The Federal Health Insurance MarketplaceFebruary 27, 2014

John RogersManager, Self-Pay ServicesRevCare, Inc.

2

Federal Marketplacewww.healthcare.gov

Ohio’s Federal Health Insurance Marketplace

• Ohio and 36 other states did not build a state exchange, deferring to the Marketplace for individuals/families, and a Federal Small Group Health Options Program (SHOP) marketplace for employer groups of 50 and under. (SHOP enrollment delayed until November 2014.) These two exchanges will operate separately and with different risk pools.

• Ohio Marketplace is accessed at www.healthcare.gov.• Ohio Department of Insurance (ODI) regulates and manages state plan

participation. • 15 Ohio payer applied to ODI to offer 200+ plans through exchange. ODI

reviewed plan rates and readiness in July. 12 plans approved and operating in 2014.

• FFE Open enrollment: October 1st, 2013 through March 31, 2014. Plans effective January 1st, 2014. Next open enrollment is November 15, 2014 through January 15, 2015.

• Enrollment primarily facilitated by consortia of community organizations called “Navigators”, approved and funded by CMS for 12-month periods. Navigators are responsible for outreach, education, and assistance with plan selection and enrollment. Ohio’s share of Navigator funds was $2.6M ($54M available nationally).

• “Certified Application Counselors” (CAC), designated and trained by CMS, can also facilitate enrollment.

• Exchange provides subsidized insurance options from 100-400% of FPL, most coverage begins at 138%. Subsidies in form of advanced tax credits and premium subsidy. 138% and under are assessed Medicaid eligible by Marketplace and application data forwarded to ODM. Per ODM, 106,000 Ohio Medicaid assessments are backlogged in Marketplace.gov, and are being triaged and distributed to ODJFS offices statewide this week.

3

4Source: Enroll America, 2013

Ohio Navigators for 2013-14Ohio Association of Foodbanks (as“OhioForHeath”)Ohio Association of Free ClinicsCuyahoga Health Access PartnershipCarmella Rose Health FoundationToledo/Lucas County CareNetCommunity Access Program CorporationCommunity Action Committee of Pike CountyClermont Recovery Center, Inc. Helping Hands Community Outreach CenterNeighborhood Health Association

Source: Ohio Department of Insurance, 2014.

5

Ohio Medicaid Expansion: Legislative Timeline• Patient Protection and Affordable Care Act (ACA) signed into law by President Obama on March

23, 2010. Upheld by USSC on June 28, 2012, but mandatory state Medicaid expansion ruled unconstitutional.

• Governor Kasich backs Medicaid expansion in his proposed budget on February 4, 2013.• April 2013: State House strips Medicaid expansion from budget before sending to Senate.• May 5, 2013: State legislative subcommittees begin exploring alternatives to expansion, but

make little progress. • May 7, 2013: Ohio Hospital Association indicates a ballot proposal for expansion is being

developed for November 2014. (Current polls show 60% of Ohioans favor expansion.)• May 22, 2013: State Representative Barbara Sears (R-Monclova) introduces bill proposing

expansion to 138% of FPG, per ACA, but fails to gain party support.• June 30, 2013: 2014-2015 State Budget signed by Gov. Kasich, with no provision for Medicaid

Expansion after House and Senate fail to bring any bill to a vote. • July 30, 2013: State Senator Capri Cafaro (D-Hubbard), introduces expansion/reform bill with

input from bipartisan subcommittees; expands Medicaid to 138% FPG, includes workforce development and new oversight body. “Circuit breaker” provision rolls back expansion if federal funding is withdrawn in out-years.

• October 21, 2013: State Controlling Board votes 5-2 to approve appropriation of $2.56B in additional federal Medicaid funds for expansion of coverage up to 138% of FPG (275,000 individuals).

• December 20, 2013: Ohio Supreme Court upholds Controlling Board decision to expand Medicaid

• January 1, 2014: Newly extended Medicaid eligibility guidelines go into effect.

6

With expansion, Federal Government to pay 90-100% of benefits for newly eligible Medicaid

recipients. Currently pays 63%.

7

Source: Partnership of Regional Economic Models, Inc., the Urban Institute, Ohio State University, and Health Policy Institute of Ohio, 2013

Medicaid expansion raises the income limits for these groups to 138% of FPL (MAGI), providing some form of Exchange or Medicaid eligibility for all

groups under 400% of FPL. Without expansion, these groups would still have a coverage gap until 100% of FPL, and only qualify for HCAP.

8

Source: Health Policy Institute of Ohio, 2013

Eligibility Requirements for Marketplace QHP Enrollment

• US Citizen, qualified alien, or LPR• Not incarcerated• No existing access to affordable, minimum

essential coverage (affordability defined as 8% max of gross household income)

• Live in plan area

9

Open Enrollment and Qualifying Events

• Open enrollment: October 1st, 2013 through March 31, 2014. Plans effective January 1st, 2014.

• Next proposed open enrollment is November 15, 2014 through January 15, 2015.

• Individuals may enroll outside open enrollment within 60 days of qualifying event:

Lost coverage at work (or other) health coverage Gained or became a dependent through marriage, birth, adoption, or

placement for adoption Contract errors by insurance company Change in eligibility for financial assistance Relocation outside coverage area

10

Individual MandateMost American households are required to have minimum essential coverage for all members by March 31, 2014, or face the higher of these two tax penalties.

2014:• $95 per person for the year ($47.50 per child under

18). $285 max.• 1% of annual household income over the tax filing

threshold. 2015: 2% of income or $325 per person (minors assessed at 50%)2016: 2.5% of income or $695 per person (minors assessed at 50%)2017: 2.5%, adjusted for inflation (minors assessed at 50%)

Max annual household penalty is 300% of the minimum penalty for that year, e.g., max penalty for 2016 would be $695 X 3.0 = $2085. Total penalty for tax year cannot exceed national average of bronze plan annual premiums. If uninsured for part of the year, 1/12 of the yearly penalty applies to each uninsured month. If uninsured for less than 3 months, there is no penalty.

Source: Marketplace.gov; CMS, 2014

Exemptions to Individual Mandate and Tax Penalty

• Hardship (economic or circumstantial)• Uninsured less than 3 months of the year• Below 133% FPG• Below tax filing threshold • Lack of Affordable Coverage (8% standard)• Religious Conscience• Federally recognized tribe or eligible for Indian Health Services• Health Care Sharing Ministry• Incarceration• Not lawfully present• Existing plan cancelled due to ACA

All told, an estimated 26 million Americans are exempt. Source: Marketplace.gov; CMS, 2014

QHP Premium Grace Period

13

Source: ECG Management Consultants, 2013

Requirements for Qualified Health Plans (QHP)• Be licensed and in good standing with state• Offer plans that fall within the bronze, silver, gold, platinum or catastrophic cost-

sharing tiers• Offer at least one silver and one gold QHP through the marketplace• Meet Essential Health Benefits (EHB) standard by providing comprehensive

package of covered services• Meet provider network standards: Essential Community Providers (ECP)• Limit out-of-pocket to $6,350 (individual) and $12,700 (family) for 2014• CMS guidance of February 7th indicates hospitals may be able to

subsidize patient QHP policies through private not-for-profit foundations.

14

QHP Precious Metal Tiers • Bronze: 40% consumer cost share (deductibles and other cost

shares)*• Silver: 30% consumer cost share (deductibles and other cost

shares)**• Gold: 20% consumer cost share (deductibles and other cost

shares)• Platinum: 10% consumer cost share (deductibles and other

cost shares) • Catastrophic: (Under age 30, minimum coverage, no subsidy,

does not meet actuarial value standards of “precious metal” tiers)

* Average cost share per life** Silver plans are the Marketplace standard to which subsidy levels are pegged, and cannot exceed 9.5% of gross household income for families under 400% FPG. 15

Payers in Ohio’s Federal Marketplace1) Community (Anthem)2) AultCare3) Buckeye Community Health Plan4) CareSource5) Coventry6) HealthSpan7) Humana Health Plan of Ohio8) Kaiser9) Medical Health Insuring Corporation of Ohio10) Molina11) Paramount12) SummaCare Source: Ohio Department of Insurance, 2014. This list comprises Marketplace plans only. There are additional payers offering QHPs outside the marketplace.

16

Marketplace Enrollment Trends: 10/1/13 through 2/1/14

• 53% increase in total Marketplace plan selections in January• 62% increase in plan selections for Federally Facilitated

Marketplaces• 3,299,500 total enrollment to date• 3.2M Medicaid/CHIP determinations through Marketplace • 55% female,45% male• 53% age 45-64• 25% age 18-34• 82% selected plan with Financial Assistance• 72% of FFM enrollees selected silver plan, 93% of FFM silver

plan enrollees selected plan with financial assistance

17

Source: CMS, 2014

Ohio Enrollment Trends10/1/13 through 2/1/14

• Total Eligible to Enroll in a QHP: 159,694*• Total Eligible to Enroll in a QHP with financial assistance:

91,285• Total assessed eligible for Medicaid by Marketplace: 78,575

(Per CMS, as compared to Ohio Department of Medicaid estimate of 106,000)

• Total number of QHP selections (not Medicaid): 60,122, or 37% of total eligible applicants from 10/1/13 through 2/1/14

*Represents the total number of individuals for whom a completed Marketplace application has been received and who are determined eligible for a plan selection.

18

Source: CMS, 2014

Marketplace Enrollment Trends: 10/1/13 through 2/1/14

19

Source: CMS, 2014

Marketplace Enrollment Trends: 10/1/13 through 2/1/14

20

Source: CMS, 2014

21

Source: CMS, 2014

Marketplace Enrollment Trends:

10/1/13 through 2/1/14

QHP Premium Grace Period

22

Source: CMS, 2014

23

Source: CMS, 2014

Ohio Metal Selection by Gender:

Females: 59% Silver, 21% BronzeMales: 56% Silver, 22% BronzeTotal: 58% Silver, 21% Bronze (79%)

National:

62% Silver, 19% Bronze (81%)

Bronze and Silver Plans in Northeastern Ohio

24

• Buckeye: “Ambetter”• Anthem: “Direct Access”• Aultcare: “Silver”,“Bronze”• CareSource: “Just4me”• SummaCare: “SummaCare

Individual”• Kaiser: “KP Silver”,“KP Bronze”• Molina: “Molina Marketplace”• Paramount”: “Paramount HMO

[Silver]”• HealthSpan: “HealthSpanOne”• HealthAmerica One:

“Silver”,“Bronze”

Silver and Bronze QHPs in Northeastern Ohio(with Marketplace plan names)

Source: CMS/HHS; data.healthcare.gov

25

HHS/CMS QHP databases

Site search term: QHP landscape

Average QHP Premiums (National)

26

Source: HHS, 2014

27Source: CMS, 2014

Cost of Coverage, including Financial Assistance:

• Up to 133% of poverty: 2% of income toward premiums • 133 - 150% of poverty: 3 - 4% of income toward premiums • 150 - 200% of poverty: 4 - 6.3% of income toward premiums • 200 - 250% of poverty: 6.3 - 8.05% of income toward

premiums • 250 - 300% of poverty: 8.05 - 9.5% of income towards

premiums • 300 - 400% of poverty: 9.5% of income towards premiums

28

Source: Stack, Shawn; Wexner Medical Center, Ohio State University, 2013

Ongoing Enrollment Challenges

• Initial Marketplace bugs: account creation, datahub issues• Capacity issues (CMS intends February capacity increase from

25,000-50,000 simultaneous users) • Medicaid eligibility determination issues: Per ODM,

Marketplace assessment data to state has been unreliable• Marketplace-to-state data transfer issues• Enrollment figures not accounting for unbound coverage

(some insurers reporting up to 30% of first month premiums unpaid)

• Appeals and exemption processing errors• Enrollment target of 7 million unlikely to be met,

current enrollment at 75% of Month 4 target, 5-6 million likely at current rate.

• Heightened political pressure: calls for IM delay, ACA repeal 29

Learn more about RevCare’s Eligibility Solutions at EligibilityExperts.com

Get the latest healthcare news at RevCare.com

30

John Rogers Manager, Self-pay Services RevCare, Inc. 3250 West Market St. | Suite 304 | Akron, OH 44333 (office) 330.873.1820| (toll free) 800.837.3328 x153 jrogers@improvefinancialhealth.com