Health insurance exchanges What to expect in 2014

Transcription

1 Helth insurnce exchnges Wht to expect in CAEENABC 11/12

2 The bsics of exchnges As prt of the Affordble Cre Act (ACA or helth cre reform lw), strting in 2014 ALL Americns must hve minimum mount of helth insurnce or be txed by the government. The lw lso requires ech stte to hve helth insurnce exchnge where people cn buy helth insurnce coverge. People who don t get helth insurnce t work, or cn t fford it, my be ble to get it through n exchnge. The exchnges do not replce buying helth insurnce privtely. They re simply new plce to shop nd buy. Exchnge = new plce to shop for nd buy helth insurnce Three exchnge model options On the exchnges, individuls nd smll businesses cn buy qulified helth plns (QHPs). Exchnges cn be set up in one of three wys. Ech stte determines how its exchnge will be set up: Stte-run fcilittor model Any crrier meeting minimum federl nd stte requirements set for the helth insurnce exchnges cn be in this exchnge. Crriers compete in n open mrket. Stte-run ctive purchser model The stte solicits bids from helth insurnce compnies nd determines which plns it will offer. The stte directly negotites the price nd benefits offered. Federlly run model The U.S. Deprtment of Helth nd Humn Services (HHS) runs the exchnge in sttes tht choose not to crete one. 2

3 Four levels of coverge on the exchnges Exchnge plns will be offered in tiered formt. The tiers re nmed fter metls: bronze, silver, gold nd pltinum. Ech tier will hve severl plns to choose from nd will include essentil helth benefits. Bronze plns will hve the lowest monthly premium, but cost shres will be more when helth cre services re provided. Pltinum plns will hve the highest monthly premium, but cost shres will be less. All plns must include essentil helth benefits s defined by the helth cre reform lw. Specificlly, the plns must include items nd services from t lest these 10 ctegories of cre:* 1. Ambultory ptient services 2. Emergency services 3. Hospitliztion 4. Mternity nd newborn cre 5. Mentl helth nd substnce use disorder services, including behviorl helth tretment 6. Prescription drugs 7. Rehbilittive nd hbilittive services nd devices 8. Lbortory services 9. Preventive nd wellness services nd chronic disese mngement 10. Peditric services, including orl nd vision cre Exchnge plns re tiered: Pltinum 90% coverge Gold 80% coverge Silver 70% coverge Bronze 60% coverge *Helthcre.gov: Essentil helth benefits (ccessed October 2012). 3

4 Qulified Helth Pln (QHP) requirements All helth plns must follow new coverge nd benefit rules strting in 2014 (see the chrt below nd red on for detils bout exchnge coverge nd essentil helth benefits). These requirements re bsed on: If the pln is offered on or off the exchnge. If the pln is fully insured or self-insured. Group size. Premiums for these individul nd smll group plns will not be bsed on helth sttus. Insted, they will be bsed on fmily tier, ge, geogrphy nd tobcco use. (Stte-specific rules my vry when federlly run model is not in plce.) These plns lso must use 3 to 1 ge bnds. This mens the highest premium cnnot be more thn three times the lowest premium for the sme pln. All of these requirements my hve n impct on rtes, lthough the specific effects re difficult to define t this time s qulified helth plns continue to be developed. Inside exchnge Outside exchnge fully insured smll group nd individul Outside exchnge fully insured lrge group nd self-insured Include essentil helth benefits Provide 60% cturil vlue minimum * Adhere to deductible nd out-of-pocket mximum limits Comply with metl levels benefit tiers with specified cturil vlues (60% 70% 80% 90%) Be certified by the exchnge through which the pln is offered (certifiction requirement to be determined) *The helth cre reform lw does not require crriers to offer plns with t lest 60% cturil vlue, nor does it require employers to provide helth coverge. However, it imposes penlties on 50+ employers tht do not provide minimum coverge. 4

5 Five functions the exchnges offer: 1. Consumer ssistnce Stff will mnge the exchnge website nd cll centers. Nvigtors will help consumers use the exchnges. 2. Pln mngement Consumers will be ble to choose QHPs sold on exchnges nd see importnt dt for ech QHP. 3. Eligibility Applicnt informtion is collected nd verified to determine eligibility for enrollment, tx credits or subsidies. 4. Enrollment Stff help consumers enroll nd send informtion to helth plns s well s trnsmit informtion relted to premium tx credits nd cost-shring reductions s required by HHS. 5. Finncil mngement Exchnges will perform severl finncil functions including hndling user fees, risk djustment, reinsurnce nd risk corridor progrms (this progrm runs from nd gives HHS governnce over refunds nd chrges for QHPs tht go over or under projected costs). Exchnge timeline If ll goes s plnned, exchnges will open for enrollment on October 1, Coverge effective dtes will begin Jnury 1, And in 2017, sttes hve the option to offer plns on the exchnges to lrge group employers with 100 or more employees. Stte legisltive sessions (typiclly run first hlf of yer) Stte pplictions for exchnge certifiction due to HHS December 14, 2012 In 2014, sttes must decide whether to expnd Medicid HHS indictes sttes must select essentil helth benefits benchmrk pln by Q3 of 2012 By the end of 2012, sttes must show HHS tht they re redy to operte n exchnge in 2014 to void federl fllbck 5

6 Individuls Three options for helth insurnce in 2014 The lw requires helth insurnce to be gurnteed issue. Tht mens person (or fmily) cn t be denied coverge or chrged more becuse of helth condition he or she lredy hs. Individuls not covered by government helth pln hve three choices: Get coverge through their employer, if vilble. Buy pln through either: The individul mrket exchnge. The trditionl mrket. Go uninsured nd py penlty, unless exempt. Subsidies nd credits for individuls Those who don t hve ccess to ffordble, minimum essentil helth coverge cn buy helth pln from the exchnge nd get credit or subsidy if they meet income requirements. Credits nd subsidies help with the cost of premiums nd out-of-pocket helth cre expenses. Income requirements 133% to 400% of federl poverty level For n individul tht equls $14,856 to $44,680 per yer (in 2012). For fmily of four tht equls $30,656 to $92,200 per yer (in 2012). Those tht meet the income level, cn get tx credit tht my be pplied to ny level exchnge pln (bronze, silver, gold or pltinum). The cost-shring subsidy is vilble to those who ern up to 250% of federl poverty level nd enroll in silver exchnge pln only. An ffordble helth pln = individul s shre of premium is no more thn 9.5% of income 6

7 Penlties for individuls In 2014, legl U.S. citizens who do not hve minimum mount of helth coverge will receive penlty of $95 or 1% of their txble income, whichever is greter. Penlty timeline Penlties will increse ech yer through In future yers, the penlties will djust nnully Greter of $95 or 1% of txble income 2016 Greter of $695 or 2.5% of txble income 2015 Greter of $325 or 2% of txble income 2017 nd beyond Annul djustments 7

8 Smll group employers (less thn 49 employees) Smll businesses lso cn use n exchnge to find insurnce for their employees. These re clled Smll Business Helth Options Progrms, or SHOPs, for short. The individul nd SHOP exchnges my be seprte or combined. Three options for helth insurnce in 2014 Offer fully insured pln through either: A SHOP exchnge. The trditionl mrket. Offer n ASO pln, if llowed by stte lw, where essentil helth benefits nd metl level requirements don t exist. Stop offering coverge nd let employees buy n individul pln on or off the exchnge. Subsidies for smll employers Tx credits will increse for employers with 25 or fewer employees (with n verge wge of less thn $50,000 yer) who offer coverge through n exchnge. 8 The credit will cover up to 50% of the employer s cost (35% for smll nonprofit orgniztions). Employers will be eligible for credits in the first two yers they offer coverge through n exchnge. } } Credits decrese on sliding scle s group size nd employee wges increse. Other options my exist such s defined contributions or djusting contributions by employee. This mens employers give ech employee certin mount to spend on helth insurnce they find themselves.

9 Lrge group employers (50+ employees) Three options for helth insurnce in 2014 Offer helth insurnce (either fully insured or ASO) tht meets the minimum coverge definition* nd is ffordble. Offer some level of coverge tht does not meet minimum requirements nd py the employer penlty. Stop offering coverge, let employees buy through the Individul mrket exchnge, nd py the employer penlty. *Minimum coverge is ny medicl insurnce coverge tht does not limit coverge to specific benefits such s dentl or vision only. This includes mjor medicl (or ctstrophic) plns. Minimum coverge does not hve n cturil vlue minimum (such s 60%) nd does not need to be considered ffordble. Penlties for lrge group employers If minimum coverge is not offered to full-time employees, nd t lest one employee gets subsidized coverge through n exchnge, then $2,000 penlty is ssessed for ech employee (fter the first 30). If minimum coverge is offered to full-time employees but it is not ffordble for n employee, nd tht employee gets subsidized coverge through n exchnge, then $3,000 penlty is ssessed for ech employee getting subsidized coverge. Helth cre reform does NOT require employers to: } Contribute to the premium. (Although if they do not, their pln my not be ffordble, putting the employer t risk for penlties.) } Offer dependent coverge. 9

10 Other txes nd fees Individuls nd employers my be responsible for other txes nd fees relted to the helth cre reform lw. The chrt below highlights some of them. Tx/Fee Effective Dte Responsible Prty Annul Tx/Fee Amount Phrmceuticl industry fee n nnul fee on brnded prescription drug mnufcturers nd importers Medicl device mnufcturer fee n nnul fee on medicl device mnufcturers nd importers Indoor tnning services tx tx on ny service tht uses n electronic product with 1 or more ultrviolet lmps for skin tnning Comprtive effectiveness reserch fee this fee funds reserch on the effectiveness, risks nd benefits of medicl tretments through the Ptient-Centered Outcomes Reserch Institute Applies to ny brnded prescription drug sles fter December 31, 2008 Applies to ny medicl device sles fter December 21, 2008 Applies to services performed on or fter July 1, 2010 Pln/policy yers tht end fter September 30, 2012 nd beginning before October 1, 2019 Mnufcturers or importers with gross receipts from brnded prescription drug sles Mnufcturers or importers with gross receipts from medicl device sles Individuls tht use the services Issuers of fully insured plns Self-insured pln customers Amount is determined by the brnded prescription drug sles during the clendr yer nd percentge of gross receipts tken into ccount. Amount is determined by the medicl device sles during the clendr yer nd percentge of gross receipts tken into ccount. Tx equl to 10% of the mount pid for service. For pln yers tht end during October 1, 2012, through September 30, 2013, this fee is $1 per prticipnt per yer. For pln yers tht end during October 1, 2013, through September 30, 2014, the fee increses to $2 per prticipnt per yer. After tht, the rte increses ech yer by the medicl infltion rte. 0.9% Medicre surtx on wges in excess of $200,000 single/$250,000 mrried couples. Tx on high erners nd unerned income n nnul tx on wges or unerned income of more thn $200,000 for singles nd $250,000 for mrried couples Tx yers beginning Jnury 1, 2013 nd lter Individul txpyers 3.8% tx on unerned income for txpyers with modified djusted gross income in excess of $200,000 single/ $250,000 mrried couples. 10

11 Tx/Fee Effective Dte Responsible Prty Annul Tx/Fee Amount ACA insurer fee n nnul excise tx on helth insurnce to fund premium subsidies nd Medicid expnsion Tx yers beginning Jnury 1, 2014 nd lter Issuers of fully insured plns Bsed on the insurer s mrket shre of net premiums written bsed on the previous yer. For exmple, the 2014 fee will be bsed on 2013 premiums. Totl fee mount to be collected cross ll insurers strts t $8 billion in 2014 nd increses to $14.3 billion in After 2018 the fee increses nnully bsed on premium growth. Strting in 2014 the fee is 2.46% of premium. Funds will be used to mke reinsurnce pyments to helth insurnce issuers tht cover highcost individuls in nongrndfthered individul mrket plns. ACA reinsurnce fee this will support the trnsitionl reinsurnce progrm tht ims to stbilize premiums for coverge in the individul mrket nd lower the effects of dverse selection Pln/policy yers beginning in the 3-yer period strting Jnury 1, 2014 Issuers of fully insured plns Sponsors/ dministrtors will collect nd send the contributions on behlf of self-insured plns Issuers of fully insured plns This fee is $6.35 per prticipnt per month. Tx of 40% on helth pln costs tht exceed Cdillc pln thresholds of $10,200 for single coverge or $27,500 for fmily coverge. High-cost insurnce tx n nnul excise tx on high-cost helth plns Tx yers beginning Jnury 1, 2018 nd lter Sponsors/ dministrtors of self-insured plns Producers * The exchnges don t replce privte helth insurnce. They re simply new plce for qulified individuls nd smll group employers to shop for nd buy it. HHS expects producers will work with individuls nd smll group employers looking for coverge on the exchnges, but ech exchnge will decide how producers will be involved. They my llow producers to help people enroll in QHPs or help them with their pplictions for credits nd subsidies. As more guidnce is given bout the producer role, more informtion will be provided, including how the sttes will continue to oversee licensing of producers. *Helthcre.gov: Affordble Insurnce Exchnges: More Choices, Competition nd Clout (ccessed October 2012). Our compny We re proctively prepring for the exchnge mrketplce cross our orgniztion nd in ll of the sttes we serve. We re working to develop qulified helth plns tht comply with the new 2014 benefit requirements set forth by the helth cre reform lw. And, we re stying focused on improving the lives of the people we serve nd the helth of our communities. Here s wht tems in our compny re doing: Product development tem Providing pln informtion to helthcre.gov Updting pln designs to comply with qulified helth pln requirements Developing nd mintining pln designs tht meet post benefit requirements Public policy tem Federl level evluting the guidnce nd providing comments Stte level dvocting for exchnge rules tht mintin choice nd don t disrupt the existing mrketplce Exchnge strtegy tem Working with locl leders to define opportunities nd priorities in ech stte 11

12 Anthem Blue Cross is the trde nme of Blue Cross of Cliforni. Anthem Blue Cross nd Anthem Blue Cross Life nd Helth Insurnce Compny re independent licensees of the Blue Cross Assocition ANTHEM is registered trdemrk of Anthem Insurnce Compnies, Inc. The Blue Cross nme nd symbol re registered mrks of the Blue Cross Assocition.