What s new for the ACA in 2019 and what do consumers need to know?

Transcription

1 What s new for the ACA in 2019 and what do consumers need to know?

2 Figure 1 The market is starting to look more attractive to insurers and over a dozen states will see a new or returning insurer State Arizona Florida Iowa Maine Massachusetts Michigan Missouri North Carolina Ohio Oklahoma Pennsylvania Tennessee Utah Virginia Wisconsin Parent Insurer Entrance(s) Oscar entering; Cigna reentering Oscar entering Wellmark reentering Anthem reentering UnitedHealth reentering Oscar entering Medica entering Centene entering Anthem entering (as Community Insurance Company) Medica entering PA Health & Wellness (Centene) entering Bright Health entering; Centene entering Molina reentering Virginia Premier Molina reentering Source: Kaiser Family Foundation analysis of rate filings to state regulators

3 Figure 2 Insurers on average are profitable in 2018 and many would be unable to justify premium increase in 2019 Average 2nd Quarter Individual Market Gross Margins PMPM Average 2nd Quarter Individual Market Medical Loss Ratios $ % $160 $ % $140 $120 $100 $80 $ % 90% 85% 81% 83% 82% 91% 93% 89% $60 $40 $20 $41.00 $39.25 $39.72 $23.31 $21.40 $ % 75% 70% 77% 69% $ % Note: Q2 data is year-to-date from January 1 June 30 Source: Kaiser Family Foundation analysis of data from Mark Farrah Associates Health Coverage Portal TM

4 Healthcare.gov ND DE HI NE KY WV OR MT KS IA SD SC OK VA AR OH FL TX GA MS WY MI IN NC UT AL IL AK NV LA WI MO ME AZ NM NJ NH PA TN 30% 20% Figure 3 On average benchmark silver premiums are dropping in 2019 by -1.5%, but there is significant geographic variation 20.2% 10% 0% -1.5% -10% -20% -30% -26.2% CMS data for states that use healthcare.gov

5 Figure 4 ACA premiums are higher than they would otherwise be due to individual mandate repeal, loosely regulated plans, CSRs Premium Impacts from Legislative and Policy Changes to the ACA Legislative or Policy Change Average percent by which 2019 unsubsidized premiums are higher than would be the case without change Individual mandate penalty repeal Expansion of AHP / STLD plans Loss of Cost Sharing Reduction (CSR) payments Combined Impact: Individual mandate penalty repeal Loss of CSR payments Expansion of AHP / STLD plans 6% (all premiums on/off exchange) 10% (silver exchange premiums)* 16% (silver exchange premiums)* NOTES: Premium changes represent the change in premiums before accounting for the premium tax credit. How each premium impact relates to other impacts depends on how each insurer calculates rate impacts. We conservatively assume the rates are additive (6% + 10% = 16%), as opposed to multiplicative (1.06 x 1.1 = 1.166, or 16.6%). *The CBO estimate of the loss of CSR payments effect was specifically for silver exchange premiums. However, some insurers also applied a CSR load onto other metal levels and/or off-exchange premiums. SOURCE: Kaiser Family Foundation analysis of insurer rate filings to state regulators, state insurance regulators, and ratereview.healthcare.gov. Premium impact due to CSR loss is from Congressional Budget Office (CBO) estimate.

6 Figure 5 Benchmark silver premiums in 2019 will be 16% higher due regulatory and legislative changes $68 Individual mandate penalty repeal Loss of cost-sharing reduction payments Expansion of loosely regulated plans (short-term and association plans) + $427 Premium in absence of policy and legislative changes $495 Total unsubsidized benchmark premium on healthcare.gov for a 40-year-old Source: Kaiser Family Foundation analysis of rate filings to state regulators and premium data published by CMS.

7 Healthcare.gov WY NE IA OK DE NC WV MT SD VA KS SC TN AL UT ME WI MS MO GA PA IL FL AZ KY ND LA TX OR NV NH MI OH AR NM NJ IN Figure 6 Because of the premium tax credit, most exchange enrollees pay a fixed amount for the benchmark plan 2019 premium for a 40-year-old non-smoker making $30,000 $1,000 $900 $800 $700 $600 $500 $400 $300 $200 $100 $0 Total: $495 $289 Total: $865 $659 Enrollee Pays Tax Credit $206 $206 $206 Total: $339 $133 Source: Kaiser Family Foundation analysis of data published by CMS

8 Figure 7 Most individual market participants buy through the marketplace and are eligible for subsidies Individual market enrollment first quarter Q M 1.5M 4.9M 3.7M 18.8 M Q M 1.7M 5.1M 2.3M 18.5 M Q M 1.6M 4.0M 2.0M 16.4 M Q M 1.4M 2.5M 1.3M 14.4 M On-Exchange (Subsidized) On-Exchange (Unsubsidized) Off-Exchange (Compliant) Off-Exchange (Non-Compliant) Source: Kaiser Family Foundation analysis of data from Mark Farrah Associates Health Coverage Portal TM and Centers for Medicare and Medicaid Services (CMS) Notes: Data on the share of off-exchange enrollment in compliant vs. noncompliant plans in 2018 are not available, so this assumes the share to be the same as in For 2015 through 2017, we assume the share of off-exchange enrollment in noncompliant plans in Q1 is the same as share of annual enrollment in non-compliant coverage. Enrollment is measured as average members per month.

9 Figure 8 Individual mandate tax penalty is $0 starting in 2019 Individual mandate remains in effect for 2018 Simpler to claim hardship exemption to waive 2018 federal tax penalty MA, NJ, DC individual mandate in 2019 (VT in 2020) Regardless of tax penalty, it is important to have coverage in case you get sick

10 Figure 9 Short-term health insurance is also available in 2019 Short-term policies can offer coverage up to 364 days Short-term health insurance coverage ends when the policy term is reached, sometimes as short as 3 months Generally, policies with longer terms of coverage cost more Insurer option to offer extension/renewal, up to 36 months total Policyholders who get sick likely cannot extend/renew Short-term policy loss during year does not trigger a special enrollment period (SEP)

11 Figure 10 Short-term policies are medically underwritten Applications ask about health status, health history Denial likely for people with pre-existing conditions

12 Figure 11 Other features distinguish short-term policies from ACAcompliant coverage Applications for ACA-compliant plans will not ask questions about health status Notice required on short-term policy application and policy documents: This coverage is not required to comply with certain federal market requirements for health insurance, principally those contained in the Affordable Care Act. Be sure to check your policy carefully to make sure you are aware of any exclusions or limitations regarding coverage of preexisting conditions or health benefits (such as hospitalization, emergency services, maternity care, preventive care, prescription drugs, and mental health and substance disorder services.) Your policy might also have lifetime and/or annual dollar limits on health benefits. If this coverage expires or you lose eligibility for this coverage, you might have to wait until an open enrollment period to get other health insurance coverage. Some states (CA, HI, MA, NJ, NY, OR) prohibit short-term policies or apply ACA rules Short-term policies cannot be offered through the Marketplace and are not eligible for ACA tax credits, subsidies

13 Figure 12 Open enrollment for 2019 will last 6 weeks in most states. November 1 December 15, 2017 in HealthCare.gov states State run marketplaces have option to extend dates, and many have OR CA AK WA NV ID UT AZ MT HI WY CO NM ND SD NE KS TX OK MN IA MO AR WI IL MS LA IN MI TN AL OH KY WV GA PA SC VT VA NC FL NY ME NH MA CTRI NJ DE MD DC HealthCare.gov State (39 States) State-Based Marketplace (12 States including DC) State-based Marketplace Open Enrollment Dates CA Oct 15 Jan 31 CO Nov 1 Jan 15 CT Nov 1 Dec 15 DC Nov 1 Jan 31 ID Nov 1 Dec 15 MD Nov 1 Dec 15 MA Nov 1 Jan 23 MN Nov 1 Jan 13 NY Nov 1 Jan 31 RI Nov 1 Dec 31 VT Nov 1 Dec 15 WA Nov 1 Dec 15

14 Figure 13 When the benchmark premium decreases, so does the amount of the premium tax credit Advanced premium tax credit amounts and consumer share of premiums for 40-year-old in Nashville, Tennessee with an income of $30,000 Consumer Share Premium Tax Credit $824 $813 $585 $384 $280 $486 $351 $384 $440 $351 $201 Lowest Bronze Benchmark Silver Lowest Gold 2018 Monthly Premiums $342 $280 $533 $280 $206 $62 Lowest Bronze Benchmark Silver Lowest Gold 2019 Monthly Premiums Source: Kaiser Family Foundation analysis of rate filings to state regulators

15 Figure 14 Nearly one in five federal marketplace enrollees autorenewed for 2018 coverage 2018 Federal Marketplace Plan Selections by Enrollment Type Auto-renewal will still be an option in 2019, but active shopping is strongly recommended New Enrollees 28% Auto Renewals 19% Active Renewals 52% Changes in 2019 premiums and participating insurers could substantially change subsidy amounts Consumers will not have the opportunity to change plans in January if they do not like the autorenewal results Source: Marketplace Open Enrollment Period Public Use Files for 2018, Centers for Medicare and Medicaid Services (CMS), Department of Health and Human Services.

16 Figure 15 Federal Navigator help will be more limited, or not available, in many areas this year State Nav Grant Award 2016 Nav Grant Award 2018 Florida $9.5 m $1.3 m Georgia $3.7 m $0.5 m North Carolina $3.4 m $0.5 m Illinois $2.6 m $0.4 m Virginia $2.2 m $0.5 m Total - All FFM States $67 m $10 m Source: Kaiser Family Foundation, Data Note: Changes in 2017 Federal Navigator Funding, October 2017,

17 Figure 16 Medicaid coverage is available for low-income adults throughout the year in Medicaid expansion states WA OR NV CA AK ID AZ UT MT WY CO NM HI ND SD NE KS OK TX MN WI* IA IL MO AR MS LA VT NY MI PA OH IN WV VA KY NC TN SC AL GA FL ME* NH CT RI NJ DE MD DC MA 15.1 million adults enrolled in the expansion group in FY 2016 Adopted (34 States including DC) Medicaid expansion on Nov. ballot (3 States) Not Adopted (14 States) NOTES: Current status for each state is based on KCMU tracking and analysis of state executive activity. *ME adopted Medicaid expansion through a ballot initiative in 2017, but has not yet implemented. WI covers adults up to 100% FPL in Medicaid, but did not adopt the ACA expansion. SOURCE: Status of State Action on the Medicaid Expansion Decision, KFF State Health Facts, updated January 1,

18 Figure 17 What else to look for in 2019 and beyond ACA post-midterms Administrative Actions Texas Lawsuit Medicaid and Marketplace Waivers for States

19 CMS INNOVATION CENTER Presentation to the National Health Council Michael J. Lipp, MD, MBA Senior Advisor and Medical Officer November 29, 2018

20 Disclaimer This presentation was prepared as a tool to assist providers and is not intended to grant rights or impose obligations. Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services. This presentation is a general summary that explains certain aspects of the Medicare Program, but is not a legal document. The official Medicare Program provisions are contained in the relevant laws, regulations, and rulings. Medicare policy changes frequently, and links to the source documents have been provided within the document for your reference. The Centers for Medicare & Medicaid Services (CMS) employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this guide. 2

21 Discussion Background Innovation Center Structure and Portfolio Alternative Payment Models Model Development Process Innovation Center Range of Impact Innovation Center Models & CMS Putting People First Goals New Direction for the CMS Innovation Center 3

22 In billions In millions CMS Trust Fund Hospital Insurance (Part A) Trust Fund $ $ $ $ $ $ $50 10 $ Beneficiaries Trust fund assets 4

23 Growth in Premiums 5

24 The CMS Innovation Center Statute The purpose of the [Center] is to test innovative payment and service delivery models to reduce program expenditures while preserving or enhancing the quality of care furnished to individuals under such titles. Three scenarios for success from Statute: 1. Quality improves; cost neutral 2. Quality neutral; cost reduced 3. Quality improves; cost reduced (best case) If a model meets the statutory requirements for expansion, the statute allows the Secretary to expand the duration and scope of a model through rulemaking. 6

25 The CMS Innovation Center Portfolio Aligns with Broader CMS Goals Focus Areas CMS Innovation Center Portfolio Pay Providers Deliver Care Test alternative payment models Accountable Care ACO Investment Model Pioneer ACO Model Medicare Shared Savings Program (run by the Center for Medicare) Comprehensive ESRD Care Initiative Next Generation ACO Primary Care Transformation Comprehensive Primary Care Initiative (CPC) & CPC+ Multi-Payer Advanced Primary Care Practice (MAPCP) Demonstration Independence at Home Demonstration Graduate Nurse Education Demonstration Home Health Value Based Purchasing Medicare Care Choices Frontier Community Health Integration Project Medicare Diabetes Prevention Program Expanded Model Support providers and states to improve the delivery of care Learning and Diffusion Partnership for Patients Transforming Clinical Practice Health Care Innovation Awards Accountable Health Communities Bundled payment models Bundled Payment for Care Improvement Models 1-4 Oncology Care Model Comprehensive Care for Joint Replacement Initiatives Focused on the Medicaid Medicaid Incentives for Prevention of Chronic Diseases Strong Start Initiative Medicaid Innovation Accelerator Program Dual Eligible (Medicare-Medicaid Enrollees) Financial Alignment Initiative Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents Medicare-Medicaid ACO Model Medicare Advantage (Part C) and Part D Medicare Advantage Value-Based Insurance Design Model Part D Enhanced Medication Therapy Management State Innovation Models Initiative SIM Round 1 & SIM Round 2 Maryland All-Payer Model Pennsylvania Rural Health Model Vermont All-Payer ACO Model Million Hearts Cardiovascular Risk Reduction Model Distribute Information Increase information available for effective informed decision-making by consumers and providers Information to providers in Innovation Center models Shared decision-making required by many models 7

26 CMS has Engaged the Health Care Delivery System and Invested in Innovation Across the Country Sites where innovation models are being tested Models run at the state level Source: CMS Innovation Center website, November

27 CMS Innovation Center s Range of Impact > 18 million Beneficiaries touched CMS Innovation Center models impact over 18M beneficiaries 1,2 in all 50 states > 207,000 Providers participating Over 200,000 health care providers and provider groups 2 across the nation are participating in CMS Innovation Center programs 1 Includes CMS beneficiaries (i.e., individuals with coverage through Medicare FFS, Medicaid, both Medicare and Medicaid (as Medicare-Medicaid enrollees), CHIP, and Medicare Advantage) and individuals with private insurance, including in multi-payer models 2 Figures as of September 30, 2016 Source: Innovation Center Report to Congress, December

28 What is an Alternative Payment Model? Alternative Payment Models (APMs) are payment approaches, developed in partnership with the clinician community, that provide added incentives to deliver high-quality and costefficient care. The CMS Innovation Center develops new payment and service delivery models. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) defined APMs as: - Innovation Center models under Section 1115A authority - Demonstrations mandated by federal law (e.g., Rural Community Hospitals Demonstration) - Medicare Shared Savings Program - Demonstration under the Health Care Quality Demonstration Program MACRA defined Advanced Alternative Payment Models, which must meet three criteria: bear more than nominal financial risk or be a Medical Home Model expanded under the Innovation Center authority, bases payment on quality measures comparable to those used in MIPS, and require participants to use certified EHR technology. 10

29 CMS Innovation Center Models & CMS Putting People First Goals Focus on Empowering Patients and Doctors by making it easier for individuals and their families to access high-value, coordinated care; more deeply engage in decision-making; and prioritize prevention and wellness to improve individuals health. Foster State Flexibility/Local Leadership through funding, technical assistance, and spread of lessons learned to states and local health care providers as they transform health care. Consumer-directed care models could empower Medicare, Medicaid, and CHIP beneficiaries to make choices from among competitors in a market-driven healthcare system. Take Innovative Approaches to Improvement by building upon lessons learned from earlier model tests and a growing evidence base in care delivery and payment research. Improving Customer Service through consulting and working with a broad array of stakeholders across the country, other federal agencies, and other components within CMS to help design CMS Innovation Center models. 11

30 CMS Innovation Center Models & CMS Putting People First Goals: Empowering Patients and Doctors Comprehensive Primary Care Plus Model (CPC+): In designing CPC+, the Innovation Center built upon the lessons learned from participants and stakeholders involved in all primary care models to date, including Comprehensive Primary Care initiative and the Multi-Payer Advanced Primary Care Practice Demonstration. CPC+ s multi-payer design brings together CMS, commercial insurance plans, and State Medicaid agencies to provide the financial support and alternative payments necessary for practices to make fundamental changes in their care delivery. Oncology Care Model (OCM): OCM was designed in collaboration with stakeholders from the medical, consumer and business communities who believed an alternative model for oncology care would better support beneficiaries and clinicians work with their patients. OCM incentivizes physician practices to comprehensively and appropriately address the complex care needs of Medicare beneficiaries receiving chemotherapy treatment, and heighten the focus on furnishing services that improve the patient experience and/or health outcomes. 12

31 CMS Innovation Center Models & CMS Putting People First Goals: State Flexibility and Local Leadership State Innovation Models Initiative (SIM): SIM provides states and health care providers in those states the flexibility to use their policy and regulatory levers to accelerate health care transformation efforts in their states. Through SIM, CMS is partnering with states to address specific issues in that state. Maryland All-Payer Model: Partnership between the state of Maryland and CMS focused on modernizing Maryland s unique all-payer rate-setting system for hospital services to improve patients' health and reduce costs. 13

32 CMS Innovation Center Models & CMS Putting People First Goals: Innovative Approaches to Improvement Medicare Diabetes Prevention Program (MDPP) Expanded Model: The MDPP Expanded Model is a structured intervention with the goal of preventing type 2 diabetes in individuals with an indication of pre-diabetes. The clinical intervention consists of a minimum of 16 intensive core sessions of a CDC-approved curriculum furnished over six months in a group-based, classroomstyle setting that provides practical training in long-term dietary change, increased physical activity, and behavior change strategies for weight control. Next Generation ACO Model (NGACO): NGACO builds upon experience in both the Pioneer ACO Model and the Shared Savings Program. NGACO uses a prospective benchmark, a financial methodology informed by the lessons learned in the Pioneer ACO Model, and several tools to help ACOs improve engagement with beneficiaries. The NGACO Model is testing whether financial incentives for ACOs can improve health outcomes and reduce expenditures for Medicare fee-forservice (FFS) beneficiaries. 14

33 CMS Innovation Center New Direction Guiding Principles We are analyzing our portfolio of models to determine what is working and should continue, and what isn t and shouldn t. The following principles will guide our work moving forward: 1) Choice and competition in the market Promote competition based on quality, outcomes, and costs. 2) Provider choice and incentives Focus on voluntary models, with defined and reasonable control groups or comparison populations, to the extent possible, and reduce burdensome requirements and unnecessary regulations to allow physicians and other providers to focus on providing high-quality healthcare to their patients. Give beneficiaries and healthcare providers the tools and information they need to make decisions that work best for them. 3) Patient-centered care Empower beneficiaries, their families, and caregivers to take ownership of their health and ensure that they have the flexibility and information to make choices as they seek care across the care continuum. 4) Benefit design and price transparency Use data-driven insights to ensure cost-effective care that also leads to improvements in beneficiary outcomes. 5) Transparent model design and evaluation Draw on partnerships and collaborations with public stakeholders and harness ideas from a broad range of organizations and individuals across the country. 6) Small-scale testing Test smaller scale models that may be scaled if they meet the requirements for expansion under Section 1115A(c) of the Social Security Act. Focus on key payment interventions rather than on specific devices or equipment. 15

34 CMS Innovation Center New Direction Request for Information The CMS Innovation Center released an RFI that seeks broad input related to a new direction for the CMS Innovation Center that will promote patient-centered care and test market-driven reforms that empower beneficiaries as consumers, provide price transparency, increase choices and competition to drive quality, and improve outcomes. The administration plans to launch models in several focus areas: 1. Expanded Opportunities for Participation in Advanced APMs 2. Consumer-Directed Care & Market-Based Innovation Models 3. Physician Specialty Models Physician-Focused Payment Model Technical Advisory Committee (PTAC) Recommended Models 4. Prescription Drug Models 5. Medicare Advantage (MA) Innovation Models 6. State-Based and Local Innovation, including Medicaid-focused Models 7. Mental and Behavioral Health Models 8. Program Integrity Guiding Principles Choice and competition in the marketplace Provider choice and incentives Patient-centered care Benefit design and price transparency Transparent model design and evaluation Small scale testing 16

35 Opening Medicare Access Prepared for the National Health Council November 29, 2018

36 Description Examples There Is a Spectrum of Proposals to Expand Access to Medicare Coverage Public Option Medicaid Buy-In Medicare Buy-In Medicare-for-All Establishes a new, governmentsponsored Medicare coverage option that would be sold alongside commercial insurance. Allows uninsured who are ineligible for Medicaid to buy into a state Medicaid plan. Typically exists alongside an otherwise unchanged commercial insurance market. Allows an expanded group of individuals, outside of current Medicare eligibility groups, to buy into Medicare coverage. Typically exist alongside an otherwise unchanged commercial insurance market. Expands access to Medicare to all U.S. citizens and residents over a specified period of time. S. 1970: Medicare X- Choice Act of 2017 (Bennet) S.2708: Choose Medicare Act (Merkley) S.2001: State Public Option Proposal (Schatz) S.1742: Medicare at 55 (Stabenow) HR.3748: Medicare Buy-In and Health Care Stabilization Act (Higgins) HR.2065: Medicare You Can Opt Into Act (Shea- Porter) S.1804: Medicare for All Act of 2017 (Sanders) HR.676: Expanded & Improved Medicare For All (Conyers) Copyright Avalere Health LLC. All Rights Reserved. 2

37 No Matter the Model, Key Questions Will Guide How Government-Sponsored Insurance Programs Expand Eligibility Who is eligible to enroll? Is expanded eligibility based on age alone? Covered Benefits What benefits are covered? Do program reforms rely on existing benefits offered by government programs or are there changes to what is covered? Program Choice Do newly-eligible enrollees have access to the current spectrum of choices for existing government program enrollees, or is there a restricted set of options? Affordability Provider Network Design Provider Payment Rates How much do enrollees pay for monthly premiums and out-of-pocket costs? Does the government help make coverage and care more affordable? How does the proposal address access to and availability of providers? How much will providers be paid for delivering covered services? Financing Who pays for the costs associated with the new insurance program? Copyright Avalere Health LLC. All Rights Reserved. 3

38 The Model for Opening Coverage to More Consumers Has the Potential to Both Benefit and Challenge Patients Potential Benefits Potential Challenges Increased choice and options Comprehensive coverage Fewer complexities Greater buying power Increased plan competition Lower out-of-pocket costs Lower premiums Narrow networks and long waits Limits on needed care System capacity constraints Tax hikes or cuts that offset Reduced plan competition Higher out-of-pocket costs Higher premiums Copyright Avalere Health LLC. All Rights Reserved. 4

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