introduction to health insurance exchanges. affordable care act (aca) insurance reforms – no...

Introduction toHealth Insurance Exchanges

Mim Dixon USET Training

Tunica Biloxi Tribe, LAMay 22, 2012

The Patient Protection and Affordable Care Act (P.L. 111-148) was enactedMarch 23, 2010.

Affordable Care Act (ACA)

• Insurance Reforms– No lifetime limits, annual limits– Pre-existing conditions

• Medicaid Expansion• Health Insurance Exchanges

– Individuals– Small businesses

• Medicare Part D “donut hole” changes• Quality, Prevention, Innovation • Health Care Workforce • Indian Health Care Improvement Act

– Title X, Subtitle B, Part III, Sec. 10221

ACA Strategies to Reduce Number of Uninsured in America• Remove barriers

• Insurance reform• Medicaid expansion• Create market structure (Exchanges)• Risk reduction for insurance companies

• Carrots• Federal premium assistance for individuals• Federal tax credits for businesses <25 employees

• Sticks• Tax penalty for uninsured

• “Individual mandate” - AI/AN are exempt• Business with >50 employee

• Fined $2,000/person over 30 people

What is Health Insurance Exchange?

• Consumers and businesses can compare insurance plans and purchase

• Federal subsidies of premiums• Enrollment in Medicaid, CHIP, Basic Health Plan (if available)• Web based approach• State or federal exchanges • Operational by January 1, 2014

“Metallic” Plans in Exchange

• All plans: same Essential Health Benefits• Plans may differ:

• Networks of providers• Cost of premiums, co-pays and deductibles

• Actuarial values of plans equal within metallic categories

• Bronze – 60% actuarial value• Silver – 70% actuarial value• Gold – 80% actuarial value• Platinum – 90% actuarial value

Exchange Functions• Select Qualified Health Plans (QHP)• Enrollment• Determine individual eligibility • Enroll people in QHPs• Contract with Navigators• Call centers

• Financial management• Premiums• Tax Credits• Cost Sharing• Risk adjustments

Why are Exchanges Important for Indian Health?

• New source of funding• Covers adults < 65• Premium assistance

• Up to 400% FPL

• I/T/U can bill plan • Shift CHS costs to plans

• Medicaid Expansion• Up to 133% FPL• Assets not counted• Covers all adults• Enroll through Exchanges

AI/AN have special protections and provisionsin ACA related to Exchanges.

American Indians and Alaska Natives are

• Exempt from penalty for being uninsured• Exempt from most cost sharing in

Exchange Plans• Cost sharing = deductible + co-pay• Federal government pays cost sharing to

Plans• Able to enroll monthly

Exemptions from Cost Sharingfor AI/AN Enrolled in Exchange Plans

• No deductibles ever• No cost sharing ever for people served in I/T/U• I/T/U collects 100% of charges from plan

• No cost sharing in private sector for AI/AN with referral from I/T/U• CHS does not pay any portion of care covered by plan

• For AI/AN below 300% FPL, no cost sharing in private sector without referral from I/T/U.

Premium Subsidies

• AI/AN have same premium subsidies as everyone else in Exchanges

• Based on Modified Adjusted Gross Income (MAGI)

• Sliding scale up to 400% FPL (96%-35%)• Silver level is benchmark• Advanced tax credits• Paid to insurance company• Reconciliation at end of year

2012 Federal Poverty Level2011 HHS Poverty Guidelines

Personsin Family

48 ContiguousStates and D.C. Alaska Hawaii

1 $11,170 $13,970 $12,860

2  15,130  18,920  17,410

3  19,090  23,870  21,960

4  23,050  28,820  26,510

5  27,010  33,770  31,060

6  30,970  38,720  35,610

7  34,930  43,670  40,160

8  38,890  48,620  44,710

For each additionalperson, add

   3,960    4,950    4,550

Annual Federal Subsidy of Health Insurance Premiums by Income Level for Individuals

% FPL Premium Limitas % Income

Individual Premium(Tribal Sponsorship)

138-150 2% < $690

151-200 3-4% $1,037

201-250 4-6.3% $1,875

251-300 6.3-8.05% $2,776

301-400 8.05-9.5% $3,391-$4,099

Example: Tribe Pays Portion of Premium

• Tribe pays 2% of premium for individual below 150% FPL with high cost medical needs.

• Tribal Sponsorship is $690 per year.

• Tribe collects payments from plan for all visits and medications provided to individual.

• No cost to CHS for specialty medical care and hospital services.

• More money is available to provide more services for all Tribal members.

With no cost sharing, AI/AN can choose QHPs with lower premiums.

Barriers to AI/AN Enrollment• Premium• Tribal sponsorship can eliminate barrier• Basic Health Plan can eliminate barrier

• IRS rules and regulations• Advanced tax credits + reconciliation• No enrollment for non-filers• Complex rules• Basic Health Plan can eliminate barrier

• Lack of insurance experience, knowledge • No motivation to enroll• Federal and State Exchange regulations

Regulations, Design, Plans

Federal

TribalState

Exchange Federal Regulations

• Regulations issued by two agencies• CMS, Center for Consumer Information and

Insurance Oversight (CCIIO)• Department of Treasury, IRS

• Federal government is deferring to States to give them flexibility.

• National Tribal Participation• NIHB, MMPC, TTAG, NCAI, TSGAC

Federal Regulations Issued

• Establishment of Exchanges and QHPs• Standards Related to Reinsurance, Risk

Corridors and Risk Adjustment• Health Insurance Premium Tax Credit• Exchange Functions: Eligibility

Determinations, Employer Standards • Medicaid Eligibility Changes under the ACA• Essential Health Benefits• Actuarial Values

More NPRMs are coming. . .

• Federal payment of cost sharing for AI/AN• Tax penalties for individuals, businesses• Basic Health Program• Standards for Oversight of Quality and

Reporting

Planning at State Level

• Laws, Executive Orders to Establish Exchanges

• Federal Exchange Establishment Grants

• Health Insurance Commissioners• Medicaid, CHIP, Basic Health Plans• Tribal Consultation

• Letter from HHS Secretary to State Governors

Planning within your Tribe

• Designate individual or team to become informed about ACA and Exchanges

• Advocacy at State and Federal levels• Participate in Exchange planning for State• Tribal planning and budgeting • Premium payments• Provider contracts• Outreach and enrollment assistance• Communications plan

Key DatesJanuary 1, 2013 – HHS decides whether

state is ready to operate an ExchangeOctober 15, 2013- First open enrollment

period starts for ExchangesJanuary 1, 2014 – QHPs start offering services

through the Exchange

Tribal Leaders and I/T/U managementmust devote attention toHealth Exchange decisionsnow through 2013.