Presenting a live 90-minute webinar with interactive Q&A. Today s faculty features:

Transcription

1 Presenting a live 90-minute webinar with interactive Q&A Health Insurance Exchanges: Impact on Healthcare Providers Navigating Legal Developments on Exchanges and Analyzing the Interplay With Managed Care Contracts TUESDAY, FEBRUARY 12, pm Eastern 12pm Central 11am Mountain 10am Pacific Today s faculty features: Jackie Selby, Member, Epstein Becker Green, New York Jane L. Kuesel, Senior Attorney, Epstein Becker Green, New York Kathrin E. Kudner, Member, Dykema Gossett, Ann Arbor, Mich. Christina Hage, General Counsel, HealthyCT, Wallingford, Conn. The audio portion of the conference may be accessed via the telephone or by using your computer's speakers. Please refer to the instructions ed to registrants for additional information. If you have any questions, please contact Customer Service at ext. 10.

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5 Exceptional service. Dykema delivers. Health Insurance Exchanges And Healthcare Providers Presented by Kathrin E. Kudner February 12, 2013 California Illinois Michigan North Carolina Texas Washington, D.C.

6 Overview Affordable Care Act (ACA) allows each State the opportunity to establish an Affordable Insurance Exchange to assist individuals and small employers to purchase affordable health insurance through Qualified Health Plans (QHPs) Premise is that the Exchanges will permit comparison of plans, increase access to coverage, and increase competition among plans 6 Exceptional service. Dykema delivers.

7 Time Line Coverage through the Exchanges will begin January 1, 2014 with enrollment beginning on October 1, 2013 Extension of deadline to submit Blueprint Application to operate a State Exchange to December 14, 2013 Declaration Letter and Blueprint Application to operate a Partnership Exchange by February 15,2013 State may apply to operate an Exchange at any time in future State Exchanges must be self-sustaining by January 1, Exceptional service. Dykema delivers.

8 How Will Exchanges Operate? Establishment and operation of Exchange Non-profit established by State, independent public agency or as part of existing State agency State Exchange, Regional Exchange, Federallyfacilitated Exchange (FFE) or Partnership Exchange Qualified Health Plans Enrollment eligibility individual and through Plan Employer eligibility in Small Business Health Options Program 8 Exceptional service. Dykema delivers.

9 How Will Exchanges Operate? (cont d) Qualified Health Plans (QHPs) Health plans must be certified as QHPs to operate through Exchange Must meet minimum statutory standards Eligibility May impose additional standards Web-based system for individual to apply Enrollment 9 Exceptional service. Dykema delivers.

10 Exchange Functions Federal/state coordination with state continuing traditional regulatory review Participant eligibility and enrollment Plan management Certification and oversight of QHPs Assess network adequacy Issuer account management Operation of website for plan comparison Consumer technical assistance and support Data collection and reporting 10 Exceptional service. Dykema delivers.

11 Options State, Federal or Partnership State Exchange (or Regional with more than 1 State) ACA authorizes the Secretary to establish and operate an FFE in any State that either: Chooses not to establish an Exchange; or Has been determined by the Secretary to be unlikely to have an operable Exchange by January 1, 2014 States also have the option to enter into a Partnership with an FFE 11 Exceptional service. Dykema delivers.

12 State Exchange State must submit a declaration letter and blueprint for approval or conditional approval by HHS HHS determined by January 1, 2013 whether State Exchanges are ready to perform Exchange operations by January 1, 2014 State responsible for all Exchange functions Greatest flexibility for States Can determine how selective to be with QHPs 12 Exceptional service. Dykema delivers.

13 Federally-Facilitated Exchange HHS intends to work with States to preserve State regulatory role Licensure and solvency HHS responsible for all Exchange functions Certification of QHPs Eligibility determination 13 Exceptional service. Dykema delivers.

14 State Partnership Exchanges State must submit a Declaration Letter and Blueprint Application for approval or conditional approval by HHS Mirrors application for State Exchange plus standards for data sharing and coordination Viewed as potential transition to State based Exchange ACA requires HHS to retain overall authority over FFE but HHS will look to States for recommendations Intent is to integrate into existing State policies Reliance on State for regulatory approvals 14 Exceptional service. Dykema delivers.

15 Who Does What? Task State HHS QHP Certification Process application Collect data Rate determination Recommend certification actions Transmit data Develop standards Review and determine approval of credentialing decisions QHP Issuer Account Management QHP Oversight and Monitoring Quality Day to day management Point of contact for communications Compliance with standards Enforcement actions under State law Recommend Exchange compliance actions to HHS Coordinate with HHS on operational oversight Coordinate with HHS on data collection Conduct quality/performance monitoring Provide web link to quality data Coordination and technical assistance Respond to consumer complaints Oversee QHPs related to Exchange rather than State regulatory issues Coordinate with State on oversight Determine Exchange enforcement decisions Develop quality rating, quality improvement, quality data standards 15 Exceptional service. Dykema delivers.

16 Where is your State? STATE FFE PARTNERSHI P California* Colorado* Alabama Alaska Arkansas* Connecticut* Dist. of Columbia* Arizona Florida Delaware* Hawaii* Idaho* Georgia Indiana Illinois Kentucky* Maryland* Kansas Louisiana Iowa Massachusetts* Minnesota* Maine Missouri Michigan Mississippi** Nevada* Montana Nebraska North Carolina New Mexico* New York* New Hampshire New Jersey West Virginia Oregon * Rhode Island* North Dakota Ohio Utah* Vermont* Oklahoma Pennsylvania Washington* South Carolina South Dakota Tennessee Texas Virginia Wisconsin Wyoming * Received HHS Conditional Approval ** Rejected by CMS Will be Federal 16 Exceptional service. Dykema delivers.

17 Progress of States Default to the Federal For political reasons Not willing to support ACA Waited for Supreme Court case and election so not ready Partnership Compromise Not ready but want State involvement (Michigan, Illinois) State Well developed (NY, Calif., NV, Connecticut) In progress (just received conditional approval) Rejected (Mississippi) 17 Exceptional service. Dykema delivers.

18 Connecticut Health Insurance Exchange Christina Hage HealthyCT, Inc., General Counsel x 1007 chage@healthyct.org

19 Access Health CT 19 Connecticut s Health Insurance Exchange Scope of Outlined Duties: Administer the HIX for both qualified individuals and qualified employers Survey individuals, small employers, and health care providers on health care coverage issues Implement procedures for certifying, recertifying, and decertifying health benefit plans as QHP, consistent with CT and HHS guidelines

20 Access Health CT 20 Operate a toll-free consumer assistance hotline Provide for enrollment periods (provided for in PPACA) Maintain an internet website where consumers may obtain standardized comparative information on QHPs, including enrollee satisfaction survey information and other tools to assist in evaluating the plans

21 Access Health CT 21 Publish on its website the average costs of licensing, regulatory fees, and any other payments the Exchange requires as well as the Exchange s administrative costs, including information on amounts lost to waste, fraud, and abuse Rate each QHP offered through the Exchange and determine each plan s level of coverage in accordance with HHS criteria and regulations Use a standardized format for presenting health benefit options in the Exchange

22 Access Health CT 22 Screen applications to determine if applicants are eligible for Medicaid, the State Children s Health Insurance Program, or other state public insurance programs; enroll eligible applicants in such programs Collaborate with DSS to allow a person to stay enrolled in his or her plan and provider network, if he or she loses premium tax credit eligibility and becomes eligible for Medicaid Establish and make available a calculator that allows individuals to determine their actual cost of coverage, taking into consideration any applicable federal premium tax credit and cost-sharing reduction

23 23 Access Health CT Qualified Health Plans Exchange must make QHPs available to qualified individuals and employers by January 1, 2014 Qualified Health Plan : Health benefit plan certified as meeting criteria outlined in the PPACA and the Connecticut Public Act Qualified Individual : State resident, seeking to enroll in a qualified health plan offered to individuals through the Exchange, who is a U.S. citizen, national, or lawful alien and not incarcerated (except for pretrial inmates) Qualified Employer : A small employer with its principal place of business in Connecticut that elects to make its full-time employees eligible for one or more qualified health plans offered through the Exchange Employer may also elect to make some or all part-time employees eligible Employer must provide coverage through the Exchange to either all its eligible employees wherever they work or all its eligible employees employed in Connecticut

24 24 Access Health CT Certifying Qualified Health Plans Plan must provide the federally designated essential health benefits (with a few small exceptions) Insurance Commissioner has approved the premium rates and contract language The Plan provides at least a bronze level of coverage (covering 60% of the cost of essential health benefits) unless it is certified as a catastrophic plan offered only to people eligible for such plans

25 Access Health CT Certifying 25 Qualified Health Plans The plan must comply with federal limits on out-of-pocket costs The plan meets the Exchange s certification requirements and those in HHS regulations The Exchange determines that making the plan available is in the interests of qualified individuals and employers in the state

26 26 Access Health CT Health Carrier Requirements Be licensed and in good standing to offer health insurance in Connecticut Offer through the Exchange at least one plan at the silver coverage level (covering 70% of the cost of essential health benefits) and one plan at the gold coverage level (covering 80% of the cost of essential health benefits) through each Exchange in which it participates Charge the same premium rate for each QHP whether offered: Through the Exchange or outside it Directly by the carrier or through an insurance producer

27 27 Access Health CT Health Carrier Requirements Charge no coverage termination fee or penalty if an individual enrolls in another type of minimum essential coverage because he or she is newly eligible for the coverage or his or her employer-sponsored coverage has become affordable under federal standards Comply with HHS regulations and any other requirements the Exchange may establish

28 Access Health CT Navigators 28 Purpose: Educate the public about the availability of QHPs sold through the Exchange Distribute fair and impartial information about enrollment in QHPs and the availability of premium tax credits and costsharing reductions under the federal PPACA Facilitate enrollment in QHPs Refer individuals with a grievance, complaint, or question about a plan, a plan s coverage, or a determination under a plan s coverage to the healthcare advocate or any customer relations unit the Exchange establishes Provide information in a culturally and linguistically appropriate manner

29 Health Insurance Exchanges and Healthcare Providers Jane Kuesel Jackie Selby

30 NEW YORK 30

31 NY Health Benefit Exchange New York QHP s must: Offer Essential Health Benefits Meet network adequacy standards: Federal and NY Department of Health Apply to provide coverage for their entire service area Offer an out-of-network offering for their Exchange product for any county in which they are currently offering an out-of-network offering outside of the Exchange but only at the silver and platinum levels -- for both the Individual Exchange and the SHOP Exchange Comply with quality component and reporting Have a treatment cost calculator for both in-network and out-ofnetwork providers 31

32 NY Plans One time chance to apply to participate for Provider network part of the application due April 12 th 32

33 Federally Facilitated Exchanges Half of the exchanges will be FFEs Still awaiting detailed guidance from HHS Application for QHPs to be published early 2013 Multi-State Payers (MSPs) will contract with Office of Personnel Management (OPM) 33

34 Where is Your State on this Spectrum? Will Have Its Own Exchange, FFE or Federal Partnership? Requirements for QHPs Identified Any Willing QHP? Any Other Requirements (e.g. NY OON requirement if offered outside exchange) Exchange Networks Identified By QHPs QHP s Provider Agreements Amended re: Exchange Products Essential Health Benefits Identified Network Requirements Identified (e.g. network adequacy, options for limited networks) Plan Premiums Proposed by QHPs/Approved By State QHPs Approved By State 34

35 Let s Get Practical 35

36 The Plan Perspective Plans seem to be viewing the Exchange as a new benefit category or product Between general commercial products and Medicaid plans Anticipate rates in range between commercial and Medicaid Larger national plans moving forward; smaller plans taking wait and see approach 36 Exceptional service. Dykema delivers.

37 Considerations for each Plan Will the Plan participate in the Exchange? What products will the Plan offer through the Exchange? What is needed to be certified as a QHP? Are changes in Plan structure or operations needed? Review of provider networks Review of Participation agreements New agreements or amendments to current agreements Expiration and evergreen provisions Termination 37 Exceptional service. Dykema delivers.

38 The Provider Participation Agreement the Plan s View Form of Agreement New, amendment to current amendments to separate Exchange agreements Consistency of terms and definitions Application to new products or lines of business Compliance with changes in law Rate structure Benefit levels Expiration and evergreen provisions Termination Tied to Exchange participation? Imposition of Exchange requirements on provider 38 Exceptional service. Dykema delivers.

39 The CO-OP Perspective 39 CO-OPs are required to be non-profit New entity new contracting opportunity for all providers Patient-centered medical homes are HealthyCT s core approach

40 From the Provider s Perspective: Do YOUR Agreements With QHPs (or plans expected to be QHPs) Already Apply to Exchange Products? Look at the definitions of: Benefit Plan or Benefit Program Product Line of Business Payer or Payor Member or Customer Does agreement automatically apply to ALL commercial products? 40

41 How Does YOUR Agreement Define Product? Example Mutual Consent Required to Add Products Not Already Covered: Products mean the list of healthcare benefit Products and Programs offered by Payor to its Members attached hereto as Exhibit A. Persons not enrolled in a Product listed in Exhibit A shall not be entitled to access this Agreement. Any and all amendments to Exhibit A shall require the mutual prior written consent of the parties 41

42 How Does YOUR Agreement Define Product? Example Provider Consent Not Required to Add New Products: Payor may add or remove Products and Programs at any time and from time-to-time. At Payor s sole election, Provider shall be required to participate in any new Product or Program offered by Payor on the same terms and conditions as set forth under the Agreement 42

43 Are Exchange Products Covered by Existing Rates and Fee Schedules? Can Payer Change Unilaterally? Review fee schedules and rate attachments Review payer s ability to amend fee schedules and rates, or to amend more generally 43

44 Mutual or Unilateral Consent to Amend? Example: This Agreement, including any and all exhibits, attachments and appendices hereto, can be modified or amended only by a written document, expressly referencing this Agreement and the parties mutual intent to amend it 44

45 Does YOUR Agreement Address Limited or Tiered Network Products? Example: The parties acknowledge that Payor offers or may offer Benefit Plans or Products which include tiering of Providers on the basis of cost and/or quality performance, as determined by Payor, and which provide Enrollees with financial incentives to utilize Providers from tiers with lower cost and/or higher quality performance 45

46 Does YOUR Agreement Address Increases In Bad Debt (uncollected amounts from members)? Does HMO hold harmless clause apply? If not, will Payer negotiate? Member Cost Share (Copays, Coinsurance, Deductibles) may be harder to collect 46

47 Some Members Will Switch Between Medicaid and Exchanges Does your agreement cover Medicaid? What are continuation of care requirements for exchange members? 47

48 For Primary Care Providers Most exchange products will be gatekeeper models, requiring referrals and prior authorization Does your agreement require open panels for exchange members? 48