The ACA Health Care Exchange

Transcription

1 The ACA Health Care Exchange Greater Las Cruces Chamber of Commerce ACA Briefing Luncheon Martin Hickey, MD July 16, 2013

2 What Goes Up Must Currently Defying Gravity 25% 60% Health System Micro Economies The rate of growth in expenditures on hospital care and physician & clinical services is remarkable. And while that rate of growth has been on a steep upward curve for two decades, the curve becomes nearly vertical in the last five years. Data shown is total, inflation adjusted dollars that are going into healthcare through commercial insurance, Medicare, and Medicaid Source: Neal C. Hogan, PhD. BDG Advisors, LLC. The End of the Third Bubble. Winter

3 Industry Trends 4/30/09 Pittsburgh has more MRI Machines than Canada (Healthcare Economist) Scans per thousand insured people went from 85 to 234 in the U.S. between 1999 and (Forbes) Side effects to these scans, including increased levels of radiation exposure, especially dangerous for kids. (The New England Journal of Medicine) A doctor who owns his own machine is four times likely to order a scan as a doctor who doesn t. (Forbes) Nonradiologists performing their own imaging are at least times as likely to order imaging as non-self-referring physicians. (AJR:179, October 2002) 3

4 Facts 2 X Average GDP is spent on Healthcare in US vs. what other industrialized countries spend Morbidity and Mortality is 38th in the industrialized nations Premiums - Sharp annual increases Cost Shift 20 to 25% of premiums Deductibles - $6,000 and climbing Taxes 25% of State Budgets to health care 60%of American bankruptcies are generated by healthcare bills 4

5 Unsustainable, but change will be HARD Romney Care Heritage Foundation Mandate Almost all Americans are covered Penalties Law of large numbers - Massachusetts Innovation Pioneer ACOs, Medical Homes Medicaid Expansion to 138% FPL New Mexico Exchange with Subsidies 138% - 400% FPL Guaranteed Issue no past history exclusions or higher costs Competition re-injecting the market 5

6 Simple Choice 6

7 Exchange Practice Plan Design Essential Health Benefits (EHBs) Ten criteria Second cheapest Silver plan in New Mexico is basis for subsidy Metallic Plans Co-Insurance Platinum 10% Gold 20% Silver 30% Bronze 40% Catastrophic 50% 7

8 Premium Credit and Cost Subsidy If an individual falls within 400% of the FPL they will qualify for an Advanced Premium Tax Credit. That is any individual who earns up to $44,680 or a family of 4 who earns up to $92,200. (2012 figures) Cost Share Subsidy is available for individuals earning up to $27,000 or family of 4 earning up to $56,000. This allows them to have lower co-pays, deductibles, and maximum out of pocket plans than people making above those numbers. All tax credits and subsidies are reconciled on tax returns at year end 8

9 Who Must Comply? Individual Mandate An Applicable Individual must have Minimum Essential Coverage for them and their applicable dependents by or suffer a penalty. Penalty: 2014 The Greater of $95 or 1% of annual household income per person in a family up to $325 or 2% of Income up to 3 per family $695 or 2.5% of Income up to 3 per family Increasing Annually thereafter 9

10 Small Business 50 No penalties for not purchasing insurance for employees Small Business Tax Credits if 25 70% Participation 60% Actuarial Value Employer pays 50% of premium Average employee income $50,000 must purchase through the exchange 50% Tax Credit possible Goes to 100 in 2015 SHOP Small Business Health Options Program Single plan choice only in 2014, several in 2015 No tax deductions 10

11 Business > 50 in % today buy health insurance Purchase insurance equal to 60% of Actuarial Value No deductible, co-insurance and co-pay total can exceed $6,350 Employee costs (premium share and out-of-pocket expense) can not exceed 9.5% of employee (household) income > 30 hours equals full time (Senate bill raises to 40) Part timers hours add together to equivalent Full Time Employees $2,000 Penalty if don t purchase health insurance for employees (after 30 FTE) $3,000 penalty if inadequate and individual employee goes to Exchange Engage your broker (and or accountant)!!!! 11

12 How Exchanges work and Premium Tax Credit 12

13 How Exchanges work and Premium Tax Credit 13

14 Ratings for Plans Rates will be based on 3 things Location MSA Age Oldest can t be more than 3 x s youngest Smoker or Non Allowed to rate up 1:1.5 Individual tax credit is based on the premium for the Silver Plan. Doesn t change based on the plan chosen. Credits only available on individuals not on employer group plans. 14

15 Affordable Care Act in New Mexico Total population = 2,100,000 Total uninsured population = 23% Uninsured individuals = 417,000 Expanded Medicaid eligible = 179,000 Health Insurance Exchange eligible = 235,000 15

16 New Mexico State Based Exchange (Hybrid) 17 other states financially beneficial for New Mexico Federal Enrollment for Individual/Family in 2014, State in 2015 State for SHOP 2014 and beyond $20 Million for Marketing and Personal Assistors Regional Rating 4 MSA s + all other Albuquerque no longer the subsidizer Current Rate Submissions: 0 5% increase over last year! Same in other states Still in flux. 16

17 Community Operated and Oriented Program (COOP) Section 1322 of the ACA Member Board Non profit margins to benefits, lower premiums, community health infrastructure Primary care, Behavioral Health OSI Certified (QHP s); NM licensed 24 Experiments 6 Million Loan; 64 Million Reserves 17

18 What is our Market? NMHC will focus on providing coverage for uninsured individuals, families and small businesses. Individuals or employer groups without affordable healthcare. New Mexico Health Connections will provide a high quality and affordable choice for rural New Mexicans. New Mexico Health Connections will offer plans state-wide on and off the exchange. 18

19 We Did Do This: Managed Care 1990 s 19

20 New Mexico Health Connections MY-NMHC 2440 Louisiana Blvd., NE, Suite 601 Albuquerque, NM