Healthcare Reform for Tennesseans A NEW ERA IN HEALTH CARE FOR TENNESSEANS

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1 Healthcare Reform for Tennesseans A NEW ERA IN HEALTH CARE FOR TENNESSEANS

2 Agenda What s a CO-OP? Who benefits from it? Get to know CHA Timeline Who s Affected Marketplace New Requirements Questions 2

3 Milestones & Changes 1862 President Lincoln started the precursor of the Food and Drug Administration 1902 The Public Health Service was started 1943 IRS declared employer-sponsored health insurance to be tax exempt 1946 Communicable Disease Center was established, later to become the CDC 1955 Polio vaccine licensed 3

4 Milestones & Changes 1965 Creation of Medicare and Medicaid 1974 Employee Retirement Income Security Act (ERISA) 1985 Consolidated Omnibus Budget Reconciliation Act (COBRA) 1996 Mental Health Parity Act 1996 Health Insurance Portability and Accountability Act (HIPAA) 2003 Medicare Prescription Drug Act was enacted 2010 The Affordable Care Act was signed into law 4

5 CO-OPs 2010 The Affordable Care Act was heavily debated in Washington The public option vs. the private option with the Fed competing with private carriers (very unpopular) CO-OPs were brought to the table as a bipartisan private market solution The CO-OP model is designed to create increased market competition (good for all) 5

6 CO-OP States 6

7 CO-OPs are not new Group Health Co-operative Founded in 1947 in Seattle, Washington Member / Consumer governed Focused on putting the member/patient first Started out as a coalition dedicated to making quality health care available and affordable Now serves 600,000 residents in Washington and North Idaho Offers group and individual plans 7

8 CO-OPs are not new HealthPartners Founded in 1957 in Bloomington, Minnesota Member / Consumer governed Largest consumer governed nonprofit health care organization in the U.S. Now serves 1.4 million members Top ranked commercial health plan in Minnesota 8

9 CO-OPS & CHA CO-OPs/CHA are designed to: Promote long term industry sustainability Not owned, can t be bought or sold Promote healthy market competition Improve quality and value Focus on individuals and small businesses Through your broker (CBIZ) and the health insurance Marketplace Remove barriers to care Help Transform the health care delivery system Through innovation, integration and operational efficiencies Patient / Member Centered approach to care 9

10 CO-OPS & CHA How are we similar to other carriers: Approved Insurance carrier / State and Federal Regulated and monitored by Tennessee Department of Commerce and Insurance Member of State Guaranty Fund 10

11 CO-OPS & CHA What makes CHA different? Funded by federal start-up loan 501(c) nonprofit - Excess revenue returned to members by reduced premiums, prevention/wellness incentives or potential year end dividend distribution Home-grown (Tennessee Based) All stakeholders interacting with Community Health Alliance have board representation (Assures Transparency) Consumers PCPs, Specialists, Hospitals Brokers Member Governed policy holders elected to three year term 11

12 Who We Serve Initial Service Areas 12

13 Vision Help improve the well-being of Tennesseans by promoting an integrated health care delivery model that engages and rewards participants and providers alike, resulting in high-quality outcomes. 13

14 Timeline Open Enrollment Period October 1, 2013 March 31, 2014 Two ways to enroll: Online Health Insurance Exchange/Marketplace Through your certified professional insurance agent/broker (CBIZ) Coverage Effective Date January 1,

15 Who s Affected? Individuals Small Businesses (under 50 Full Time Employees) Large Businesses

16 Individual Mandate Individual Mandate Everyone must have health insurance Pay or Play Guaranteed Insurability /Eligibility you cannot be turned down or denied coverage No more Denials Exclusionary riders Limited benefits 16

17 Individuals: How will they be covered? Federal Poverty Level 0-100% % Coverage Available in 2014 TN Plan Marketplace (with tax credits) Number of Tennesseans eligible 400, ,000 Over 400% Marketplace 50,000 17

18 Essential Health Benefits (EHB) EHB must include items and services within at least the following categories. Self-funded plans are exempt. 1. Ambulatory Patient Services 2. Emergency Services 3. Hospitalization 4. Maternity and Newborn Care 5. Metal Health and Substance Use Disorder Services (including Behavioral Health Treatment) 6. Prescription Drugs 7. Rehab and Habilitative Services and Devices 8. Lab Services 9. Preventive and Wellness Services and Chronic Disease Management 10. Pediatric Services, Including Oral and Vision Care 18

19 Marketplace: How It Works Internet-based Marketplace for individuals and small groups (less than 50 employees) SHOP to shop for and buy health insurance CHA / CO-OP offered both on and off of the Marketplace Determine eligibility for subsidies Consumers can compare and purchase plans Bronze, Silver, Gold, Platinum and Catastrophic plan levels 19

20 2014 Group Coverage Mandates For plan years beginning on or after 1/1/2014 for large and small employers: o guaranteed issue and renewal of fully insured plans (except nonpayment of premiums, fraud, violation of contribution or participation rules) o insurers cannot charge higher premiums for health status, gender, or occupation o premiums only allowed to vary based on age, tobacco use, geographic location, and household composition and size o required coverage of routine cost for qualified clinical trials 20

21 2014 Requirements (Cont d) Marketplace Individual Mandate Employer Mandate Guaranteed Issue/No pre-existing conditions Limit premium rates No more than 90-day waiting period No annual or lifetime limits on the dollar value of essential health benefits. Wellness Incentives may increase rewards from 20% - 30% 21

22 Resources Center for Consumer Information and Insurance Oversight US Department of Health & Human Services 22

23 Countdown 2014 New information arriving daily We continue to gather the latest innovative ideas and best practices Your input, ideas, suggestions and knowledge are of great importance We need your help! 23

24 Thank You QUESTIONS? or Sign up to receive CHA electronic newsletter Buck Orrison Community Relations Director Stan Gaines Jeff Dempsey Lisa Preiss West Tennessee Middle Tennessee East Tennessee