (CSO) Readiness Operational Rules: Eligibility Open Enrollment Application Delivery Effective Dates Premium Payments Grace Periods Special Enrollment Who to Call? (On/Off Exchange) Resources 29

29 Marketplace Eligibility Marketplace eligibility requires consumers to: Live in its service area Be a U.S. citizen or national Be a non-citizen who is lawfully present in the U.S. for the entire period in which enrollment is sought Not be incarcerated In addition, Coventry requires Subscribers and Dependents to meet all criteria listed in the Member Contract. Note: There is no longer a maximum age for Subscribers or Spouses. 30

30 Open Enrollment Period & Effective Dates Open Enrollment occurs between October 1, 2013 March 31, 2014* *For year one only Ongoing, Open Enrollment will run from October 15 th to December 7 th. If the member enrolls any time between October 1, 2013 and December 15, 2013 and makes their first premium payment by December 31 st, their new health coverage starts January 1,

31 Effective Dates (cont d) If the member enrolls between the 1 st and 15 th day of the month and pays their premium, their coverage will begin on the 1 st day of the next month. Member Enrolls Effective Date January 1 st 15 th February 1, 2014 February 1 st 15 th March 1, 2014 March 1 st 15 th April 1,

32 Effective Dates (cont d) If the member enrolls between the 16th and the last day of the month and pays their premium, their effective date of coverage will be the first day of the second following month. For example: Member Enrolls Effective Date January 16 th 31 st March 1, 2014 February 16 th 28 th April 1, 2014 March 16 th 31 st May 1,

33 Premium & Payments Draft Dates - TBD 5 th day of the month Payment Options - EFT, Paper Statement, Credit Card ERS/Ebox, Ebill, Web EFT, Paper Statement, Credit Card, Web Binder Payments 100% must be received to issue the policy If not paid in full, two attempts are made to collect the remaining balance before the partial payment is refunded Rate Guarantee Period All policies are based on calendar year All members will renew January 1 st of each year, regardless of original effective date 34

34 Grace Period (d)(3), issuers must notify providers that may be affected that an enrollee has lapsed in his or her payment of premiums. Issuers should include the following information in the provider notification: Purpose of the notice; A notice-unique identification number; The name of the QHP and affiliated issuer; Names of all individuals affected under the policy and possibly under the care of this provider; An explanation of the three month grace period, including applicable dates, including: whether the enrollee is in the second or third month of the grace period, consequences of grace period exhaustion for the enrollee and provider, and options for the provider; and the QHP customer service telephone number specifically for use by providers, if available. Generate a RA to the provider and an EOB to the member that the following denial code reason: AWAITING ELGIBILITY DETERMINATION FROM HEALTH INSURANCE MARKETPLACE DUE TO NON-PAYMENT OF PREMIUM. 35

35 Grace Period Process Non-APTC members have a 1 month grace period APTC members have a 3 month grace period Up to 3 past due notices will be sent on the 7 th, 45 th & 65 th day Members receive a 1 month grace period A single past due notice is sent around the 10 th of the month 36

36 Special Enrollment The Exchange must allow qualified individuals and enrollees to enroll in or change from one QHP to another as a result of the following triggering events: Loss or Gain Erroneous or Violation Newly Eligible or Ineligible Qualified Individual 37

37 Enrollment & Billing Vendor (HPS) Health Plan Services (HPS) is an existing vendor that has been contracted to perform all enrollment and billing functions for Coventry. HPS currently performs all enrollment and billing tasks for the existing CoventryOne Membership. All billing inquiries will be handled by HPS. Complex enrollment issues that cannot be answered by the CSO or the FFE call center will be resolved by HPS. 38

38 Who to Call? Members & Brokers can contact the CSO (On Exchange) for the following: General exchange & enrollment inquiries Questions about authorizations Customer satisfaction surveys Disease management programs Life event programs Self-service tools Cost sharing Networks Provider locator Premium rebates CSO contact #: Escheatment letters Claims or complaints about claims Benefits Wellness programs Request an ID card or SBC 39

39 Who to Call? Members & Brokers should contact the Exchange for the following: Member terms Address changes Dependent Add/Term Renewal options during open enrollment/life event Complaints or appeals about the Exchange Addition/deletion of a dependent, with an enrollment date discrepancy, or when a dependent turns age 26 Plan changes when eligible Contact the Exchange Requests for member renewal letters Rates for specific plans Renewal letter copies 40

40 Who to Call? Members & Brokers should contact HPS for: Bank drafts Payments Billing inquiries Contact HPS: Enrollment dates that cannot be verified by Coventry 41

41 Resources Helpful websites containing Exchange knowledge and updates include: (English Content) (Spanish Content) 42

42 Overview Broker Partnership with Altius Role of the Broker & Navigators Broker ACA Certification Selling on the Exchange Retention Sales Opportunities 43

43 Role of the Broker with the Marketplace Brokers will play a vital role as millions of Americans sign up for insurance on the Exchange. Agents and brokers will play an important role in: educating consumers about Marketplaces and insurance affordability programs helping consumers receive eligibility determinations helping consumers apply for premium tax credits and cost-sharing reductions helping consumers compare plans, and enroll in coverage helping qualified employers, employees, and individuals enroll in coverage 44

44 How does a Navigator differ from a Broker? Broker Navigator Role Educate individual and small group employers and help them purchase health plans through the public exchange Brokers can assist customers in the carrier and plan decision making Broker cannot do both roles. Must decide if he/she will be a broker or Navigator. Focus on education and support by helping consumers understand their options and how to enroll, what financial help they my qualify for etc. Navigators cannot provide advice to customer Compensation Managed directly from carrier to broker; will vary by state. Compensation is same for products through the exchange The exchange is responsible for compensating navigators Cannot accept direct or indirect compensation from carrier Registration Broker must register with the exchange. They will receive a unique ID number used for tracking AOR/BOR Navigators will personally register through the exchange 45

45 Broker ACA Certification All agents and brokers must register with CMS so they may assist qualified individuals for individual coverage In completing the registration process, agent or broker will: Confirm his or her identity by answering a number of simple questions Complete a Marketplacespecific online training course Agree to comply with federal and state laws, rules, standards and policies* Receive a Federally- Facilitated Marketplace user ID Provide issuers and web-brokers with Training Certificate of Completion *Including those related to privacy and security policies, as a condition of working with consumers in the Marketplace Once an agent or broker has completed these 3 steps, he or she will receive a Federally-facilitated Marketplace user ID. This FFM user ID is the agent or broker s unique identifier in the Marketplace, and along with it, the agent or broker s national producer number (NPN) Upon successfully completing all applicable exams and agreements, agents will receive a training completion certificate. Agents will a certificate for each curriculum they complete. They ll need to keep the certificates for their records. Copies should be provided to any issuers and web-brokers with which they are affiliated (i.e. carriers) 46

46 Broker ACA Certification Websites

47 AltiusOne Retention Strategy January June Membership - 12/1/13 Migration with Increases Offer New 12-month policy effective 12/1/13 (similar to an off-cycle renewal) Member remains in their selected / existing product Accumulators start over in January 2013 price increase on original policy effective date Member will need to take action to accept (mail or fax in acceptance) Those NOT accepting new policy can: Stay on their current plan until it expires (qualifying event), then move to a HIX product, OR Enroll in a HIX product at any time during OEP 48

48 AltiusOne Retention Strategy July December Membership Extension of Contracts through 12/31/2014 Members who renew (or buys a new policy) after 7/1/13 will be able to keep their policy until 12/31/14. Member remains in their selected / existing product with no rate increase Accumulators start over in January Member will not need to take action contracts will be automatically extended 49

49 Questions? Comments? 50