HEALTH INSURANCE EXCHANGES Jeff Gold Vice President, Managed Care and Special Counsel Healthcare Association of New York State September 21, 2013
HEALTH INSURANCE EXCHANGES An organized marketplace where consumers can easily compare health plan options and enroll in qualified health coverage Seeks to increase competition while providing benefit standardization and potentially lower costs Public and private exchanges may co exist 2
Public Exchanges Private Exchanges Individual SHOP Federally mandated for January 2014 Individual exchange will target uninsured and self insured population SHOP (Small Business Health Options Program) will target small group employers early on; may incorporate large group employers in 2017 Community adjusted premiums with limited risk adjustment Small business tax credits and individual subsidies will be offered Will not exist in all states Targeted to large and midsize employers Less regulated than public exchanges Will support defined contribution models May facilitate shift to selfinsured products 3
COMPARING THE MAPS 4
FEDERAL REPOSITIONING? Basic Health Program delayed Federal SHOP delayed Employer Mandate delayed 5
PROJECTED ENROLLMENT The State of New York anticipates that about 1.1 million individuals will participate in the Health Benefit Exchange statewide by 2017: 615,000 in the individual, non group market, and 450,000 in the Small Business Health Options (SHOP) market. 6
HEALTH BENEFIT EXCHANGE TIMELINE July 2013 August 2013 Final network submission due, if needed, by 6/21 Plan certification process complete by 7/15 Navigator awards announced Navigator training and education scheduled Media outreach begins October 2013 Open enrollment begins 10/1 January 2014 First policies sold take effect 1/1 March 2014 Extended first year open enrollment ends 3/31 January 2015 Financial self sufficiency required by 1/1 7
Potential Subsidized Exchange Coverage Medicaid Coverage Churning 8
INDIVIDUAL AND SMALL GROUP PREMIUM RATES The Department of Financial Services (DFS) has approved 2014 individual and small group premium rates for products offered on the Exchange Rates have been released based on seven different rating regions: Albany, Buffalo, Mid Hudson, New York, Rochester, Syracuse, Utica, and Long Island 9
DECREASED RATES... BUT UNANSWERED QUESTIONS Individual premium rates are approximately 50% lower than the average cost of available plans today Premiums did not drop as steeply in the small group market compared to the individual market Details on provider networks, out of network coverage, and patient financial responsibility are not yet available 10
REBRANDING AND MARKETING 11
Qualified Health Plans Affinity Health Plan Today s Options of NY, Inc. BlueCross BlueShield of Western NY BlueShield of Northeastern NY CDPHP Emblem Health Empire Excellus Fidelis Care HealthFirst Health Republic (Freelancers Union) Independent Health Market Plus MVP Health Care North Shore LIJ Care Connect Oscar United HealthCare/Oxford Univera Qualified Dental Plans BlueCross BlueShield of Western NY BlueShield of Northeastern NY Delta Dental DentCare Delivery Systems, Inc. Dentegra EmblemHealth Empire Guardian HealthPlex MetLife Solstice 12
OPEN ENROLLMENT Initial open enrollment period: October 1, 2013 March 31, 2014 If enrolled on or before Dec. 15, coverage effective Jan. 1 If enrolled Dec. 16 to Jan. 15, coverage effective Feb. 1 If enrolled Jan. 16 to Feb. 15, coverage effective March 1 If enrolled Feb. 16 to March 15, coverage effective April 1 If enrolled March 16 to March 31, coverage effective May 1 For future years (2015 and beyond) annual open enrollment period: Coverage effective January 1 October 15 December 7 13
TRIGGERING EVENTS FOR SPECIAL ENROLLMENT The special enrollment period will be 60 days from the date of a triggering event Losing other minimum essential coverage Gaining or becoming a dependent through marriage, birth, adoption, or placement for adoption Gaining status as a citizen, national, or lawfully present in the U.S. An error in enrollment AQHP has substantially violated a material provision of a member s contract Becoming newly eligible or newly ineligible for advance payments of the premium tax credit or experiencing a change in eligibility for cost sharing reductions Apermanent move The individual is a Native American Other exceptional circumstance, as determined by Exchange or HHS 14
CERTIFIED APPLICATION COUNSELORS CMS established CACs as a type of assistance available to provide information and to help facilitate enrollment into qualified health plans available on the Exchange, in addition to Medicaid and Child Health Plus coverage CACs will complement the existing Navigator/In Person Assistor program No grant funding for CACs; the CAC program is intended to dovetail with existing enrollment activities 15
GRACE PERIOD COVERAGE A QHP must provide a grace period of three consecutive months if an enrollee receiving advance payments of the premium tax credit has previously paid at least one full month's premium during the benefit year. During the grace period, the QHP must: Pay all appropriate claims for services rendered to the enrollee during the first month of the grace period and may pend claims for services rendered to the enrollee in the second and third months of the grace period; Notify HHS of such non payment; and Notify providers of the possibility for denied claims when an enrollee is in the second and third months of the grace period 16
STRATEGIC CONSIDERATIONS Possibilities More insured lives Comparison shopping Simplified and centralized enrollment Private exchanges Risks Rate pressure Market migration Adverse selection Churning Government pressure and political climate Self sufficiency 17
PROVIDER FINANCIAL IMPACT Uninsured Individuals Join Medicaid Existing Insured Commercial Patients Shift to Exchange Plans Small Employers With No Insurance Coverage Join Exchange Self Pay Individuals Join Exchange Plans 18
BALANCING THREATS AND OPPORTUNITIES Existing Commercial Lives Moving to the Exchange = Lost Revenue Uninsured Moving to the Exchange = New Revenue 19
SHOP EXCHANGE IMPLICATIONS 20
21
HEALTH INSURANCE EXCHANGES Jeff Gold jgold@hanys.org September 21, 2013 22