2014 Tour of Idaho 1

Transcription

1 2014 Tour of Idaho 1

2 Welcome and /ŶƚƌŽĚƵĐƟŽŶƐ dğƌƌŝğ, Ăǀ ŝɛ Medical Management Lance Coleman ACA Updates for Groups Sandy Colling Special Enrollment Periods Lisa Wilson Break Strategic Direction: Existing Solutions and Emerging OƉƉŽƌƚƵŶŝƟĞƐ :ŽŶĂƚŚĂŶD ĞĚĂůŝĞ 2014 >ĞŐŝƐůĂƟǀ ĞK ǀ Ğƌǀ ŝğǁ :ƵůŝĞTaylor 2

3 Terrie Havis, Director of Sales Support Services 3

4 To provide clients, employers and members with the best value in health insurance Ensuring the highest quality care At the lowest possible cost Member Engagement Provider Coordination To provide value through three main avenues Product Innovation 4

5 Empowering members to take an active role in their care to ensure they get the most from their health insurance Supporting clients bottom line through plan performance and product innovation Strategic direction and innovation provide solutions in an ever-changing healthcare environment By providing value we meet the needs of our customers 5

6 Brokers help deliver services and value to people throughout the state You have always been a critical part of our business. In fact, brokers were: 60% of our business on the Exchange 90% of our business off the Exchange You bring value and trust to your clients How many of you are now selling products to the children of your first clients? We want to bring you the highest level of support to grow and retain your business 6

7 We ve assembled a team of Blue Cross of Idaho staff dedicated to you and your needs Contact Information: brokerrelations@bcidaho.com Team members Terrie Havis Director of Broker Relations Lisa Wilson Broker Relations Specialist Julie Johnson Broker Commissions Specialist Crystal Hays Broker Commissions Specialist We re adding more staff to this team! 7

8 Dr. Lance Coleman, Medical Director Medical Management 8

9 Ensuring safety and quality for our members Our Medical Management Department has the tools and resources to ensure quality while driving down costs benefiting employees and our clients bottom line Predictive analytics Pharmacy and Therapeutics Committee Generic drug program Post claims review Three full-time medical directors on staff Professional staff clinicians, nurses and counselors More than 500 nationally recognized medical policies Physicians advisory panel 9

10 Supporting members to ensure they receive The right care The right time The right place 10

11 Triggering events allow us to identify members we can support Identify individuals Determine and remove obstacles to care Build relationship and provide ongoing support 11

12 Medical Quality Management Quality Programs Prevention / Disease Management Inpatient Review / Acute Care Management Complex Care Management Medical / Pharmacy Review Medical Policy Claims Review 12

13 Continuous care approach supports members Engaging members early and building relationships helps members navigate their healthcare experience Before During After a health event 13

14 Health Management and Utilization Review Preventive care and early intervention helps manage chronic conditions before a health event Health Management: attempts to slow disease progression and improve health Utilization Review: Authorizes medical, pharmacy, surgical care and equipment 14

15 Acute Care Management and Inpatient Review Ensuring members get the care and support they need during a health event. Hospital admission Acute rehabilitation Sub-acute rehabilitation Skilled nursing care Home therapies Inpatient review 15

16 Care Management and Claims Review Engaging participants to manage ongoing, complex medical conditions after health events: One-on-one interaction to facilitate health Contact with follow-up calls Interdisciplinary Team 16

17 Our Behavioral Health Management Department allows us to help coordinate our members overall care, providing a well-integrated approach to their entire health picture. Hospitalization Follow-up Care Specialized Case Management Substance Abuse Program 17

18 Medical Quality Management Department Contacts Lance W. Coleman Nancy Carosso Chris Samuelson Jenn Senio Senior Medical Director Director of Health Management Manager Quality Management Administrative Assistant

19 Sandy Colling, Manager, Major & National Accounts ACA Updates for Groups 19

20 New rules and regulations will contribute to increased costs Plans will be updated with required benefits Fees and taxes are included Grandfathered plans may avoid some requirements We will assist you with notification and reporting requirements We will provide information to help you make Play or Pay decisions 20

21 Offer affordable and minimum value coverage to all eligible employees Offer coverage to all eligible employees Unaffordable for some, who will go to the Exchange and qualify for subsidy Offer coverage to less than 70% of employees Unaffordable for some, who will go to the Exchange and qualify for subsidy Coverage not offered All employees go to the Exchange 21

22 Using employee and business-specific information, our strategic impact report can help you see how the ACA affects your employees and your bottom line, now and in the future. It offers: Premium and cost-sharing estimates for employer-based plans vs. individual plans Anticipated tax credits if you have less than 25 employees Estimated impact on premium rates if you have less than 50 employees Estimates of ACA eligibility and affordability for employees Estimates on employee compensation needed to replace value of health plan Pre- and post-tax implications of terminating current coverage 22 A projected Cadillac Tax risk

23 2015 Employers need to offer coverage to 70% of full-time employees % of full-time employees We advise you to start calculating their full-time equivalent (FTE) employees. Learn how to count hours, particularly for part-time and seasonal staff Not considered full-time Unpaid volunteers or bona fide volunteers, i.e. firefighters Seasonal employees that work less than six months Student work study programs, unpaid student interns 23

24 Dependents The definition of dependent doesn t include foster children, step children and certain non-us citizens Dependent coverage is not required in 2015, if the employer is taking steps in 2014 to offer dependent coverage. What does it means to offer coverage? Employee must have opportunity to accept coverage at least once during the plan year Opportunity to decline coverage if coverage doesn t meet ACA requirements Employee s coverage from prior year that continues every year, is considered an offer of coverage In some cases, a third party that offers coverage on the behalf of an employer 24

25 Employers need to determine if their coverage is affordable Affordable Definition: Contribution for employee only for the lowest cost option that provides a minimum value does not exceed 9.5% of W-2 wages Hourly rate of pay X 130 or monthly salary The most recent published FPL Look back method or monthly measurement method Must use the same method for all employees in same category 25

26 Penalties for Noncompliance Large employers must offer minimum essential coverage (MEC) to full-time employees and their dependent children or face a penalty Employer responsibility requirement penalties delayed until 2015 Big Penalty Employers that fail to offer MEC to full-time staff and dependents and one employee receives a tax credit or cost-sharing reduction Smaller Penalty Larger employers that offer MEC to full-time staff and dependents, but an employee receives a tax credit or cost-sharing reduction because the coverage is either not affordable or does not provide minimum value $2,000 X (FTE 80)* the lesser of $3,000 X each FTE receiving premium assistance OR the Big Penalty *This is 2015 calculation only. For 2016, formula is $2,000 X (FTE 30) 26

27 Other ACA Changes Out-of-Pocket (OOP) Allowance Total maximum for Medical and RX is: $6,600 Individual $13,200 Family CMS allows two separate OOP as long as the sum total does not exceed maximum Probationary periods for new employees cannot exceed 90 calendar days; employers may include a bona fide orientation period no greater than 30 days in order to meet enrollment timeline needs TN5 TS3 27

28 Slide 27 TS3 I had this as a 1/1/14 requirement. Should this be moved to the delayed to 201 slide? TN5 This should indicate that the probationary period cannot exceed 90 calendar days but that they may include a bona fide orientation period in order to meet enrollment timeline needs. Teddi Scales, 4/4/2014 Theresa Niland, 4/14/2014

29 51-99 FTEs Will be categorized as small groups in FTEs May purchase on the Exchange in 2017, at which time the new coverage will include all Essential Health Benefits (subject to Idaho Health Insurance Exchange) 200+ FTEs Must automatically enroll new employees (This requirement was originally slated for 2014 but was delayed until 2015.) 28

30 Health Plan Identifier (HPID) The Department of Health and Human Services (HHS) has adopted a standard for a unique health plan identifier (HPID) and an other entity identifier (OEID). The adoption of a unique HPID is designed to eliminate the need for multiple identifiers in order to streamline HIPAA transactions. The unique identifiers may also be used for any other lawful purpose to uniquely identify a health plan or other entity. 29

31 Who Needs a HPID? ASC plans with greater than $5 million in annual receipts need to obtain an HPID by November 2014 Blue Cross of Idaho is not allowed to apply for a HPID on behalf of our ASC groups Fully-insured groups are not required to obtain an HPID We expect additional information with the release of 2016 requirements 30

32 6 Steps to Obtain an HPID Step 1: Register the organization in HIOS Step 2: Access HIOS User Role Management Step 3: Access HPOES and Select an Application Type Step 4: Complete and Submit an Application Step 5: Application Review by the Authorizing Official Step 6: HPID or OEID Number Assigned Go to the CMS Enterprise Portal at access HIOS. HIOS: Health Insurance Oversight System HPOES: Health Plan and Other Entity Enumeration System 31

33 Entity Type Compliance Date for Obtaining HPID Full Implementation Date for Using HPID in Standard Transactions Health Plans, excluding Small Health Plans November 5, 2016 November 7, 2016 Small Health Plans* November 5, 2016 November 7, 2016 Covered Healthcare Providers N/A November 7, 2016 Healthcare Clearinghouses N/A November 7, * Small Health Plan means a health plan with annual receipts of $5 million or less (45 CFR ).

34 Learn More about HPID See a video walkthrough of each step in the application process to obtain a HPID for: controlling health plan (CHP) subhealth plan (SHP) other entity identifier (OEID) At: cms.gov/regulations-and-guidance/hipaa-administrativesimplification/affordable-care-act/health-plan-identifier.html 33

35 HRA Integrations Allowed 34

36 HRA Integrations Not Allowed 35

37 SSNs and Annual Statements Insurers and ASC groups will need to collect and store SSNs in 2015 Collect SSN at the time of enrollment Two solicitations of SSN: Dec. 31 year of enrollment, and year after enrollment Otherwise, date of birth may be accepted If the group offers MEC a report must be sent to IRS Statements of coverage (similar to a W-2 or 1099) must be sent to enrollee (truncated SSN may be used) Includes grandfathered & grandmothered plans but not Standalone Dental/Vision Wellness programs Medicare Advantage Part B or Medicare Supplement On-site medical clinics 36

38 IRS Reports First report is due February 28, 2016 Report includes Enrollee name Enrollee taxpayer ID number SSN The months the enrollee had coverage for at least one day Name, Address and Employer ID number Insurer or ASC contact person and phone number Form 6055 = info on who is providing coverage and which individuals are covered Form 6056 = info on employer offering coverage and each employee s coverage by month 37

39 Lisa Wilson, Broker Relations Specialist Special Enrollment Periods 38

40 While the open enrollment period ended March 31, there are life events that will allow people to enter a special enrollment period (SEP). These are some of the more common events that will trigger an SEP, allowing your clients or employees to change to or purchase a qualified health plan. Please note: This is information provided is a general overview of the rules and regulations of the ACA. It may not address every specific situation you face with a client or employee, and is not intended to be legal advice. 39

41 Both spouses get an SEP. Both spouses can enroll in a new or different QHP. One spouse can add the other to their plan as a dependent. They must choose a plan within 60 days of the event. Their effective date is the first day of the month following selection of a plan. Buddy and Peggy Sue get married on April 6. Their SEP ends on June 5. They have the option of enrolling in a new QHP, changing their QHP, or if Peggy Sue already has a plan she likes, she can add Buddy as a dependent. If they decide to buy a new plan on April 15, their effective date is May 1. However, if they decided to buy a plan on June 1, their effective date is July 1. 40

42 SEP: Birth/Adoption/Embracing a Foster Child The parent and the child have an SEP. The new mom can add her child to her QHP or enroll in a new QHP. Other family members receive an SEP, regardless of their current enrollment. They must choose a plan within 60 days of the event. The effective date is the date of birth, adoption or placement of foster child. Morticia has a baby boy on June 6. She has a QHP, but now wants to make some changes to her plan. Ultimately, she purchases a new plan on July 4 for her new baby Pugsley and her husband Gomez. Their effective date is June 6. 41

43 SEP: Permanent move to an area served by the Idaho Exchange An individual or family moves into the area and now has access to new QHPs. They must choose a plan within 60 days of the event. All family members are eligible to enroll in a coverage or change to a different QHP. If a plan is purchased between the 1st and 15th of the month, then the effective date is the 1st of the following month. If a plan is selected between the 16th and end of the month, the effective date is the first day of the second following month. Ward, June and Wally move from Pocatello to Coeur d Alene on July 2. They look into a new health insurance plan and purchase on July 17. Their effective date is September 1. 42

44 Nearly any loss of minimum essential coverage (MEC) results in a SEP for your client. The loss of coverage must be completely involuntary and not due to inability or failure to pay premiums. Dependent turns 26 and ages off parent s plan Divorce or legal separation Employer terminates group coverage Expiration of COBRA coverage Loss of retiree coverage Loss of eligibility for an employer plan (i.e. job loss, reduction in work hours, employer bankruptcy) Death of policyholder SEP Period Up to 60 days after the event ī ĞĐƟǀ Ğ ĂƚĞ First day of the month following the event Policyholder is entitled to Medicaid benefits and dependent loses coverage 43

45 According to the ACA, if a plan covers children, parents can add or keep them on their health insurance policy until they turn 26 years old even if they are: married not living with their parents attending school not financially dependent on their parents eligible to enroll in their employer s plan However, once a dependent turns 26, he or she must purchase a new healthcare plan (if continuing healthcare coverage). 44

46 Contacting Members Turning 26 Blue Cross of Idaho is identifying dependents before their 26th birthday Sending letters to both the subscriber and dependent Information about the upcoming changes in coverage and how they can remain a Blue Cross of Idaho members Qualify for 60-day SEP If there is an agent of record attached to the policyholder, we will send copies of correspondence to brokers We encourage you to reach out to your clients 45

47 Rules, regulations and requirements surrounding renewals are still being determined We will send you all information surrounding renewals as soon as possible 46

48 Your Health Idaho HealthCare.gov Blue Cross of Idaho Broker Relations Team We ve added two outstanding presentations on special enrollments to the broker portal. You ll find these at bcidaho.com/brokers under the Special Enrollment Period section. 47

49 Break 48

50 Jonathan Medalie, Director of Sales Strategic Direction: Existing Solutions and Emerging Opportunities 49

51 Providing value combines quality with cost To provide clients, employers and members with the best value in health insurance, we ensure: THE HIGHEST QUALITY CARE AT THE LOWEST POSSIBLE COST 50

52 Three keys to improving value in health insurance Member Engagement Empowered membership with an active role in their health care Provider Coordination Better care coordination between providers and payers Product Innovation Consumer driven health plans health savings accounts 51

53 Educated members are empowered to take an active role in their health and healthcare. We engage members through: One-to-One quarterly member newsletter Online physician search Updated member website Comprehensive Medical Management programs Award-winning Customer Service 52

54 Member engagement looking forward Mobile App Take our member portal with you on your smartphone search for providers, check your benefits and save an electronic version of your member ID card. Transparency Tools We are enriching our website with cost transparency tools and proactive savings alerts that match healthcare services with a member s benefits to show actual out-ofpocket expenses. We are also adding an expanded employer portal with online enrollment. Wellness Platform We want to be our member s go-to resource for health and wellness information so we re enhancing our website with a state-of-the-art wellness engagement solution. 53

55 Coming this summer, take our member portal with you on your smartphone where you can: Find urgent care Search for providers Check your benefits Save an electronic version of your member ID card 54

56 Fall 2014 brings new cost transparency tools and proactive savings alerts that match healthcare services with a member s benefits to show actual out-of-pocket expenses. Members will have online access to: Ways to Save Alerts Savings Options Targeted Engagement Alerts Wellness and Prevention Medication Management Care Management Engagement Cost of Care Calculator 55

57 Calculating the cost of care Empowers members to make informed care decisions by providing personalized cost and quality information for prescription, medical, dental and vision services. Specific network pricing Provider and Facility Quality Ratings Provider Network Integration 56

58 Clients currently have access to a robust suite of reporting tools, including: Monthly activity and solution utilization Delta report (month-overmonth activity) Demographics reporting (age, gender, marital status, dependent children, etc.) In 2015, we will add the benefit of online enrollment, allowing for ongoing status updates to member records from convenient employer portal. 57

59 We want to be our member s go-to resource for health and wellness information so we re enhancing our website with a state-of-the-art wellness engagement solution. Group specific wellness programs Healthy Measures incentive-based product Educational materials Activity-based initiatives Customized web portal for you and your employees Web-based self-management tools Data sharing with other devices (FitBit, FitLinx, etc.) Mobile app to track progress and results 58

60 We manage Total Cost of Care, not just network discounts and provider access Results in reduced cost to employees and employers A move from volume to value Volume Fee-for-service rewards high utilization Value Reward outcomes Improved access to quality care and improved health outcomes Accountability for cost and quality outcomes Our Accountable Care Organization (ACO) is our ConnectedCare Network in southwestern and eastern Idaho ACO Activities: Shared goals and financial incentives Shared governance between provider and payer Adoption of evidence-based medicine Increased clinical collaboration Transition away from fee-forservice payments 59

61 Promoting provider accountability and quality care Balance payments between primary and specialty care Pay for performance features in all contracts 2009 Separated primary care and specialty fee schedules and began closing the reimbursement gap 2012 Implemented pay-forperformance metrics in all physician contracts 2013 Added access and availability requirements for primary care providers 2014 Increased key performance indicator targets 2015 Scheduled to add costefficiency metrics 60

62 In 2015, we will add our own ACO/PCMH programs to the growing list of Blue Distinction Total Care national network for primary care We will further develop our ConnectedCare provider networks in eastern Idaho and the Treasure Valley We are expanding provider participation in existing networks and adding new networks 61

63 ConnectedCare Individual and group dental plans Consumer driven, high deductible health plans BlueCard and GeoBlue Traveler Blue Distinction Total Care 62

64 Expanded ConnectedCare insurance plans and locations Partnership of high deductible health plans and health spending account administrator Online chat feature for Nurse Advice Line Employer Private Exchange In Fall 2014, an online platform for employerdefined contributions as a pilot program Coupled with online enrollment, this shopper site will provide employees a larger choice of insurance products 63

65 Julie Taylor, Director of Governmental Affairs 2014 Legislative Overview 64

66 Influences on the 2014 session 2014 laws, bills and resolutions 65

67 QUESTIONS Would opponents seek to repeal or weaken the law? Would there be another heated debate as there was in 2013? Two bills were introduced to repeal the law but never given hearings. Three bills were introduced to force the vote again: one bill harmless to exchange, the other two were not. Speaker and President of Senate were adamant they did not want to re-debate issue. 66

68 Will the vote on the exchange be the litmus test for the 14 elections? Passed by the Idaho Republican Party: A resolution opposing the state Exchange; a second resolution passed to repeal the state Exchange law GOP State Party Chairman Barry Peterson stated the 2014 primary elections would be the most active in decades due to the vote on the Exchange. 67

69 QUESTION: Will exchange support or opposition be a factor in the 2014 primary elections? Voters typically do not vote on a single issue Idaho ended up with the second largest enrollment in the nation per capita 68

70 36% of Republicans who supported the Exchange have a primary challenger 36% of Republicans who opposed the Exchange have a primary challenger Speaker Bedke: (State) Party leadership had been trying to make this a bigger deal than it is, and I don t mean to downplay it but it looks like a wash to me. (Idaho Statesman, March 23) 69

71 LATEST ACTION: HELD Sponsor: Department of Health & Welfare Purpose: Develop a managed care program for the dual-eligible Medicaid/Medicare population pursuant to a 2013 law Blue Cross of Idaho is interested in pursuing this state contract Program requires that at least two health plans offer benefits Due to lack of interest from a second carrier, governor chose not to pursue this year 70

72 LATEST ACTION: LAW Sponsor: Department of Health & Welfare Purpose: Restores funding for Medicaid dental coverage for adults with disabilities and special needs Funding was reduced in recent years due to state budget shortfall 71

73 LATEST ACTION: HELD Sponsor: Representative Hardy Barrett Purpose: Full repeal of state Exchange law Held in Ways & Means Committee 72

74 LATEST ACTION: LAW Sponsors: Senators Thayn and Rice and Representatives Luker, Rusche and Packer Purpose: Requires state Exchange to have an anonymous shopping option also requires that exchange website contain a warning regarding potential repayment of premium credits if income information changes Sponsors received input from the director of Your Health Idaho (YHI); then YHI legislative board members (Rice, Rusche, and Packer) joined as sponsors 73

75 LATEST ACTION: HELD Sponsor: Representative Hixon Purpose: Require creation of a website and mobile application for citizens to shop and compare prices on 50 most common inpatient and outpatient non-surgical procedures and 25 most common inpatient and outpatient surgical procedures from all hospitals and surgical centers in Idaho Original draft included disclosure of health plan data Bill had good intentions, but was expensive Bill not given a hearing; committee supported a similar effort by Representative Rusche. 74

76 LATEST ACTION: HELD Sponsors: Senators Bayer, Fulcher, Mortimer, Nonini, Nuxoll, Pearce, Vick, and Winder Representatives Barrett, Agidius, Andrus, Barbieri, Bateman, Batt, Boyle, Crane, DeMordaunt, Denney, Gestrin, Harris, Holtzclaw, Loertscher, McMillan, Mendive, Monks, Moyle, Nielsen, Palmer, Shepherd, Sims, Trujillo, VanderWoude, and JoAn Wood All sponsors are those who voted against the Exchange bill in Purpose: Repeal the state exchange; identical to first bill, H418. Held in House Health and Welfare Committee. 75

77 LATEST ACTION: HELD Sponsor: Pfizer Pharmaceuticals Purpose: Require health plans to provide for prorated daily cost sharing rate for less than a 30-day supply of drugs so that members could coordinate the renewal of their prescriptions to a single day of the month. Proposal was unnecessary since members can already coordinate their medications now; bill also had negative (unintended?) consequences to members and their health plans. 76

78 LATEST ACTION: LAW Sponsor: Representative Hixon Bill increases the annual contribution limit to medical savings account to $10,000 per person for state tax purposes, up from the previous $2000; funds held in a medical savings account must be exhausted before the account holder, the account holder's dependent or the account holder's dependent child receives any state assistance for medical care. 77

79 LATEST ACTION: ADOPTED Sponsor: House Minority Leader John Rusche Purpose: Calls for the Department of Health and Welfare to convene a group of stakeholders that will develop a plan for health data collection and analysis through two sources hospital discharge data and health plan claims data Health plans worked actively with sponsor to ensure language in the resolution allows that claims data collection is done in most efficacious and cost effective manner e.g. distributed model 78

80 LATEST ACTION: ADOPTED Sponsor: House Minority Leader John Rusche Purpose: Calls for the Department of Health and Welfare to: Establish a telemedicine council Comprised of a broad group of stakeholders Charged with coordinating and developing a comprehensive set of standards, policies, rules and procedures For the use of telemedicine in Idaho 79

81 LATEST ACTION: HELD Sponsors: Senator Thayn and Representative Luker Purpose: Allow physicians and patients to enter into payment arrangements of a fixed monthly fee for range of services Some physicians have practices using this model exclusively (do not take insurance); others combine this with patients who have insurance Some legislators thought this proposal was problematic when combined with insurance and in light of ACA mandate 80

82 LATEST ACTION: LAW Sponsor: Senator Jim Guthrie Purpose: Current program allows Idaho Department of Health and Welfare (DHW) to purchase childhood vaccines at the reduced CDC rate for use by Idaho physicians who treat patients with private health insurance; health plans are then assessed the cost of the vaccines by DHW New law repeals the sunset clause so the program becomes permanent 81

83 LATEST ACTION: LAW Sponsors: Representatives Rusche and Wood and Senators Schmidt and Hagedorn Purpose: New law provides for development of a coordinated and comprehensive system of evidence-based care that addresses public education and prevention, 911 access, response coordination, transport, hospital emergency/acute care, rehabilitation and quality improvement 82

84 NO ACTION TAKEN Governor and House and Senate leaders did not want to undertake Medicaid this session given the difficult debate and vote on the exchange last session Governor and legislative leaders interested in a private sector approach for the new Medicaid population 2015 will be the year for Medicaid redesign so a workgroup will be convened to create program design Private approach allows the use of federal Medicaid money for individuals at % of Federal Poverty Guidelines to purchase private insurance on the Exchange Health and Human Services has given waivers to Arkansas and Iowa for this approach with Wyoming and Pennsylvania waivers pending 83

85 For further information about these bills, see the State of Idaho legislative website at legislature.idaho.gov 84

86 Questions? 85