Health Insurance ExchangeHIX

Robert E Goff

Before the Exchanges Big Change

2010 2011 2013 2014 2015-2017

• Small business tax credit

• Prohibitions against lifetime benefit caps & rescissions

• Phased-in ban on annual limits

• Annual review of premium increases

• Public reporting by insurers on share of premiums spent on non-medical costs

• Preventive services coverage without cost-sharing

• Young adults on parents’ plans

Source: Commonwealth Fund Analysis of the The Affordable Care Act (Public Law 111-148 and 111-152).

• Insurers must spend at least 85% of premiums (large group) or 80% (small group / individual) on medical costs or provide rebates to enrollees

• HHS must determine if states will have operational exchanges by 2014; if not, HHS will operate them

• State insurance exchanges

• Medicaid expansion• Small business tax

credit increases • Insurance market

reforms including no rating on health

• Essential benefit standard

• Premium and cost sharing credits for exchange plans

• Premium increases a criteria for carrier exchange participation

• Individual requirement to have insurance

• Employer shared responsibility penalties

• Penalty for individual requirement to have insurance phases in (2014-2016)

• Option for state waiver to design alternative coverage programs (2017)

•States adopt exchange legislation and begin implementing exchanges

•Phased-in ban on annual limits

2014 The Year of the Health Insurance Exchanges

What is the HIX?

Simply put: Health Insurance products, different

benefit packages, different plans available for purchase at a single “market”

Two markets▪ Small Business Health Options Program

(SHOP) 50 or less▪ Individual Market

What makes HIX “Game changing” No pre-existing condition restrictions Subsidies based on income available

Who is offering in the NY HIX?Medical Plans

6

http://www.nystateofhealth.ny.gov/PlansMap

Who is offering in the NY HIX?Dental Plans

7

http://www.nystateofhealth.ny.gov/PlansMap

Required Ten Essential Health BenefitsPreventive services will be offered at with not patient cost sharing

1. Ambulatory patient services2. Emergency room services3. Hospitalization4. Maternity and newborn care5. Mental health and substance abuse disorders6. Prescription drugs7. Rehabilitation and habilitation services and devices8. Laboratory services9. Preventive and wellness services and chronic disease

management10. Pediatric services, including oral and vision

SAMPLE

What is being offeredPlatinum, Gold, Silver,

Bronze

Exchange Responsibilities

Exchange Functions

Operate a toll-free telephone hotline to help usersEnroll applicants in their chosen plan

Maintain a website to sell plansWork with federal and state agencies regarding subsidies

and tax creditsEnroll eligible individuals into Medicaid

Set annual Open Enrollment Period and special Enrollment PeriodsCertify and rate plans

Only Available in Exchanges• Subsidies for individuals from 133%-400% of FPL• Small employer tax credits

11

What is NY State of Health?

Organized marketplace One-stop shopping for subsidized and unsubsidized

coverage Easily compare health plan options The only place to check eligibility and apply for

financial assistance Enroll in qualified health plans

Two programs Individual Marketplace Small Business Marketplace

12

Individual Marketplace (58%)

Small Business Marketplace (42%)

Who Will Enroll In NY State Of Health?

Health Plan Marketplace enrollment is estimated to be 1.1 million New Yorkers

13

450,000

615,000

NY State of Health Enrollment

Open Enrollment begins on October 1 Individuals may enroll in health plans during open

enrollment October 1, 2013 - March 31, 2014) or with a qualifying event

Individuals who qualify for Medicaid/CHP may enroll any month of the year

Small employers may choose open enrollment dates for their employees any month of the year

14

Customer Service Call Center

Assistance available in over 170 languages Many staff will be bilingual and oral

interpretation available for remaining languages.

• Will take applications over the phone starting in October

Can refer to in-person assistors

15

3 Types of In-Person Assistors

16

• Complete Applications• Compensation from DOH grant program• Training and certification required• Serve Individuals and Small Business Marketplace

IPA/Navigators

• Complete Applications• No compensation from Marketplace• Training and certification required

Certified Application Counselors

• Complete Applications• Commission-based compensation• Training and certification required• Choose to certify in Small Business Marketplace, Individual, or

both

Insurance Brokers/Agents

Individual Responsibility• Jan. 1, 2014: Individuals must enroll in coverage

or pay a tax penaltyPenalty amount: • Greater of $ amount or a % of income

– 2014 = $95 or 1%– 2015 = $325 or 2%– 2016 = $695 or 2.5%– Family penalty capped at 300% of the adult flat dollar

penalty or “bronze” level premium

Family ResponsibilityPenalty amount: Greater of $ amount or a % of income

– 2014 = $285 or 1%– 2015 = $975 or 2%– 2016 = $2,085 or 2.5%– Family penalty capped at 300% of the adult flat dollar

penalty or “bronze” level premium

19

Employer Penalty

Please note that the information in this chart is based on an interpretation of the Patient Protection and Affordable Care Act. This chart is for general information purposes only and is not intended to constitute legal advice or a recommended course of action in any given situation and should not be relied upon in making decisions of a legal nature.

20

Subsidies, Tax Credits, Penalties

Individuals may be eligible for premium assistance – 133% to 400% FPL if employer: Doesn’t offer minimum essential coverage or Offers coverage, but premium isn’t affordable However, if employer does offer affordable MEC

and the employee purchases on HIX, not eligible for subsidy

Cost sharing assistance Individuals 133%-250% of FPL Must purchase silver plan

Small employer tax credits Employers < 25 Must purchase on SHOP, other requirements apply

Penalties for not having/offering health insurance

What does this mean to physicians? 1.1 million New Yorker's added to the

“insured population” Reduced bad debts Increased access to care Increased demand for services

What they aren’t telling physicians These “new” patients

come with lower reimbursement rates

Most of the HIX offering are paying between 6% and 25% LESS than the commercial rates for the same company

Some plans are making participation mandatory

There “new” patients come with continued risk of bad debts

Federal regulations put the physician at risk of not being paid when patients are late in paying their premiums.

Carriers HIX products must provide a 3 month grace period to enrollees that haven’t paid their premiums. During the first 30 days plans must pay claims, but in the last 60 days, the payer will hold the claims.

If the patient coverage is cancelled after 90 days for failure to pay premiums, plans are not required to pay any claims in those last 60 days. It falls to the practice to go after the patient, for services rendered.

What should a physician do? It Depends Do you need this

volume? Do you believe

increasing your access to patient sis the ‘right” thing to do?

Are you “par” by virtue of your current participation agreements?

Can you limit your participation to x number of HIX plans? X number of enrollees?

Know what you are getting into reimbursement wise.

Verify each patient’s benefit plan at time of 1- appointment scheduling and 2- at time of service.

Require a contingent credit card authorization on all patients

Nystateofhealth website

Stuff you want to ask

?25

Thank you

Robert E. Goff