Kansas Insurance Department

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1 Kansas Insurance Department A Kansas Guide to Health Insurance Changes Public Policy Session Panel Discussion KAMU Annual Conference Sept. 26, 2013 Sandy Praeger, Commissioner of Insurance 2014 Affordable Care Act provisions Elimination of pre existing condition exclusions & Exchanges () Issues Guaranteed issue and renewability of coverage Rating factors limited to age (3:1), tobacco use, geography and family structure Tax credits and subsidies to help pay premiums and out of pocket costs; up to 400% of the Federal Poverty Level (more than $92,000) Limits on out of pocket costs in qualified health plans ($6,350 for individuals; $12,700 for families) 1

2 2014 provisions & Exchanges () Issues Mandated coverage for essential health benefits Uniform explanation of benefits and standardized definitions Individual mandate to ensure consumers do not wait until they are ill to seek coverage (with some exceptions) Establishment of an online (formerly referred to as the exchange) Health Insurance New federally facilitated commercial insurance where qualified employers and qualified individuals can shop for and enroll in private health insurance plans First Open Enrollment October 1, 2013 March 31, 2014; the sooner enrollment is completed, the sooner coverage can begin (starting Jan. 1, 2014) Annual Open Enrollment (after first year) October 15 December 7; coverage begins January 1 of the next year 2

3 Health Insurance Individuals who are eligible for a public program (like Medicaid or CHIP) will be able to enroll in that program at any time. Individuals with modified adjusted gross incomes between 100% and 400% of the federal poverty level (between $23,550 and $94,200 for a family of four) will also be able to determine whether they qualify for tax credits or subsidies to help pay for private insurance. Tax credits paid each month by the federal government to the insurer; credits will be reconciled on the taxpayer s tax return. Essential Health Benefits Essential Health Benefits (EHB) in health plans must contain at least the following 10 categories: Ambulatory patient services Emergency services Hospitalization Maternity and newborn care Mental health and substance use disorder services, including behavioral treatment Prescription drugs Rehabilitative and habilitative services and devices Laboratory services Preventive and wellness services and chronic disease mgmt. Pediatric services, including oral and vision care 3

4 Essential Health Benefits All plans sold to individuals and small employers, both inside and outside of the, must include the Essential Health Benefits. The original EHB benchmark plan approved for Kansas contained 8of the 10 categories of benefits; it was supplemented to add dental & vision benefits for children and habilitative services. Levels of Plan Coverage Bronze plan covers 60%, enrollee pays 40% Silver plan covers 70%, enrollee pays 30% Gold plan covers 80%, enrollee pays 20% Platinum plan covers 90%, enrollee pays 10% Catastrophic high deductible plan for those under age 30 and those exempt from individual mandate. Provides firstdollar coverage for preventive health services and three primary care visits/yr. When deductible is met, plan covers essential health benefits 4

5 Health Insurance The marketplace will be connected to a Federal Data Services Hub that will allow real time verification of citizenship, immigration status, and federal tax information. Individuals will receive a real time determination of eligibility for public programs or premium tax credits and subsidies to help pay for a qualified health plan (QHP). Individuals will be able to accept or decline financial assistance. Health Insurance Special Enrollment Periods for: Loss of minimum essential coverage Marriage, birth, or placement for adoption Gain citizenship or qualifying immigration status Enrollment errors by HHS or the QHP violates its contract Change in eligibility for tax credits or cost sharing reductions Gain access to new plans as a result of a move Indians may enroll or change QHPs one time per month Exceptional circumstances Enrolled in non qualifying employer coverage 5

6 Health Insurance will: Provide an Internet website that will present qualified health plans (with all essential health benefits) and stand alone dental plans available for purchase by Individuals and employers. Provide a national call center (began operation on 06/21/2013) ; SHOP Call Center, Operate a Navigator program, which will provide individual assistance to persons enrolling on the Exchange. Health Insurance HHS will select, train, certify, and monitor the performance of the Navigator organizations and individuals operating in Kansas. Navigators will conduct public education, distribute information, and facilitate enrollment. Licensed agents and brokers who agree to register with the, complete training, and adhere to privacy, security and other state and federal requirements will be able to help qualified individuals and employers enroll in coverage through the. 6

7 Health Insurance HHS will authorize, certify and train Kansas agents who wish to sell on the. will launch agent/broker registration and training site in late summer. HHS will be collecting from Kansas insurers 3.5% per month of the premiums received by the insurers to finance the required activities and ongoing operation. Kansas Market Health insurance companies were required to submit all 2014 qualified health plan (QHP) policy forms and rates by May 1, Forms and rates were submitted by Blue Cross and Blue Shield of Kansas; Blue Cross and Blue Shield of Kansas City, Coventry Health Care of Kansas and Coventry Life and Health. Plans will be available in all 105 counties in Kansas; each county will have at least two companies offering coverage. 7

8 Kansas All QHP forms and rates were reviewed and approved by KID and uploaded to the federal by July 31 in order to ensure that the companies plans could be offered on the. Health insurance companies that intend to offer coverage outside of the were filed all policy forms and rates with KID by July 31 to ensure they are available for sale when open enrollment begins on October 1. SHOP To enroll, an employer must have at least 1 eligible employee and fewer than 50 full time equivalent employees (FTEs) (rises to 100 FTEs in 2016). In most cases, spouses and children cannot be counted. Sole proprietors without other employees must enroll through the individual. The federal SHOP will use FTE counting methodology when establishing group size to determine employer eligibility. 8

9 SHOP All full time employees (30+ hours per week) are eligible for coverage through the SHOP. 70% participation rate requirement is allowed. Starting in 2014 the Small Business Tax Credit is only available to employers who purchase coverage through the SHOP up to 50% tax credit on employer contributions. Agents and brokers of all sizes (including general agencies, brokerages, and independent brokers) will be able to help small employers enroll through the SHOP. SHOP For 2014, employers will only be able to choose one plan through the SHOP for their employees. Employees will make individual plan selection and complete enrollment process. Beginning in 2015 (assuming multiple insurers offer coverage in the SHOP), agents and brokers will be able to help employers offer their employees a choice of qualified health plans (one plan or one or more coverage levels) and help employees choose a plan. 9

10 SHOP In 2015, will also collect and combine premiums and send to carriers. Employees will be individually rated based on four rating factors age (within 3:1 age band); tobacco use; geographic location; and family status Total premium charged to the group is determined by summing the premiums of covered participants and beneficiaries. Employers can decide how to allocate contributions to coverage. Agents in the Amount and terms of compensation (including appointments) as negotiated between the agents and insurance companies. State appointment and commission regulations remain in effect. Federal will not pay commissions. Agents participating in the should expect to be paid the same commission that insurers pay outside the. 10

11 Agents in the To participate in the, agents must be licensed and in good standing in their state. States will continue to be the primary regulatory authority overseeing agents. To participate in the, agents must: Adhere to all state requirements for licensure, appointment, and market conduct. Complete on line training. Complete security authentication steps. Complete the agent/broker agreement. Agents in the In the federal individual agents can work with consumers in either of two ways: Through issuer websites or work with the consumer using the website. In the federal SHOP agents will work with consumers using the website to complete the employer and employee applications. 11

12 challenges Exchanges Short timeline Open enrollment scheduled to begin in Oct. 1, and ongoing uncertainty exists regarding how the will work Consumer education New way of doing health insurance, new technology, new, inexperienced population entering the market Provider community Are there enough providers, special need for primary care Kansas Insurance Department 420 SW 9 th St. Topeka, KS Phone: Consumer Assistance: Fax:

13 Sheldon Weisgrau KAMU Annual Conference September 26, 2013 Introduction Medicaid Expansion under the The Supreme Court decision Effects of Medicaid expansion (or not) Q&A Health Reform Resource Project 26 13

14 Assist in public education and stakeholder engagement related to health reform Provide technical assistance to advocacy organizations and other stakeholders Assist Kansas entities in securing grants and programs available under the Affordable Care Act () Health Reform Resource Project 27 Supported by Kansas Grantmakers in Health: Kansas Health Foundation Health Care Foundation of Greater Kansas City REACH Healthcare Foundation Sunflower Foundation: Health Care for Kansans United Methodist Health Ministry Fund Wyandotte Health Foundation Health Reform Resource Project 28 14

15 Shared federal-state program Cost sharing: 57% federal / 43% state Eligibility depends on income and category ~380,000 enrolled Health Reform Resource Project 29 requires states to expand Medicaid to cover all eligible individuals (< age 65) with income up to 138% FPL Household Size 2013 Annual Federal Poverty Guidelines (138%) 1 $15,856 2 $21,404 3 $26,951 4 $32,499 5 $38,047 6 $43,594 Health Reform Resource Project 30 15

16 Cost sharing: Federal government covers all costs for first three years Year Federal Share State Share % Nothing % Nada % Zilch % 5% % 6% % 7% % 10% Health Reform Resource Project 31 Health Reform Resource Project 32 16

17 Medicaid expansion was challenged in the Supreme Court The Court ruled that the federal government may not withhold Medicaid funding for existing program if state does not expand So, expansion is optional... Health Reform Resource Project 33 Health Reform Resource Project 34 17

18 300,000+ Kansas adults meet new income eligibility criteria 130,000 are uninsured 50%+ under age 35 75%+ adults without dependent children 50%+ are male 70% white 97% U.S. citizens Health Reform Resource Project 35 About 130,000 eligible uninsured Additional state Medicaid costs of about $625 million over 10 years Reductions in other parts of state and local budgets (?) Economic stimulus (?) Health Reform Resource Project 36 18

19 KHA study Increased state Medicaid spending offset by: Economic stimulus of new federal money 4,000 new jobs New state revenues Offsets in other parts of state budget Local tax savings Net savings for state of $82 million through 2020 Health Reform Resource Project 37 tax credits available to those with household income of 100%-400% of Fed Poverty Level 2013 Federal Poverty Guidelines Household Size 100% 400% 1 $11,490 $45,960 2 $15,510 $62,040 3 $19,530 $78,120 4 $23,550 $94,200 5 $27,570 $110,280 6 $31,590 $126,360 Most Kansans who would have been covered by Medicaid expansion will be too poor to qualify for tax credits Health Reform Resource Project 38 19

20 Local impact New revenue for providers Expansion of capacity, services, and jobs Case studies revenue impact on safety net clinics Health Reform Resource Project 39 33% covered 40% covered 67% covered Clinic A $215,210 $260,861 $436,942 Clinic B $381,493 $462,416 $774,547 Clinic C $430,702 $522,063 $874,455 Clinic D $1,076,993 $1,305,446 $2,186,622 Clinic E $1,196,355 $1,450,327 $2,428,963 Health Reform Resource Project 40 20

21 Sheldon Weisgrau, Director Health Reform Resource Project 1129 S. Kansas Avenue, Suite B Topeka, KS (785) Health Reform Resource Project 41 21

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