Health Benefit Exchange Q&A Prepared by Nolan Langweil, JFO and Jennifer Carbee, Legislative Council Updated February 5, 2013

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1 Health Benefit Exchange Q&A Prepared by Nolan Langweil, JFO and Jennifer Carbee, Legislative Council Updated February 5, 2013 What is a Health Exchange? A health care exchange is a mechanism enabling individuals and small businesses (and their employees) to compare and purchase health insurance. The health exchange will: Certify qualified health Allow for apples-to-apples comparison of qualified health, including a rating system based on quality and price Allow consumers to enroll in qualified health on-line, by phone, or by mail using a uniform paper form Help consumers determine eligibility for premium tax credits and cost-sharing subsidies Screen and enroll eligible people in Medicaid and Dr. Dynasaur The Exchange will only include Qualified Health Plans. What is a qualified health plan? Qualified health are that provide the essential health benefit (EHB) package required by the federal Affordable Care Act, meet the Act s limitations on cost-sharing, and are certified by the Exchange as meeting certain standards and requirements. For 2014 and 2015, must offer benefits that are substantially equal to the benefits offered in a benchmark plan selected by the state from among several options, including the largest plan by enrollment in any of the three largest products in the state s small group market. Vermont chose this option, which was a Blue Cross Blue Shield plan. What if a state doesn t create an Exchange? Under the Affordable Care Act, if a state chooses not to set up a health exchange, the federal government will set up one for the state. When will the Exchange start? State exchanges must be operational by. Open enrollment begins October 1, 2013 and will end March 31, 2014 for individuals and at the end of calendar 2014 for small group, which will enroll on a rolling basis as the renew. Who will operate the Exchange? The Vermont Health Benefit Exchange is a Division of the Department of Vermont Health Access (DVHA). How is the Exchange funded? The federal government has provided states with millions of dollars to plan and establish state-based Exchanges. Beginning in 2015, Exchanges must be self-sustaining.

2 Who will be able to purchase insurance through the Exchange? The Exchange will be open to individuals who do not have access to employersponsored insurance and employees of small businesses that offer coverage to all fulltime employees. For 2014 and 2015 small employers are defined as businesses with 50 or fewer employees. Under federal law, in 2016 the definition of small employer will be 100 or fewer, and starting in 2017, states may allow large employers to purchase insurance through the Exchange, as well. Who is eligible for tax subsidies and credits? Premium tax credits and cost sharing subsidies are available only to individuals who purchase coverage through the Exchange. Individuals: Individuals and families (who do not have access to employer-sponsored insurance) with incomes below 400% of the federal poverty level (FPL) who purchase coverage through the Exchange are eligible for a refundable premium tax credit to reduce the cost of coverage. Individuals and families with incomes below 250% FPL are also eligible for cost-sharing subsidies to reduce their out-of-pocket exposure. Small employers: Small employers that pay at least half the cost of self-only health coverage for their employees, have fewer than 25 full-time equivalent employees (FTEs), and have an average wage of less than $50,000 a year are eligible for small business tax credits on a sliding scale. The credits are available to eligible employers during the period from 2010 through 2013, and for any two years after 2014, when the amount of the credits increases. For more information, visit the IRS website on small business health care tax credits: Are there any requirements on employers? There is no affirmative requirement for employers to offer insurance. The Affordable Care Act does, however, impose penalties on employers with 50 or more employees in two instances: Employers with 50 or more full-time equivalent employees (FTEs) are subject to a penalty of $2,000 per employee (beyond the first 30) if they do not offer health insurance coverage and at least one employee receives subsidized coverage in the Exchange. Employers with 50 or more FTEs who offer health insurance coverage will pay a penalty of $3,000 for each full-time employee who receives a premium tax credit or cost-sharing subsidy through the Exchange if the employee s required contribution for self-only coverage exceeds 9.5% of the employee s household income or if the employer s plan pays for less than 60% of covered expenses. An employer s total penalty under this provision is capped at the total number of employees (beyond the first 30) multiplied by $2,000.

3 What are navigators and who will they be? Navigators will facilitate enrollment, consumer support, and education in the Exchange. According to the Affordable Care Act, navigators may be consumer-focused non-profit groups; trade, industry, and professional organizations; chambers of commerce and unions; licensed agents and brokers; and other entities capable of carrying out the required duties. Can brokers sell insurance inside the Exchange? Brokers may not receive fees or any other kind of compensation from insurers for enrolling people in the Exchange. However, brokers may have the opportunity to be navigators for the Exchange and would be paid through grants from the Exchange. What is the relationship between Medicaid and the Exchange? The Exchange will be the portal for people to apply for and enroll in Medicaid and other health insurance programs, although Medicaid beneficiaries will not be part of the Exchange pool. What will happen to the Catamount and VHAP programs? Catamount and VHAP will end December 31, Single adults with income less than 133% FPL (approximately $15,290 annually) will now qualify for Medicaid services as set forth in the Affordable Care Act. The remainder of this population will be eligible for offered through the Exchange (and most will be eligible for premium tax credits and/or cost-sharing subsidies). The following chart provides estimates of the transition: How are large group and self-insured affected by the Exchange? Starting in 2017, the Affordable Care Act permits states to allow large employers to purchase through the Exchange. Self-insured will not participate in the Exchange. What about associations that offer health insurance? Under the Affordable Care Act there will no longer be association market pools as we currently know them in Vermont. The Affordable Care Act requires each insurer to pool together all of its risk in the individual market and in the small group market, or, if applicable, in a merged individual and small group market. Associations may continue to exist for purposes other than insurance market risk pooling.

4 What is risk adjustment? Risk adjustment (often referred to as risk equalization) is a mechanism designed to correct market imbalances that occur when insurers attract pools of subscribers whose expected medical costs are substantially greater or less than market-wide averages. Risk adjustment attempts to encourage competition among insurers based on price and quality and not by attracting the healthiest enrollees and deterring those in poorer health. It accomplishes this by subsidizing insurers that end up with disproportionate share of high-cost patients and assessing a charge on competing insurers that, whether through strategy or happenstance, end up with a better selection of health risks. How does a plan become grandfathered? Grandfathered were created pursuant to the Affordable Care Act and are defined by federal law. Grandfathered must have been in existence on March 23, 2010, when the Affordable Care Act took effect. In order to maintain grandfathered status, must not: Significantly cut or reduce benefits Increase co-insurance Significantly increase co-pays Significantly increase deductibles Reduce employer contributions by more than 5% Add or tighten an annual limit on what the insurer pays Plans that cut benefits or increase consumer out-of-pocket spending as defined above can lose their grandfathered status. What does actuarial value (AV) mean? Actuarial value is the average share of medical spending paid by a plan for a defined set of covered services across a standard population. For example, if a plan has an actuarial value of 70%, the plan will pay an average of 70% of medical spending for covered services and the beneficiary would pay the remaining 30% out-of-pocket in the form of deductibles, co-pays, and co-insurance. The higher the actuarial value of a plan, the lower the out-of-pocket exposure is for a beneficiary (and the premium will likely be higher as well). What is meant by Metal Levels? The Affordable Care Act established metal levels in an attempt to make it easier for consumers to compare based on cost-sharing features. Each metal level corresponds to an actuarial value (AV), which is based on the amount of out-of-pocket expenses under the plan. Bronze = Silver = Gold = Platinum = 60% AV 70% AV 80% AV 90% AV

5 What other insurance reforms were in the Affordable Care Act? Which are affected? The Affordable Care Act includes a number of health insurance reforms in addition to the Exchange. Most of these, including the Essential Health Benefits Package and the Metal Levels apply inside and outside of an Exchange. Here are some of them: Provision Requirement to offer at bronze, silver, gold, and platinum levels Requirement to offer essential health benefits package Annual cost-sharing limits equal to limits for Exchange Ban on pre-existing condition exclusions applied to children Ban on pre-existing condition exclusions in any plan Ban on lifetime limits for essential health benefits Ban on annual limits for essential health benefits Ban on cost-sharing (copays, coinsurance, or deductible) for preventive services Coverage for dependent children up to age 26 Plans affected, regardless of whether they are offered through an exchange All individual and small group, except grandfathered All individual and small group, except grandfathered group, except grandfathered group, except grandfathered group, including grandfathered group but not grandfathered individual market group, including grandfathered group, including grandfathered group but not grandfathered individual market group, except grandfathered All individual, small group and large group, including grandfathered (for grandfathered until 2014, coverage only if the dependent does not have access to employersponsored insurance) Applicability and effective date Plans issued on/after September 23, 2010 (six months after the ACA was enacted) Plans issued on or after September 23, 2010 Plans issued on or after September 23, 2010 Plans issued on or after September 23, 2010

6 What is the Shumlin Administration proposing? As mentioned above, the Affordable Care Act provides premium tax credits (up to 400% FPL) and cost-sharing subsidies (up to 250% FPL) for individuals in the Exchange who do not have access to employer-sponsored insurance. The Shumlin Administration proposes to provide financial assistance in addition to these premium tax credits and cost-sharing subsidies. Premium tax credits premium tax credits are designed so that individual and family premiums (for those without access to employer-sponsored insurance) won t exceed a specified percentage of the household s modified adjusted gross income (MAGI). Under the Affordable Care Act, this ranges from 3% of household income (for those at 133% FPL) to 9.5% (for those at 400% FPL). The Administration proposes to subsidize an additional 1.5% of household income for those up to 350% FPL. For instance, someone at 150% FPL would not pay more than 4% of modified adjusted gross income under the Affordable Care Act. Under the Administration s proposal, he or she would only pay 2.5% (4% - 1.5% = 2.5%). Under this same example a person in a single-person household would see his or her premium reduced by $22/month and a family of four would see its premium reduced by $44/month. Cost-sharing subsidies The Administration s proposal would further reduce the out-ofpocket exposure for individuals and families beyond the cost-sharing subsidy offered under the Affordable Care Act by increasing actuarial values based on income thresholds similar to those under the Affordable Care Act. It would also expand the cost-sharing subsidy beyond individuals and families at 250% FPL (the threshold in the Affordable Care Act) to those up to 350% FPL.

7 How much would the Administration s proposal Cost and how is it proposing to pay for it? The Administration to fund its proposal with a combination of (1) a reduction in expenses from the discontinuation of the Catamount and VHAP programs, (2) a twoyear enhancement in federal medical assistance percentage (FMAP) dollars as part of the Affordable Care Act, (3) carry-forward, and (4) increasing the health care claims assessment by 1% (incrementally over SFY 15 and SFY 16). What do the federal poverty level numbers translate to in dollars? Where can I found out more information about Vermont s Health Insurance Exchange (AKA Vermont Health Connect) as well as updates on its progress?

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