Nebraska Health Insurance Exchange Update

Transcription

1 Nebraska Health Insurance Exchange Update Affordable Care Act Implementation March 2013

2 IMPLEMENTATION TIMELINE Temporary High Risk Pool Program Temporary Reinsurance Program For Early Retirees Immediate Reforms: No Lifetime Limits Restricted Annual Limits Restrictions on Rescission First Dollar Coverage of Preventive Services Extended Dependent Coverage Internal/External Review No Pre-Existing Conditions for Children Disclosure of Justifications for Premium Increases Medical Loss Ratios with Rebates Market Reforms Guaranteed Issue No Pre-Existing Condition Exclusions for Adults Rating Rules Essential Benefits Plans No Annual Limits for Essential Benefits Exchanges Subsidies Individual/Employer Mandates Co-Op Plans & Multistate Plans Risk Adjustment Individual Market Reinsurance Program & Risk Corridors

3 UPCOMING DEADLINES OF NOTE» Exchanges: Carriers begin submitting federal Exchange applications: April 1, 2013 All federal Exchange applications due: April 30, 2013 State certification complete: July 31, 2013 Carriers notified: September 4, 2013 Exchange sales begin October 1, 2013» Market Rule Gives States until March 29 th to Request: Family Tiers; Rating Areas; Age Ratio; Age Curve; Tobacco Ratio Merging of Small Group and Individual Markets

4 RECENT REGULATIONS» Market Reform Regulations 2014 Market Reforms» Essential Health Benefit/Accreditation/Actuarial Value Regulations Final EHB Benchmarks; AV Calculations; Accreditation Requirements» Notice of Benefit and Payment Parameters Risk-Sharing Payments; MLR Adjustments; Exchange Funding» Multi-State Plan Regulations Office of Personnel Management Requirements» Plus, Annual Letter, which outlines what is required of Qualified Health Plans in federal Exchanges 4

5 WHAT WE ARE WAITING FOR?» Final SHOP Exchange Regulations» Navigator Guidance and Funding Opportunity Announcement» Enforcement Determinations» The Hub link to federal agencies

6 Preemption Provisions of PPACA can potentially preempt state laws» Similar to HIPAA: Nothing in this title shall be construed to preempt any State law that does not prevent the application of the provisions of this title. PPACA 1321(d)» States can go beyond federal rules, but if a state s laws or regulations prevent a federal law from being implemented, then that law or reg is preempted» Assumption is that the state will enforce federal rules

7 ENFORCEMENT ANALYSIS Does plan cover mental health? Yes, per state law No Plan is in compliance with state and federal law State law preempted. HHS ENFORCES Plan violates Federal law Plan satisfies state law. Federal law applies Plan violates state law. Federal law does not apply Yes No, plan caps benefits, per state law Does plan apply same terms and conditions?

8 HEALTHCARE REFORM SO FAR» September 23, 2010 Immediate reforms: No lifetime limits and restricted annual limits Internal and external review standards Guarantee issue for children under age 19 Child coverage up to age 26 Coverage of preventive benefits (contraceptive issue)» Temporary High-Risk Pools (enrollment suspended Feb 2013)» Rate Review Standards (rate increases 10%+ reviewed)» Medical Loss Ratios with Rebates» Summary of Benefits and Coverage (September 2013)

9 2014 MARKET REFORMS For Small Group and Non-Group Coverage Sold or Renewed on or after 1/1/2014:» Guaranteed Issue» No Pre-Existing Condition Exclusions» Adjusted Community Rating & Single Risk Pool for Each Market» Essential Health Benefits & Cost-Sharing Must Meet Actuarial Value Levels These apply inside and outside of an Exchange

10 ADJUSTED COMMUNITY RATING» For the Small Group and Non-Group Markets: > No rating based on health status > Maximum age variation of 3:1 (ages 21-64) > Maximum variation based on tobacco use of 1.5:1 > Actuarially justified variation based on geographic areas (state may set areas) > Family rates built up based on age and tobacco use of each member» Plus, single risk pool in small group market and individual market (except for grandfathered plans)» This will significantly impact rates for younger/healthier enrollees in most states.

11 CURRENT SMALL GROUP MARKET WA VT NH ME CA OR NV ID AZ UT MT WY CO NM ND SD NE KS OK MN WI IA MO AR IL MS NY MI PA OH IN WV VA KY NC TN SC AL GA CT NJ DE MD DC MA RI Note: Nebraska is preempted on rating and will be 3:1 HI TX LA FL AK *Note: Michigan HMOs and Blue Cross/Blue Shield are restricted to 3.12:1 maximum variation. All others may use 3.96 maximum variation Community Rating Adjusted Community Rating Rating Band Variability: 13:1 or less 13.1:1 19:1 No Rating Structure 19.1:1 25:1 25.1:1 or greater

12 Current Individual Market WA ME CA OR NV ID UT MT WY CO ND SD NE KS MN IA MO WI IL MI OH IN KY TN WV NY PA VA NC VT NH MA RI CT NJ DE MD DC AZ NM OK AR MS AL GA SC HI TX LA FL AK No Rating Structure Community Rating Adjusted Community Rating Rating Bands Hybrid Michigan Blue Cross/Blue Shield must use community rating. There is no rating structure for other carriers.

13 Benefit Design & Cost-Sharing» Individual and small group plans must include Essential Health Benefits (EHBs). Large group and self-insured plans may not have annual or lifetime limits on EHBs.» EHBs based on benchmark plan in each state» Cost-sharing levels: > Bronze = 60% actuarial value > Silver = 70% actuarial value > Gold = 80% actuarial value > Platinum = 90% actuarial value > Catastrophic Plan (limited to young and those without affordable option in the market)

14 PLAN TRANSPARENCY» Plans must submit a justification for any premium increase prior to implementation and post on website» Plans must disclose to the public: Claims payment policies and practices Periodic financial information Data on enrollment and disenrollment Number of claims denied Rating practices Cost-sharing and payments for out-of-network coverage Enrollee rights under PPACA Other information required by the Secretary

15 Grandfathered Plans» Coverage in which individuals were enrolled prior to March 23, 2010 are exempt from most provisions of the bill. Provisions that DO Apply: > Lifetime limits > Restrictions on rescissions > Extension of dependent coverage > Medical loss ratios > Annual limits (group only) > Preexisting condition exclusions (group only)» Grandfather Status Can Be Lost» Pooled separately from newly sold plans. > State laws that attempt to include them in single risk pools are preempted.» Grandfathered plans will satisfy individual mandate.

16 ENFORCEMENT (a) STATE ENFORCEMENT 1) STATE AUTHORITY. Subject to section 2723{2724}, each State may require that health insurance issuers that issue, sell, renew, or offer health insurance coverage in the State in the small or large group markets individual or group market meet the requirements of this part with respect to such issuers. 2) FAILURE TO IMPLEMENT PROVISIONS. In the case of a determination by the Secretary that a State has failed to substantially enforce a provision (or provisions) in this part with respect to health insurance issuers in the State, the Secretary shall enforce such provision (or provisions) under subsection (b) insofar as they relate to the issuance, sale, renewal, and offering of health insurance coverage in connection with group health plans or individual health insurance coverage in such State.

17 ENFORCEMENT» Options for Enforcement of 2014 Market Reforms Amend state rules to meet minimum federal standards Use general authority (form review, rate review, unfair trade practices) to enforce federal rules Enter into a Collaborative Enforcement Agreement with CCIIO under which the state reviews for compliance, but CCIIO uses federal penalties State enforces state rules; CCIIO enforces federal rules Nebraska has provision that states that policies must conform to state and federal law.» Letter sent to commissioners on Feb 15 outlining where CCIIO believes state enforcement authority exists most states assumed to have authority» Nebraska has been deemed a plan management marketplace and will enforce 2014 market reforms

18 SERFF AND TEMPLATE ASSISTANCE» EHB Validations» Substitution of Benefit Evaluation» A/V and Cost Sharing Validations» Single-Risk Pool for Plans in each Mkt» Age-Band, Tobacco, Geography, and Family Size Analysis» Accreditation» Network Adequacy» And more

19 FEDERAL ENFORCEMENT ACTIONS» Penalties The maximum amount of penalty imposed under this paragraph is $100 for each day for each individual with respect to which such a failure occurs No penalties if reasonable diligence found Administrative review Judicial review» Deny Exchange Participation

20 Individual Mandate Individuals required to have minimum qualified coverage beginning January 1, 2014 Penalties $95 per adult up to $285 or 1% of household income, whichever is higher $395 per adult up to $885 or 2% of household income, whichever is higher $695 per adult up to $2,085 or 2.5% of household income, whichever is higher Penalty for a child is ½ that of an adult Penalties indexed to the growth of CPI after 2016

21 Individual Mandate IRS is prohibited from filing liens or charging interest for penalties. No fines or criminal charges for nonpayment. Exemptions: Cost of coverage is more than 8% of household income Religious objection Financial hardship

22 EMPLOYER RESPONSIBILITIES» Employers over 200 employees must auto-enroll with opt-out» Employers with more than 50 employees fined if employees qualify for subsidies because cost of coverage for employee exceeds 9.5% of income of employee > Penalty is $3,000 per employee receiving subsidy up to $2,000 times number of employees > First 30 employees disregarded in calculating penalties

23 THE EXCHANGES (MARKETPLACES)» Individual Exchange: Provides information on subsidies and Medicaid eligibility» Small Group (SHOP) Exchange: For small employers ( 1 defined as employer and one employee) 70% participation rate allowed in federal SHOP State may elect to define as 1-50 until January 1, 2016 Employer may choose coverage level and allow employees to choose from carriers offering at that level beginning in 2015 Exchange collects and combines premiums and sends to carriers beginning in 2015» State may elect to combine individual and small group markets

24 EXCHANGE OPTIONS» Federally Facilitated Exchange Feds set standards and operate the Exchange State maintains oversight of health plans and may coordinate with the federal Exchange Grant funds available to states for coordination costs Plans charged 3.5% of premium per month» Partnership Feds operate Exchange, but state makes many key decisions and may do plan management and/or some consumer assistance Grant funds available to states for plan management/consumer assistance costs

25 EXCHANGE OPTIONS» Plan Management Market Place Letter of Intent from DOI ASAP that the state will fulfill QHP certification functions and/or consumer assistance functions Plans need only submit to state regulator Grant funds available» State Exchange State operates Exchange Determining eligibility for subsidies optional Grant funds available to establish Exchange; must be sustainable

26 FUNDING OPTIONS» Exchange Establishment Grants Changed the scope of the Establishment grant to work with the federally facilitated exchange Last deadline for application: Oct 2014» Rate Review Grants Must be related to rate review process Applied for a second rate review grant» Ongoing Funding

27 EXCHANGE FUNCTIONS At a minimum, an Exchange must:» Implement procedures for certification, recertification, and decertification of health plans.» Operate toll-free hotline.» Maintain Internet website with standardized info.» Assign a rating to each plan.» Utilize standardized format for presenting options.» Inform individuals of eligibility for Medicaid, CHIP or other applicable state or local public programs.» Certify exemptions from individual mandate.

28 EXCHANGE FUNCTIONS (CONTINUED)» Make available a calculator to determine the actual cost of coverage after subsidies.» Grant a certification attesting that the individual is not subject to the coverage mandate because: there is no affordable option available, or the individual is exempt from the mandate.» Transfer to the Treasury a list of exempt individuals and employees eligible for tax credit.» Provide to each employer the name of employees eligible for tax credit.» Establish a Navigator program.

29 PLANS AVAILABLE IN EXCHANGE» Qualified Health Plans» Stand-Alone Dental Plans» CO-OP Plans» Multi-State Plans

30 At a minimum QHPs must: QUALIFIED HEALTH PLANS 1. Be licensed and provide Essential Health Benefits 2. Offer at least one Silver (70%) and one Gold (80%) plan 3. Charge same price in and out of Exchange for same plan 4. Meet marketing requirements (state rules in ) 5. Meet network adequacy requirements (state rules in ) 6. Include essential community providers in network 7. Be accredited by organizations recognized by Secretary 8. Implement quality improvement strategies (2016) 9. Utilize uniform enrollment form and standard format for presenting plan options Note: HHS and/or States could impose additional certification requirements. QHPs may be sold off Exchange. Mandates provision applies to all QHPs.

31 APPROVAL OF QHPS» Submission of Rates and Forms SERFF and/or HIOS Rate Review Template NOTE: FFE QHP applications due April 30 th» Review of Rates and Forms (Completed by July 31 st ) Essential Health Benefits Actuarial Value Calculator New Rating Rules Risk-Sharing Non-Discrimination Meaningful Difference» Network Adequacy (based on State/NAIC rules) Nebraska will use the HMO Network adequacy review standards» Marketing (by State)» Quality (postponed)

32 SERFF AND QHP REVIEW AND APPROVAL - SBE» Underlying Rate/Form Review» QHP Submission Tied to Rates/Forms» Verification of Licensure and Accreditation» QHP Data Collection» Federal and/or State Data/Templates» Validation of Federal Templates» Separation of Product Review and QHP Certification, if desired» Electronic or Manual Transmission to an Exchange» FM Data Transfer to CMS» Inside and Outside Markets

33 SERFF AND QHP REVIEW AND APPROVAL - SPE AND PLAN MANAGEMENT MARKETPLACE» Underlying Rate/Form Review» QHP Submission Tied to Rates/Forms» Verification of Licensure and Accreditation» QHP Data Collection» Federal and/or State Data/Templates» Validation of Federal Templates» QHP Certification» Electronic Transmission to CMS» Inside and Outside Markets

34 CO-OP PLANS» Federal government will foster the creation of qualified nonprofit insurers Loans for start-up costs Grants to help meet solvency requirements Unobligated funds cut off in fiscal cliff deal CO-OP loans granted to plans in: IL, AZ, CO, CT, IA, NE, KY, LA, ME, MD, MA, MI, MT, NV, NJ, NM, NY, OH, OR, SC, TN, UT, VT, WI» Must be governed by majority vote of members» Profits must be used to reduce premiums, increase benefits, or improve quality of care» Must be licensed by state and follow state insurance laws

35 STAND-ALONE DENTAL» Stand-Alone Dental plans may be sold inside the Exchanges Not required to follow market rules; they are excepted benefits Not eligible for subsidies» If Stand-Alone Dental plan includes pediatric coverage, other QHPs do not need to include pediatric coverage Option for outside market CIIO believes that there will be 6 stand alone dental carries in the federally facilitated exchange

36 MULTI-STATE PLANS» U.S. Office of Personnel Management (OPM) contracts with insurers to offer at least 2 plans in each state (at least one a non-profit)» Contracting process similar to the Federal Employees Health Benefit Plan (FEHBP)» Insurers must be licensed in every state in which they operate Must be in at least 60% of states in first year; 70% of states in second year; 85% of states in third year; and all states in fourth year Not required to cover entire state unless required by state» Plans must comply with state rules and regulations, if they exist

37 NAVIGATORS» Exchanges must make grants to Navigators. Trade, industry, and professional associations Fishing, ranching, and farming organizations Community and consumer-focused nonprofits Chambers of commerce Unions Licensed agents and brokers (if they do not receive any compensation from carriers)» Navigators Conduct public education and distribute information» Navigators facilitate enrollment, but may not advise or enroll» Navigators provide referrals to consumer assistance offices

38 NAVIGATORS (CONTINUED)» HHS to develop standards to ensure that Navigators are qualified and trained» Navigators may not be insurers or receive direct or indirect compensation from insurers for enrollment in a QHP» States may not require a Navigator to be licensed as an agent or broker» States should be careful to ensure that Navigators do not perform functions that would require a producer's license» There is currently a bill in the legislature to license Navigators

39 OTHER ASSISTERS» State Assisters (grant funds available)» Application Assisters (Counselors) Primarily in hospitals and clinics Volunteers with training and certification» Agents and Brokers Listed on the Exchange Commissions Paid by Insurers Appointment Issues

40 NAIC AND PRODUCER LICENSING DATA» Support Validation of Producer Licensing in SPE, Quasi-Partner and FFE» Data Transmission from NAIC State Producer Licensing Database» Daily Transmissions» FName, LName, NPN, State, Bus. Address, Company Name, CoCode

41 Premium Cap as % of Income SUBSIDIES: PREMIUM TAX CREDIT Premium Tax Credits» Available from 100% - 400% FPL.» Covers the difference between premium for the second-lowest-cost Silver plan and a percentage of income.» Advanced to insurer. 10% 9% 8% 7% 6% 5% 4% 3% 2% 1% 0% 100% 133% 150% 200% 250% 300% 400% Household Income as % of FPL

42 Actuarial Value of Silver Plan SUBSIDIES: REDUCED COST-SHARING» Available from 100% - 400% FPL.» Increases actuarial value of silver plan.» First achieved by reducing out-of-pocket limit.» Advanced to insurer. 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Cost-Sharing Subsidies 94% 87% 73% 70% % % % % Household Income as % of FPL

43 SUBSIDIES: SMALL BUSINESS TAX CREDIT» Businesses with 25 or fewer employees.» Average wages less than $50,000.» Contribute at least 50% of premium.» Phases out as size and wages of business increase.» : Up to 35% of total employer contribution.» 2014 and later: Up to 50% of contribution.

44 NDOI ACTIVITIES» Stakeholder Outreach» Update Plan Management Functions and Hire New Staff» Market Conduct Updates and Complaints System Coordination» Analysis of Laws and Regulations

45 QUESTIONS? Martin Swanson (402) Health Policy Counsel ACA Project Director John Paul Sabby (402) Policy Analyst