CMS/IHS/I/T/U Training Covered California April 17, 2018

Transcription

1 CMS/IHS/I/T/U Training Covered California April 17, 2018

2 AMERICAN INDIAN BENEFITS OVERVIEW 1

3 AI/AN Eligibility: FPL Table 2

4 AI/AN Eligibility: Zero Cost Share Plans AI/AN applicants are eligible for a zero cost sharing qualified health plan (QHP) if the applicants: Meet the eligibility requirements for APTC (Advance Premium Tax Credit) and CSR (Cost-Sharing Reduction) Are expected to have a household income that does not exceed 300 percent of the federal poverty level (FPL) for the benefit year for which coverage is requested If the AI/AN applicant meets the above eligibility requirements for zero cost sharing plans, that applicant must be treated as an eligible insured and the QHP must eliminate any cost sharing AI/AN consumers can only access these benefits if enrolled in a zero cost sharing plan through Covered California Consumers can enroll in a non zero cost sharing plan, but will not receive the zero cost sharing benefit 3

5 AI/AN Eligibility: Limited Cost Share Plans AI/AN applicants are eligible for limited cost sharing plans when their household income exceeds 300 percent of the FPL for the benefit year for which coverage is requested If the AI/AN applicant meets the above eligibility requirements for limited costsharing plan, the QHP must: Eliminate any cost-sharing under the plan for the services or supplies received directly from an Indian Health Service, an Indian Tribe, Tribal Organization, or Urban Indian Organization Apply standard cost-sharing for the QHP s provider network outside of Indian and Tribal providers AI/AN consumers can only access these benefits if enrolled in a limited cost sharing plan through Covered California Consumers can enroll in a non limited cost-sharing QHP, but will not receive the reduced cost-sharing benefit 4

6 AI/AN Benefit Example The following is an example of the differences in cost-sharing between a Bronze standard plan, a zero cost share AI/AN plan and a limited cost share AI/AN plan for some covered services. Bronze Standard Plan Bronze Zero Cost Share AI/AN Plan Bronze Limited Cost Share AI/AN Plan Primary Care Visit $75 $0 $75* Specialist Visit $105 $0 $105* Laboratory Tests $40 $0 $40* Urgent Care Visit $75 $0 $75* *This cost share would be $0 if the AI/AN member received services from an Indian Health Service, an Indian tribe, Tribal Organization, or Urban Indian Organization. 5

7 AI/AN Specific SBCs and EOCs QHPs provide separate Evidence of Coverage (EOC) and Summary of Benefits and Coverage (SBC) for each metal tier by product type 6

8 Coverage for Out of Network Services The requirement for a QHP to offer zero cost share or limited cost share benefits applies to covered services under the plan QHPs are not required to offer zero cost share or limited cost-share benefits for services received by out-of-network providers AI/AN enrollees would be responsible for 100 percent of the cost of received services from out-of-network providers when enrolled in a plan with a closed provider network Closed provider networks include: Health Maintenance Organizations (HMO) Exclusive Provider Organizations (EPO) 7

9 AI/AN Metal Tier Offerings The Exchange requires QHPs to offer the lowest cost AI/AN zero cost share plan in the standard set of plans for each product (HMO, PPO, EPO) For example, if a QHP offers a PPO product for all metal tiers, the QHP must offer a Bronze AI/AN zero cost share plan because it s the lowest cost premium The QHP may not offer the zero cost share AI/AN plan at the higher metal levels within the set of plans for each product QHPs offering additional plans, that do not include a Bronze plan, must offer the AI/AN zero cost share plan at the lowest cost in the additional set of plans 8

10 American Indian/ Alaska Native Enrollment Per Issuer Slight increase in enrollment from September 2017 to March 2018 September 2017 March 2018 Issuer # of Individuals Issuer # of Individuals Anthem Blue Cross 1,583 Blue Shield 930 Chinese Community < 10 Health Net 126 Kaiser 1,338 LA Care 15 Molina Health Care 165 Oscar Health Plan 15 SHARP Health Plan 84 Valley Health 10 Western Health 38 Grand Total 4, Plan Selections Active or Pending for Consumers indicating they are a member of AI/AN Tribe Anthem Blue Cross 673 Blue Shield 1,717 Chinese Community < 10 Health Net 319 Kaiser 1,785 LA Care 48 Molina Health Care 110 Oscar Health Plan 81 SHARP Health Plan 111 Valley Health 18 Western Health 45 Grand Total 4, Plan Selections Active or Pending for Consumers indicating they are a member of AI/AN Tribe 9

11 American Indian/ Alaska Native Enrollment Per Region September 2017 Pricing Region # of Individuals Grand Total 4, Plan Selections Active or Pending for Consumers Indicating they are Member of AI/AN Tribe March 2018 Pricing Region # of Individuals Grand Total 4, Plan Selections Active or Pending for Consumers Indicating they are Member of AI/AN Tribe 10

12 Certified Enrollment Entities (26) American Indian Health & Services, Inc. Consolidated Tribal Health Project, Inc. Feather River Tribal Health, Inc. Fresno American Indian Health Project Indian Health Center of Santa Clara Valley Indian Health Council, Inc. Karuk Tribe Lassen Indian Health Center Native American Health Center Northern Valley Indian Health, Inc. Riverside San Bernardino Co Indian Health Sacramento Native American Health Center San Diego American Indian Health Center Santa Ynez Tribal Health Clinic Shingle Springs Tribal Health Program Sonoma County Indian Health Project Southern Indian Health Council, Inc. Toiyabe Indian Health Project Tule River Indian Health United Indian Health Services PIT RIVER HEALTH SERVICE, INC. MACT Health Board, INC. San Pasqual Band Of Mission Indians Elk Valley Rancheria Lake County Tribal Health Consortium, Inc. Name of Entity Program NAV NAV *Updated September

13 Job Aids 12

14 Certification Portal Update Required Documents Manage Locations Manage Counselors 13

15 Need Additional Assistance? 14

16 QUESTIONS 15

17 RECENT DISCUSSIONS REGARDING REFERRALS 16

18 Referrals to QHP Providers Issue brought up during last Tribal Advisory Workgroup in May 2017 Clarification needed with the goal of streamlining process for consumer: o o o QHP referral process for providers PRC/CHS referred services How to streamline referral process from IHS clinic to QHP/QDP 17

19 Discussion Questions What information do QHPs/QDPs offer their providers regarding AI/AN benefits (limited vs zero cost-share)? Do providers need any additional information regarding referred services? What information do QHP/QDP need to streamline the referral process from an IHS clinic? Are there any educational tools/resources needed for IHS clinics and QHP/QDP providers? Is there a suggested standardized form that can be provided to IHS clinics when referring patients? 18

20 Identified Issues Indian Health clinic to QHP Provider to QHP AI/AN Education: AI/AN members with Covered California coverage need specific information about their AI/AN benefits with the QHP plan. Many AI/AN members are utilizing Indian health clinics for services that are covered under their QHP plan, therefore, causing the clinic to use limited PRC funds to cover the cost. QHP Contact: Indian health clinics do not have a QHP contact or dedicated line when troubleshooting issues arise with regards to referrals. Provider Knowledge: QHP providers may not knowledgeable of AI/AN plans. Referral Process: There is no streamlined process for Indian health clinics to refer patients. How referrals are received vary. Receiving referrals: QHPs need to receive the referral prior to rendering services and a time frame that services are to be provided. Identify Services: QHPs do not have a description of services that should be covered under the referral per the PRC/CHS program. 19

21 Tribal Referral Subcommittee Creation of a subcommittee comprised of: o o o o o IHS Tribal Advisory Workgroup members (or designated representatives) Tribal Organizations- CRIHB and CCUIH Qualified Health Plans Covered California Goal of subcommittee is to improve AI/AN consumer experience with a seamless transition when they are referred from an Indian health clinic to their QHP. 20

22 Next Steps Covered California to send suggested dates to meet in May or June Subcommittee will need to identify needs and challenges Subcommittee will need to agree upon: o o o o o o o Goal of the committee Meeting frequency Roles and responsibilities Solutions to streamline the referral process Timeline (work plan) Data that may be needed How to evaluate process once agreed activities are implemented 21

23 TRIBAL CONSULTATION 22

24 Fall Tribal Consultation End of September Dates sent to Tribal Advisory Workgroup members and Tribal advocacy organizations for feedback. 23

25 QUESTIONS 24

26 THANK YOU! Waynee Lucero, Tribal Liaison (916)

27 APPENDIX 26

28 The Stability Was Shaken In 2018, But Overall Markets Were Remarkably Steady Huge uncertainty going into 2018: Reduced marketing to consumers living in states supported by the federal marketplace Penalty enforcement unclear Fall decision to end direct funding of cost-sharing reduction subsidies Results huge state-by-state variation, but: Much cajoling and nudges kept coverage in all counties, but we now have 30 percent of Americans in marketplaces with only one plan. Most states did CSR work around result was DECREASE in premium for those with subsidies (down 3 percent for FFM states) and unsubsidized shielded from the CSR Surcharge (unsubsidized premiums up 15 percent or more). Spike in earned media coverage filled some of the gap from drop in marketing. While marketplace enrollment dropped slightly, big unknown is changes in off-exchange enrollment all unsubsidized. 27

29 2018 OPEN ENROLLMENT: PROGRESS FOR NEW SIGN UPS 423,484 Individuals have selected health care plans as of February 7,

30 2017 RENEWALS 1.2 million Individuals went through renewal. Approximately 43% actively renewed. Renewal rate very similar to

31 Many More News Stories About Enrollment in Health Coverage Across the Nation During Open Enrollment for 2018 Compared to As measured in U.S. media markets nationwide, Oct. 1 Dec. 15, 2016 (for 2017) compared to Oct. 1 Dec. 15, 2017 (for 2018), in English and Spanish. Report conducted by Ogilvy, a global leader in communication media ( 2 Source: NORC at the University of Chicago Covered California Overview of Findings from the Third California Affordable Care Act Consumer Tracking Survey. Oct

32 Coverage Expansion Having Dramatic Effects in California With California s expansion of Medicaid and the creation of a state-based marketplace, the rate of the uninsured has dropped to historic lows. Almost four million new enrollees are in the Medi-Cal program and 1.3 million people are enrolled through Covered California. Source: U.S. Centers for Disease Control and Prevention s National Health Institute Survey 31

33 Californians Facing New Opportunities for Coverage The Affordable Care Act has dramatically changed the health insurance landscape in California with the expansion of Medicaid, Covered California and new protections for all Californians. California s 2015 Health Care Market (in millions ages 0-64) As of June 2016, Covered California had approximately 1.4 million members who have active health insurance. California has also enrolled nearly 4 million more into Medi-Cal. Consumers in the individual market (offexchange) can get identical price and benefits as Covered California enrollees. From 2013 to 2016, the Centers for Disease Control and Prevention report cutting the rate of uninsured in half (1.5 million are ineligible for Covered California due to immigration status). Not counting those ineligible puts California s uninsured at 1.2 million. Estimates based on survey data and adjusted for latest available administrative data, including: - American Communities Survey, year estimates (Table B27010) - CDC/National Health Interview Survey (2017) ( - Covered California Active Member Profile ( - DMHC and CDI data on enrollment in December 2015 ("AB 1083 reports") as compiled by California Health Care Foundation ( - Department of Health Care Services Medi-Cal Medi-Cal Monthly Enrollment Fast Facts (Sept 2016) ( 32

34 Even with Great Recognition of Our Brand- Ongoing Marketing and Outreach is Crucial 96 percent of those surveyed are aware of Covered California and the Affordable Care Act. However, nearly 75 percent of the uninsured don t know they qualify for subsidies. Those who are eligible for a subsidy are twice as likely to enroll. If consumers know they are subsidy eligible, they are twice as likely to enroll Covered California Sentiment Research Wave 2: A Quantitative Study on Current Attitudes and Select Insured Californians Toward Health Insurance Coverage. Greenberg Strategy. Oct. 5, 2017 ( FINAL.pdf) See Marketing Matters: Lessons From California to Promote Stability and Lower Costs in National and State Individual Insurance Markets : 33

35 Marketing Matters: Lessons From California to Promote Stability and Lower Costs in National and State Individual Insurance Markets 34

36 Effective Marketing and Outreach: Multi-Channel Marketing and Multiple Service Channels Continued investments for 2018 of over $105 million. Investments that for fourth open enrollment meant nearly every Californian was exposed to one of our TV, radio, print, billboards or digital ads on average 49 times, generating nearly 2 billion impressions. 35

37 Assuring Competition, Choice and Affordability Eleven health plans participate in Covered California in different combinations across 19 rating regions. Covered California is also an entry point to Medi-Cal for those who qualify. 36

38 Covered California Board presentation slides on Attachment 7: Covered California is Promoting Improvements in the Delivery of Care Note: for detailed information about improvements in the delivery of care, Covered California requires health insurance companies to abide by Attachment 7 of the model contract. To view Attachment 7, go to 37

39 The Roller Coaster for Consumers Continues A new Covered California analysis provides a brief summary of what occurred in 2018 and an overview of the potential impacts for 2019, along with a review of some of the major mitigating policies that could be adopted: Issuers and states faced considerable challenges in 2018 due to federal policy changes and uncertainty (e.g., the removal of direct federal cost-sharing reduction funding). Reduced marketing and outreach for the federally-facilitated marketplace began in the final week of Open Enrollment 2017 and has continued into Open Enrollment The 2019 plan year has the potential to be just as uncertain and volatile as 2018 due to major policies changes that include: o The removal of the individual mandate tax penalty; o The potential continuation of reduced marketing spending for the federal marketplace; and o Implementation of association health plans and short-term, limited-duration plans. Statewide average premium increases in 2019, absent federal policies to stabilize these markets, could range from 15 to 30 percent, but could be higher for some carriers. Action on three federal policy options in early 2018 could significantly mitigate the potential 2019 rate increases: 1. Funding state-based invisible high-risk pools or reinsurance programs 2. Restoring marketing and outreach funding 3. Reinstituting the health insurance tax holiday for 2019 For more information, see: 38

40 Absent Policy Changes, Premium Increases in 2019 Likely to Range From Percent; Three Year Cumulative Increases from 36 to 94 Percent Estimates reflect potential state average increases; some states and individual carriers could be higher or lower. Premium estimates reflect gross premiums and would be fully born by the 6 million Americans who do not receive subsidies. For those who receive subsidies, premium increases would likely be far less. See: Individual Markets Nationally Face High Premium Increases in Coming Years Absent Federal or State Action, With Wide Variation Among States ( 39

41 National Variation in Potential Premium Increases for 2019 to 2021: From Bad to Really Bad 40

42 Federal and State Actions that Could Promote Stability Policy Actions That Could Promote Stability for 2019 and Beyond Reinsurance: State-based and/or national reinsurance programs, could have a dramatic impact on premiums and carrier participation in Directly Fund Cost-Sharing Reduction (CSR) Subsidies: Funding CSRs would not directly reduce premiums but would provide needed stability for health plans and reduce federal spending. Increased Subsidies: Increasing the financial assistance that is available to consumers would help more Americans afford coverage and increase the overall health of the consumer pools. Increased Marketing and Outreach: Increasing spending on targeting marketing promotes enrollment among healthier individuals and benefits federal taxpayers who benefit from reduced per-person Advanced Premium Tax Credits and those who do not receive subsidies and face lower premium increases. State-Based Penalties for Non-Coverage: States could adopt state-based penalties to promote enrollment. State Regulations on Association Health Plans or Short-Term, Limited-Duration Plans: States could adopt regulations that limit carriers from offering plans that do not provide comprehensive coverage or protect consumers with pre-existing conditions, which could harm the risk pool in the individual market. Auto-Enrollment: State or federal policies could promote automatic enrollment of eligible individuals, such as for those who 41 lose employer-based coverage, earn too much for Medicaid or age out of coverage eligibility from parents plans

43 Federal Policy Actions That Could Mitigate 2019 Premium Increases Estimates reflect the range of how each stabilizing policy would affect states based on their circumstances. The effect on premiums in some states for individual carriers could be greater. See: Individual Markets Nationally Face High Premium Increases in Coming Years Absent Federal or State Action, With Wide Variation Among States ( 42