Insights AdvocateCare Health Insurance Exchanges

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1 Insights AdvocateCare Physician Edition April 16, 2013

2 Executive Summary (HIX, also called Health Insurance Marketplace) a key provision of The Patient Protection and Affordable Care Act (ACA, Affordable Care Act or Health Care Reform) of 2010, are online market places where individuals and small businesses can compare and purchase health insurance on the basis of benefit coverage, cost and quality. This issue of Insights will provide background and context on HIX. Advocate Physician Partners (APP) is considering the potential HIX scenarios to represent the best mutual interest of its member physicians and hospitals, near and long-term. Physicians can prepare by evaluating patient access and embracing AdvocateCare, Clinical Integration, and medical management services. While this report incorporates our best current understanding of HIX, many rules and regulations are in the process of development and are not final. Payers and providers will continue to evaluate their involvement and participation in HIX as decisions unfold over the next several months. ACA created two different types of HIX: Individual market and the Small Business Health Options Program (SHOP). The HIX open enrollment begins October 1, 2013 with plans starting on January 1, The federal government provides subsidies for individuals and families up to 400% of the Federal Poverty Level (FPL) $92,200 for a family of four in 2012 to purchase health insurance. Plans offered on the HIX must meet benefit coverage standards metal tiers (Bronze, Silver, Gold, Platinum) which are above today s benefits. The market will not bear price increases. Therefore, to meet the benefit standards, health plans will pressure providers to accept lower reimbursement rates. As a trade-off for lower reimbursement rates, providers will negotiate for tiered networks to gain access to the newly insured lives and to more tightly manage utilization. A modest increase in physician office visits, particularly in primary care, is expected. *Please see Glossary for definition of key terms Confidential and Proprietary, Advocate Health Care 2

3 Section I: Understanding HIX Types of HIX HIX can be divided into public and private exchanges. Each can further be subdivided into individual and employer based. This report will focus on the individual public HIX, as it is anticipated to have the most impact on physicians in Illinois Public HIX By the Numbers Illinois/Federal Partnership HIX Timeline Confidential and Proprietary, Advocate Health Care 3

4 Section II: The Implications of HIX The Payer Perspective The Consumer Perspective Three primary forces are at play: personal economics, choice, and government subsidies for premiums. The individual mandate under the ACA requiring that U.S. citizens and legal residents have insurance was upheld by the Supreme Court last summer as a lawful tax on individuals. The individual mandate will be phased in beginning in The penalty is small at first at $95 per adult, but increases to $695 per adult by While the penalty is less than the full cost of health insurance, the federal government subsidies are designed to reduce health insurance cost to affordable levels. These federal subsidies will be available for those earning up to 400% of the FPL, which is $92,200 for a family of four in As a result of the mandate and the subsidies, it is believed that over half of today's uninsured will be covered by While consumers are not yet choosing providers based on quality and cost, they are beginning to seek out this information. Communicating costs and quality to consumers is challenging given the complexity of health care. Increased transparency is inevitable as consumers have a more direct role in choosing plans and networks. Confidential and Proprietary, Advocate Health Care 4

5 Consumer Case Study Meet the Smiths The Smiths, a family of four, had an annual household income in 2012 of $69,150, which is equivalent to 300% of the Federal Poverty Level (FPL). Mr. Smith works as an independent contractor. Mrs. Smith works part-time as a home health aide. The Smiths are eligible for a partial subsidy from the federal government to participate in the Illinois HIX. Plan A: Silver Plan Plan A Annual Premium = $13,000 ($1,083 per month) Federal Limit on Personal Premium Responsibility: $6,569 (per month $547) The Smiths Annual Premium = $6,569 (per month $547) Federal Subsidy = $6,431 ($536/month) $1,000 deductible 20% Co-insurance Out-of-Pocket Maximum (excluding premium) $7,000 Plan B: Silver Plan, Narrower Network but lower premium Plan B Annual Premium = $10,000 ($833/month) Federal Limit on Personal Premium Responsibility: $6,569 (per month $547) The Smiths Annual Premium = $4,500 ($375/month) Federal Subsidy = $5,500 ($458/month) $3,000 deductible 20% Co-insurance Out-of-Pocket Maximum (excluding premium) $5,000 The Smiths select Plan B which results in a savings of $172 in monthly health premiums, a significant amount for a family on a tight monthly budget paying a mortgage in Chicago with two school aged children. Mr. Smith recently injured his knee playing soccer with his daughter and is contemplating seeing an orthopedic surgeon for an evaluation which may involve an MRI, surgery, and physical therapy. The Smiths are also planning on growing their family in the coming years. With a few visits to pediatric specialists for their 5-year-old son for concerns about delayed development and an ER visit involving an MRI for intense unexplained headaches, the Smiths can quickly meet their out-of-pocket maximum of $5,000, which is over 10% of their take home pay. Together with the premium payments, the Smiths would spend nearly 20% of their income on health care. To help balance the monthly budget, the Smiths will increasingly select high-deductible plans as a way to hold down monthly fixed costs and compromise on choice of providers. The Smiths, and thousands of others like them, will increasingly scrutinize the cost of visits to the doctor and hospital. Patients like them will demand increased transparency on cost and quality and will bring their business where they perceive the greatest value. Confidential and Proprietary, Advocate Health Care 5

6 Public HIX Impact on Your Practice Much remains unknown with the Public HIX, including which payers and providers will ultimately participate. Negotiations are actively taking place between payers and providers as they evaluate the options from "wait and see" to aggressively lowering reimbursement rates to gain access to the newly insured. Impact on Physicians How to Prepare Utilization Managed Care Contracting Tiered Networks Medical Management Medicaid Preventative care services are covered benefits for all HIX plans Anticipate a modest increase in primary care utilization due to previously postponed care Payers will pressure providers, including physicians, to accept lower reimbursement rates to gain access to the newly insured. Providers (hospitals and physician networks) will trade-off lower reimbursement rates for tighter networks. Tiered benefits will create strong incentives for patients to use network providers. Payers are actively negotiating with providers to define networks. Tiered networks will require medical management of utilization to reduce inefficiencies. Greatest benefit to consumers and providers is more coordinated care IL House is currently evaluating expansion of Medicaid for single adults which could reduce the number of people in the public exchange. State is progressively moving toward Medicaid managed care products. IL has temporarily increased Medicaid rates for 2013 and 2014 to the level of Medicare for primary care physicians. Evaluate existing office visit capacity for same/next day appointments. Consider extended office hours, open access, and e-visits. Attend an APP Access Collaborative. Expect initial enrollment to be approximately 2-4% of the average practice s payer mix. APP will represent the best mutual interest of its member physicians and hospitals as it considers potential scenarios. APP will consider different approaches from wait-and-see (sit out for a year) to aggressive (steep reimbursement rate cuts to gain new market share). APP will consider scenarios which balance upside for new membership while preserving profitability for physicians and hospitals. Paying close attention to provider and payer strategy will be important as details emerge over the next six months to year. Continue to actively engage in AdvocateCare programs, Clinical Integration, and APP medical management services (referral management, utilization management). Plan for additional visits to add contribution margin for current self-pay patients. Prepare for patient population with more complex health needs. Confidential and Proprietary, Advocate Health Care 6

7 Glossary of Terms Actuarial Value: The measure of the average share of medical spending paid by the plan (benefit cost), rather than paid out of pocket by the consumer. This requires products to meet defined product tiers (bronze-60%, silver-70%, gold-80%, platinum-90%). Actuarial Value allows for direct comparisons of plans which benefit coverage requirements at the product tiers, but can have different premiums, deductibles, co-pays, co-insurance, and networks. Co-Insurance: The percentage of claim costs paid after the deductible has been met by the member up to the out-of-pocket maximum. Co-Pay: The portion of costs (often for a physician office visit or ER visit) that a member is responsible for paying for the visit. Deductible: The amount paid by the plan member (or reimbursed by the employer) before insurance coverage picks-up the remaining cost. Health Insurance Exchange (HIX): An online marketplace where consumers can compare and purchase health insurance plans. Out-of-Pocket Maximum: The costs that a member is responsible for paying (not including the premium) before the plan pays the full health benefit costs. Public Exchange: A key provision of ACA was the creation of public HIX for individuals and small-businesses. The law allows for individual states to create exchanges or participation through the federal exchange. Premium: The cost of insurance that an employer or individual pays to purchase a health plan. Private Exchange: Employers with self-funded health plans participate in a private exchange to provide employees with more plan options and to create plan competition. The exchange operator handles the funds flow distributions between employers and the plans. Tiered Networks: Managed care insurance plans (HMO or PPO) tier insurance benefit coverage to providers based on network participation, cost, and quality. The cost to members varies for using in-network versus out-of-network providers. Providers who participate in the network gain access to the membership base in exchange for lower reimbursement rates. Confidential and Proprietary, Advocate Health Care 7

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