The Impact of Health Reform s State Exchanges

Transcription

1 The Impact of Health Reform s State Exchanges May 2, 2013 Orlando, Florida Presented by: Layna S. Cook lcook@bakerdonelson.com The Affordable Care Act The Patient Protection and Affordable Care Act (H.R. 3200) The Health Care Education and Reconciliation Act (H.R. 4872) Totals more than 2,000 pages Became effective March 23, 2010 Most provisions upheld by the U.S. Supreme Court on June 29,

2 ACA Promoting Health Coverage Individual mandate Employer pay or play Tax credits for small employers Insurance market regulation Insurance exchange Premium subsidies Medicaid expansion ACA - Promoting Health Coverage Universal Coverage Medicaid Coverage (up to 133% FPL) Individual Mandate Exchanges (subsidies % FPL) Employer-Sponsored Coverage 2

3 What is an Exchange? Online marketplace Individuals and small groups Will allow individuals to apply for premium subsidies and tax credits An individual can also apply and have eligibility determined for Medicaid and the Children's Health Insurance Program Small Business Options Program If a state operates an Exchange, it must offer a SHOP Exchange Essentially required to meet all the requirements that apply to the individual Exchanges except those dealing with premium tax credits and cost sharing reduction subsidies Qualified employers can either offer coverage to their employees through one SHOP Exchange that covers the principle place of business or through multiple SHOP Exchanges that cover the primary workplaces of their employees 3

4 Health Reform by the Numbers Patient Protection and Affordable Care Act Enrolled in Exchange Subsidized in Exchange Premium Subsidies Cost Additionally Covered by Medicaid/CHIP Medicaid Expansion Cost Remaining Uninsured Total 10-Year Cost of Coverage Provisions 10-Year Federal Deficit Savings 24 million 19 million $464 billion 16 million $434 billion 23 million $938 billion $124 billion SOURCE: Congressional Budget Office, Implementation Challenges States Consumers Providers Federal Government New administrative and financing responsibilities New private insurance responsibilities Creation/definition of Essential Health Benefits Creating Exchanges (state/federal/partner) Enforcing new regulations on insurers and employers Medicaid expansion, Supreme Court allows flexibility Outreach and enrollment Integrating Medicaid with the Exchanges Access and building provider networks Increasing infrastructure and capacity, including primary care Affordability of premiums and cost-sharing Scope of benefits, adequacy of coverage (EHB s) Understanding new rules and options, enrolling in coverage Access to care Enforcement of individual mandate Understanding and meeting new requirements Increased demand Possible payment reductions (though increases for some) Reorganizing how care is delivered Regulatory burden and capacity Oversight requirements 4

5 Health Insurance Exchange Timeline States authorize exchange through legislation December 2012 January 2013 February 15 State-based Exchange blueprint due HHS determines if state is willing and able to open exchange by January, 2014 Partnership Exchange blueprint due March, 2013 October 2013 January 2014 January 2015 HHS Approves Partnership Exchanges (on rolling basis) Exchange enrollment begns State exchange must be fully operational Exchange must be self-sustaining 2016 Small group must be expanded to groups up to 100 EEs 2017 State may open exchange to large groups (>100 EEs) 9 Figure 1 State Decisions For Creating Health Insurance Exchanges WA OR NV CA ID UT AZ MT WY CO NM ND MN WI SD IA NE IL KS MO OK AR MS VT NY MI PA OH IN WV VA KY NC TN SC AL GA ME NH MA CT RI NJ DE MD DC TX LA FL AK HI Declared State-Based Exchange (18 states + DC) Planning for Partnership Exchange (7 states) Default to Federal Exchange (25 states) As of January 4, 2013 SOURCE: Data compiled through review of state legislation and other exchange documents by the Kaiser Family Foundation 5

6 Qualified Health Plan Requirements Exchanges must ensure health plans meet two basic requirements to be certified as a QHP: the issuer must demonstrate compliance with the minimum certification requirements the Exchange must determine that offering the plan is in the interest of qualified individuals and employers Network Adequacy An Exchange must ensure that a QHP offers a sufficient choice of providers Exchanges are given discretion to establish network adequacy standards, with no minimum requirements specified QHPs must include essential community providers in their network 12 6

7 Transparency Issuers must disclose the following for QHPs: claims payment policies and practices financial data data on enrollment and disenrollment data on the number of claims that are denied rating practices information on cost sharing and payments with respect to any out-of-network coverage information on enrollment rights 13 Standards for QHP Issuer Offer QHP through the Exchange Comply with state licensure requirements and ACA requirements Meet benefit design standards (including essential health benefit coverage and cost-sharing requirements) Abide by Exchange procedural requirements Implement and report on quality improvement strategies Comply with standards related to risk adjustment 14 7

8 Standards for QHP Issuer Offer at least one QHP in the silver and gold coverage level Offer a child-only plan at the same level of coverage Offer the QHP at the same premium rate when the QHP is offered directly by the issuer or through an agent or broker Cannot discriminate on the basis of race, color, national origin, disability, age, sex, gender identity or sexual orientation 15 Essential Health Benefits Beginning in 2014, all plans in the exchange and nongrandfathered plan in the individual and small group markets outside the exchange must offer a standard set of benefits, referred to as essential health benefits (EHB) States must select a benchmark plan to define the EHB Benchmark plans include: Three largest small group plans Three largest state employee health plans Three largest federal employee health plan options Largest commercial, non-medicaid HMO 8

9 Essential Health Benefit Benchmark Plan Selections Essential Health Benefits Ambulatory patient services Emergency services Hospitalization Maternity and newborn care Mental health and substance use disorder services, including behavioral health treatment Prescription drugs Rehabilitative and habilitative services and devices Laboratory services Preventive and wellness services and chronic disease management Pediatric services, including oral and vision care 18 9

10 Benefit Categories Bronze Plan: provides essential health benefits and pays for 60% of the costs of the plan with the HSA out-of-pocket limits Silver Plan: provides essential health benefits and pays for 70% of the costs of the plan with the HSA out-of-pocket limits Gold Plan: provides the essential health benefits and pays for 80% of the costs of the plan with the HSA out-of-pocket limits Platinum Plan: provides the essential health benefits and pays for 90% of the costs of the plan with the HSA out-of-pocket limits Catastrophic Plan: available to those up to age 30 or to those who are exempt from the mandate to purchase coverage 19 Rationale for Benefit Categories Allow consumers to easily compare across plans Make the consumer shopping experience transparent and simple Promote competition on premiums Allow plans flexibility to design cost sharing structures 10

11 Accreditation Standards Certification QHP Issuers Without Existing Accreditation QHP Issuers With Existing Commercial & 2015 Schedule accreditation review QHP policies and procedures must be accredited Existing accreditation accepted Existing accreditation accepted if accredited policies and procedures comparable to QHP 2016 QHP issuers must be accredited on the basis of local performance of its QHP QHP issuers must be accredited on the basis of local performance of its QHP What is a Navigator? Education and assistance to individuals and small businesses Public or private entities or individuals Maintain expertise in eligibility, enrollment and program specifications and conduct public education activities Facilitate selection of a QHP Referrals to (1) health insurance consumer assistance, (2) health insurance ombudsman, or (3) any other state agency or agencies 11

12 QUESTIONS? 12