Health Insurance Exchanges and

the Changing Marketplace

Leanne Gassaway, MHA

Regional Vice President – West Region, State Advocacy

July 31, 2013

End Goal

Key Elements:

• Address Affordability

• Minimize Disruptions

• Ensure Workability

• Maximize Coordination

• Maximize Choice and Competition

An Efficient, Effective, Competitive and Robust

Health Insurance Market

2014 Marketplace Changes

Guarantee Issue and Defined Enrollment Periods October 1, 2013 – March 31, 2014

Individual Purchase Requirements Subsidies for Coverage Available for Persons 100-400% FPL

Employer Shared Responsibility (Delayed) Large Group, Adequate Coverage, FTEs, and Penalties

Essential Health Benefits 10 Categories of Benefits, AV and Cost-Sharing

Adjusted Community Rating Rules & Regions Age, Geography, Family Size and Tobacco Use

Health Insurance Exchanges Opening October 1, 2013

Individual and Family Coverage Options

SHOP for Small Businesses (1-50)

© America’s Health Insurance Plans, 2013

Medicaid Expansion-State Implementation of ACA (as of July 2013)

HI

AK

AL

AZ

AR

CA CO

CT

DE

FL

GA

ID

IL IN

IA

KS KY

LA

ME

MD

MA

MI

MN

MS

MO

MT

NE NV

NH

NJ

NM

NY

NC

ND

OH

OK

OR

PA

RI

SC

SD

TN

TX

UT

VT

VA

WA

WV

WI

WY

DC

Implementing ACA Medicaid

Expansion (22 plus DC)

Likely Implementing ACA

Medicaid Expansion (2)

Not Implementing ACA Medicaid

Expansion (13)

Unlikely to Implement ACA

Medicaid Expansion (10)

Undecided /No consensus (3)

Pursuing Alternative Options

© America’s Health Insurance Plans, 2013

State Implementation of ACA: Exchange Activity (as of July 2013)

HI

AK

AL

AZ

AR

CA CO

CT

DE

FL

GA

ID

IL IN

IA

KS KY

LA

ME

MD

MA

MI

MN

MS

MO

MT

NE NV

NH

NJ

NM

NY

NC

ND

OH

OK

OR

PA

RI

SC

SD

TN

TX

UT

VT

VA

WA

WV

WI WY

DC

State-Based Exchanges

(16 plus DC)

Federally-Facilitated

Exchange (FFE) (19)

Marketplace Partnership

Agreements (7)

State Partnership

Exchanges (7)

HHS will run an Exchange

in the individual market

while the state runs a

state-based SHOP

Exchange (2)

16 states plus DC, the UT

SHOP and NM SHOP are

State-Based Exchanges.

33 states plus the UT and

NM Individual Market will

function under a FFE

platform.

CA, CO, CT, DC, HI, ID,

KY, MD, MA, MN, NV, NM,

NY, OR, RI, UT, VT and

WA received conditional

approval of their state-

based Exchanges from

HHS. AR , DE, IL, IA, MI,

NH and WV received

conditional approval to

establish partnership

Exchanges.

Time is Running Out …

62 Days to

Open

Enrollment

Key Dates

May 2013

QHP bids due and HHS & State

review begins

Summer 2013

Testing;

Call Center Live, Navigator

Program, Agent & Broker Portal

State Review Complete (July

31)

Late Summer 2013

Agreements with QHP Issuers

finalized, Health Plan

Preview

Oct 1, 2013

Open Enrollment

Begins

Jan 1, 2014

Health Plan Coverage

Begins

Mar 31,

2014

Open Enrollment

Ends

8

Federally Facilitated Marketplace (33 States)

State Based Exchanges/Marketplace (16 states plus DC)

December

2012 – July

2013

QHP Filings

due to State

Regulators;

QHP LOI

and

Applications

Due to SBE

Late Summer

2013

QHPs Approved by

State Regulators &

Certified by SBE,

Testing with Health

Plans and Fed

HUB

Oct 1,

2013

Open

Enrollment

Begins

January 1,

2013

Health Plan

Coverage

Begins

March 31,

2014

Open

Enrollment

Ends

June - July

2013

Testing;

SBE Hiring

and Training

Staff;

Navigator

Designation;

Technology Challenges

Eligibility and enrollment

Subsidy administration for new tax credits and cost-

sharing reductions

Shopping experience

Customer service (pre and post enrollment)

Technical integration

9

States in Hyper-drive

Branding and web design

Stakeholder and implementation teams

Focused on operations/build

Planning for post – 2014 Exchange funding and

sustainability

Reviewing QHP applications, rates and form filings

Schedule for testing

Testing with Federal “Hub”

Executing outreach, education and marketing plans

Plans in Hyper-drive

HHS and SBEs continue to release the technical criteria

and protocols – issuers’ operations teams on countdown

Issuers waiting on 1st round review results for QHP

applications, EHBs, AVs and Metal Levels for

participation in SBEs, SBMs, SPMs and FFMs

Tracking changing rules, outstanding final rules needed

(SHOP, Enrollment) and 500+ FAQs

Setting up customer service

Navigators and anticipating additional guidance and

training for In Person Assisters, Application Counselors,

Agents and Brokers

Preparing Outreach and Education and Marketing

Health Care Spending – The

Biggest Challenge

2013 and Beyond

Primary Driver of Long Term Debt

Squeezing State Budgets

Source: NASBO, 2010 State Expenditure Report, p. 5

Health Care Cost Drivers

Medical Liability

Fee-for-Service

Provider Consolidation

Cost Shifting

Taxes, Fees,

Compliance Costs

Demographics

“Innovation” Bias

Lifestyle Choices

Cost Opacity

Interaction of ACA Provisions

Premium Subsidies

Health Insurance

Tax

Age Rating

Compression

Essential Benefit

Changes

Modest Incentives to

Purchase Coverage

Cost-sharing Subsidies

Transitional Reinsurance

Competition

Health Plans Leading the Way

Delivery System and Payment Reform

Value Based Benefit Structures

Transparency

Under the ACA, you need to have MEC. Pick your QHP which covers EHBs with OOPMs categorized by AV in your SBC. The QHP could be an HMO or PPO

with ECPs and must be accredited by NCQA or URAC. You could be eligible for an APTC and CSR

depending on your FPL and your MAGI. The QHP may use an ACO, VBID, VBN, or a CDHP

with an HSA.