AMERICAN HEALTH BENEFIT EXCHANGES

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1 AMERICAN HEALTH BENEFIT EXCHANGES As we have previously reported, beginning January 1, 2014, the GHLIT will stop offering AVMA members medical insurance. However, members and small employers will be able to purchase health insurance through the American Health Benefit Exchanges (commonly referred to as "Exchanges"). To help assist members in preparing for this change, this summary provides an overview of what is currently known about the Exchanges and how they will work. What is an Exchange? As required by the Patient Protection and Affordable Care Act, an Exchange will be set up in each state by the state, or the federal government on the state's behalf, through which insurance issuers will offer qualified health plans ("QHPs") to individuals. The Exchanges will be online marketplaces through which multiple insurers will provide QHPs for individuals to compare and choose the coverage option for their needs. While this overview deals exclusively with coverage for individuals, it is important to note that each Exchange will also offer coverage to small employers through the Small Business Health Options Program ("SHOP"). Additional information about the SHOP will be provided in the future. Update: How is the Exchange different than the private exchange offered by the AVMA-GHLIT? The private exchange that will be offered by the AVMA-GHLIT will be similar to the Exchanges in ease of use and ability to shop for and compare health coverage options. Insurers in both the private exchange and the Exchange must accept all applicants and generally must allow all participants to renew their coverage. However, individuals will not be eligible for premium tax credits or cost sharing reductions in the private exchange. Additionally, the health coverage offered through the private exchanges may not offer the same benefits as will be offered by the QHPs. Finally, small employers will not have access to the SHOPs or the small employer tax credit in the private exchanges. What functions will the Exchange perform? Exchanges will perform the following functions: 1. Certify QHPs. All issuers in an Exchange must offer only QHPs (discussed further below). 2. Provide consumer assistance. Exchanges must operate a call center and a website to assist individuals with their questions about the Exchange. The website will include information about each QHP offered through the Exchange, such as premium and cost sharing information, copies of the summaries of benefits and coverage, and a calculator to help individuals compare QHPs. Individuals will also be able to request eligibility determinations and enroll in a QHP through the website. Additionally, Exchanges will offer experts called "Navigators" that will assist individuals within the Exchanges and will conduct public education on the Exchanges. 3. Eligibility Determinations. Exchanges will determine whether an individual is eligible to enroll in a QHP through the Exchange. SKALMER/ v2

2 4. Insurance Affordability Programs. The Exchange will determine whether an individual is eligible for Medicaid, CHIP, cost sharing reductions or advance payment of premium tax credits. If an individual is eligible for advance payment of premium tax credits, the Exchange will also calculate the credit. 5. Administer Enrollment Periods. An individual will be able to enroll in a QHP through the Exchange during an initial enrollment period, an annual enrollment period or a special enrollment period (discussed below). What is a Qualified Health Plan ("QHP")? A QHP is an Exchange-certified health plan that offers an "essential health benefit package" through the Exchange. An essential health benefit package: 1. Provides essential health benefits. "Essential health benefits" will include items and services within the following categories: ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services (including behavioral health treatment), prescription drugs, rehabilitative and habilitative services and devices, laboratory services, preventive and wellness services and chronic disease management, and pediatric services (including oral and vision care). 2. Has limits on cost sharing. The deductible in an essential health benefit package cannot exceed $2,000 per person or $4,000 per family. Additionally, the out-of-pocket maximum cannot exceed the out-of-pocket maximum for high deductible health plans. The maximum for 2014 is not yet known, but for 2013, the maximum is $6,250 per person and $12,500 per family. 3. Provides coverage at a "metal level". A QHP must offer coverage at the silver and gold level and may also offer coverage at bronze or platinum level. The metal level corresponds to the actuarial value provided by the coverage and is intended to provide a method of determining the value of the plan based on the percentage the plan is projected to pay. The actuarial value of the bronze level is 60%, silver is 70%, gold is 80% and platinum is 90%. Generally, this means that a silver plan will pay 70% of expenses and an enrollee would be responsible for the remaining 30%. Am I eligible for coverage in a QHP? To be eligible to enroll in a QHP, an individual must be a citizen, a national or be lawfully present in the United States, not be incarcerated, and reside in the service area (generally the state) in which the Exchange operates. For children under age 21, the child's parent(s) must reside in the state in which the Exchange operates. Am I eligible for a premium tax credit? An individual with a household income between % of the federal poverty level can receive advance payments of premium tax credits if the individual is not eligible for affordable employer sponsored coverage that provides minimum value and enrolls in a QHP through the Exchange. For 2012, 100% of the federal poverty level was $11,170 per year for an individual and $23,050 per year for a family of four; 400% of the federal poverty level was $44,680 per SKALMER/ v2 2

3 year for an individual and $92,200 per year for a family of four. Individuals eligible for Medicare are not eligible for a premium tax credit, even if they choose not to enroll in Medicare. Am I eligible for cost sharing reductions? Individuals with household incomes between % of the federal poverty level may be eligible for cost sharing reductions if they enroll in a silver level QHP (except for Native Americans, who may enroll in any metal level). For 2012, 100% of the federal poverty level was $11,170 per year for an individual and $23,050 per year for a family of four; 250% of the federal poverty level was $27,925 per year for an individual and $57,625 per year for a family of four. Individuals eligible for Medicare are not eligible for cost sharing reductions even if they choose not to enroll in Medicare. Individuals may, however, be eligible for cost sharing reductions under Medicare; for more information please contact the Medicaid-Medicare Coordination Office or your local Medicaid office. We will be providing more information in the near future regarding guaranteed issue under Medicare Advantage or Medigap coverage. How do I enroll? An individual determined to be eligible for coverage in a QHP may enroll in coverage during the initial enrollment period, the annual enrollment period, or a special enrollment period. Individuals may enroll in person, by telephone via the Exchange call center, or by submitting the enrollment form online via the Exchange website or through the mail. Initial Enrollment Period. The initial enrollment period is the first time that individuals will be eligible to enroll in QHPs through the Exchanges. The initial enrollment period will begin October 1, 2013 and will close March 31, For those enrolling prior to December 15, 2013, coverage will be effective January 1, Thereafter, coverage for those who enroll between the first and fifteenth of a month will be effective the first day of the following month. Coverage for those who enroll between the sixteenth day and last day of the month will be effective the first day of the second month. Annual Enrollment Period. For benefit years after 2014 (i.e. for coverage in 2015 and later), individuals must generally enroll during an annual enrollment period. The annual enrollment period will open October 15 and will close December 7. The Exchange will provide written notice of the enrollment period between September 1 and 30th each year. Coverage will be effective January 1 of each following year. Special Enrollment Periods. Individuals who experience a trigger event will have a 60 day special enrollment period to enroll in a QHP. There are multiple trigger events for a special enrollment period; a few of the most common include: Loss of minimum essential coverage (e.g., losing employer-sponsored coverage). Gaining a dependent or becoming a dependent, through birth, adoption or marriage. Becoming a citizen, a national or lawfully present in the United States. Becoming newly eligible or ineligible for advance payment of premium tax credits or cost sharing reductions or losing affordable employer sponsored coverage or employer sponsored coverage that provides minimum value. SKALMER/ v2 3

4 Gaining access to new QHPs because of a move. Native Americans have a special enrollment rule whereby they may enroll in or change coverage once per month. If an individual enrolls between the first and fifteen day of the month, coverage will be effective on the first day of the next month. If an individual enrolls between the sixteenth and last day of the month, coverage will be effective on the first day of the second month. For special enrollment due to birth, adoption or placement for adoption, coverage will be effective as of the date of birth, adoption or placement. How will I pay my premiums? Individuals will be permitted to pay premiums directly to the QHP issuer. However, the Exchange may establish a process to collect premiums electronically and pay the QHP issuers. When would my coverage terminate? An enrollee's coverage in a QHP through the Exchange will terminate upon the following events: Upon request. An enrollee may terminate coverage at any time upon notice to the Exchange and QHP. Coverage will terminate on the date specified in the notice if the notice is provided fourteen days in advance. If the notice is not provided fourteen days in advance, coverage will terminate fourteen days after the date of the notice. Loss of eligibility. If an enrollee no longer satisfies the eligibility requirements, coverage will terminate on the last day of the month following the month in which notice of the eligibility determination is provided. Non-payment of premiums. If an enrollee fails to pay the required premium and the three-month grace period has expired, coverage will terminate on the last day of the first month of the three-month grace period. Enrollees are eligible for the three-month grace period if they receive premium tax credits and they have paid a full month's premium at least once during the benefit year. It is unknown at this time when coverage will terminate due to non-payment for enrollees who are not eligible for the three-month grace period. Coverage is rescinded. If an enrollee's coverage is rescinded, coverage will terminate retroactively. Coverage may be rescinded only for instances of fraud or intentional misrepresentation by an enrollee. Termination or decertification of the QHP. It is unknown at this time when coverage will terminate due to a QHP terminating or being decertified. Enrollment in a different QHP/becoming eligible for Medicaid or CHIP. If an enrollee enrolls in a different QHP or becomes eligible for Medicaid or CHIP, coverage will terminate the day before the new coverage begins. Notice of the termination will be provided at least thirty days prior to the effective date of the termination and will include the reason for the termination. SKALMER/ v2 4

5 Can I purchase insurance in 2013? QHPs will not be available until 2014 but an individual can purchase insurance on the individual market at any time. Coverage purchased on the individual market in 2013 should be sufficient to satisfy the requirement that all individuals purchase minimum essential coverage beginning in However, individuals who do not purchase a QHP through the Exchanges will not be eligible for any premium tax credits or cost sharing reductions. Additionally, it is unknown whether the coverage purchased in 2013 will continued to be available in Can I get Medicare Coverage Through the Exchange? The Exchange will be separate from Medicare. Accordingly, an individual will not be able to purchase original Medicare prescription drug ("Medicare Part D") or Medicare Advantage coverage through the Exchanges. However, the Center for Medicare Services ("CMS") maintains an Exchange-like internet search tool for use in finding the right Medicare Part D and Medicare Advantage plan for you. For more information, see Individuals choosing original Medicare coverage also have the option of enrolling in Supplemental Medicare ("Medigap") coverage. While Medigap is privately offered insurance, it cannot be offered on the Exchange because it does not offer an essential health benefits package and therefore does not qualify as a QHP. However, like with Medicare Advantage plans, CMS offers an Exchange-like service to help you in selecting a Medigap policy. For more information, see While Medicare Advantage and Medigap coverage are not available on an exchange, there are federal and some state laws that may provide guarantee issue and these provisions will be explained in a future communication. Where can I find more information? More information about the Exchanges is available here: Unresolved Questions What will the Exchange look like? We know that the Exchange will operate online, but no Exchange is currently running or has provided sample screen shots. Accordingly, we do not know what an Exchange may look like for the upcoming open enrollment. How will I interact with the QHP insurer? Presumably there will be a method for interacting directly with the QHP insurer without having to go through the Exchange. What doctors and facilities will be available in the QHPs? The Exchange website will have a list of providers for each QHP, but because the QHPs have not yet been approved by the Exchanges, we do not know which providers will be available for each QHP. What happens if I move to a new state? We know that individuals who move to a new state will be eligible for a special enrollment if there are new QHPs available, but we do not know if they will lose the coverage purchased through the previous state's Exchange. SKALMER/ v2 5

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