State Considerations for Health Insurance Exchanges. Krista Drobac, Director, Health Division September 21, 2012 American Osteopathic Association

Transcription

1 State Considerations for Health Insurance Exchanges Krista Drobac, Director, Health Division September 21, 2012 American Osteopathic Association

2 Consumer Consumer Relationships Public Payors Qualified Health Plans Community Organizations for Outreach & Enrollment Services Employers Navigators Brokers Satisfaction Survey Customer Service Establish Navigator Standards Individual Application Employer/Employee App Eligiblility Communication Shopping Enrollment/ Maintenance Enrollment Communication Enrollment Documentation (electronic images) Request Appeal Grant Permissions QHP Oversight Information Architecture Reporting HHS Secretary C D Exchanges (State/Federal) Call Centers QHP Management Navigator Management Outreach & Education Notice & Appeals Enrollment Reporting Financial Management Eligibility Insurance Market Place Plan/Payor Selection Determine Eligibility Eligibility Issues Cost Share A Share Eligibility Data Verify Medicaid Eligibility Treasury B Federal Eligibility HUB 834 Enroll 834 Termination 834 Maintenance 834 Reconciliation Additional Information Verify Income Verify Citizenship Verify Legal Residence Verify Eligibility Verify Eligibility Other Public Data National Directory of New Hires EWE IEVS PARIS US Postal Address Internal Revenue Service Social Security Administration Department of Homeland Security Federal Insurance Programs Other Exchanges Department of Insurance Applications Rate Review Network Adequacy Regulatory Oversight Bill/Draft Access Web Sites Pay Premiums Consumer Access (Single Sign On) Certification. Recertification and Decertification Plan Setup A Tax Credit Payment BCBSA Private/Public Plan HUBs BCBSA United Healthcare AETNA Insurance COOPs B Cost Share Payment C Tax Credot Payment Notification C Qualified Health Plans D Non-Pay Premium QHP Apps Confirm QHP App Eligibility 834 Enroll 834 Enrol Acknowledge Enroll Complete 834 Termination 834 Maintenance Private and Public Payors 834 Reconciliation CHIP SC DHHS Public HUB Public Payors Basic Health Plan Medicaid Eligibility Medicaid Legend Fulfillment Setup Consumer Eligibility Enrollment Premium & Cost Share Risk (TBD)

3 Status of State Exchanges 5

4 Current Activities to Make Deadline for State-based Exchange Executive branch authority to spend federal grant funding Eligibility and enrollment IT procurements well underway Decisions about integration or interoperability of Medicaid/Exchange/DOI/Human Services systems Planning for business operations, including plan bidding process, administration of risk sharing, tax credits, etc. Focused on CMS certification process Examining sustainability options 4

5 Core Functions of the Exchange Consumer Assistance* Consumer support assistors; education and outreach; Navigator management; call center operations; website management; and written correspondence with consumers to support eligibility and enrollment. Plan Management* Eligibility Enrollment Financial Management Plan selection approach (e.g., active purchaser or any willing plan); collection and analysis of plan rate and benefit package information; issuer monitoring and oversight; ongoing issuer account management; issuer outreach and training; and data collection and analysis for quality. Accept applications; conduct verifications of applicant information; determine eligibility for enrollment in a Qualified Health Plan and for insurance affordability programs; connect Medicaid and CHIP-eligible applicants to Medicaid and CHIP; and conduct redeterminations and appeals. Enrollment of consumers into qualified health plans; transactions with Qualified Health Plans and transmission of information necessary to initiate advance payments of the premium tax credit and cost-sharing reductions. User fees; financial integrity; support of risk adjustment, reinsurance, and risk corridor programs. Source: Centers for Medicare and Medicaid Exchanges: A Proposed New Federal-State Partnership (September 19, 2011) 3

6 Exchange Considerations Start with Partnership and move to State based? What is the sustainability model in the Partnership? What is state level of effort, i.e. programming language? How does MOU look? Apply for grant to establish interface between Medicaid and Federal Exchange? (45 states have approved Advanced Planning Documents) Make own Medicaid eligibility determination or accept assessment? 6

7 Other State Considerations Churn between Medicaid and Exchange Transition of existing programs (high-risk pool, HIV programs, IMD populations) Other market reforms, i.e. guaranteed issue, community rating, ban on health status rating. Workforce planning

8 Medicaid Questions Can states expand only up to 100% FPL? Can states expand over time? What will happen to state s Medicaid DSH funding under partial expansion? What will future match rate be if state expands later? Children s expansion and foster care? Does the statute allow eligibility reduction below 133% FPL? 8

9 State Medicaid Considerations 9 In estimating impact, what are the right assumptions? Woodwork effect almost 10% of adults who could be newly enrolled in Medicaid might be already eligible and not qualify for enhanced match. Cost of current state-only programs, i.e., community mental health, uncompensated care pools, state high risk pool. What will state receive in DSH payments? In 2011, DSH payments were $11.3 billion Scheduled to decrease by 61% by 2019

10 State Medicaid Considerations 10 Provider reaction? Cost to state, counties, shift to insured individuals? What are the added administrative costs? Expansion population characteristics: disproportionate burden of mental illness and/or substance abuse, pent up demand From early Medicaid expansion states: more costly than parent enrollees, less costly than disabled enrollees New kind of churn, continuity of care

11 Newly Covered Populations Total Non-Elderly Uninsured, Number 49,111,900 (Kaiser) Newly Covered Exchange Medicaid million (CBO) Was million (CBO), Now 10 million Enrollment Change Private Insurance 10.3% decrease in uninsured (Urban) Medicaid 27.4% increase (Kaiser)

12 Map of Newly Covered Populations

13 State Supply of Primary Care Physicians

14 Profile of Newly Covered Exchange population is relatively older, less educated, lower income, and more racially diverse Mean age 35 Minimal access to primary care services 1/3 of projected enrollees had no check-up in over 2 years 2 out of 5 of projected enrollees had no usual source of care 29% had no interaction with the health care system Behavioral health needs Among expected adult enrollees, 8% report that they are in fair or poor mental health Chronic conditions 12% of enrollees will have 3 or more conditions (hypertension, high cholesterol, and depression)

15 Workforce Implications Increase number of primary care physicians, nurse practitioners and allied health professionals before 2014? Develop state-wide workforce development and planning strategy Focus on health professional shortage areas Focus on recruitment and retention Loan forgiveness National Health Service Corps GME scholarships Scope of practice rules? Establish multi-disciplinary care teams that can support delivery of coordinated care