Ohio Health Insurance Exchanges Information contained within the this presentation is subject to change.
Affordable Care Act (ACA) Comprehensive health care reform law enacted in March 2010 in two parts: The Patient Protection and Affordable Care Act--- enacted on March 23, 2010. The Health Care and Education Reconciliations Act--- enacted on March 30, 2012 (amended the Patient Protection and Affordable Care Act) The name Affordable Care Act is used to refer to the final amended version of the law. One of the provisions of the ACA requires all individuals to have health insurance as of January 1, 2014. 2
CMS Transitional Policy November 14, 2013 President Obama announced a transitional policy recommendation allowing individuals to keep their current plans beyond the grandfathering defined by the ACA, leaving it up to the discretion of each state s insurance commissioner and each insurer if they choose to extend this option to customers. Many carriers and state insurance departments may face operational constraints that would prevent them from fully implementing this new policy in a timely way. We have closely reviewed market conditions in Ohio, which has its own set of unique factors and specific health insurance regulations. Our goal has been to proceed in a manner that not only protects our members access to quality health care coverage, but also offers affordable coverage in the longterm as well as the short-term. To that end, we believe it is important to stay the course by continuing to provide consumers options to purchase a new policy with their current benefits or purchase new on or Off-Exchange products, which we believe preserves the longer-term viability of our offerings. We have communicated to our members that they have choices and will be able to choose any of our open plans with the new comprehensive benefits. Additionally, we have instructed members that they will be able to choose our plans on the Health Insurance Marketplace (Exchanges) where they can also find out if they qualify for financial help based on their annual income. If our members like the plans they had, they will be able to find new policy options with similar benefits and coverage. 3
Small Group Delay Announcement from the Obama Administration that it plans to delay online enrollment for the small group side of the federal Exchange (FF-SHOP) by one year. This delay also allows Health and Human Services (HHS) to dedicate more resources to making improvements on the individual side of the federal Exchange. The Administration announced small employers will no longer use FF-SHOP to enroll in coverage that is eligible for the small employer tax credit for 2014. Instead, employers will be able to purchase Qualified Health Plans (QHPs) directly from insurers and submit an application to FF-SHOP to determine eligibility for the tax credit. Anthem offered additional time for both individuals and small groups to early renew through 11/30/14. Anthem is not allowing groups to renew on legacy products on other dates (e.g., their anniversary date.) Other than the early renewal process, we did not allow any other individual members or small groups to keep their current or other non-aca compliant products. 4
Insurance Options for 2014 Continue to obtain insurance though their employer if available. Buy an individual plan through the Exchange or the traditional individual market. Enroll in a government-sponsored plan, if eligible. Go uninsured and pay a penalty (unless the consumer qualifies for an exemption) The penalty amount will start at $95 or 1% of taxable income (which ever is greater), and increase over the years with annual adjustments through 2017 and beyond. 5
Health Insurance Marketplace Commonly called Exchange Online marketplace where individuals and small businesses can: Shop for insurance and compare health plans. Get answers to questions. Find out if they are eligible for tax credits for private insurance. Enroll in a health plan that meets their needs. Exchanges started to offer health plans to individuals and *small businesses on October 1, 2013, with a coverage effective date of January 1, 2014. Exchange website: www.healthcare.gov *Please note on 11/27/2013 the administration delayed 6
Purpose of Health Insurance Exchanges The primary purpose of health insurance Exchanges is to create a more organized and easy-to-compare market for health insurance by offering a choice of plans, establish common rules about the plans and price of health insurance, and provide information to help consumers better understand the options available to them. Exchanges became operational by January 1, 2014 For states utilizing the HHS website, some SHOP capabilities were delayed. 7
Health Insurance Exchanges Offer There are 5 functions that health insurance Exchanges offer: 1) Consumer Assistance: Staff manage the Exchange website and call centers. Navigators help consumers use the Exchanges. 2) Plan Management: Consumers are able to choose QHP s sold On- Exchanges and see important data for each QHP. 3) Eligibility: Applicant information is collected and verified to determine eligibility. 4) Enrollment: Staff help consumers and send information to health plans as well as transmit information related to premium tax credits and costsharing reductions. 5) Financial Management: Exchanges perform several financial functions including handling user fees, risk adjustment, reinsurance and risk corridor programs. 8
Subsidies & Credits Subsidies and credits are available to individuals and families if their income is between 133% and 400% of the federal poverty level $15,282 to $45,960 for individuals and $ 31,322 to $94,200 for families, as of 2014. They must also not have access to minimum essential coverage through their employer or the coverage being offered is not affordable. It is deemed not affordable if their share of the premium is more than 9.5% percent of their income. Credits may be applied to any Exchange plan, from the bronze plan (which pays about 60% of covered costs) to the platinum plan (which pays about 90% of covered costs). Cost-sharing subsidies are available for individuals enrolling in the silver plan (70% coverage) only. Cost-sharing subsidies raise the actuarial value of the plan by lowering out-of-pocket maximums. These subsidies are only be available for those who earn up to 250% of the federal poverty level. Disclaimer- This content is provided solely for informational purposes: it is not intended as and does not constitute legal advice. The information contained herein should not be relied upon or used as a substitute for consultation with legal, accounting, tax and/or other professional advisors. 9
Qualified Health Plan (QHP) Under the Affordable Care Act, starting in 2014, an insurance plan that is certified by the Health Insurance Marketplace: Provides Essential Health Benefits (EHBs). Follows established limits on cost-sharing (like deductibles, copayments, and out-of-pocket maximum amounts). Is certified by the Health Insurance Marketplace. 10 10
Essential Health Benefits (EHBs) Plans available in the Exchange marketplace must offer what are called Essential Health Benefits. EHB s include the following services: Ambulatory Services Hospitalization Preventive/Wellness Services Rehabilitative/habilitative Services Pediatric Services, including oral and vision care Emergency Services Laboratory Services Maternity/Newborn Care Mental/Behavioral Health Chronic Disease Management Prescription Drugs Despite President Obama s recent announcement, allowing plans to continue to offer legacy plans that are noncompliant with ACA designs, Anthem plans to fully implement the metal levels and essential health benefits as originally required. 11 11
Grandfathered & Non-grandfathered Health Plans Grandfathered health plan A plan in effect on or before March 23, 2010 No changes since March 23, 2010, to materially reduce benefits or employer contributions Exempt from many changes required under the Affordable Care Act Non-grandfathered health plan Purchased after March 23, 2010; or Had changes after March 23, 2010, that caused it to lose grandfathered status ACA compliant 12 12
On-Exchange and Off-Exchange On-Exchange Individual or Small Group qualified health plan purchased through the Health Insurance Marketplace. Off-Exchange Individual or Small Group health plans purchased outside of the Health Insurance Marketplace. o i.e. Broker, Sales Agent, Private Exchange, or directly through a health insurance company. Future members may call 877-373-9856 to obtain information about plans and providers. 13 13
Ohio Network Names Pathway X Tiered Hospital Network Individual and Small Group products offered on the Exchange Pathway Tiered Hospital Network Individual products offered in the commercial market outside of the Exchange. Prefix Network Type of Exchange JWR Pathway X Tiered Hospital Individual On-Exchange JWT Pathway Tiered Hospital Individual Off-Exchange JWS Pathway X Tiered Hospital *Small Group On-Exchange JWQ Blue Access PPO *Small Group Off-Exchange *Please note on 11/27/2013 the administration delayed 14 14
Blue Access PPO Network Supports Small Group Off- Exchange Plans Health care reform laws will continue to bring many changes in 2014. The Affordable Care Act (ACA) calls for the development of new health plans, effective beginning January 1, 2014. All new individual and small group plans must include the Essential Health Benefits required by ACA. Anthem Blue Cross and Blue Shield (Anthem) is offering new products that are sold on the Health Insurance Marketplace (commonly referred to as the Exchange) as well as new products not purchased on the Exchange, i.e., they are bought directly from Anthem Blue Cross and Blue Shield, a broker, etc. The Blue Access PPO network supports new small group plans not sold on the Exchange. As a result, if you are a participating provider in Anthem's Blue Access PPO network, you are an in-network provider for our new small group plans purchased Off-Exchange that utilizes for following: Prefix Assigned Provider Network Type of Plan Provider Service JWQ Blue Access PPO Small Group Off-Exchange (855) 330-1107 15 15
New Health Plan Names New health plans sold on and off the Exchange have new product names. The new product names for Ohio include Anthem (Gold/Silver/Bronze) DirectAccess and Anthem (Preferred/Essential/Core) DirectAccess, followed by a four-digit alpha code. Health plans purchased on the Exchange indicate a metal level in the product name on the member ID card. 16 16
Plan Names: Individual On & Off And Small Group On-Exchange Prefix Network Name Plan Name Product Plan Type JWR Pathway X Tiered Hospital Bronze DirectAccess w/hsa Individual On-Exchange JWR Pathway X Tiered Hospital Gold DirectAccess Individual On-Exchange JWR Pathway X Tiered Hospital Bronze DirectAccess Individual On-Exchange JWR Pathway X Tiered Hospital Bronze DirectAccess w/child Dental Individual On-Exchange JWR Pathway X Tiered Hospital Gold DirectAccess w/child Dental Individual On-Exchange JWR Pathway X Tiered Hospital Silver DirectAccess Individual On-Exchange JWR Pathway X Tiered Hospital Silver DirectAccess w/hsa Individual On-Exchange JWR Pathway X Tiered Hospital Catastrophic DirectAccess Individual On-Exchange JWS Pathway X Tiered Hospital Bronze DirectAccess Plus w/hsa Small Group On-Exchange JWS Pathway X Tiered Hospital Silver DirectAccess Plus w/hsa Small Group On-Exchange JWS Pathway X Tiered Hospital Gold DirectAccess Plus Small Group On-Exchange JWS Pathway X Tiered Hospital Silver DirectAccess Plus Small Group On-Exchange JWT Pathway Tiered Hospital Preferred DirectAccess Individual Off-Exchange JWT Pathway Tiered Hospital Core DirectAccess Individual Off-Exchange JWT Pathway Tiered Hospital Core DirectAccess w/child Dental Individual Off-Exchange JWT Pathway Tiered Hospital Core DirectAccess w/hsa Individual Off-Exchange JWT Pathway Tiered Hospital Essential DirectAccess Individual Off-Exchange JWT Pathway Tiered Hospital Essential DirectAccess w/hsa Individual Off-Exchange JWT Pathway Tiered Hospital Catastrophic DirectAccess Individual Off-Exchange JWT Pathway Tiered Hospital Preferred DirectAccess w/child Dental Individual Off-Exchange 17 17
Plan Names: Individual On & Off And Small Group On-Exchange The Blue Access PPO network supports new Small Group plans not sold (Small Group Off-Exchange) on the Exchange. As a result, if you are a participating provider in Anthem's Blue Access PPO network, you are an in-network provider for our new small group plans purchased Off-Exchange. Prefix Network Name Plan Name Product Plan Type JWQ Blue Access Essential DirectAccess w/hsa Small Group Off-Exchange JWQ Blue Access Essential DirectAccess Plus w/hsa Small Group Off-Exchange JWQ Blue Access Preferred DirectAccess w/hsa Small Group Off-Exchange JWQ Blue Access Preferred DirectAccess w/hra Small Group Off-Exchange JWQ Blue Access Core DirectAccess w/hsa Small Group Off-Exchange JWQ Blue Access Preferred DirectAccess Plus Small Group Off-Exchange JWQ Blue Access Preferred DirectAccess Plus w/dental Small Group Off-Exchange JWQ Blue Access Preferred DirectAccess Plus w/hsa Small Group Off-Exchange JWQ Blue Access Core DirectAccess Plus Small Group Off-Exchange JWQ Blue Access Core DirectAccess Plus w/dental Small Group Off-Exchange JWQ Blue Access Core DirectAccess Plus w/hsa Small Group Off-Exchange JWQ Blue Access Essential DirectAccess Small Group Off-Exchange JWQ Blue Access Essential DirectAccess Plus Small Group Off-Exchange JWQ Blue Access Essential DirectAccess Plus w/dental Small Group Off-Exchange JWQ Blue Access Preferred DirectAccess Small Group Off-Exchange JWQ Blue Access Core DirectAccess Small Group Off-Exchange 18 18
Coverage Levels Metal levels mean that a health plan was purchased on the Exchange and indicate the richness of the benefits associated with a product or health plan. For plans purchased on the Exchange, the product name on the ID card includes a metal level. For example, a member ID card for a plan purchased on the Exchange may reflect Anthem Bronze Direct Access as the name of the member s health plan. Four levels of tiered plans offered in the Exchange marketplace, referred to as metal levels Bronze--- highest cost shares, lowest premium Silver Gold Platinum--- lowest cost shares, highest premium Visit our Summary of Benefits page for an overview of the benefits. 19 19
Suitcase Logo Member ID cards for PPO health plans purchased on the Exchange may include a PPO suitcase logo followed by the letter B. The presence of the PPO B suitcase logo on an Anthem member ID card indicates the member has access to the National BlueCard PPO Basic Network (a new national Exchange network) for covered services received out-of-area. If you are participating in Anthem s Pathway X Tiered Network in Ohio, and an Exchange member from another state is seeking care, then you are participating in the National BlueCard PPO Basic Network (PPOB). If you are not participating in the Pathway X Tiered Network in Ohio, then you are not participating in the National BlueCard PPO Basic Network (PPOB). PPO health plans with limited outof-area benefits include a disclaimer on the back of the member ID card. Providers should continue to verify eligibility and benefits for all members. Member ID cards for PPO health plans purchased off the Exchange will include the PPO suitcase logo. Some On-Exchange health plans may also include the PPO suitcase logo. The presence of the PPO suitcase logo (without the letter B) indicates a member has access to the BlueCard PPO Network for covered services received out-of-area. If you are participating in Anthem s Blue Access PPO network and a member from another state is seeking care, then you are participating in the BlueCard PPO Network (PPO). PPO health plans with limited out-of-area benefits include a disclaimer on the back of the member ID card. Providers should continue to verify eligibility and benefits for all members. ID cards for members with HMO health plans will include the blank suitcase logo. The presence of the blank suitcase logo indicates a member has access to the BlueCard Traditional Network for services received out-of-area that are urgent or emergent care only. Providers should continue to verify eligibility and benefits for all members. 20 20
Member ID Cards: Off-Exchange Member ID cards have a similar format to prior Anthem member ID cards. New information included on the member ID card includes the network name, new prefixes, and drug list names. Other important information includes contact phone numbers, plan names, and metal levels (if applicable). The following sample represents the general look of the new member ID cards for Off-Exchange. *Please note, this is a sample ID card. The policy and benefit information indicated does not necessarily represent benefit information for new member health plans. Policy and benefit information on actual member ID cards will vary by plan. 21 21
Member ID Cards: On-Exchange Member ID cards have a similar format to prior Anthem member ID cards. New information included on the member ID card includes the network name, new prefixes, and drug list names. Other important information includes contact phone numbers, plan names, and metal levels (if applicable). The following sample represents the general look of the new member ID cards for On-Exchange. *Please note, this is a sample ID card. The policy and benefit information indicated does not necessarily represent benefit information for new member health plans. Policy and benefit information on actual member ID cards will vary by plan. 22 22
Member ID Cards: Small Group Off-Exchange Member ID cards have a similar format to prior Anthem member ID cards. New information included on the member ID card includes the network name, new prefixes, and drug list names. Other important information includes contact phone numbers, plan names, and metal levels (if applicable). The following sample represents the general look of the new member ID cards for Small Group Off-Exchange members that access providers through the Blue Access PPO Network. *Please note, this is a sample ID card. The policy and benefit information indicated does not necessarily represent benefit information for new member health plans. Policy and benefit information on actual member ID cards will vary by plan. 23 23
Member Benefits Member benefits for the new Individual and Small Group health plans vary based on options that are available for the member. In general, Individual health plans purchased on and off the Exchange, and Small Group plans purchased on the Exchange have a slightly higher out of pocket, lean pharmacy benefits (which may vary between plans), and a more focused provider network. Small Group health plans purchased off the Exchange look a lot like they did in the past, but there are options which may include select drug lists. All Individual and Small Group health plans purchased on and off the Exchange, include Essential Health Benefits (or EHBs). Large Group benefit plans did not change to meet the requirements for EHBs and because they are not subject to many of the new requirements for Individual and Small Group plans. They look much like they did in the past. Providers should continue to verify eligibility and benefits for all members. Benefit information for these new health plans is available on the Availity Web Portal. 24 24
Member Welcome Kit After a new plan is selected, members receive either a Welcome Kit by mail or information by email. Welcome kits provide members with benefit information and coverage details to help them understand their copays, deductibles, and coinsurance responsibilities. These kits also include information about health and wellness programs, and online tools to help members find innetwork providers. When members prefer electronic communications, they receive an email with details about how to access all of this information and more through our member website. To find more updates about these new health plans, please access the Health Insurance Exchange page online at www.anthem.com> Providers (select Ohio)>Health Insurance Exchange. 25 25
Am I Participating In Pathway Networks? A subset of Anthem s participating doctors, hospitals and other health care professionals are participating in the new networks. The networks include a broad base of ancillary providers. Providers were notified that they were selected for participation in the new networks via a certified letter and/or through a provider contract amendment. Providers not participating in the Pathway X Tiered Hospital and Pathway Tiered Hospital networks remain participating providers in Anthem s other provider networks, as applicable, under their existing provider agreements. Providers may view their participation status by using the Find a Doctor tool at www.anthem.com>providers (select Ohio)>Find a Doctor. You ll be able to search by a specific provider name, or view a list of local in-network providers using search features such as provider specialty, zip code, and plan type. Providers may also contact their Network Relations contact to verify network status. 26 26
Out of Network The new health plans in Ohio are PPO products with out-of-network benefits; however, there may be a greater cost share for members using out-of-network providers. For example, members who visit an out-of-network provider, for non-emergent services, will be responsible for 40% coinsurance, whereas, in most cases, if the member visited a network provider, they may have only a co-pay or 20% coinsurance. Visit our Summary of Benefits page for an overview of the benefits and the impacts on utilizing network versus non-network providers. 27 27
Emergent Care Emergency care services are covered under the new Exchange plans. If a member is seen by an out-of-network provider for emergency services (due to the seriousness of the illness or injury), these charges are covered as in-network benefits. 28 28
Pharmacy Benefits: Drug List Information Under the Affordable Care Act (ACA), pharmacy benefits are considered an Essential Health Benefit and are covered under all individual and small group health plans in 2014. Effective January 1, 2014, individual and small group health plans purchased on and off the Exchange include drug benefits for medications from one of two different drug lists the National Drug List or the new Select Drug List: Anthem National Drug List, Anthem Select Drug List-OH. Providers may already be familiar with our National Drug List, which includes a broad list of covered drugs. Please note that many new plans purchased on and off the Exchange utilize the new Select Drug List, which covers a select number of medications in all therapeutic categories and classes. Although the Select Drug List covers fewer drugs than those covered under the National Drug List, both drug lists meet ACA requirements. *See appendix for additional information 29 29
Administrative Functions Anthem s preauthorization/precertification requirements that were in place prior to January 1, 2014, are applicable for new policies on and off the Exchange. This includes precertification submitted to AIM Specialty Health. Claim edits (bundling rules, incidental services, etc.) are applicable for the new Exchange plans. Remittance Advices for Exchange members look the same as they always have. Providers can send secure messaging via the Availity Web Portal for On and Off-Exchange member just as they do for Managed Care and Medicare Advantage members. Providers should utilize the same Atlanta, GA PO Box for submitting claims. 30 30
Transplant Network and Benefits Exchange benefit language directs members to a Centers of Excellence Program for in-network transplant services. Blue Distinction Centers for Transplant Contracts and Anthem Centers of Medical Excellence Transplant Contracts provide access to transplant services during the global period of care. The designated BDCT programs in Ohio are Cleveland Clinic, University Hospitals Cleveland, Ohio State University, Nationwide Children s Hospital, Jewish Hospital Cincinnati, University of Cincinnati and Children s Hospital in Cincinnati. At this time only University Hospitals Cleveland and Nationwide Children s Hospital are participating in the Exchange Network. There aren t any designated pediatric lung, heart lung or adult living donor liver transplant programs in Ohio 31 31
Transplant Network and Benefits Cont. Pre- and Post-transplant services are typically delivered by the Provider performing the transplant. Pre- and Post-transplant services are not included in the global contracts. Discussion is in process with the designated Transplant Providers in Ohio and other Anthem Plans to include pre and post transplant services for the Exchange Member at an in network level through a letter of agreement. Kidney Transplants are currently included in the Hospital Agreement. If the Hospital is not participating in the Exchange, these services are out of network. We are currently in process of moving these designated kidney programs to Centers of Medical Excellence Agreements to include the global period and pre and post transplant services. 32 32
Transplant Network and Benefits Cont. A process is in place for Transplant Case Management to authorize as in network, pre- and post-transplant services rendered by Hospitals and Transplant Physicians not participating in the Exchange Network. Case Managers will also authorize transplant services performed outside of the state ( inter- and intra-plan) as in network. Operations will handle claims for Exchange Members with the same processes that were in place before January 1, 2014 for transplant authorized services that are deemed to be paid at an in-network level. 33 33
Availity Providers are able to verify eligibility, benefits and claim status information via www.availity.com. 34 34
Grace Period The Affordable Care Act (ACA) mandates a three month grace period for individual members who purchase their health plan on the Exchange, are eligible for a premium subsidy from the government, and are delinquent in paying their portion of premiums. This grace period applies after the individual has paid at least one month s premium within the benefit year. In cases where the member has not paid their premium, Anthem will take the following steps, as defined by the legislation: Anthem will process claims for services received during the first month. Anthem will pend claims for services received during the second and third months of the grace period, until the full premium is received. After the third month, if the member s premium is not received, the member s health plan will be terminated and the claims for services received during the second and third month will be denied. The member will be responsible for payment of services received during this time. o Note: Anthem will not retract payment for dates of service within the first month of the grace period for non-payment of premium 35 35
Grace Period Cont. How will the provider be notified the member is in the 2 nd or 3 rd month of a grace period? Provider remits Claims for services in the 2 nd or 3 rd month of the grace period will be soft-denied and the remit will indicate that the member is in their grace period with potential for final denial if premium is not paid by end of grace period. Provider calls to Provider Services Call center representatives will notify providers that a member is in a grace period when providers call to check eligibility and benefits. Availity Anthem is evaluating how we might make this information available to our providers via the Availity Web Portal. We will inform providers of any updates to self-service tools related to the accessibility of member grace period information in our provider newsletter, Network Update, and online at anthem.com when it becomes available. During Pre-authorization process UM reps will review/approve preauth requests based on medical necessity. 36 36
Immediate Notification of New Information In addition to our bi-monthly newsletter and our website updates, we also use our email service, Network eupdate, to communicate new information. If you are not yet signed up to receive Network eupdates, we encourage you to enroll now so you ll be sure to receive all information we ll be sending about Exchanges. To sign up, visit www.anthem.com > Providers (enter state) Network eupdate. 37 37
Questions Availity, an independent company, provides claims management services for Anthem Blue Cross and Blue Shield. Anthem Blue Cross and Blue Shield is the trade name of Community Insurance Company. Independent licensee of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. 38 38
Appendix The new Health Insurance Marketplace Important terms and definitions Important drug list information for plans purchased on and off the Exchange New Member ID Cards for Plans Purchased On and Off the Exchange Provider Checklist: The Health Insurance Marketplace is Here. Are You Ready? Important Message to Hospitals, Physicians, and Other Healthcare Providers About Anthem s Health Insurance Exchange Plans Grace Period for Individual Health Plans Purchased On The Exchange Provider Fact Sheet: The New Health Insurance Marketplace Important Information About Provider Referrals For Plans Purchased On & Off the Exchange 39 39