Understanding the Marketplace

Transcription

1 Understanding the Marketplace Stacey Pogue, Senior Policy Analyst Center for Public Policy Priorities December 3, 2013 CPPP.org

2 Marketplace Basics Terminology: Health Insurance Marketplace (formerly known as the Exchange) and SHOP for small employers Compare private insurance plans based on price, benefits, quality, and other features Most people will get a break on costs No wrong door with Medicaid and CHIP Open enrollment started October 1, Coverage effective beginning on January 1, 2014

3 The Marketplace is Just One of the ACA s Key 2014 Reforms Medicaid expansion: US citizens to 133% FPL ($15,300 individual; $31,300 for 4 in 2013). State option. Private health insurance market reforms: can t be turned down or charged more based on health status; no pre-existing condition waiting periods; standard minimum benefits for individuals and small employers; no annual or lifetime maximums, etc. Health Insurance Marketplace: private insurers options can be compared and purchased. Sliding scale help with premiums Sliding scale help with deductibles/co-pays and out-of-pocket caps Individual mandate to have coverage (with several exceptions). Employer penalties possible in 2015 if employees get sliding-scale help in Marketplace, but exemption for all employers with 50 or fewer FTE workers. 3

4 Marketplace Administration State-based Partnership Federally facilitated Source: The Commonwealth Fund,

5 Texas ACA Enrollment Opportunity Assumes ACA Medicaid expansion, which accounts for about half of projected coverage gains Cline M, Murdock S. Estimates of the Impact of the Affordable Care Act on Counties in Texas. Hobby Center for the Study of Texas, Rice University, Report to Methodist Healthcare Ministries, April 2012

6 Texas Marketplace Eligible 2,049,000 Texans eligible for premium subsidies in the Texas Marketplace. (Includes both uninsured and people with individual market coverage today) 3,143,000 Potential Marketplace size Estimates of total eligible, NOT projections of who will actually enroll Kaiser Family Foundation, State-by-State Estimates of the Number of People Eligible for Premium Tax Credits Under the Affordable Care Act, November 5, 2013

7 Actual Enrollment October 2013 From October 1, 2013-November 2, 2013 Individuals applied for coverage Found eligible for Marketplace, but no plan selection Selected a Marketplace Plan Determined/ assessed eligible for Medicaid or CHIP Texas 108,410 77,969 2,991 11,682 United States 1,509, , , ,261 U.S. Department of Health and Human Services, Health Insurance Marketplace: November Enrollment Report Initial low enrollment expected and in line with other coverage programs. For example, Texas CHIP enrolled only 30 children in the first month, and has nearly 600,000 kids today.

8 INFORMATION NOW: HealthCare.gov & CuidadodeSalud.gov Available 24/7: ; TTY: , or chat online

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10 Marketplace Provides No Wrong Door In-person Assistance: Agents/Brokers Navigators Certified Application Counselors

11 Family Income ACA Support Fitted to Your Income >$94,200 for a family of four; >400% of FPL Job-based coverage, or Full-cost coverage in the Marketplace $70,650-$94,200; % of FPL $47,100-$70,650; % of FPL $31,322-$47,100; % of FPL CHIP Job-based coverage, or Subsidized Marketplace coverage: premiums capped at 2% - 9.5% of income <$31,322 for a family of four; < 133% FPL Medicaid Children Family income based on 2013 federal poverty income levels for a family of four Coverage Gap below poverty line ($23,550 for family of four) Adults (not eligible for Medicare or Medicaid today)

12 Who Is Eligible for the Marketplace? To buy coverage U.S. citizen or legal resident Not incarcerated (unless pending disposition of charges) For financial help Income from % of the poverty level, generally Not eligible for other minimum essential coverage

13 Premium Credits: Eligibility Primary Group: Individuals and families between 100 and 400 percent of poverty, ineligible for other coverage. Two additional groups: 1) Lawful immigrants below 100% of poverty who are not Medicaid eligible 2) People who would have to spend more than 9.5% of income to participate in employer plan or whose employer plan has less coverage than the bronze exchange plan

14 Subsidies in the Marketplace Advance Premium Tax Credits Individuals and families b/w 100% and 400% of poverty (FPL) Sliding scale relative to income Must be used to purchase inside the Marketplace Can be paid directly to insurer, so you only owe the balance as a monthly premium Family Size Annual income range premium credits 1 $11,490 - $45,960 2 $15,510 - $62,040 3 $19,530 - $78,120 4 $23,550 - $94,200

15 Subsidies in the Marketplace Cost-Sharing Reductions Individuals and families b/w 100% and 250% FPL Lower deductibles and copays Must select a silver-level plan to qualify Family Size Annual income range cost sharing reductions 1 $11,490 - $28,725 2 $15,510 - $38,775 3 $19,530 - $48,825 4 $23,550 - $58,875

16 Example Premiums for an Individual Austin non-smoker ages 27 and 64 Annual income Premium for cheapest Silver plan Age 27 Age 64 Costsharing reductions Out-of-pocket limit (for an individual) < $11,490 (<100% FPL) $169 $483 No $6,350 $11,490 (100% FPL) $0 $0 Yes $2,250 $17,235 (150% FPL) $21 $0 Yes $2,250 $22,980 (200% FPL) $85 $18 Yes $5,200 $28,725 (250% FPL) $157 $90 No $6,350 $34,470 (300% FPL) $169 $170 No $6,350 $45,960 (400% FPL) $169 $261 No $6,350 > $45,960 (>400% FPL) $169 $483 No $6,350

17 Marketplace Timeline Open enrollment begins Coverage can start (must enroll by 12/23/13 for a 1/1/14 start date) Open enrollment ends

18 Marketplace Coverage Levels All plans have essential health benefits % covered by plan Platinum Gold 80% 90% % paid by enrollee 10% 20% Silver Bronze 70% 60% 30% 40% 0% 20% 40% 60% 80% 100% Catastrophic plan for people under 30 or if no other coverage is affordable

19 10 Essential Health Benefits standard floor for coverage for individuals and small employers* 1. ambulatory services 2. emergency services 3. hospitalization 4. maternity care 5. mental health and substance use disorder services 6. prescription drugs 7. rehabilitative and habilitative services and devices 8. laboratory services 9. preventive and wellness services 10.pediatric dental and vision care * Grandfathered plans those created before March 23, 2010 are exempt

20 Essential Health Benefits Help Fill In Holes in MH/SUD Coverage Gaps in Individual Market Coverage (not jobbased) Today: 34% 18% 9% no coverage for substance abuse services no coverage for mental health services no coverage for prescription drugs U.S. Department of Health and Human Services, Essential Health Benefits: Individual Market Coverage, December 16, 2011

21 MH/SUD Free Preventive Services Under the ACA, most health plans* must cover certain preventive services without a copayment, co-insurance, or deductible, including behavioral health services such as: Depression screening Alcohol misuse screening Alcohol and drug screenings for adolescents Behavioral assessments for children of all ages * Grandfathered plans those created before March 23, 2010 are exempt

22 The ACA, MH/SUD Benefits, and Parity Type of Plans Individuals who buy directly from insurers (not job-based) Small employers (50 or fewer employees) Medicaid benchmark plan minimum standard for adult Medicaid expansion group Large employers (51+ employees) Must Cover Mental Health/ Substance Use Services As of January 1, 2014* No Mental Health/ Substance Use Coverage Must be at Parity As of January 1, 2014* Yes * Grandfathered plans those created before March 23, 2010 are exempt For more information: CPPP, The Affordable Care Act and Mental Health, March 2013

23 The Individual Mandate If you are uninsured but have access to affordable coverage, you must purchase insurance for yourself, or pay a tax. Coverage that satisfies the individual mandate: o Job-based coverage o Medicare o Medicaid/CHIP o VA o Tricare o Plans bought in the Marketplace o Individual market plans purchased directly from insurers

24 Exemptions and Penalties Exemptions to mandate/penalty if you: Are uninsured for less than 3 months of the year Enroll in the Marketplace by March 31, 2013 (even if coverage doesn t start until May 1) Coverage costs more than 8% of income Are not required to file a tax return because income is too low Would qualify for Medicaid, but state has not to expanded Medicaid (must get an exemption certificate from the Marketplace) And others Penalties: 2014 Penalty is $95 per adult and $47.50 per child (up to $285 a family) or 1% of family income, whichever is greater 2015 Penalty is $325 per adult and $ per child (up to $975 a family) or 2% of family income, whichever is greater 2016 and Beyond Penalty is $695 per adult and $ per child (up to $2,085 a family) or 2.5% of family income, whichever is greater

25 Medicaid Expansion

26 State Action on Medicaid Expansion

27 Texas Medicaid/CHIP: Who is Helped Today Disabled, 422,467 CHIP, 591,756 January 2013, HHSC data Elderly, 326,501 Poor Parents, 144,040 TANF Parent, 83,772 Maternity 86,975 Medicaid Children, 2,547,199 Total enrolled 1/1/2013: 3.6 million Medicaid; 592,000 CHIP 1 in 7 Texans, but 42% of Texas kids 27 27

28 Income Caps for Texas Medicaid and CHIP, % 200% 150% 100% 50% 0% $35,317/yr Pregnant Women $35,317/yr 185% 185% $25,390/yr 133% $19, % $2,256 $3,696 12% Newborns Age 1-5 Age 6-18 TANF parent of 2, no income Working Parent of 2 $8,376* 19% 75% SSI (aged or disabled) $25,128* 225% Long Term Care $38, % CHIP Mandatory Optional indicates Texas Choices to go ABOVE federal minimum Income Limit as Percentage of Federal Poverty Income Annual Income is for a family of 3, *except Individual Incomes shown for SSI & Long Term Care 28

29 Coverage Gap for Adults in Poverty Texas is 12-19% FPL

30 Medicaid Expansion Will Significantly Increase Eligibility for Parents in Many States Medicaid Eligibility Levels for Parents, January 2013: 133% NOTE: Ten states (CT, IL, ME, MA, MN, NJ, NY, RI, VT, WI) and DC already offer coverage to parents at or above 133% FPL; under the ACA an income disregard of 5 percentage points will be applied to this limit increasing the effective income limit to 138% FPL. SOURCE: Based on the results of a national survey conducted by the Kaiser Commission on Medicaid and the Uninsured and the Georgetown University Center for Children and Families, 2013.

31 Family Income About 1.5 Million Uninsured Texas Adults are Eligible for Medicaid Expansion Experts and Texas HHSC estimate million uninsured U.S. citizen adults in Texas would be eligible for the Medicaid expansion in % FPL $25,975 for family of 3 133% FPL $25,975 for family of 3 With Medicaid Expansion Marketplace with Subsidies Medicaid $0 Parents and Childless Adults

32 Family Income Coverage for Low-income Adults With Medicaid Expansion vs. Without Medicaid Expansion 133% FPL $25,975 for family of 3 Marketplace with Subsidies Marketplace with Subsidies Marketplace with Subsidies 100% FPL Medicaid Coverage Gap Coverage Gap $19,530 for family of 3 19% FPL $0 Parents and Childless Adults Childless Adults Medicaid Working Parents $3,696 for family of 3

33 Without Medicaid Expansion, Only Half as Many Texas Uninsured Gain Coverage 6.1 million uninsured Michael E. Cline, Ph.D., and Steve H. Murdock, Ph.D., Rice University, Estimates of the Impact of the Affordable Care Act on Counties in Texas, April

34 The Coverage Gap Unless our leaders take action, on January 1, 2014: an uninsured parent with two children living on $18,000 will have NO help from ACA for health coverage, but another uninsured parent with 2 children earning $20,000 a year will qualify for full coverage on a sliding scale for $33 a month or less. About 1 million U.S. citizen adults are uninsured in Texas and will have no coverage options.

35 Coverage Gap Advocacy A diverse network of Texans and Texas organizations are working to help Texans in the Gap Group tell their stories and seeking inclusion of Texas working poor in the ACA s health reforms. For individuals: For organizations:

36 Behavioral Health Benefit Requirements and Central Texas Marketplace Insurance Plans Dianne Longley Principal HEALTH MANAGEMENT ASSOCIATES

37 Essential Health Benefit Requirements for Health Plans Treatment for MH/SU is an essential health benefit requirement applicable to all individual and small group plans, both within and outside the marketplace Benefits must be covered at parity with medical/surgical benefits Cannot impose separate limitations for MH/SU that do not also apply to medical/surgical Texas plans must provide benefits substantially equal to those provided in the state s benchmark plan, available at: Resources/Downloads/texas-ehb-benchmark-plan.pdf. See separate Texas Department of Insurance summary at: EHB_su.pdf

38 MHPAEA Final Rules US Departments of Health and Human Services, Labor and Treasury adopted final Mental Health Parity and Addiction Equity Act rules in November MHPAEA initially applied only to large groups, but under EHB final rules, small and individual plans must also comply with the parity regulations in order to meet Essential Health Benefit requirements Highlights of regulation include: Prohibits separate financial or quantitative treatment limits Applies to inpatient, outpatient, in-network, out-of-network, emergency care and prescription drugs Prohibits separate deductibles or out-of-pocket maximums, annual or lifetime day or visit limits Prohibits plans from imposing nonquantitative treatment limitations (NQTLs) such as medical management techniques like prior authorization, unless the same techniques are comparable to those applied to medical/surgical benefits, except that recognized clinically appropriate standards of care may permit a difference. Requires that the medical criteria for medical necessity determinations and the reason for denial of payment be available upon request in certain circumstances Rules apply to plan years beginning July 2, 2014

39 Drug Formulary Requirements As one of the 10 essential health benefit requirements, prescription drug formulary rules apply to small group and individual plans offered inside and outside the Marketplace Health plans must cover at least the greater of : One drug in every category and class OR The same number of drugs in each category and class as the benchmark plan Drug products must be chemically distinct ( i.e., if a benchmark plan offers two drugs per category or class, another plan offering two dosage forms or strengths of the same drug, or a brand drug and the generic equivalent,would not be chemically distinct)

40 Drug Formulary Requirements Co-payments/coinsurance payments for prescriptions count toward the annual limitation on total out-ofpocket maximums; an exception for the first year ONLY if a health plan uses a separate administrator for prescription drugs and medical benefits, in which case the plan may impose separate out-of-pocket maximums for drugs and medical benefits Formularies, like other EHB requirements, may not be constructed in a discriminatory manner; States and HHS will monitor for potential discrimination Plans must have procedures that allow patients to obtain clinically appropriate prescriptions not on the formulary; important distinction in gain access to and not simply request a drug HHS will use complaints, appeals and drug lists to evaluate future changes in regulations and formulary requirements

41 Insurers in the Texas Marketplace 11 Insurers in the Texas Individual Marketplace Aetna Ambetter from Superior Health Plan Blue Cross Blue Shield of Texas Cigna CommunityFirst Community Health Choice Firstcare Health Plans Humana Molina Healthcare of Texas Scott & White Health Plan Sendero Health Plan 7 insurers in green offer 80 plans in Travis/Hays/Williamson Counties

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43 Austin Area Marketplace Plans Coverage Tier Number of Plans Platinum 1 Gold 20 Silver 30 Bronze 25 Catastrophic 4

44 Summary of Marketplace Plans for single, 38 year-old, non-smoker in Austin

45 BCBSTX Has Least Expensive Bronze HMO and PPO Plans in Austin-area

46 Least Expensive Silver Plan Humana Connect Silver 4600/6300 HMO Plan $4,600/$9,200 deductible (indiv/family) $6,300/$12,600 out-of-pocket maximum Reduced for people under 250% of poverty HMO: no benefits out-of-network, other than emergencies $25 copay for primary care office visit. $35 copay for specialist. Inpatient mental/behavioral health and substance use disorder: after deductible, 20% coinsurace. Preauthorization may be required, penalty of 50% or $500 whichever is less. Outpatient mental/behavioral health and substance use disorder: after deductible, 20% coinsurace. Rx: Subject to separate $1,500/$3,000 deductible. Rx5 Complete formulary. Generics available for $10-$20 and not subject to deductible. Other drugs subject to deductible first, then $50 copay or 50% coinsurance.

47 MH-related Limitations and Exclusions Examples from Sendero IdealCare Essential: All inpatient MH/SUD must be preauthorized Traditional MH/SUD outpatient services do not need authorization for first 30 sessions Care in psychiatric day treatment facility, crisis stabilization unit/facility, or residential treatment center for children and adolescents in lieu of hospitalization will be covered like benefits for inpatient hospitalization Medial social services and marriage/family therapy excluded Services/supplies to treat adolescent behavioral disorders, including conduct and oppositional disorders excluded Residential level treatment in a chemical dependency treatment center excluded

48 MH-related Exclusions Examples from Humana Connect Silver: Inpatient stay primarily related to behavioral, social maladjustment, lack of discipline or other antisocial actions which are not specifically the result of mental health Services rendered in connection with mental illnesses not classified in the International Classification of Diseases of the U.S. Department of Health and Human Services Services extended beyond the period necessary for evaluation and diagnosis of behavioral disabilities Marriage counseling excluded

49 Potential Areas of Concern to Monitor Closely Formularies availability of medications will vary by plan; enrollees should evaluate options carefully to ensure current medications are covered Access to Care/Network Adequacy tiered networks are allowed; are often offered with lowest cost plans; may include fewer providers and create problems accessing services Coverage of Out-of-Network emergency services for true emergencies, balance billing is prohibited Enforcement TDI has deferred to HHS the enforcement of provisions not required under Texas law/regulations

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