Overview of Health Insurance Exchanges in the USET Area. USET Impact Week February 4-7, 2013 Washington, DC

Transcription

1 Overview of Health Insurance Exchanges in the USET Area USET Impact Week February 4-7, 2013 Washington, DC 1

2 Affordable Care Act (ACA) Insurance Reforms No lifetime limits, annual limits Pre-existing conditions Medicaid Expansion Health Insurance Exchanges Individuals Small Businesses Medicare Part D donut hole changes Quality, Prevention, Innovation Health Care Workforce Indian Health Care Improvement Act Title X, Subtitle B, Part III, Sec

3 ACA Strategies to Reduce Uninsured in America Remove barriers Insurance reform Medicaid Expansion Create market structures o New Exchanges in each state o Insurance outside Exchanges Risk reduction for insurance companies 3

4 More ACA Strategies to Reduce Uninsured Carrots o Federal premium assistance for individuals o Federal tax credits for business <25 employees Sticks o Tax penalty for uninsured Individual Mandate AI/AN are exempt Business with >50 employees o Fined $2,000 per person over 30 people 4

5 Why is ACA Important for American Indian Health Care? Single enrollment form o Medicaid, Medicaid Expansion, CHIP, Exchanges New sources of funding o Exchanges Covers adults <65 yrs. Premium assistance up to 400% FPL I/T/U can bill plan Shift CHS costs to plans o Medicaid Expansion Up to 133% FPL (+ 5% disregard = 138%) Assets not counted Covers all adults 5

6 Exchange Functions Select Qualified Health Plans (QHP) Enrollment Determine individual eligibility Enroll people in QHPs and MSPs Call Centers Contract with Navigators and Assisters Financial management Premiums Tax Credits Cost Sharing Risk Adjustments 6

7 Metallic Plans in Exchange All plans have same Essential Health Benefits. Plans may differ o Networks of providers o Cost of premiums, co-pays and deductibles Actuarial values of plans equal within metallic categories Bronze: Silver: Gold: Platinum: 60% actuarial value 70% actuarial value 80% actuarial value 90% actuarial value 7

8 Catastrophic Plans Catastrophic Plans have extremely high deductibles and low premiums. Can be sold on Exchange only to a. People under 30 y.o. b. People for whom coverage is unaffordable (to be defined later) Not eligible for tax credits or cost sharing reductions Prevents tax penalties 8

9 Types of Plans on Exchange Qualified Health Plans (QHPs) Issued by insurance companies in state Selected by the Exchange Multi-State Plans (MSPs) Issued by insurance companies operating in > 31 states in 2014 phased in to all states in 2018 Minimum of 2 MSPs selected by Office of Personnel Management (OPM) for each Exchange 9

10 OPM Multi-State Plan Program (MSPP) OPM makes rules for MSPP OPM operates MSPP Separate from OPM FEHBP OPM negotiates premiums and profit margin with insurance company. Child-only plans available Considering only offering silver and gold levels 10

11 AI/AN have special protections and provisions in ACA related to the Exchanges. 11

12 AI/AN are: Exempt from penalty for being uninsured Exempt from most cost sharing in Exchange plans Cost sharing = deductible + co-pay Federal government pays cost sharing to plans Able to enroll monthly 12

13 Exemptions from Cost Sharing for AI/AN Enrolled in Exchange Plans No cost sharing for people served in I/T/U o I/T/U collects 100% of charges from plan No cost sharing in private sector for AI/AN with referral from I/T/U o CHS does not pay any portion of care covered by plan For AI/AN below 300% FPL, no cost sharing in private sector without referral from I/T/U 13

14 AI/AN Plan Variations for QHPs and MSPs Zero Cost Sharing Variation For AI/AN under 300% FPL Individual at 300% FPL = $41,910 Family of 4 at 300% FPL = $86,460 Limited Cost Sharing Variation For AI/AN above 300% FPL Has zero cost sharing for services provided by I/T/U or through CHS Cost sharing applies in other circumstances 14

15 Premium Subsidies AI/AN have same premium subsidies as everyone else in Exchanges Based on Modified Adjusted Gross Income (MAGI) Sliding scale up to 400% FPL (96% - 35%) Silver level is benchmark Advanced payment of tax credits (APTC) o Paid to insurance company o Reconciliation at end of year 15

16 Persons in Poverty guideline family/household 1 $11, , , , , , , ,630 For families/households with more than 8 persons, add $4,020 for each additional person.

17 Annual Federal Subsidy of Health Insurance Premiums by Income Level for Individuals % FPL Premium Limit as % Income Individual Premium (Tribal Sponsorship) % < $ % $1, % $1, % $2, % $3,391-$4,099

18 With no cost sharing, AI/AN can choose bronze plans with lower premiums. 18

19 Barriers to AI/AN Enrollment Premiums o Tribal Sponsorship can eliminate barrier IRS rules and regulations o Advanced tax credits + reconciliation o No enrollment for non-filers o Complex rules Lack of insurance experience, knowledge No motivation to enroll Exchange regulations 19

20 Tribal Planning and Budgeting Premium payments Provider contracts Communications plan Outreach and enrollment assistance 20

21 State-Based Exchanges in the USET Area State Federal Approval Status Structure of Exchange Type of Exchange Connecticut Conditional Approval Quasi-Governmental Active Purchaser Massachussetts Conditional Approval Quasi-Governmental Active Purchaser Mississippi In Review Non-Profit TBD New York Conditional Approval Operated by State TBD Rhode Island Conditional Approval Operated by State Active Purchaser SOURCE: Kaiser Family Foundation 21

22 Exchange Table Definitions Federal Approval Status: Conditional Approval- HHS has reviewed the state s blueprint application and found that the exchange is making progress and is expected to be ready for enrollment on October 1, 2013; In review- state's Exchange blueprint application is in review with HHS; Blueprint not yet submitted-state has not yet submitted the exchange blueprint application for a partnership exchange to HHS. Structure of Exchange: States have the option of establishing the exchange as part of an existing state agency or office (Operated by State), as an independent public agency (Quasi-governmental), or as a non-profit entity (Non-profit). Type of Exchange: States have flexibility in determining the role of the exchange with respect to contracting with health plans. All exchanges are required to contract only with health plans the meet minimum federal requirements for qualified health plans. States can choose to have the exchange contract with all qualified health plans (clearinghouse) or states can choose to have the exchange contract with selected health plans and/or negotiate premium prices with health plans (active purchaser). SOURCE: Kaiser Family Foundation 22

23 Consultation and SBE State exchange final approval is contingent on Tribal consultation. Insist that your state work with its Tribe(s) to develop a consultation policy. In the event of state non-compliance, contact DHHS. 23

24 Federally-facilitated Exchanges (FFE) Regulation by many agencies Center for Consumer Information and Insurance Oversight (CCIIO) in CMS, HHS U.S. Office of Personnel Management (OPM) Internal Revenue Service (IRS) State insurance regulators (Insurance Commissioners) Policy coordination through White House 24

25 General Guidance on FFE Issued by CCIIO on May 16, 2012 Outlines Partnership options for States Plan management Consumer assistance Both Partnership transition to State Exchanges Establishment Grants can be used for planning Partnerships 25

26 Plan Management States may elect to take on plan management in FFE, including: QHP certification QHP account management Oversight of plan marketing Collect data from issuers Quality rating functions Reinsurance and Risk Adjustment programs 26

27 Consumer Assistance States may elect to provide consumer assistance functions in an FFE, including: Navigator program In-person assistance FFE is responsible for Website Call center 27

28 Blueprint Application State submits Blueprint Tells how states will run their own Exchange or perform Partnership activities in FFE Requires copy of legislation and legal authority Signed by state s Governor Public transparency requirements 28

29 Pure FFE = No Partnership One set of standards and operating procedures for all states served by FFE One national call center Funded by fees on issuers State insurance departments will carry out their traditional regulatory functions 29

30 Funding for FFE Functions No federal funding for operations User fee to fund FFE 3.5 percent of premiums, collected from issuers HHS permanent Risk Adjustment program $1/year/enrollee on insurance offered both inside and outside Exchanges Re-insurance (3 year program) Commercial insurance inside and outside Exchange must provide data and funding. 30

31 FFE Plan for 2014 All Exchange federal regulations apply Will not exceed minimum federal standards All health plans that meet QHP standards will be included in FFE EHB benchmark is largest small group market product in the State s small group market 31

32 Delayed Implementation for FFE Plans must attain accreditation in 2016 NCQA or URAC Quality reporting starts in 2016, with data available for 2017 open enrollment 32

33 Eligibility and Enrollment Single application Coordination with State Medicaid/CHIP FFE may make eligibility determinations FFE may assess and refer to State Medicaid/CHIP States must provide data to FFE People currently on Medicaid and CHIP Wage and employment data base 33

34 Additional Guidance on Partnerships (issued Jan 3, 2013) Appendix A: HHS Approach for Certification of FFE QHPs for 2014 Network Adequacy Standards Inclusion of Essential Community Providers (ECP) 20% ECP participation in network and issuer agrees to offer contracts to all available Indian providers with QHP Indian Addendum encouraged, or 10% ECP participation and issuer submits a satisfactory narrative justification as part of its Issuer Application, or Issuer submits justification (stricter review by CMS) 34 34

35 What you need to know to be a network provider in FFE QHP Indian Addendum is optional Process and timing Early 2013 Issuers submit intent to apply QHP Issuer Application released Certification review begins Late Summer 2013 QHP issuer agreements completed October 2013 Open Enrollment begins 35

36 Tribal Consultation for FFE Guidance issued May 16, 2012: CCIIO will consult with Tribes in development of FFE and on an ongoing basis Acknowledges Sec 206 (billing for off plan services by I/T/U) applies to QHP TTAG ACA Policy Workgroup Indian Addendum and network adequacy Tribal Sponsorship Separate process for identification of AI/AN in application 36

37 FFE Exchanges in USET States Alabama STATUS: FFE Medicaid: No Florida STATUS: FFE Medicaid: Undecided Louisiana STATUS: FFE Medicaid: No Maine STATUS: FFE Medicaid: No North Carolina STATUS: Partnership Medicaid: Undecided South Carolina STATUS: FFE Medicaid: No Texas STATUS: FFE Medicaid: No 37

38 Key Dates Mid July Plans should have their networks established. October 15, 2013 First open enrollment period starts for Exchanges January 1, 2014 Plans start offering services 38

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