August: ACA Learning Session on Exchange, and Navigators

Affordable Care Act (ACA) Learning Sessions for Social Sector Leaders & Community Advocates

August 17, 2012

Coordinated by Access HealthColumbus Community Advisory Committee

Purpose Spread knowledge of federal health care reform in non-profit organizations to improve their ability to serve clients during the implementation of the Accountable Care Act (ACA). Today’s Objectives 1. Improve knowledge on the value of:

• American Health Benefits Exchanges • Navigators intended to personally assist consumers in understanding their

choices and selecting insurance coverage 2. Inventory learning on barriers encountered when reaching out to vulnerable people

Affordable Care Act

Near Universal Insurance Coverage

Guaranteed Issue &

Insurance Mandate

Improvement Programs

(and grants)

Health Benefit

Exchanges

Expansion of Medicaid

Subsidized commercial

insurance for middle-income

families (market based)

Source: Supreme Court Policy Brief, Health Policy Institute of Ohio, July 2012, http://bit.ly/SjDBca

Health coverage sources for Ohioans in 2014

http://bit.ly/SjDBca

Health coverage sources for Ohioans in 2014

Source: Supreme Court Policy Brief, Health Policy Institute of Ohio, July 2012, http://bit.ly/SjDBca


Affordable Care Act


Guaranteed Issue &

Insurance Mandate


(and grants)

Health Benefit

Exchanges

Affordable Care Act


Guaranteed Issue &

Insurance Mandate

ImprovementPrograms

(and grants)

Health Benefit

Exchanges

Affordable Care Act


Guaranteed Issue &

Insurance Mandate


(and grants)

Health Benefit

Exchanges

Current Exchange Status

• 15 Established State Exchange

• 1 Planning for Partnership Exchange

• 18 Studying Options

• 11 No Significant Activity

• 6 Decision Not to Create State Exchange

Supreme Court Ruling

The insurance market reforms and subsidies

were upheld and will go into effect.

Insurance market reforms

The 2010 insurance reforms will remain in

effect

– No lifetime limits and restricted annual limits

– Coverage of dependents up to age 26

– No rescissions except for fraud

– No pre-existing condition exclusions for children

– Preventive care at no co-pays or cost sharing

Insurance market reforms

The 2011 insurance reforms will remain in

effect

– Medical Loss Ratio Limits

Medical loss ratios must be at least 85% for large group

coverage and 80% for small group and individual

coverage.

– Premium Rates Review standards (2011).

Premium rates in excess of 10% must undergo

heightened review.

Permanent Market Reforms

• The 2014 permanent market reforms were

upheld.

– Guaranteed issuance of coverage

– Modified community rating of coverage

• Rates can only vary by age (3 to 1) and smoking status

(1 ½ to 1).

• No pre-existing condition exclusions

• Individual mandate

• Employer mandate

Low Income Subsidies

The 2014 low income subsidies were upheld.

– Sliding scale subsidies are available at incomes

between 100% to 400% FPL

– At 100% FPL, the cost of coverage will be:

$223 per year or $18.50 per month for

individuals; or

$461 per year or $38.40 per month for a family

of 4.

Health Insurance Exchanges

Exchanges were upheld.

– Each state shall establish a qualified Exchange by

January 1, 2014.

– If a state chooses not to operate an exchange,

the federal government will do so.

Exchange Options

1. An Ohio Exchange

2. A Federal Exchange

3. A Hybrid Exchange

– States control plan management including

certification of qualified plans

– States operate the consumer assistance function

– HHS retains authority and approve state partners

– States may control reinsurance and Medicaid

eligibility determinations

Timeline

Reforms already in effect: – 2010 Insurance Benefit Reforms

– Medical Loss Ratios

– Premium Rate Review

November 6, 2012 - The Election – Change in direction as to implementation

– Can’t change requirements on insurance companies

Timeline

November 16, 2012 – States must submit an Exchange Blueprint to

HHS, including (1) a Declaration of Intent signed by the Governor and (2) an Application indicating the state’s intentions.

– A state may submit a “Blueprint” for an exchange which will become operational after 2014, but November 16th is the deadline.

Timeline

January 1, 2013 – HHS must certify state exchanges that become

operational on January 1, 2014. The state must demonstrate “the ability to satisfactorily

perform all required Exchange activities.”

– Conditional approval can be granted to states making “significant progress” if they will be ready by October, 2013.

– It is hard to believe a state filing a “Blueprint” after the election could establish a 2014 exchange.

Timeline

2012 - 2013 – IT/Consumer Infrastructure established

– Qualified health plans certified

– Vendor/partner agreements executed Agents/Navigators

– Operations established

– Marketing/outreach to consumers

Fall, 2013 – People begin to enroll in exchanges

Timeline

January, 2014 – Permanent reforms take effect

– Low income subsidies start

– Mandates take effect

– Coverage through exchanges becomes effective

Examples

The Enroll UX 2014 design offers a new standard for public and private health insurance enrollment, and serves as a reference model for a first-class user experience (UX) design for health insurance exchanges.

Massachusetts Health Connector

UHCAN Ohio is a statewide nonprofit organization working for high quality, accessible, affordable health care for all Ohioans.

Navigators in the New Health Benefits Exchange

How to create a strong navigator program for our communities

Cathy Levine Executive Director, UHCAN Ohio


Why do we need Navigators in the Exchange?

• Up to 1.5 million uninsured Ohioans

• Many do not know they have new options for getting affordable coverage in 2014

• Many do not know how insurance works – how to shop for insurance

• Many will not know about the Exchange or how it works

• Many will not have access to computer


What is a Navigator?

• A guide to help you get where

you need to go.

• The ACA created a Navigator

function to – Inform people about their new insurance options

– Help people enroll in their plan of choice

– Help people keep their coverage (stay enrolled)

• The Navigator does not choose a plan or influence the choice of a plan.


Need for Community-Based Navigators

• Consumer or community-focused non-profits

• Licensed insurance agents and brokers

• Industry, trade, professional associations

• Unions

• Chambers of commerce, small

business groups

• Commercial fishing industry

organizations

• Farming and ranching organizations

• Others to reach specific populations


Duties of Navigator According to ACA • Conduct public education activities about what’s

available

• Distribute impartial information about

plan enrollment and availability of tax

credits

• Help people enroll in “qualified health plans”

• Provide referrals for people with complaints and questions about their health plan

• Provide information in culturally, linguistically appropriate manner for populations served


Consumer Protections through Navigators

• Navigators must receive no direct or indirect payments from health insurers

• Insurers are explicitly prohibited from being navigators.

• Therefore, navigators are funded through grants provided by Exchange funds.


Who will enroll in Exchange? From Congressional Budget Office study

• More than 1/3 haven’t had check-up and will have had difficulty accessing care

• Because of tax credits, most will have lower incomes than today’s privately insured

• More racially diverse than currently insured

• 77% will have high school diploma or less

• Languages other than English

• Majority will have been previously uninsured


Features of Strong Navigators

• Training in Exchange, Medicaid, public programs and private insurance market

• Ability to explain eligibility, benefits, cost-sharing, appeals processes to consumers

• Have community’s trust to provide correct, clear information

• Act in interests of consumer, not insurers

• Ability to reach hard-to-reach, poor people

• Ability to explain tax-credits and financial impact

• Represent diverse organizations to serve diverse people eligible for insurance through Exchange


Under Federal Exchange, How is the Navigator program created?

• Ohio could request to have a “partnership” – allows Ohio to run Navigator program

• Otherwise, federal exchange issues requests for proposals from entities to navigate

• How does it all come together?

– Still many unanswered questions

– Community groups have to organize

themselves to participate in meaningful way


What’s Next?

• UHCAN Ohio is tracking NAIC, federal regulations

• Community organizations need to figure out what role they want to play develop joint proposals

• Role of Ohio Benefit Bank? United Way? Other big players?

• UHCAN Ohio will host phone calls,

live meetings to facilitate

coordination and participation

from diverse communities


Interested in Further Discussions and Information?

• Sign up for our navigation email list

• Call us to do presentations and lead discussions for groups you convene

• Help us to educate communities

about benefits of the Exchange

• Let us call on you to give input

to policymakers and regulators

UHCAN Ohio

@UHCANOhio

Cathy Levine Executive Director

370 S. 5th St Ste G3

Columbus, OH 43215 (614) 456-0060 x222

[email protected]

UHCAN Ohio’s mission is to achieve

high quality, accessible,

affordable health care for all Ohioans.

www.uhcanohio.org

Visit our website for updates!

Find us on Facebook and Twitter!

Want to learn more about the Affordable Care Act?

Health Policy Institute of Ohio - Supreme Court Policy Brief: http://bit.ly/SjDBca

Kaiser Family Foundation - A Guide to the Supreme Court's

Affordable Care Act Decision: http://www.kff.org/healthreform/upload/8332.pdf

Next Learning Session • September 28, 9:30-11:30AM • Focus: Overcoming the outreach barriers identified today


http://www.kff.org/healthreform/upload/8332.pdf

August: ACA Learning Session on Exchange, and Navigators

Documents

Transcript of August: ACA Learning Session on Exchange, and Navigators