Health Care Reform WA s Insurance Exchange WSMOS November 7, 2014

Transcription

1 Health Care Reform WA s Insurance Exchange WSMOS November 7, 2014

2 What we re going to cover, What is an Exchange? Exchange Basics What about the SHOP? What has been going on the last year? Changes in the law Grace Period

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4 The Exchange Consumer tool

5 The Exchange Basics

6 WA s Health Benefit Exchange The Washington Health Benefit Exchange was created in state statute in 2011 Governance structure public- private partnership separate and dismnct from the state. The Exchange is responsible for the creamon of Washington Healthplanfinder which is an, online marketplace for individuals, families and small businesses(?) to find, compare and enroll in qualified health insurance plans and Medicaid.

7 How many carriers in Exchange in 2015? Individual Market SubmiWed in May: 12 issuers and 100 plans OIC approved: 10 issuers and 90 plans (includes 8 mulm- state plans) SHOP SubmiWed in May: 2 issuers and 23 plans OIC approved: 2 issuers and 23 plans Dental plans included, too! Open enrollment for paments begins Nov. 15 th!

8 Qualified Health Plan Criteria Carriers selling their wares must meet certain criteria: Be licensed and good standing with Fed and State law Comply with market rules (e.g., offer at gold and silver level) Bronze (60%), Silver (70%), Gold (80%), PlaMnum (90%) Comply with non- discriminamon rules Meet network adequacy requirements Comply with essenmal health benefits (EHBs) Comply with limits on cost sharing/metal levels Others

9 PracMces Everything else Exchange Insurers PaMents

10 What is the SHOP? Small Business Health OpPons Program (SHOP) Offers new insurance purchasing choices to small businesses and their employees. To parmcipate, businesses must have: 2 to 49 employees, be based in or have an employee worksite in Washington State, and achieve minimum group parmcipamon rates: 100 percent for businesses with 2 to 4 employees, or 75 percent for businesses with 5 to 50 employees.

11 What is the SHOP? In 2014: Only Kaiser parmcipated in the SHOP Exchange in 2014, operamng only in Clark and Cowlitz CounMes (operamons based in Portland). Dodged a bullet? For 2015: SMll minimal interest.

12 Ok where are we again? Private Market As is today (some market changes) Some existing plans are "grandfathered" Health Insurance Exchange Optional Basic Health Plan/ Exchange Premium Subsidies: % FPL Individual and Small Employer coverage Catastrophic plans for those up to 30 years old Premium subsidies: % FPL Medicaid All individuals below 133% FPL

13 Metals, CounMes, Carriers

14 Medicaid and QHP enrollment Medicaid total=839,200 New Medicaid=423,000 QHP=153,000 (v.280k expected)

15 Did someone say Grace Period?

16 Grace Period - Background Background: CMS rule implemented post- ACA passage. Consumer protecmon was intent. Allow pament to catch up on premiums to keep coverage in force. What is the Grace Period? 90- day period before pament s coverage is cancelled for non- payment of premiums. Who does the Grace Period apply to? Individuals purchasing subsidized coverage through the insurance exchanges.

17 Grace Period - Background What is the problem? Claims paid in first 30 days. Claims NOT paid in last 60 days.

18 Grace Period - Background What is the papent s status while in the Grace Period? PaMents are considered to be covered. The physician is subject to the terms of the contract.

19 Grace Period - implementamon So how do we find out whether or not a papent is in the Grace Period? CMS rule requires nomce to physicians when pracmcable. No further guidance. Here is what we needed to address: Whether/how nomce to physician/pracmce will be provided. Whether/how nomce to pament will be provided. Whether/how to (eventually) be reimbursed for services rendered.

20 WSMA s solumon Grace period (SB 6016) (1) NoMce to health care professionals and facilimes Real- Mme eligibility checks. Response within three days if claim is submiwed. (2) NoMce to paments Qualifying event for increased subsidy level or Medicaid? Eligibility checks? (3) NoMce to Legislature Annual report detailing grace period populamon. Need informamon on the problem.

21 Grace Period WSMA s solumon Washington s legisla@on is most comprehensive approach in na@on to this issue. - AMA

22 Other Grace Period QuesPons

23 Grace Period - Background What happens in the last 60 days of the Grace Period? Insurers are allowed to pend claims for services provided. What if the papent pays (catches up on) their premiums during the Grace Period? The pament keeps health insurance coverage for the second and third months of the Grace Period. The insurer will pay the pended claims.

24 Grace Period - Background What if the papent doesn t pay their premiums in full by the end of the Grace Period? Health insurer will retroacmvely terminate coverage for months two and three of the Grace Period. Insurer will deny claims for services provided during that Mme. PaMent is then responsible* for paying the bill for services rendered during the second and third months. *Be careful! In losing one type of insurance coverage, a pament may have another insurance coverage (Medicaid? Spousal coverage?), rather than becoming self- pay.

25 Exchange IT Issues, at least we re not Oregon!

26 Problems compound IT Problems Grace Period problems A well funcmoning Exchange

27 May, 2014 Customers of Washington s online health- insurance marketplace who say they have paid their premiums but are being told by insurers they have no coverage aren t imagining things. They re vic@ms of system defects and data issues, the CEO of the Washington Health Benefit Exchange said late last week. - SeaWle Times

28 August, 2014 Seven months arer major glitches in the Washington health exchange were discovered, acknowledge that thousands of state residents don't have insurance they can use to go to the doctor or fill a prescrip@on. - AP/Bloomburg Businessweek

29 Break it down PracMces contract with insurers to be in network PaMents pay (or don t pay) premiums for insurance Grace Period allows insurers not to reimburse during Grace Period IT problems disallow/mask Grace Period and coverage problems. At this point we don t know who is actually in the Grace Period and who isn t!

30 In detail The WSMA conmnues its legislamve and other advocacy with Exchange leadership as it awempts to fix the glitches. AffecMng over 6,000 individuals whose enrollment and premium payments cannot be verified. Large carriers reported 52,000 pended claims Some pracmces have received lewers from health insurers advising them of these enrollment problems.

31 PracMce Guidance WSMA guidance informamon from WSMA Prac,ce Resource Center website. Office of Insurance Commissioner advice - paments can pay premiums through insurers. Temporary enrollment Aug. 27 Nov. 14. Washington Healthplanfinder Customer Support Center at to ensure they are aware of the specific situamon. Network Adequacy - Determine which network(s) your pracmce and pracmmoners are in currently.

32 Looking ahead to 2015 SB 6016 Grace Period data to Legislature by Dec. 2014? Insurers can t get enrollment data from Exchange, Exchange has IT problems Don t know universe of problem Data due Dec Grace Period and Medicaid look back? Grace Period Reimbursement? Other ideas? To be determined

33 What else can you do? Tell your legislator what is happening in your pracmce Tell us what s happening in your pracmce TesMfy?

34 Looking ahead to 2015 Exchange self- sustainability is required must pay for itself Exchange budget Will legislators agree?

35 QuesMons? Other issues of interest?

36 Thank you! For more informapon contact: Kathryn Kolan, JD Director of LegislaMve and Regulatory Affairs