national health council - preparing for exchange enrollment (july 2013)
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Preparing Your Staff and Patientsfor Exchange Enrollment
July 17, 2013
Essential Health Benefits: We’ve Only Just Begun
Marc Boutin, JDExecutive Vice President and COO
National Health Council
The mission of the National Health Council is to provide a united voice for people with
chronic diseases and disabilities.
© National Health Council
Putting Patients First®
Cover Everyone
Curb Costs Responsibly
Abolish Exclusions for Pre-existing Conditions
Eliminate Lifetime Caps on Benefits
Ensure Access to Long-tem and End-of-life Care
GOAL: Engage individuals in a nationwide effort to create and implement a modern health care system, based on 5 Principles for Putting Patients First®
© National Health Council
© National Health Council
Essential Health Benefits
Broad Definition of Covered Services
―Specific List of
Exclusions
© National Health Council
Patient Protections
Anti-Descrimination
Medical Necessity
Exceptions and Appeals
Continuity of Care
Prohibition of Specialty Tiers
Limited Cost Sharing
Part D Protected Classes
© National Health Council
Patient Community Wins
Drug Formulary must have the same number of prescription drugs in each class as that of the EHB-benchmark plan
States must monitor and identify discriminatory benefit designs
The ability of health plans to substitute benefits is limited.
© National Health Council
Tools: Choosing an appropriate plan
Evaluation and Tracking Tool
Patient Advocacy Tools
© National Health Council
Public Policymaking Process in the U.S.
Interest Group Preferences, Demographics, Technological Inputs
Policy Modification Phase – Feedback
Policy Formulation
Phase
Development ofLegislation
Policy Implementation
Phase
Rulemaking Application
Based on Health Policymaking in the United States, 2nd Edition, by Beaufort B. Longest Jr.
State Exchangesand Medicaid Expansion:
What do you need to know?
Kelly BrantleySenior Manager
Avalere Health, LLC
© Avalere Health LLCPage 13
Agenda
Coverage Expansion
Affordability in Exchanges
Enrollment
Federal and State Consumer Outreach and Enrollment Activity
» Opportunities for NHC Members to Participate
Next Steps
Q&A
Coverage Expansion
The intersection of businessstrategy and public policy
© Avalere Health LLCPage 15
The ACA Is Expected to Reduce Number of Uninsured, Primarily through Enrollment in Medicaid and Exchanges
Source: Avalere Enrollment Model, June 2013. Assumes 26 states opt out of the Medicaid expansion. Avalere assumes that: Arkansas enrolls new Medicaid eligibles into the exchange through premium support, Iowa enrolls new Medicaid eligibles over 100 percent of poverty into the exchange through premium support, and Wisconsin reduces Medicaid eligibility to 100% FPL and moves these individuals in the exchanges.ACA = Affordable Care Act
2013 2014 2015 2016
49 40 35 26
54 59 6162
16 13 12 11
141 140 141 141
5 5 5 5
50 52 53 55
8 12 22
Expected Sources of Coverage (in Millions), 2013-2016
MedicareOther Public ProgramsEmployerNon-Group ExchangesMedicaid and CHIPUninsured
© Avalere Health LLCPage 16
Health Reform Broadens Medicaid Eligibility Substantially
The ACA required states to expand the Medicaid program…» Required states, beginning in 2014, to cover all individuals who are under 65,
do not receive Medicare, and have income below 133% FPL» Largely affects parents and childless adults who are not disabled
…but the Supreme Court rendered the expansion optional» The court ruled that states must be given a choice about whether or not to
move forward with the ACA’s Medicaid expansion» The federal government cannot cut off existing Medicaid funding to states that
choose not to proceed with the expansion
ACA = Affordable Care ActFPL = Federal Poverty Level
Expansion largely will help parents and childless adults who are not disabled. Most states only cover parents at much lower income levels, and very few states cover any childless adults unless they are disabled.
© Avalere Health LLC
To Date, 23 States & DC Plan to Expand Medicaid Eligibility in 2014, 21 Will Not Expand, and the Remainder Are Undecided
AK
HI
CA
AZ
NV
OR
MT
MN
NE
SD
ND
ID
WY
OK
KSCOUT
TX
NMSC
FL
GAALMS
LA
AR*
MO
IA*
VA
NCTN*
IN
KY
IL
MIWI
PA
NY
WV
VT
ME
RICT
DEMD
NJ
MANH
WA
OH
DC
Will Expand (23 + DC)
State Commitment to Expand Medicaid Eligibility in 2014
Leaning No (6)
Will Not Expand (21)
Source: Avalere State Reform Insights, Updated July 15, 2013* Considering a premium assistance model for expansion using exchange plans for some or all beneficiaries
© Avalere Health LLCPage 18
Exchanges Aim to Offer One-Stop Shopping to Individuals and Small Businesses, Similar to Online Travel Sites
Exchange Governing Body
Individual Exchange
SHOP Exchange
26 M enrollees Majority are subsidized
individuals; No subsidies for those with
ESI*
Unknown number of groups with ≤100
workers
* Individuals with an offer of employer-sponsored insurance (ESI) are not eligible for subsidies unless their individual employer premium exceeds 9.8% of their income or does not provide minimum value.Source: Avalere Health Enrollment Model, June 28, 2013.
© Avalere Health LLCPage 19
By 2019, About 26 Million People Will Gain Health Insurance Coverage through the Exchanges
Projected Number of Exchange Enrollees, 2014-2019
En
roll
men
t (
Mil
lio
ns)
2014 2015 2016 2017 2018 20190
5
10
15
20
25
7
10
1921 21 21
1
2
4
4 4 5
Subsidized Unsubsidized
Source: Avalere Enrollment Model, June 2013. Assumes 26 states opt out of the Medicaid expansion. Avalere assumes that: Arkansas enrolls new Medicaid eligibles into the exchange through premium support, Iowa enrolls new Medicaid eligibles over 100 percent of poverty into the exchange through premium support, and Wisconsin reduces Medicaid eligibility to 100% FPL and moves these individuals in the exchanges.
© Avalere Health LLCPage 20
State-Run Exchange State Partnership Exchange (SPE)
Federally Facilitated Exchange (FFE)*
States Have Three Options with Varying Degrees of State Responsibility for Exchange Functions
States have three options:1) Perform plan
management only2) Perform consumer
assistance only3) Perform both plan
management and consumer assistance
HHS will manage technical functions – eligibility and enrollment, financial management, etc.
Partnership blueprints were due on February 15, 2012
States manage core exchange functions:» Plan management
» Consumer assistance
» Eligibility and enrollment
» Financial management
The ACA appropriates state establishment grants to support these activities through 2014
Exchange blueprints were due on November 16, 2012
ACA requires HHS to run a FFE in any state that does not set up an exchange
States with the FFE will not control key exchange functions, although the federal government is consulting with states on its design
FFE states will retain traditional responsibilities of their insurance departments
HHS = Department of Health and Human Services* HHS has approved eight FFE states—KS, ME, MT, NE, OH, SD, UT and VA—to operate the “Marketplace Plan Management” model in which these states will perform plan management.
© Avalere Health LLCPage 21
16 States and DC Will Run Exchanges in 2014, While 6 States Will Pursue Partnerships, and the Rest Will Rely on the FFE
Source: Avalere State Reform Insights, July 15, 2013.*In addition to the marketplace plan management model for its individual exchange, Utah will rely on its existing small group exchange as its SHOP.**While New Mexico will operate a partnership for its individual exchange, the state will run its own SHOP.*** Although Idaho will operate a state-based exchange, it will rely on HHS for certain functions, such as eligibility and enrollment.
Insurance Exchange Operational Model
AK
HI
CA
AZ
NV
OR
MT
MN
NE
SD
ND
ID***
WY
OK
KSCO
UT*
TX
NM**SC
FL
GAALMS
LA
AR
MO
IA
VA
NCTN
IN
KY
IL
MI
WI
PA
NY
WV
VT
ME
RICT
DEMD
NJ
MANH
WA
OH
D.C.
FFE – Marketplace Plan Management (8)
State-Run (15 + DC)
FFE (20)
Partnership (7)
Affordability in Exchanges
The intersection of businessstrategy and public policy
© Avalere Health LLCPage 23
Plans in the Individual and Small Group Market, Including Exchange Plans, Must Offer the Essential Health Benefits1. Essential Health Benefits
» Applies to all individual and small group plans
2. Out-of-Pocket Limits (OOP)
» Applies to all plans – OOP cap is tied to annual HSA limits ($6,350 for an individual in 2014)
3. Actuarial Value
» All individual and small group plans in the exchange must offer Silver and Gold
Ambulatory patient services Prescription drugs
Emergency services Rehabilitative and habilitative services and devices
Hospitalization Laboratory services
Maternity and newborn care Preventive and wellness services and chronic disease management
Mental health and substance abuse services Pediatric services (including oral and vision care)
Bronze Plan covers 60% of healthcare costs
Silver 70% of healthcare costs
Gold 80% of healthcare costs
Platinum 90% of healthcare costs
Actuarial Value = A measure of a benefit generosity that is expressed as percent of expenses paid by the insurerHSA = Health Savings Account
© Avalere Health LLCPage 24
Exchange Plans Will Follow Set Metal Levels & Will Be Less Generous than Employer Coverage
Insurance Plan % of Patient Costs Covered by Plan
Typical Employer Plan (HMO)1 93%
Platinum 90%
FEHBP Blue Cross Blue Shield Standard Option (PPO) 1
87%
Typical Employer Plan (PPO)1 80.0% - 84%
Gold 80%
Medicare Parts A, B and D1 76%
Silver 70%
Bronze 60%
1. Peterson, Chris. “Setting and Valuing Health Insurance Benefits.” Congressional Research Service. (2009)
Most enrollees are expected to select lower-premium Silver and Bronze plans, which will include very high out-of-pocket requirements for patients.
May have very high cost-sharing—enrollees could be
underinsured
© Avalere Health LLCPage 25
Exchanges Will Offer Premium and Cost-Sharing Subsidies
Premium Subsidies: Sliding scale tax credits to limit premium spending as a percent of income for individuals under 400% FPL; Applies to the second lowest cost Silver plan available in the exchange
Cost Sharing Reductions: Provides cost-sharing subsidies for individuals with incomes below 250% FPL
Income Premiums Limited to % of Income
<133% FPL 2.0%
133 – 150% FPL 3.0 - 4.0%
150 – 200% FPL 4.0 – 6.3%
200 – 250% FPL 6.3 – 8.05%
250 – 300% FPL 8.05 – 9.5%
300 – 400% FPL 9.5 %
FPL = Federal Poverty LevelOOP = Out-of-Pocket
Household Income
Reduction in OOP Limit Actuarial Value
100 - 150% FPL 2/3 94%
150 – 200% FPL 2/3 87%
200 – 250% FPL 1/5 73%
250 – 400% FPL None, given AV level 70%
© Avalere Health LLCPage 26
Initial Rate Filings Show Wide Variation in Silver Plan Premiums within and among States
CA (13) CO (10) CT (4) OH (5) OR (12) RI (2) VA (5) VT (2) WA (7) $-
$100
$200
$300
$400
$500
$600
$700
Monthly Silver Plan Premiums for Nonsmoking 40-Year-Olds for Exchange Plans*
Maximum
State (Number of Carriers)
Mo
nth
ly P
rem
ium
* Rates are for plans filed to be offered through exchanges for nonsmoking 40-year-old individual. Data are for the minimum, maximum, and averages across all regions within a state. Source: Avalere Health analysis of health insurance rate filings publicly available as of June 12, 2013.
© Avalere Health LLCPage 27
Case Study: Despite Health Care Reform’s OOP Limit, Patients with Rare Diseases Will Face High Initial Costs for Their Drugs
First Month's Rx Fill Second Month$0
$1,000
$2,000
$3,000
$4,000
$5,000
$6,000
$7,000
Estimated Drug Spending for Rare Disease Patients in Exchange Coverage
Assumes $15,000 Monthly Drug Cost
VT DeductibleCA Silver Coinsurance PlanMA, NY Silver*OR Standard Silver PlanCT Standard Silver
Source: Avalere Health analysis based on states’ 2014 standardized benefit designs for silver-level plans in their exchanges. Calculations are based on a prescription drug with a cost of $15,000 per month that is placed on a plan’s highest-cost formulary tier. Assumes no other drug or medical spending by the patient during the year.* MA and NY each have a standard silver plan design with the same overall deductible amount, tier 3 cost sharing, and OOP maximum, although the benefit designs differ on cost sharing amounts for other services not included in this analysis.
© Avalere Health LLCPage 28
The Affordable Care Act Introduces New Protections Invaluable to Patients with Special Healthcare Needs
• Insurers must cover treatment for conditions patients had prior to obtaining coverage
Pre-existing Condition Exclusions
• Insurers cannot turn down patients based on health status for initial enrollment or renewals
Guarantee Issue
• Insurers may only vary the premium rates for enrollees on the basis of four factors: family size, rating area, age, and tobacco use
Rating Rules
• Insurers must combine the claims experience across all enrollees in each market when setting premiums
Single Risk Pool
Enrollment
The intersection of businessstrategy and public policy
© Avalere Health LLCPage 30
Options for Enrollment in Exchange Coverage Will Include an Online Web Portal and In-Person Assistance
Medicaid / CHIP
Apply for Coverage Select Benefit & Health Plan
Platinum (90%)
Gold (80%)
Silver (70%)
Bronze (60%)
United
Humana
CIGNA
Aetna
WellPoint
BC/BS
Regional
Complete Enrollment
Income Verification
Process
Exchange without Subsidy
Exchange with
Subsidy
Exchange portals will allow individuals to determine eligibility for exchanges and subsidies
Consumers will be allowed to select from three to four coverage levels* and from a variety of benefit designs and carriers
In-person assistance will be available to aid consumers in enrollment decisions
* Individuals receiving cost-sharing reductions must purchase silver-level coverage
© Avalere Health LLCPage 31
Patients Can Enroll Beginning in October, with Coverage Effective as Soon as January 1
July August Sept October Nov Dec Jan Feb March April
2013 2014
For enrollments between October 1 and December 15, 2013, coverage will be effective January 1, 2014
After December 15, for enrollments between the 1st and 15th day of the month, coverage will begin the first day of the next month. For enrollments between the 16th and the last day of the month, coverage begins the first day of the second following month.
Patients will be able to enroll outside of the open enrollment period only if they experience qualifying events including:
» Marriage or divorce
» Loss of other insurance coverage (from an employer, for example)
» Become eligible for subsidies due to change in income
October 1: Open Enrollment Begins
January 1: New Coverage Effective
March 31: Open Enrollment Closes
© Avalere Health LLCPage 32
The ACA Requires People Who Do Not Have Health Insurance to Pay a Penalty, Which Phases Up in Later Years
Year Penalty
2014 Greater of $95 or 1% of income (offset by filing threshold)
2015 Greater of $325 or 2% of income (offset by filing threshold)
2016 Greater of $625 or 2.5% of income (offset by filing threshold)
2017Greater of $625 (+ cost of living
adjustment) or 2.5% of income (offset by filing threshold)
Penalty amounts increase in future years, but are capped at bronze premium levels
Source: IRS, Proposed Rule, Shared Responsibility Payment for Not Maintaining Minimum Essential Coverage, January 2013.
© National Health Council
State Navigators, Assisters, and Counselors: How to work with them
Purva RawalSenior Manager
Avalere Health, LLC
Consumer Outreach and Enrollment Activity
The intersection of businessstrategy and public policy
© Avalere Health LLCPage 35
HHS and States Focused on Consumer Outreach and Enrollment As October 1 Approaches
Exchanges must have fixed, annual open enrollment periods with special enrollment periods for particular circumstances
» Initial open enrollment period will run from October 1, 2013 through March 31, 2014 » In subsequent years, annual enrollment will run from October 15 through December 7
of each year
Major federal, state, and private marketing efforts are expected to begin this summer to draw attention to the coverage expansions and the exchange marketplaces in time for enrollment assistance on October 1, 2013
APR MAY JUN JUL AUG SEPT OCT NOV DEC JAN FEB MAR
October 1, 2013-March 31, 2014: Initial open enrollment in the individual exchange
October 15-December 7: Annual open enrollment
in the individual exchange
© Avalere Health LLCPage 36
Patients Will Need Support across Three Domains•Althoug
h many people will qualify for federal subsidies in the exchanges, individuals may still have trouble affording premiums
•Affordability may vary greatly by state depending on enrollment trends and the payer landscape
Premiums
•Awareness of new coverage options is low and the process for applying will be complex for many to navigate
•Patients will require non-bias, informed support from navigators and non-navigator assisters in order to enroll in the plan that best meets their needs
Enrollment
•Cost sharing for upper tiered medications is expected to be high, ranging from 20-50% on tiers 3 and 4 in states with standardized plan designs
•While some patients will be eligible for cost-sharing subsidies, many will need support accessing medications before they meet the OOP limit
Access to Providers and
Treatments
© Avalere Health LLCPage 37
HHS Has Proposed Three Separate Consumer Assister Entities to Boost Exchange Enrollment
Navigator In-person AssistersCertified Application Counselor
Roles and Responsibilities
Assist and educate individuals to receive eligibility determination from exchange and help with enrollment
Provide similar assistance as Navigator to supplement the Navigator program for the initial years of the exchanges
Assist consumers in completing and gathering information for single streamlined eligibility application for Medicaid, exchanges
Funding Grants from HHS in FFE and SPEs, grants from the state exchange in SBEs
Exchange Establishment Grants
Self-funded; federal and exchange grants not available
States FFE, SPE, SBE SPE, Optional SBE FFE, SPE, SBE
FFE = Federally Facilitated Exchange; SPE = State-Partnership Exchange; SBE = State Based Exchange Source: Centers for Medicare & Medicaid Services. Proposed Rule on Standards for Navigators and Non-Navigator Assistance Personnel. Released April 3, 2013.
The multiple consumer assister options, differing funding streams, and staggered application deadlines –in the absence of final rules - are challenging to those trying
to identify what consumer assister roles they can play and where.
© Avalere Health LLCPage 38
States with RFPs for Navigators, IPAs, or Certified Application Counselors
AK
HI
CA
AZ
NV
OR
MT
MN
NE
SD
ND
ID
WY
OK
KSCO
UT
TX
NMSC
FL
GAALMS
LA
AR
MO
IA
VA
NCTN
IN
KY
IL
MIWI
PA
NY
WV
VT
ME
RICT
DEMD
NJ
MANH
WA
OH
D.C.
RFP Released (12 + DC)
No RFP (40)
To Date, 12 States and DC Have Issued RFPs for Consumer Assistance Programs
Source: Avalere State Reform Insights, July 15, 2013.
© Avalere Health LLCPage 39
States Are Spending on Consumer Assistance More Heavily than HHS
FFE AK CA CO CT DC HI IL MD MN NV VT
54,000,000
$16
43,000,000
17,000,000
4,550,000
10,000,000
$0.43
28,000,000
24,000,000
4,000,000 3,990,000
12,840,000
Spending on Consumer Assistance Programs, in Millions
Avalere analysis based on publicly reported spending on consumer assistance programs, including navigators and IPAs.Source: Avalere State Reform Insights, July 15. 2013
© Avalere Health LLCPage 40
HHS Has Made Steady Progress on Consumer Assistance Programs, But Significant Work Still Must Be Accomplished
Funding Delays Training PlanA
Outstanding Activities
The funding announcement for the Navigator program was delayed until April 9, 2013 and CMS indicated only one round of awards would take place.
The anticipated award date is now August 15, 2013 and CMS expects to make awards to at least two different applicants in each of the 34 FFE states and 33 FF-SHOP states.
Federally funded in-person assisters, including Navigators, must be trained and certified before conducting outreach assistance activities.
CMS plans to complete the development of the Navigator training curriculum and certification exam by August 2013 and will begin training once the curriculum is published.
CMS recommended that in-person outreach activities begin in the summer of 2013 to educate small employers and employees in advance of the open enrollment period.
In addition, HHS is targeting marketing and outreach efforts to specific populations, such as young adults and Hispanics.
Source: GAO Report: Status of Federal and State Efforts to Establish Federally Facilitated Health Insurance Exchanges. June 2013. Available at: http://www.gao.gov/assets/660/655291.pdf
© Avalere Health LLCPage 41
Navigators and Assisters Must Be Trained Quickly and Prepared to Reach Varied Populations
•Minorities expected to be disproportionately represented—need for consumer assister services in other languages
•Population expected to have lower educational attainment compared to those with ESI requiring materials at appropriate literacy levels, etc.
Population
•Navigators and non-Navigator assistance personnel must obtain certification through the exchange, complete and pass an HHS-approved training, and obtain continuing education and be recertified
•CMS estimates training will take up to 30 hours for certification
Training
•Navigators and non-Navigator assistance personnel must be trained and certified quickly in anticipation of open enrollment October 1
•Interested entities must apply by June 7, with awards made by August 15 (letter of intent due May 1)
Timing
Patient groups and community-based organizations could play a critical role in educating Navigators and IPAs on the benefit design features enrollees with special
needs or chronic health conditions should consider before selecting a plan.
© Avalere Health LLCPage 42
Opportunities for NHC Members to Engage
Patient advocacy groups have a key role to play in educating Navigators and In-Person Assisters in serving exchange enrollees with special needs or chronic conditions
Key considerations in plan design for assisting patients
» Provider Access: Ensure patients’ physician(s), facilities of choice are in-network
» Drug Cost-Sharing and Other Access Limitations: Understand formulary rules for specialty drugs and biologics, including costs and utilization management
NHC members should seek opportunities to partner with other stakeholders who share the goal of maximizing exchange enrollment and promoting high levels of appropriate plan choice
QUESTIONS?
If you have any questions or commentsabout the National Health Counciland its work on behalf of patients,
the essential health benefits, or enrollment in the exchanges,
contact us at info@nhcouncil.org.
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