introducing ohio’s health marketplace
DESCRIPTION
Introducing Ohio’s Health Marketplace. Presented by John Dodd and John McGough September 17, 2013. So tell me more about that new free health insurance…. Confusion in the market. Starts with the name 85% recognize the name “Obamacare” < 30% recognize “ACA” PPACA ??????? - PowerPoint PPT PresentationTRANSCRIPT
Introducing Ohio’s Health Marketplace
Presented byJohn Dodd and John McGough
September 17, 2013
So tell me more about that new free health insurance…
Confusion in the market
Starts with the name 85% recognize the name “Obamacare” < 30% recognize “ACA” PPACA ???????
Is the Patient Protection Affordability and Accountability Act a law or bill?
What pieces were delayed and until when? Who is eligible for a subsidy and what does it mean to me? What about those tax credits? What will be available and how much will it cost? If I do nothing now, what is the worst that could happen to me? Will the options be same in NW Ohio, Cleveland, Columbus,
Cincinnati and Youngstown? Ohio will have more volatility than other states
Patient Protection Affordability and Accountability Act – Signed into Law
March 23, 2010
Current Political Dynamic
PPACA/ACA/Obamacare
Since passage the law has never gotten above 50% approval in public opinion polls
The law survived a Supreme Court challenge with only a change to the penalty to states not expanding Medicaid to 133-138% of FPL
The law survived two national elections with one of those re-electing President Obama
Current split government in Congress will not bring any legislative changes. Period.
Even if the Republican controlled House of Representatives is successful in de-funding the law, all the other provisions will go forward. We are past the point of return to pre-2010.
PPACA – what does it look like?
What Is The Health Care Reform Law All About? It is NOT a total takeover of the health care system to create a
single payer Canadian or European style health care system.
It is a MASSIVE new law that brings federal regulation to health insurance as opposed to the traditional state regulation of the insurance industry.
It does include a number of new regulations for healthcare providers, but falls short of total takeover of the entire system.
Citizens will still be dealing with private health care providers and private insurance companies unless covered by Medicaid.
Timeline for Implementation 2010
26 total provisions scheduled to be implemented
26 total provisions implemented
2010 PPACA Scheduled Provisions
Review of Health Plan Premium Increases More scrutiny in premium rate review More justification required
Changes in Medicare Provider Rates Qualifying Therapeutic Discovery Project
CreditMedicaid and CHIP Payment Advisory
Commission
2010 PPACA Scheduled Provisions (cont.)
Comparative Effectiveness Research Prevention and Public Health Fund Medicare Beneficiary Drug Rebate Small Business Tax Credits
2010 PPACA Scheduled Provisions (cont.)
Medicaid Drug Rebates Coordinating Care for Dual Eligibles
New efficiencies for those with Medicare and Medicaid
Generic Biologic Drugs New requirements on Non-profit Hospitals
True non-profit??????
2010 PPACA Scheduled Provisions (cont.)
Medicaid Coverage for Childless Adults Reinsurance Program for Retiree Coverage
This was a program for plan sponsors to encourage them to continue retiree plans
Pre-existing Condition Insurance Plan High Risk Pool closed earlier in 2013
New Prevention Council Consumer Website
2010 PPACA Scheduled Provisions (cont.)
Tax on Indoor Tanning Services Expansion of Drug Discount Program Adult Dependent Coverage to Age 26 Consumer Protections in Insurance
Eliminating lifetime limits on coverages No pre-ex limitation for children
Insurance Plan Appeals Process
2010 PPACA Scheduled Provisions (cont.)
Coverage of Preventive Benefits Health Centers and the National Health
Service Corps Health Care Workforce Commission Medicaid Community-Based Services
Timeline for Implementation 2011
20 total provisions scheduled to be implemented
18 total provisions implemented
2011 PPACA Scheduled Provisions
Minimum Medical Loss Ratio for Insurers Closing the Medicare Drug Coverage Gap
$250 check to those hitting Part D doughnut hole in 2011
Beginning 2012 increased % of prescription drugs paid in doughnut hole until reaching 75% in 2020
Medicare Payments for Primary Care Medicare Prevention Benefits Center for Medicare and Medicaid Innovation
Schedule of Progress--Part DMedicare Beneficiary pays this % for Brand-Name in Gap
Medicare Beneficiary pays this % for Generic in Gap
2012 50% 86%
2013 47.5% 79%
2014 47.5% 72%
2015 45% 65%
2016 45% 58%
2017 40% 51%
2018 35% 44%
2019 30% 37%
2020 25% 25%
2011 PPACA Scheduled Provisions (cont.)
Medicare Part B Premium Increase for Higher-Income Beneficiaries
Medicare Advantage Payment Changes Less government payment to Advantage plans
going forward—Will that increase premiums, reduce benefits, or both?
Medicaid Health Homes Chronic Disease Prevention in Medicaid National Quality Strategy
2011 PPACA Scheduled Provisions (cont.)
Changes to Tax-Fee Savings Accounts Penalty for ineligible withdrawals increased from
10% to 20% Grants to Establish Wellness Programs * Teaching Health Centers Medical Malpractice Grants Funding for Health Insurance Exchanges
Exploratory grants to states Followed by implementation grants for those states
choosing to implement a state exchange Ohio choose not to establish a state exchange
2011 PPACA Scheduled Provisions (cont.)
Nutritional Labeling * Medicaid Payments for Hospital-Acquired
Infections Graduate Medical Education Medicare Independent Payment Advisory
Board An independent board that will begin making
decisions on eligible expenses and amounts paid for eligible expenses
Medicaid Long-Term Care Services
Timeline for Implementation 2012
11 total provisions scheduled to be implemented
10 total provisions implemented
2012 PPACA Scheduled Provisions
Accountable Care Organizations in Medicare Uniform Coverage Summaries for Consumers
Summary of Benefits and Coverage Medicare Advantage Plan Payments Medicare Independence at Home
Demonstration Medicare Provider Payment Changes
2012 PPACA Scheduled Provisions (cont.)
Fraud and Abuse Prevention Annual Fees on the Pharmaceutical Industry Medicaid Payment Demonstration Projects * Data Collection to Reduce Health Care
Disparities
2012 PPACA Scheduled Provisions (cont.)
Medicare Value-Based Purchasing Tougher reimbursement rules Proceeding to performance based pay----not
payment per procedure Reduced Medicare Payments for Hospital
Readmissions Changed name of the “Exchange” to
“Marketplace”
Timeline for Implementation 2013
14 total provisions scheduled to be implemented
11 total provisions implemented
2013 PPACA Scheduled Provisions
Employer Notification to Employees Regarding Exchanges Delayed from March 1, 2013 to October 1,
2013 Employers required to provide notice whether
or not they offer a plan—if subject Fair Labor Standards Act (FLSA)
Medicare Bundled Payment Pilot Program Medicaid Coverage of Preventive Services Medicaid Payment for Primary Care
2013 PPACA Scheduled Provisions (cont.)
Itemized Deduction Floor for Medical Expenses Increased from 7.5% to 10% of AGI
Flexible Spending Account Limits Limited to $2500 per year
Medicare Tax Increase
0.9% on income exceeding $200,000 filing single or $250,000 filing jointly
Employee Retiree Coverage Subsidy Tax on Medical Devices-$2.3% on DME
2013 PPACA Scheduled Provisions (cont.)
Financial Disclose * CO-OP Health Insurance Plans
One has been approved for Ohio Did not get organized in time to be in the
exchange/marketplace in 2014 Extension of CHIP through 2015 Medicare Disproportionate Share Hospital
Payments * Medicaid Disproportionate Share Hospital
Payments *
Timeline for Implementation 2014 and Beyond
19 total provisions scheduled to be implemented
2014 PPACA Scheduled Provisions
Expanded Medicaid Coverage Not in Ohio—not yet
Presumptive Eligibility for Medicaid Streamlined application process
Individual Requirement to Have Insurance Health Insurance Exchanges/Marketplaces Health Insurance Premium and Cost Sharing Subsidies
Refundable and Advanceable Federal Income Tax Credits to be used as Premium Subsidies on Silver Level Coverage Purchased in the Exchange/Marketplace
Silver Level Coverage Will be Enhanced to Lower MOOP Limits for those with income below 250% of FPL
2014 PPACA Scheduled Provisions (cont.)
Guaranteed Availability of Insurance No Risk Rating, No Pre-ex
No Annual Limits on Coverage Essential Health Benefits Package Required
in Small Group and Individual Markets Multi-State Health Plans Temporary Reinsurance Program for Health
Plans
2014 PPACA Scheduled Provisions (cont.)
Basic Health Plan Catastrophic plan for those unable to afford coverage
and under age 30 Employer Requirements
Penalty for non-compliance delayed until 2015 Medicare Advantage Plan Loss Ratios Wellness Programs Included in Insurance Plans Fees on Health Insurance Sector
$8 Billion in 2014—looks like about 2.4% of premium Reinsurance pool charge of $5.25 PMPM
Medicare Payments for Hospital-Acquired Infections
2015 and beyond – PPACA Scheduled Provisions
2015 - Increase Federal Match for CHIP 2016 - Health Care Choice Compacts 2018 -Tax on High-Cost Insurance
What Resources Are Available?
We’re here to help you!
What Resources Are Available?
www.NAHU.org www.Healthcare.gov Health and Human Services/Center for
Medicare and Medicaid Services Health Insurance Carriers and Plans Various Professional Organizations (ie. IFEBS,
American College, WEB International, Kaiser Family Foundation, NAIFA, PIA/Big I)
Google.com Googling Your Question Produces a Number of
Qualified Answers From Consultants
Who Will Be Involved In The Exchange/Marketplace Nationally? Agents/brokers
Agents and Brokers are allowed to participate if the state allows agents and brokers to participate
Navigators By law each state must have at least 2
navigators Funded by federal grants in 2014, then by grants
obtained by the exchange/marketplace in 2015 and after
Certified Application Counselors Funded by either state or private grants
Who Can Sell On The Exchange/Marketplace In Ohio? Only licensed agents and brokers may sell,
solicit, or negotiate a contract of health insurance.
Only licensed agents and brokers may recommend a particular product, or option, to a consumer.
Within the Exchange/Marketplace Agents and Brokers are required to provided unbiased information and comparisons of plans
Agents/brokers requirements
Active State of Ohio Health Insurance License Current appointment with all carriers they are
writing Complete Exchange training – available NOW at https://Marketplace.MedicareLearningNetworkLMS.com
Two parts on the individual exchange/marketplace
Part two is now available Agreement is then signed and certification
process begins—all on line SHOP exchange education is optional
Navigators
Under Ohio law (H.B. 3):
Navigator can: (1) conduct public education activities and raise awareness of availability of Qualified Health Plans; (2) distribute fair and impartial general information concerning enrollment in all QHPs and availability of premium tax credits and cost-sharing reductions; (3) Facilitate enrollment in QHPs, without suggesting that an individual select a particular plan; (4) May provide information related to Medicaid eligibility.
Navigator cannot: (1) Sell, solicit or negotiate health insurance; (2) Provide advise concerning substantive benefits, terms or conditions of a plan or offer advice about which plan is better or worse or suitable for a particular individual or entity; (3) Recommend a particular plan or advise consumers about which plan to choose; (4) Provide any information or services related to plans or products not offered in an Exchange; (5) Engage in any unfair method of competition or any fraudulent, deceptive, or dishonest act or practice.
Navigators (cont.)
5 Navigator Grants in Ohio totaling $3,043,868 Ohio Association of Food BanksChildren’s Hospital Medical Center (out)Clermont Recovery Center, IncHelping Hands Community Outreach
CenterNeighborhood Health Association
Navigators (cont.)
Navigators do not receive commissions – their funding mechanism is via the Federal grants in 2014
Structured as a cooperative agreement - Performance period is up to 12 months from the date of the award and future awards funded by the exchange/marketplace
Navigators will be required to annually recertify Navigator includes the organization receiving the grant and
certification plus each person designated to perform navigator duties
Navigators DO NOT carry errors and omissions coverage
Certified Application Counselors
On July 17, 2013 CMS issued a final rule at 45 CFR 155.225 introducing a separate class of Certified Application Counselors (CACs), such as community health centers, health care providers and entities, and community-based organizations, to assist consumers with enrolling in coverage through the Marketplace.
Certified Application Counselors will be designated by the Marketplace to provide the same application assistance that is available from Navigators, but will not be funded through the Marketplace. However, the conflict of interest provisions that apply to navigators do not apply to CACs.
Certified Application Counselors (cont.)
Certified Application Counselors must complete the CMS Exchange Training
Certified Application Counselors do not receive commissions
Certified Application Counselors receive grants from states or other organizations
Certified Application Counselors will be required to annually recertify
Certified Application Counselors DO NOT carry errors and omissions coverage
Other players
Champions for Coverage Carriers E-Enrollment sites (web-based enrollment)
Implementation Time FrameMany Delays
July 2013----Agent/Broker and Navigator Training-running late August 2013----Agent/Broker and Navigator Certification-running late October 1, 2013----Exchange Marketplace open for annual open
enrollment in plans with effective date of 01/01/2014 Applications dated 10/01 through 12/15 get 01/01/14 effective date Applications dated 12/16/13 through 01/15/2014 get 02/01/14 date Applications dated 01/16/13 through 02/15/2014 get 03/01/14 date
Future annual open enrollment will be 10/15 through 12/07 Special enrollment events are recognized during the year
COBRA notices to be changed to proved notice of exchange January 1, 2014----New Premium Rating and Underwriting
Standards begin with renewals on or following this date March 31, 2014----Initial Open Enrollment Period for Exchange
Marketplace ends
How do I get paid on the Exchange?
How Is An Agent/Broker Compensated When Selling Inside the Exchange/Marketplace?
Agents and Brokers Will Continue to Be Paid by the Insurance Company With Whom the Business is Placed—If the Insurance Company Works With Agents and Brokers
The Exchange/Marketplace Has No Desire to Begin Paying Agents and Brokers.
Questions?
The Individual Market
916,000 Ohioans will be eligible for a subsidy – USA Families, March 2013
PPACA – Options for Individuals
Individuals will have options starting in 2014: Keep their employer-based health insurance (if
available) Purchase their health insurance via the
Exchange/Marketplace Purchase their health insurance
off-Exchange/Marketplace Enroll in government program (Medicaid,
Medicare, VA, or other---if qualified) Do not enroll and pay the penalty of $95 or 1%
of their household income (2014 penalty, increases in subsequent years)
Individual Buyers on the Exchange
Individuals may qualify for subsidies and/or benefit enhancements based on income levels From 133% to 400% FPL, various subsidies will be available The subsidies change to 100% to 400% of FPL in states that
do not expand Medicaid Up to 250% FPL, additional benefit enhancements may apply
—called cost sharing reduction Medicaid expansion in Ohio is still unknown; the Ohio
Legislature is still currently holding hearings on both Medicaid reform and possible Medicaid expansion but not for 2014
On September 4, 2013 the Service Employees International and the Ohio Hospital Association formed a coalition named “Healthy Ohioans Work” to start the process of proposing a law to authorize Medicaid expansion through the initiative petition process that could possible lead to a vote on the 2014 General Election ballot.
Federal Poverty Level--2013
Number of persons in household
100%
FPL 48 Contiguous + DC
400%
FPL 48 Contiguous + DC
1 $11,490 $45,960
2 $15,510 $62,040
3 $19,530 $78,120
4 $23,550 $94,200
5 $27,570 $110,280
6 $31,590 $126,360
Federal Poverty Level--2013
FPL % 1 person family
2 person family
3 person family
4 person family
100% $11,490 $15,510 $19,530 $23,550
133% $15,282 $20,628 $25,975 $31,322
150% $17,235 $23,265 $29,295 $35,325
200% $22,980 $31,020 $39,060 $47,100
250% $28,725 $38,775 $48,825 $58,875
300% $34,470 $46,530 $58,590 $70,065
350% $40,215 $54,285 $68,355 $82,425
400% $45,960 $62,040 $78,120 $94,200
Distribution of Population by Federal Poverty Level (2011)Bracket Range FPL
Ohio #
Ohio %
Ohio % of U. S. Total
U. S. #
U. S. %
< 100%
2,213,700
20% 4% 61,319,200
20%
100-138%
803,700
7% 3% 25,051,500
8%
139-250%
2,373,500
21% 4% 60,462,700
20%
251-399%
2,413,500
21% 4% 59,176,200
19%
400% +
3,522,500
31% 3% 101,881,900
33%
Total 11,326,900
100%
4% 307,891,500
100%
Premium subsidies and cost sharing reductions provide powerful incentives for many Americans----------------------Family of Four-------------------------
Annual Household Income % FPL
Annual Household Income Dollars
Individual Responsibility Premium % income
Annual Individual Responsibility Premium $’s
Monthly Premium Equivalent
Average Annual Premium Cost Group Plan ‘12
Amount of Taxpayer Subsidy
100% $23,050 2% $ 461 $ 38 $17,258 $16,797
133% 30,657 3% $ 920 $ 77 $17,258 $16,338
150% $34,575 4% $1,383 $115 $17,258 $15,875
200% $46,100 6.30% $2,904 $242 $17,258 $14,354
250% $57,625 8.05% $4,639 $387 $17,258 $12,619
300% $69,150 9.50% $6,569 $547 $17,258 $10,689
400% $92,200 9.50% $8,759 $730 $17,258 $ 8,499
Individual Buyers on the Exchange/Marketplace
Press Release STATE OF OHIO
DEPARTMENT OF INSURANCE
COMMUNICATIONS OFFICE
8/1/2013
Health Insurance Premiums to Increase 41 Percent
Due to Affordable Care Act
Premiums for Federal Exchange Show Higher Costs for
Ohio Consumers and Small Businesses
Individual Buyers on the Exchange/Marketplace
For individual health insurance plans, a total of 12 companies offering 200 different plans have been approved by the Department for the exchange.
Based on premiums for the current individual market, plans in Ohio today cost on average $236.29 per month compared to $332.58 in 2014. --- 40.7% increase
Individual Buyers on the Exchange/Marketplace
The process for buyers They will receive many notices from various
sources telling them they need to buy health insurance
What roll will you play? How will you continue to be a successful
insurance professional?
Individual Buyers on the Exchange/Marketplace
They need you more than ever!
Individual Buyers on the Exchange/Marketplace
In assisting consumers in the Exchange/Marketplace agents and brokers may assist the consumer in determining their qualification for Medicaid or premium subsidies as well as cost sharing reductions
Agents and Brokers will be assisting consumers with setting up an account on the Exchange/Marketplace website either directly or through a carrier’s portal to the marketplace site
Agents and Brokers may find that the consumer possibly qualifies for Medicaid or CHIP
These consumers should be referred to the Ohio Department of Jobs and Family Services through the Exchange/Marketplace
Agents and Brokers will not be enrolling consumers in these programs
Individual Buyers on the Exchange/Marketplace
If the Consumer qualifies for subsidies questions need to be askedDo they have affordable health insurance that meets the minimum value requirement (.60 AV) available through their employer?Does that coverage meet the affordability safe harbor?If both the above are met, the individual will not qualify for subsidized coverage regardless of incomePersonal situation – everyone has different needs; determine what those immediate and long term needs may be, then proceed with best course for the consumer
Individual Buyers on the Exchange/Marketplace Think of family situations Is spouse eligible for group coverage?
If not, the spouse may qualify for subsidized coverage in the exchange/marketplace
Is family eligible for CHIP? If so, CHIP is available even if employer coverage is
available—that is my understanding How will small employers arrange their benefit package?
Perhaps will purposely not meet affordability standard to allow lower paid families to qualify for subsidized individual coverage in the exchange marketplace while still maintaining a plan for higher paid employees.
How will this affect meeting participation rules for the group?
Individual Buyers on the Exchange
CMS introduction to Healthcare.gov
http://www.youtube.com/watch?v=v5p0u0S_REY&list=PLUslxKz-YuCjD-9VRKOQkd4GHoZDrbMaV
This is a how-to video for an individual using the exchange/marketplace without any assistance.
Individual Buyers on the Exchange
H.B. 3 requires an Exchange operated in Ohio to make a list available of all agents and navigators authorized to provide services in the Exchange. Includes “any website, software application, or other electronic medium, or Exchange-sanctioned outreach event that enables consumers to determine eligibility for and to purchase a Qualified Health Plan through an Exchange”.
Individual Buyers on the Exchange
Healthcare.gov – how to quote/enroll
Not yet perfectly clear
What Are the Procedures for Agents/Brokers Enrolling Someone in the Exchange/Marketplace?
As you know Ohio did not create its own state based exchange/marketplace where it could control the entire process.
Ohio has chosen a Federally-facilitated
exchange/marketplace Ohio retains management of the insurance
carriers operating in the Federally Facilitated Exchange/Marketplace (FFM)
Federal government maintains control of all other functions—website, outreach, navigators, etc.
What Are the Procedures for Agents/Brokers Enrolling Someone in the Exchange/Marketplace?
All FFM activities take place on line Individual Marketplace
There will not be Marketplace offices springing up in your city, town, or county seat
The FFM will have two sections Qualification Section
Find out premium tax subsidies and/or cost sharing reduction qualification—tied to IRS, HHS, CMS
Plan Selection Section
Shop for qualified health plans with or without subsidy
What Are the Procedures for Agents/Brokers Enrolling Someone in the Exchange/Marketplace?
Qualification Section Provide Privacy Notice to Consumer Set up account Provide information about members living in household
—name, date of birth, Social Security number Provide income information for members of household Provide employment information of members of
household—employer name, employer tax ID, basic information on employer health plan provided on exchange./marketplace notice
What Are the Procedures for Agents/Brokers Enrolling Someone in the Exchange/Marketplace?
Qualification Section Continued Eligibility to purchase in exchange/marketplace is determined
U. S citizen or Foreign National legally residing in the U.S.
Premium tax subsidy, if any, is determined Subsidy is advanceable refundable federal income tax credit
Advanceable means the credit is available throughout the year rather than awaiting tax return filing to claim credit
Refundable means the tax credit is available even if that amount of tax is not owed for the year’s income
Consumer may choose to have the credit advanced or to be paid out as income tax refund upon filing a tax return
Any miscalculation of tax credit due to incorrect estimate of annual income is reconciled on the federal income tax return
What Are the Procedures for Agents/Brokers Enrolling Someone in the Exchange/Marketplace?
Plan Selection Section Consumer takes tax credit and cost sharing
reduction estimate to this section All plans available on the marketplace are
assessable here and can be compared Credit subsidy is based on silver level plan Cost sharing reduction is made by modifying the
chosen silver level plan benefits to meet the MOOP set for the FPL income level
Enrollment in selected plan may take place here as well
What Are the Procedures for Agents/Brokers Enrolling Someone in the Exchange/Marketplace?
Agents and Brokers may assist consumers in both sections of the process
In the original plans, the FFM was to have a separate broker portal where certified agents and brokers would enter the FFM with user ID, PIN, and agent number
Agent/broker would then open account for consumer—consumer would need to attest to the information provided---and proceed as shown in previous slides
This portal was removed from plans a few months ago due to complexity—may be added later
What Are the Procedures for Agents/Brokers Enrolling Someone in the Exchange/Marketplace?
Procedures have changed, but we still have not seen a list of direct instructions to follow
Here is my best explanation of how things will work for agents and brokers
Entering through the Marketplace website Agent/broker must be certified to work in the
marketplace Agent/broker enters the Marketplace together with
the consumer to open account and verify consumer information
Eligibility for subsidies is determined
What Are the Procedures for Agents/Brokers Enrolling Someone in the Exchange/Marketplace?
Procedures Continued Consumer gives approval to agent/broker assistance Agent/broker provides ID and NPN Proceed to Plan Selection Section
Compare plans Select Plan Enrollment attestation by consumer Enter Agent/Broker ID and NPN again Enroll in plan Send x12-834 to plan issuer Set up payment by consumer
What Are the Procedures for Agents/Brokers Enrolling Someone in the Exchange/Marketplace?
Entering through an issuer website Agent/Broker must be certified to work in
marketplace On issuer website, log into broker portal Issuer website will include an ACA Calculator When Calculator is accessed, will be directed to
FFM website Register consumer with Marketplace Enter Consumer Demographics Eligibility for any assistance will flow for consumer
back to the issuer website
What Are the Procedures for Agents/Brokers Enrolling Someone in the Exchange/Marketplace?
Directed back to issuer website Compare plans Select plan Enrollment Attestation by consumer Submit enrollment Direct back to marketplace website for
acceptance of enrollment Send x12-834 to issuer Arrange payment by consumer
What Are the Procedures for Agents/Brokers Enrolling Someone in the Exchange/Marketplace?
What Are the Procedures for Agents/Brokers Enrolling Someone in the Exchange/Marketplace?
What Are the Procedures for Agents/Brokers Enrolling Someone in the Exchange/Marketplace?
One prominent health insurance carrier in Ohio suggests that a best practice suggestion is to enroll through the carrier website to assure that the agent/broker receives commission for the sale
What Are the Procedures for Agents/Brokers Enrolling Someone in the Exchange/Marketplace?
Other options Web based broker opportunities
Become certified to include link to FFM on your agency website
Final 300 page rule just released Wednesday, September 4, 2013
Work with an “aggregator” web based broker Larger GA type arrangement
Broker may work within an option of relationships May include private exchange capabilities
Private exchange may be linked to FFM Creative ideas are coming forward for agents/brokers to
consider
Individual Buyers on the Exchange/Marketplace
Carriers offering products on the Individual Exchange/Marketplace
Anthem, Aultcare, Buckeye Community Health Plan, Caresource, Coventry, Healthspan, Humana Health Plan of Ohio, Kaiser, Medical Health Insuring Corporation of Ohio (“MMO”), Molina, Paramount, and SummaCare.
Remember that a market still exists outside the exchange/marketplace that will include other carriers
The FFM carriers may not be working off the FFM
Individual Buyers on the Exchange/Marketplace
All carriers offering products on the Exchange/Marketplace must:Cover the Essential Health Benefits
Including pediatric dental and vision May be part of health insurance plan or stand alone
Cover Preventive Benefits at 100%Meet one of the Metal Levels of coverage with every plan – Platinum, Gold, Silver or BronzeOffer plans on a Guarantee Issue basisDo not apply pre-existing condition to anyoneMeet all other regulatory mandates set forth by HHS and the Ohio Department of Insurance
Individual Buyers on the Exchange/Marketplace
Carriers can vary in the following areas:NetworksPharmacy benefitsDeductible/coinsurance/copay differencesProduct design must meet the minimum actuarial values of the metal level of planExtra “value-added” benefitsCost
Individual Buyers on the Exchange/Marketplace
Sample Silver plans (meet 70% AV requirements)
Carrier A: $2000/$4000 ded – 70% co-ins - $6350/$12,700 MOOP
Carrier B: $500/$1000 ded – 90% co-ins - OV and Rx subject to Ded/Co-ins. $2100/$4200 MOOP
Carrier C:$3000/$6000 ded – 80% co-ins – OV co-pay $10/$50; Rx $10/$35/$70 co-pay-- $6350/$12,700 MOOP
Individual Buyers on the Exchange/Marketplace
Sample Bronze plans (meet 60% AV requirements)
Carrier A: $4300/$8600 ded – 70% coins - $6350/$12,700 MOOP
Carrier B: $5000/$10,000 ded –70% coins – OV copay $40/$80/$40 up to 3 per year; Rx ded and coins; $6350/$12,700 MOOP
Carrier C: $5000/$10,000 HSA – 70% coins - $6000/$12,000 MOOP
Individual Buyers on the Exchange/Marketplace
BEST Opportunities for to ensure your success:1.Get your training/certification from the Exchange2.Know your products/carriers3.Be appointed with all carriers you will write4.Decide how to assist current customers through the process of perhaps moving to the new system5.Referrals will be key to success in this initial enrollment period
The Small Employer Market (SHOP)
We’re here to help!
Small Employer on the Exchange
According to Ohio Department of Insurance press release, Premiums Increase 41 Percent:
For small group health insurance plans, 6 companies offering
184 plans have been approved to sell on the exchange.
For the small group market, today’s premiums average is $341.03 per month compared to $401.99 in 2014 (+ 17.9%). An example of the difference between premium and the cost to provide coverage is that premiums do not include cost sharing paid by the consumer, whereas cost includes both the cost to the company to provide the coverage and the cost sharing paid by the consumer.
PPACA – Options for Small Employers
Small Employers (defined in OH as 2-50 FTE for 2014 and 2015, then to 2-99 in 2016) will have options starting in 2014: Renew/start their employer-based health insurance
in 2013 (pre-modified community rating) Convert to modified community rating on first
renewal coincident with or next following 01/01/14 Purchase their health insurance via the
Exchange/Marketplace with community rating beginning 01/01/14
Purchase their health insurance off-exchange with community rating beginning 01/01/14
Do not offer health insurance benefits
Small Employers on the Exchange
Key considerations for employers:Introduce or maintain group health planAttract and retain quality employeesTotal cost considerationsEarly renewal strategy 2013 vs. new plan January 1, 2014Tax implications
Exchange & Subsidies – NO Employer Sponsored Ins.Age 33, $36,000, Family 4137% FPL, No ESIUnsubsidized Premium: $13,026Maximum % income 4.17% Person pays no more than this % of income for coverage Actual required premium $
1,501 Government Tax Credit
$11,525
** Assumes in Higher regional cost, in 2014 dollars & paid with after tax dollars
Age 57, $95,000, Family 4406% FPL, No ESIUnsubsidized Premium:
$25,193Maximum % income
None Person gets no subsidyActual required premium
$25,193 Government Tax Credit $0** Assumes in Higher regional cost,
in 2014 dollars & paid with after tax dollars
Kaiser Family Foundation – Health Reform Subsidy Calculator
Small Employers on the Exchange/Marketplace
How do I quote/enroll my small group client via the SHOP exchange?
At the time of this presentation, the actual screen shots with options are not available; however, a narrative of the process has been provided by CMS.
Small Employers on the Exchange/Marketplace
The process will be somewhat simplified compared with the process in Ohio today.
1.The employer provides their company name, tax ID, and basic census information including number of employees, dates of birth of employees and dependents if dependent coverage will be offered
Small Employers on the Exchange/Marketplace
2. The agent/broker will provide a group plan proposal for the client.
3. The client selects the single plan/carrier to be offered to the employees.
4. The employer enrolls in the SHOP exchange for the appropriate plan and carrier
Small Employers on the Exchange/Marketplace
5. The employees then enroll via the SHOP with their personal information
6. The employer receives one invoice for all enrolled employees and their dependents
7. Change through the year will be made by employer/employee on line.
8. SHOP primarily for employers using the small business tax credit
Small Employers on the Exchange/Marketplace
Carriers offering small employer group products on the Exchange:
Anthem, Aultcare, Healthspan, Kaiser, Medical Health Insuring Corporation of Ohio (“MMO”), and SummaCare.
Like the individual market, a small group market will continue to be offered outside the Exchange/Marketplace. Additional carriers who may not offer coverage in the FFM may offer cover coverage outside the FFM.
Small Employer on the Exchange/Marketplace
All carriers offering products on the Exchange must:Cover the Essential Health Benefits
Including pediatric dental and vision May be included in the health plan or stand alone
Cover Preventive Benefits at 100%Meet one of the Metal Levels of coverage with every plan – Platinum, Gold, Silver or BronzeOffer plans on a Guarantee Issue basisDo not apply pre-existing condition to anyoneMeet all other regulatory mandates set forth by HHS and the Ohio Department of Insurance
Small Employers on the Exchange/Marketplace
Carriers can vary in the following areas:NetworksPharmacy benefitsDeductible/coinsurance/copay differencesProduct design to meet the minimum actuarial valuesExtra “value-added” benefitsCost
Small Employers on the Exchange/Marketplace
Sample Silver plans (meet 70% AV requirements)
Carrier A: $1500/$3000 ded – 80% coins - $6350/$12,700 OOP max
Carrier B
Carrier C: $2000/4000 ded HSA – 80% coins - $3800/$7600 OOP max
Small Employers on the Exchange/Marketplace
Sample Bronze plans (meet 60% AV requirements)
Carrier A: $3500/$7000 ded – 70% coins - $6350/$12,700 OOP max
Carrier B:
Carrier C: $5000/$10,000 ded – 70% coins - $10/$50 OV co-pay; $15 generic/75% coins after ded Rx Card; $6000/$12,000 MOOP
PPACA – Other Options
Additional options for Ohioans Medicaid – status of expansion CHIP VA/Federal Plans Medicare Others?
Continue to Be a Person Bringing Value to the Consumer
We must prepare for what is coming. We must prepare our clients for what is
coming. If we provide value added service we will
always have a place in the marketplace. Opportunities abound!
You’re needed NOW more than EVER!
Introducing Ohio’s Health Marketplace
QUESTIONS?