David Lyons Founding Director and Chief Executive Officer

Transcription

1 The New Health Insurance Marketplace Changes Impacting Small Employers and the SHOP Opportunity David Lyons Founding Director and Chief Executive Officer CoOportunity Health 10/1/2013 1

2 Why the Change? $ Employers and individuals were terribly frustrated with the never-ending rise in health insurance costs More and more individuals and small businesses were finding coverage unaffordable and being excluded CoOportunity Health 10/1/2013 2

3 The New Health Insurance Marketplace 7 Transformational Changes in Guarantee Issue and Renewal Coverage Individual Mandate Subsidies for Individuals and Families below 400% FPL New Ways to Shop and Enroll beginning Oct. 1 Open Enrollment Periods for Individual Market Product Standardization New Rules & Play or Pay Taxes for Employer Groups No one can be denied coverage for medical reasons; no lifetime limits Tax penalties begin in 2014 for those without health insurance Tax credits for premium help and additional help with cost sharing <250% FPL Individual Marketplace (Exchange) and Small Group Marketplace (SHOP) First year: Oct 1 to Mar 31 Then: Oct 15-Dec 7 Individual and Small Group benefit designs comply with metal levels Rating factors limit age adjustment to 3:1; geographic areas; tobacco use. Fees and penalties for 51+ employers. Other fees to fund Exchange. CoOportunity Health 10/1/2013 3

4 Acronyms Gone Wild New Terms for a New Health Insurance Marketplace Words to Know Metal Levels Bronze, Silver, Gold, Platinum plan mandated levels for individual and small group market ACA Affordable Care Act EHBs Essential Health Benefits Health Insurance Marketplace QHPs Qualified Health Plans FFM Federally Facilitated Marketplace (Nebraska) Minimum Value Large group plans (51+) must meet minimum affordability test P-FFM Federally Facilitated Marketplace (Iowa) FPL Federal Poverty Level SHOP Small Business Health Options Program New Tax Credits Subsidies for individuals and small businesses CoOportunity Health 10/1/2013 4

5 What Concerns Small Employers the Most About Healthcare Reform?????? What will it cost? How much time will this take to manage? When will my employees see a benefit? Where can I get information I can trust? Who can help make sure we re prepared? CoOportunity Health 10/1/2013 5

6 Size of Employer Group Really Matters Insurance Requirement 1-25 FTEs FTEs >51 FTEs Not required to provide health insurance Not required to provide health insurance Required to provide health insurance in 2015 Penalties Exempt from penalties Exempt from penalties May be penalized whether or not they provide health coverage Size Requirements & Programs SHOP Marketplace Outside Marketplace Tax Credits Fewer than 25 FTEs Pay average annual wages below $50,000 Contribute 50% or more toward employee premiums Up to 50% for for profit firms Up to 35% for nonprofits Shopping portal for small businesses Metal plans offered by private insurance companies Increased purchasing power May continue to purchase coverage off Marketplace Shopping portal for small businesses Metal plans offered by private insurance companies Increased purchasing power May continue to purchase coverage off Marketplace Minimum Value Insurance plan must provide minimum value Plan must pay at least 60% of the cost of services Plan passes affordability test as long as premium contribution for single coverage does not exceed 9.5% of an employee s W-2 wages Iowa and Nebraska not changing definition yet Beginning in 2016, small group definition increases to fewer than 100 FTEs SHOP available to employers in 2016 May continue to purchase coverage off Marketplace CoOportunity Health 10/1/2013 6

7 Small Group Plan & Underwriting Changes Essential Health Benefits Out-of-Pocket Maximum Small Group Deductible Ceiling Limited to Metal Plans 10 required coverage categories New accumulation rules and ceiling $2,000 single $4,000 family Bronze Silver Gold Platinum CoOportunity Health 10/1/2013 7

8 Expanded Benefit Coverage Essential Health Benefits 10 categories of care must be included in all individual and small group plans No lifetime limits No annual dollar limits Emergency Services Hospitalization Maternity and Newborn Care Mental Health and Substance Use Disorder Services Prescription Drugs Rehabilitative & Habilitative Services & Devices Laboratory Services Preventive & Wellness Services, Chronic Disease Management Pediatric Dental & Vision Care Ambulatory Patient Services CoOportunity Health 10/1/2013 8

9 Encouraging Preventive Care First Three Free for office visits with primary, specialty or behavioral health clinicians Plan variations apply CoOportunity Health 10/1/2013 9

10 All Small Group Market Plans Include Rewards for Healthy Living Member completes 2 simple steps: Preventive Physical Exam Online Health Assessment Upon completion of both steps, $100 gift card mailed to member. Available to members 18+. Limit of two per family. Spanish version of Health Assessment available from Member Services. CoOportunity Health 10/1/

11 Product Standardization: Individual & Small Group Markets All Health Insurance Carriers must offer Metal Plan Levels Bronze Must pay for 60% of actuarial value Silver Must pay for 70% of actuarial value Gold Must pay for 80% of actuarial value Platinum Must pay for 90% of actuarial value Catastrophic Up to age 30 or exempt from mandate All limit out-of-pocket expenses All health plans must include coverage for preventive care like annual physicals, pediatric care, maternity and newborn care All plans offered must be certified by the Marketplace as a Qualified Health Plan and include Essential Health Benefits (10 categories of care that must be covered). CoOportunity Health 10/1/

12 New Rules: Rating and Market Rule Changes Big Changes for Small Groups 1-50 Move to adjusted community rating where ALL policyholders premiums only vary by location, 3 age bands, and tobacco use All Group Plans Removal of pre-existing conditions Guaranteed issue and renewal coverage No medical underwriting CoOportunity Health 10/1/

13 SHOP Marketplace Small Business Health Options Program Health Insurance Marketplace (Exchange) for Employers Employer applies and manages health insurance selection via SHOP Tax credits for 1-25 employers may only be used if enrolling via SHOP Increasing amounts: 50% for nonprofits; 35% all other Opens October 1, 2013 First Year will provide for enrollment in one QHP Will expand in 2014 to allow for choice and enrollment among QHPs Open year-round Expands in Future Years 2016: Small Group definition changes to : Large Employer Group expansion CoOportunity Health 10/1/

14 How Employers Use SHOP Marketplace Open Oct. 1 for Employers with <50 FTEs Step 1: Employer Shop and compare plans online Make decision about which plan to offer (one plan offering for 2014) Decide what you ll pay toward employee premiums Complete Employer Application In Iowa participation requirements of 70% In Nebraska participation requirements of 75% CoOportunity Health 10/1/

15 How Employers Use SHOP Marketplace Open Oct. 1 for Employers with <50 FTEs Step 2: Employee You, or the Marketplace, notify your employees and tell them how to sign up (use Marketplace tools to create employee roster, distribution list, etc.) You set up enrollment time parameters Employees receive offer of coverage Verify information, review plan, provide additional information (tobacco use, dependents) Accept or decline coverage Enrollment information sent directly to carrier; ID card issued CoOportunity Health 10/1/

16 Playbook QHPs on the Iowa Marketplace Individual Health Insurance Marketplace Statewide Network Coventry Health Care of Iowa Avera Health Plans Gunderson Health Plan Select Networks (Choice & Preferred) Select Networks Select Network: NW Iowa Who Is CoOportunity Health Select Network: NE Iowa Statewide SHOP Marketplace Avera Health Plans Gunderson Health Plan Sanford Health Health Alliance Midwest Select Networks (Choice & Preferred) Regional Networks CoOportunity Health 10/1/

17 Key Dates & Changes for Group Plans 2013 Notifications Employers must provide all employees with information about Marketplace in fall Employers with more than 250 employees required to put the cost of health benefits on W-2s Flexible Spending Accounts (FSAs) capped at $2,500 per plan year (indexed with inflation in future years) October 1, 2013 Open Enrollment Period Begins for the Individual Health Insurance Marketplace (Exchange) and Small Group 1-50 SHOP Marketplace March 31, 2014 Open Enrollment ends for individual market Enrollment continues year-round for Small Group Mar-Sept, 2014 Individuals can make changes outside of Open Enrollment if they have a HIPAA-qualifying event January 1, 2015 Employers with 51+ FTEs are required to offer health insurance 2016 Small Group Market (and SHOP) expands to Large Groups may be able to participate on SHOP Marketplace CoOportunity Health 10/1/

18 6 Things Small Employers Can Do Now Know the law. Depending on the size of your firm and the composition of your workforce, there are major implications View healthcare reform as a real opportunity to explore new options Model your company s situation; you may need to re-shape your workforce or capitalize on the law to vault your business forward Determine if you will continue to offer coverage and when the effective date will be; be mindful of individual market Marketplace enrollment periods Get organized with required application information if you intend to apply for coverage through the SHOP Marketplace This is an unprecedented time to shop; use a trusted advisor to help you evaluate options and make decisions; get a compliance audit completed* * Watch out for unintended consequences. CoOportunity Health 10/1/

19 Remember You Will Have Options Both On and Off the Marketplace Iowa Health Plan Offerings SHOP Marketplace Small Groups 1-50 Tax Credits for Groups with 1-25 EEs Three Core Product Offerings Premier: PPO Plans Choice: Tiered Benefit Design Plans Preferred: EPO Plans Open Market Three Core Product Offerings Premier: PPO Plans Choice: Tiered Benefit Design Plans Preferred: EPO Plans Plan Levels Bronze, Silver, Gold, Platinum Bronze, Silver, Gold, Platinum High Deductible Health Plans (HDHP) Bronze, Silver, Gold Bronze, Silver, Gold CoOportunity Health 10/1/

20 We re Open for Business Oct. 1 Find us on the Marketplace We are a QHP Issuer on the Iowa and Nebraska Health Insurance Marketplace for individual purchasers We are a QHP Issuer on the Iowa and Nebraska SHOP Marketplace for small businesses 1-50 Or, through your local Agent or Broker Individual Product Portfolio for under 65 individual purchasers Small Group 1-50 & Midsized Employers Portfolio Large Employer Solutions both fully-insured and selffunded CoOportunity Health 10/1/

21 David Lyons Founding Director and CEO P E david.lyons@cooportunityhealth.com cooportunityhealth.com CoOportunity Health 10/1/