101 EducationACA, Health Insurance Exchanges and

ATRIO – What You Need to Know

Provide information about the ACA and the new state-based health insurance exchange, Cover Oregon,

Review decisions ATRIO Health Plans has made to participate in the exchange,

Gain an understanding of impacts to current administrative operations to accommodate new product lines.

Today’s Goal

ACA Overview

Cover Oregon - The New Marketplace

ATRIO Health Plans and Cover Oregon

Provider Matters◦ Networks ◦ Medical management and Authorizations◦ URAC Accreditation and Quality Assurance

Resources

Agenda

Decrease the number of uninsured Americans◦ Require citizens to have coverage, or pay a penalty◦ Penalize employers not providing qualified coverage◦ Establishes Health Insurance Marketplace◦ Expand Medicaid coverage to more Americans

Reduce the overall cost of health care◦ Tax credits (refundable and advanceable)◦ Cost-share reductions within health plans◦ Incentivize wellness

Ultimately, create a healthier population!

Goals of the ACA

Individual (mandate) Shared Responsibility Employer (mandate) Shared Responsibility Establishment of Health Insurance

Exchange Marketplaces Individual Tax Subsidies to Offset Costs Medicaid Expansion Small Business Tax Credits to Offset Costs

Key ACA Requirements-2014

New on-line commercial insurance marketplace where qualified employers and individuals can shop for and enroll in private health insurance plans—as well as determine qualification for and gain direct access to financial subsidies.

More choice, selection and tools◦ Standardization and transparency◦ Managed Competition◦ Online tools (e.g., qualification assistance, calculators)

Cover Oregon – The New Marketplace

Enrollment starts October 1, 2013Coverage becomes effective January 1, 2014

Shop / Compare / Enroll Simple Selection – apples to apples

comparisons of costs and benefits through CoverOregon.com

Easy Enrollment – one online application for individual/family for any health plan offered

Financial Assistance – qualification and access to funds for those who need help with premiums or cost share

Personal Service – extensive help finding the right coverage through Cover Oregon staff, agents and community partners (navigators)

Cover Oregon – Key Features

Plan Design StandardizationPlan Tier Plan Covers Member Pays

Bronze 60% 40%

Silver 70% 30%

Silver CSR 201-205% FDL 73% 27%

Silver CSR 151-200% FDL 87% 13%

Silver CSR 133-150% FDL 94% 6%

Gold 80% 20%

Platinum 90% 10%

Catastrophic Plans Qualified young adults < age 30

Child-Only Plans Individuals less than age 21

Innovative Health Plans Offered within Metal Tiers

Dental Plans Free standing | Pediatric Dental

Non-Standard Plans Carriers may offer up to two NSPs in each Metal Tier in each service

area.

Why Enter the Exchange/Commercial Markets?◦ Business objectives◦ Risk considerations

Innovative Plan Approach

ATRIO Health Plans

Diversify revenues Better serve our provider partners Better serve our current member families Open new markets to MA offerings

◦ PEBB Retirees◦ OEBB Retirees◦ Federal Employees Health Plan Retirees

ATRIO Business Objectives

New Risks◦ Elimination of Pre-existing conditions◦ Merging of high risk pool◦ Coverage expansion and pent up demand for

services

Risk Considerations

Inside the Cover Oregon exchange◦ 6 Standard individual PPO products◦ 6 Innovative individual products (EPO/HMO)◦ 3 Standard small group PPO products◦ 3 Innovative small group products (EPO/HMO)

Outside the exchange (open market)◦ 3 Standard small group PPO products◦ 3 Innovative small group products (EPO/HMO)

All products designs are based on Metal Tiers to delineate the level of coverage

ATRIO Product Offerings

Individual◦ Gold Premium ID1300 & Pioneer◦ Silver Choice ID2500 & Pioneer

Silver Choice CSR 150 & Pioneer Silver Choice CSR 200 & Pioneer Silver Choice CSR 250 & Pioneer

◦ Bronze Access ID5000 & Pioneer Small Group

◦ Gold Premium SG1300 & Pioneer (On and Off Exchange)

◦ Silver Choice SG2500 & Pioneer (On and Off Exchange)

◦ Bronze Access SG5000 & Pioneer (On and Off Exchange)

ATRIO Exchange Products

Cover Oregon allows carriers to offer plans that demonstrate innovation through the use of networks, wellness programs, or other options that do not include premiums or benefits.

ATRIO will offer an innovative plan designed to exclude from the cost of coverage those treatments that, proven through evidence-based medicine, do not improve the health status of the patient. Our Pioneer Plans are modeled after the OHP Prioritized List and are referred to as Evidence-Based Health Plans.

Innovative Health Plans

Under 65 Most already have some sort of coverage Kids Some very sick, some acute, some who

don’t use any services Not as much medical management as

Medicare and Medicaid Expecting small enrollment in 2014

Population Demographics

Provider networks / contracting◦ PPO “wrap” networks

Leverage existing ATRIO network First Health (regional) Multi-Plan (national)

Provider Matters

Different timeliness and Prior Auth rules than Medicare and Medicaid◦ Standard Plans - See attached PPO Authorization List◦ Pioneer Plans - See attached EPO Authorization List

Formulary◦ MedImpact will continue to support our formulary

management. There will be 1 formulary for all plans. PA Criteria may differ depending on adherence to preferred list.

Delegation◦ ATRIO will continue to partner with the SACs for Case

Management, Disease Management, Transitions of Care and other QA programs.

Medical Management

Quality Assurance is a component with several requirements from both Cover Oregon.

Much of this is not yet defined The plan must have some form of

accreditation.◦ ATRIO has chosen to become URAC Accredited.

This is the easier one◦ All of this will leverage many programs and

policies already in place.

Quality Assurance

ATRIO website changes to accommodate under-65 products and links to Cover Oregon

Companion educational website:

www.OregonHealthAnswers.org

Website(s)

OregonHealthAnswers.org CoverOregon.com Oregon Insurance Division

◦ http://www.cbs.state.or.us/ins/ Center for Consumer Information and

Oversight◦ http://

www.cms.gov/cciio/resources/regulations-and-guidance/index.html

DOL.gov IRS.gov KFF.org

Excellent Resources