Health Insurance Exchange Proposed Rules

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1 Health Insurance Exchange Proposed Rules Karen Fisher, J.D Jane Eilbacher Will Dardani

2 Exchange Rules Overview HHS has issued two proposed rules providing the framework for the establishment of Health Insurance Exchanges (HIEs): Establishment of Exchanges and Qualified Health Plans, July 15, Federal Register Comments Due: September 28 Standards Related to Reinsurance, Risk Corridors, and Risk Adjustment, July 15, Federal Register Comments Due: September 28 HHS also released a proposed ruled, Establishment of Consumer Operated and Oriented (CO-OP) Program, July 20, Federal Register Comments Due: September 16 2

3 Exchange Rules Overview (cont.) 3 Other proposed rules released: Medicaid Program: Eligibility Changes under the Affordable Care Act of 2010, August 17, Federal Register Comments due: October 31 Health Insurance Premium Tax Credit, August 17, Federal Register Comments due: October 31 Eligibility Determination; Exchange Standards for Employers, August 17, Federal Register Comments due: October 31 Summary of Benefits and Coverage and Uniform Glossary and Templates, Instructions and Related Materials, August 22, Federal Register Comments due: October 21

4 Overarching Issues for AMCs Effects of insurance market expansion on your state, local community, and institution through both Exchanges and Medicaid Spectrum of exchange options and the implications for your institution Role of AMC providers in Exchange plan networks Financial implications of patient eligibility and enrollment, and movement between sources of coverage Possibility of tiering 4

5 5 State Exchange Status

6 Implementation Timeline Late 2011: Final rules from HHS on establishing HIEs Jan.1, 2013: States must have Exchange certified by HHS Oct. 1, 2013: Initial open enrollment period for individuals and SHOP Jan. 1, 2014: Exchanges become operational Jan. 1, 2017: States may expand SHOP eligibility to employers with 100+ employees Late 2011: Essential Health Benefits, Eligibility, and enrollment NPRMs expected July 1, 2013: CO-OPs established Jan. 1, 2014-Dec. 31, 2016: Temporary Reinsurance Program and Risk Corridors in effect; Risk Adjustment, permanent, starting

7 Federal Funding for Exchanges* Planning Grants: $49 million $800,000-$1 million AK refused funding, FL plans to return funding Early Innovator Grants $6 million-$48 million Awarded to 6 states and 1 consortium KS has returned early innovator grant funding, OK plans to return funding Exchange Establishment Grants August 12, 2011: 13 states and DC were awarded over $185 million dollars May 23, 2011: IN, RI, and WA were awarded grants 7 * As of August 2011

8 Establishment of Exchanges and QHPs Proposed Rule Key Issues that are of specific interest to AMCs: Exchange board governance composition Qualified Health Plan (QHP) network adequacy standards and the definition of sufficient number of essential community providers Insurance plan risk adjustment methodology Reinsurance and risk corridor programs 8

9 Establishment of an Exchange States may establish an Exchange to provide coverage to individuals and small businesses (Small Business Health Options Program SHOP ) Should the State not elect to establish its own Exchange, the Secretary must establish a federally administered Exchange in that State NPRM would offer states significant flexibility, including decisions surrounding governance, network adequacy, and certification of qualified health plans (QHPs) Exchange Model: Approach can range from insurance clearinghouse (e.g. the Travelocity option ) to active purchaser 9

10 Exchange Governance The ACA provides options for structuring the governance of an exchange, including: New or existing State Agency (e.g. State Medicaid Agency) Independent Public Authority Quasi-Governmental Entity Non-Profit Organization Federally-facilitated Exchange 10

11 Exchange Governance (cont.) If Exchange is governed through an independent state agency or non-profit organization, it is required to create clearly-defined governing board. Proposed Board membership requirements: Majority of voting board members without conflicts of interest Majority of voting board members with relevant experience in health care policy, delivery, purchasing, finance, and administration State discretion whether to allow insurers, insurance brokers and/or agents from serving on board 11

12 Stakeholder Consultation Exchange must regularly consult on an ongoing basis with the following stakeholders, including: Health Care Providers Public Health Experts Advocates for enrolling hard to reach populations (e.g. mental health, substance abuse) Large Employers 12

13 Exchange Quality Activities Exchanges will have role in implementation, oversight, and improvement of quality and enrollee satisfaction initiatives Quality performance will be component of QHP accreditation (quality standards for QHP issuers to be addressed in separate, future rulemaking) Must evaluate quality improvement strategies, oversee implementation of enrollee satisfaction surveys, assessment and ratings of health care quality and outcomes, info disclosures, and data reporting 13

14 Exchange Quality Activities (cont.) Exchanges may also implement quality improvement selection criteria beyond the minimum standards for QHPs Quality ratings and results of enrollee satisfaction surveys need to be available to consumers via exchange call center and website 14

15 Consumer Support Exchange must offer the following services: Call center; website offering plan comparison tools and enrollment opportunities; Exchange Navigators to assist with education, and enrollment assistance Each QHP issuer must make available a provider directory for publication on the Exchange website, including providers not accepting new patients 15

16 Consumer Enrollment Must offer a single, streamlined process for enrollment The Exchange is responsible for determining eligibility for both Exchange products and Medicaid/CHIP Enrollment Periods: Initial open enrollment period: Oct. 21, 2013 thru Feb. 28, 2014 Annual open enrollment period: Oct. 15 thru Dec. 7 of preceding calendar year (beginning 2015 benefit year) Special enrollment period: 60 days from date of triggering event (e.g. marriage, job loss, etc.) 16

17 QHP Network Adequacy QHP must include a provider network: a sufficient choice of providers for enrollees ( ) a sufficient number of essential community providers, where available, that serve predominately low-income, medicallyunderserved individuals ( ) 340B Providers Federally Qualified Health Centers Definition of sufficiency, including the geographic distribution of and timely access to providers in a service area, is also an issue 17

18 QHP Network Adequacy (cont.) Requiring issuers to offer contracts to all essential community providers would allow continuity of service for enrollees with existing relationships especially in communities where the essential community provider has been the only reliable source of care. However, such a requirement may inhibit attempts to use network design to incentivize higher quality, cost effective care by tiering networks and driving volume towards providers that meet certain quality and value goals. 76 Fed. Reg

19 Small Business Health Options Program SHOP Participation is initially open to small businesses with under 100 employees. States can elect to limit SHOP eligibility to only those employers with under 50 employees through 2015 States have the option to expand to businesses with greater than 100 employees in 2017 Small business tax credit revised in 2014, for very small employers with low wage workforce: only available through the SHOP 19

20 Consumer Operated and Oriented Plan (CO-OP) Program Provides Federal loans to foster development of consumer-governed, private, nonprofit health insurance issuers to offer QHPs in the Exchanges Only loan recipients are eligible to become a CO- OP As proposed, any organization associated with a State University system (e.g. hospital, provider group) is ineligible to participate in the CO-OP program CMS will begin awarding loans in late 2011 or early

21 Reinsurance, Risk Corridors, and Risk Adjustment Proposed Rule ACA requires the creation and implementation of transitional reinsurance and risk corridor programs and a permanent risk adjustment program Goal of these programs is to mitigate the potential effects of risk selection and stabilize premiums in the individual and small group markets as insurance reforms and the Exchanges are implemented There is a particular concern about the impact of the immediate enrollment of individuals with unknown health status 21

22 Reinsurance, Risk Corridors, and Risk Adjustment Proposed Rule Reinsurance Risk Corridors Risk Adjustment What Provides funding to plans that enroll highest cost individuals Limit insurer loss (and gains) Why Offsets high cost outliers Protect against inaccurate rate-setting Program Oversight Who Participates State or State Option if no State- Run Exchange All issuers and TPAs contribute funding; non-grandfathered individuals market plans (inside and outside the Exchange) are eligible for payments HHS Qualified Health Plans (QHPs) Transfers funds from lowest risk plans to highest risk plans Protects against adverse selection State Option in a State- Run Exchange Non-grandfathered individual and small group market plans, inside and outside the Exchange Time Frame 3 years ( ) 3 years ( ) Permanent Source: 76 Fed. Reg

23 Payment Methodologies Risk Corridor QHPs pay back or receive additional payments when allowable costs reach +/- 3% of the target amount HHS intends the collections and payments to be budget neutral in the aggregate Risk Adjustment States can use the federal risk adjustment methodology or one of their own design if it meets federal requirements Details of federally certified risk adjustment methodologies will be published in a forthcoming annual federal notice of benefits and payment parameters Reinsurance All health insurance issuers and self-insured employers (often via third party administrators) will fund the reinsurance payments through percent of premium Payments will go to issuers in the individual market, both in and outside of Exchanges, whose costs associated with an individual s essential health benefits exceeds a threshold up to a cap 23

24 Forthcoming Rules / Notices Definition of Essential Health Benefits Eligibility and Enrollment Requirements Standards for Exchanges and QHP issuers related to quality Annual federal notice of benefits and payment parameters The requirements for the small business tax credit for calendar years 2014 and beyond Accreditation of QHP issuers 24

25 For Further Information: Kaiser Family Foundation: 25

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