Anticipating the Health Insurance Marketplace in Texas

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1 Anticipating the Health Insurance Marketplace in Texas HFMA Lone Star Chapter Fall Institute September 16, About Community Health Choice Non-profit Health Maintenance Organization licensed by the Texas Department of Insurance Affiliate of the Harris Health System Serves over 230,000 Members with the following programs: Medicaid: State of Texas Access Reform (STAR) program for lowincome children and pregnant women CHIP: Children s Health Insurance Program for the children of lowincome parents includes CHIP Perinatal benefits for unborn children of pregnant women who do not qualify for Medicaid STAR 3-Share Plan: TexHealth Harris County 3-Share Plan that subsidizes the premiums of a limited benefit plan for previously uninsured, lowincome employees of small businesses 2 1

2 CHC Service Area Map 3 Membership and Revenue 250,000 $700 Membership (Thousands) 200, , ,000 50,000 $600 $500 $400 $300 $200 $100 Revenue (Millions) $0 Membership Total Revenue 4 2

3 Our Mission At Community Health Choice, our mission is to improve the health of underserved residents of Southeast Texas by facilitating access to coordinated, high quality, affordable healthcare services. Our mission is achieved through: Community Collaborating with community-based Providers and organizations to improve access, quality, coordination and cost effectiveness of services Health Developing programs to establish medical homes, manage health conditions and promote wellness and preventive care Choice Encouraging personal accountability and educated choices for individual and family health 5 6 3

4 Affordable Care Act Designed to expand access to coverage through two primary mechanisms: Medicaid Expansion Health Insurance Exchanges No/minimalcost-sharing public coverage for those below 133% FPL Subsidizedcommercial health insurance for individuals between % FPL and small (<50 employees) businesses 7 Federal Reforms with Medicaid Expansion Family of 3: $76,360 $38,180 $25,390 $19,

5 Federal Reforms without Medicaid Expansion Exchange eligible as well 9 Individual Mandate Effective January 1, 2014 most individuals will be required to purchase insurance or pay penalties Exceptions: Individuals covered under an ER sponsored plan Individuals already enrolled in an individual insurance plan meeting all ACA requirements Individuals who are eligible for Medicaid or CHIP Individuals who would have to pay more than 9.5% of their income for health insurance Individuals below the threshold required to file an income tax return (2013 = $10,000 single) Undocumented Immigrants Individuals who are incarcerated Members of Indian Tribes 10 5

6 Potential Exchange Market Size 20 County SDA Eligible for Exchange Coverage 72,917 Uninsured 457,938 Uninsured Children Adults 2% 19% 17% 8% 25% 79% Newborns Ages 1-5 Ages 6-18 Includes all legal residents < 5 years between 0-400% FPL child citizens and legal residents > 5 years between % FPL adult citizens and legal residents > 5 years between % FPL 23% 27% Ages Ages Ages Ages Ages Consumer Protection Tradeoffs Guarantee issue Guarantee renewable No pre-existing limitation exclusions No lengthy waiting periods No cost-sharing for covered preventive care/wellness Dependent children can be covered up to age

7 Qualified Health Plans Non-grandfathered plans offered in (or out) of the Exchange must include the ten categories of Essential Health Benefits specified in the ACA: Ambulatory patient services Hospitalization Mental health and substance use disorder services Rehabilitativeand habilitativeservices and devices Preventive and wellness services* and chronic disease management Emergency services Maternity and newborn care Prescription drugs Laboratory services Pediatric services, including oral and vision care** * At no cost to members ** Can be excluded in States with enough Stand Alone Dental Plans 13 QHP Issuer Requirements Be licensed in the State and in good standing Agree to report required HEDIS and CAHPS quality improvement measures Agree to pay Exchange fees Justify rate increases and publicly post justification Achieve/maintain URAC or NCQA accreditation of exchange products No medical underwriting; guaranteed issue and renewability; no waiting periods Age and tobacco status are the only allowable rating factors; no pre-existing limitations 14 7

8 Plan Levels of Coverage Levelof Coverage Plan Pays on Average (actuarial value) Enrollees Pay on Average (In addition to the monthly plan premium) Catastrophic* <60 percent >40 percent Bronze 60 percent 40 percent Silver 70 percent 30 percent Gold 80 percent 20 percent Platinum 90 percent 10 percent * Available only to those <30 yrsold or with financial hardship; includes 3 primary care visits annually and preventive care, member pays full cost up to the maximum out-of-pocket for other services. 15 Financial Assistance Two forms available through the Exchanges: Advance PremiumTax Credits Cost-Sharing Reductions Eligibility Between 100% and 400% FPL Between 100% and 250% FPL 2013 Individual/ Family of 4 Income Estimate $11,490 to $45,960/ $23,550 to $94,200 $11,490 to $28,725/ $23,550 to $58,875 Details Sliding scalebasis to reduce the cost of the monthly member portion of premium Only available for silver plans; effectively raises the AV of the plan 16 8

9 Member Contributions % FPL Annual Dollar Amount (2013 $) Premium Contribution as a % of income Monthly Premium Contribution % $11,490 - $15,282 2% $19 - $ % $15,282 -$17, % $38 -$ % $17,235 -$22, % $57 -$ % $22,980 - $28, % - 8.1% $121 - $ % $28,725 -$34, % $193 -$ % $34,470 - $40, % $272 - $ % $40,215 - $45, % $318 - $ Family Size and Income IRS household definition includes individuals for whom a person exemption deduction is claimed, regardless of living arrangements Modified Adjusted Gross Income = Adjusted Gross Income (AGI) + Any Additional Social Security Benefits + Tax Exempt Interest + Foreign Earned Interest 18 9

10 Penalties 2014: The greater of 1% of total family income or $95 adult and $47.50 per child up to $285 for a family 2015: The greater of 2% of total family income or $325 per adult and $ per child up to $975 for family 2016: The greater of 2.5% of total family income or $695 per adult and $ per child up to $2,085 for family 19 Premium Tax Credit Reconciliation Premium tax credits are paid to insurer and applied to the monthly premium in advance Reconciliation of tax credits via tax returns Advance credits provided in 2014 will be reconciled on tax returns due on April 2015 If advance payments exceed the amount of credit individuals are eligible, partial repayment is required 20 10

11 Sample Product Designs IllustrativeBronze Benefit Plan 60% Actuarial Value IllustrativeSilver Benefit Plan 70% Actuarial Value IllustrativeSilver Benefit Plan with Cost Sharing Reductions 94% Actuarial Value Deductible $2,500 $0 $0 Coinsurance 0% 0% 0% Outof Pocket Maximum (in network) $6,350 $6,350 $1,000 Office Visits Inpatient Hospitalization $35/$70copays after deductible $400 per day for first five days after deductible $40/75 copays $10/$20 copays $400 per day for first five days $200 per day for first five days Prescription Drugs $25/$75/$100 copays $25/$75/$100 $5/$20/$40 Emergency Care $250 after deductible $250 $100 Premium $240 $290 $ Provider Concerns Downward pressure on commercial reimbursement rates Potential cannibalization of existing commercial business High cost-sharing plan selections by those least able to afford 90-day grace period for APTC-eligible individuals 22 11

12 Enrollment Overview 23 Enrollment Overview Consumer Submits application to the Marketplace Online Phone Mail In Person The Marketplace verifies and determines (or assesses eligibility) Determine eligibility for: Enrollment in a qualified health plan Tax credits and costsharing reductions Medicaid or CHIP Eligible Consumer enrolls in a qualified health plan or Medicaid/CHIP Online plan comparison tool available to inform health plan choice Premium tax credit and cost-sharing reductions are sent to insurer (if eligible) Enrollment in a qualified health plan or Medicaid/CHIP 24 12

13 Plan Comparison 25 Insurer Participation in Exchanges State # of Statewide Insurers # of Silver Plans in Largest City # of Bronze Plans in Largest City CA CO IN 4 8* 15* NE OH Source: Kaiser Family Foundation * Plan information not available for certain insurers. Texas???? 26 13

14 Comparative Rates 2 nd Lowest-Priced Silver Premiums in City 25 y/o 40 y/o 60 y/o Los Angeles $200 $255 $541 Denver $196 $250 $531 Indianapolis $232 $295 $626 Omaha $213 $271 $576 Cleveland $196 $249 $529 An individual at 250% of Federal Poverty Level ($28,725 per year) would receive an APTC that would bring their contribution to the total rates above to ~$193/per month or 8% of annual income 27 Who Can Help? Consumer Assistance Programs Certified Application Counselors In-Person Assistance Programs (in SBEs only) Certified Community Based Groups, Health Centers Medicaid eligibility workers Navigators Insurance Agents, Brokers 28 14

15 Texas Navigator Grantees Agency Amount Geographic/ Population Focus United Way of Tarrant County (17 organization collaborative) Migrant Health Promotion, Inc. National HispanicCouncil on Aging Change Happens $5,889,181 Across the state $589,750 Migrant populations in the Rio Grande Valley of Texas $646,825 Uninsured Hispanic population in Dallas County $785,000 Houston area United Way of El Paso County Southern United Neighborhoods East Texas Behavioral Healthcare Network National Urban League TOTAL $642,121 El Paso county $600,678 AR, LA and TX $1,337, East TX counties $376,800 Low-income, medically underserved, urban residents in Texas $10,867,875 Less than $4/exchange eligible person 29 Key Points to Remember You have choices Employer-based coverage will continue Insurance will continue to be sold outside of the Marketplace Purchase from the Marketplace is not required The Marketplace is the only place to get New premium tax credits Cost-sharing reductions 30 15

16 Key Deadlines October 1, 2013 January 1, 2014 March 31, 2014 October 15 th December 7 th 2014 Open enrollment begins Coverage begins 2014 Open enrollment ends Annual open enrollment period for future years 31 Delays Delayed until/by Component Delayed Details 2015 Large Employer Mandate No penalties assessed large employers who do not offer coverage; must still educate workforce 2015 Employer Coverage Reporting Voluntary reporting only of coverage offered by employers in SHOP Employee Choice Small business employees will have to enroll in the single plan selected by owner 2015 Out of Pocket Cap Insurers allowed to maintain separate OOP caps for medical and prescription in 2014 One week QHP Issuer Agreement Signing No practical impact 32 16

17 QUESTIONS? Karen Love, Senior VP For more information on the Health Insurance Marketplace, sign up to get and text alerts at signup.healthcare.gov 33 17

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