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Transcript of Mississippi Insurance Department 1001 Woolfolk State Office Building 501 North West Street Jackson,...
Mississippi Insurance Department
1001 Woolfolk State Office Building501 North West Street
Jackson, Mississippi · 39201
A History of Health Insurance ExchangesNot a new conceptIdea was born in the 1970’s1990’s
“Hillarycare” introduced “buying co-ops”Republicans hated it
Early 2000’sHeritage Foundation came up with a health insurance exchange conceptLooked very similar to a “buying co-op” Included individual mandateDemocrats hated it
2006Massachusetts created the Massachusetts Health Insurance Connector
Authority under Governor Mitt RomneyBased on Heritage Foundation exchange concept 2
A History of Health Insurance Exchanges2009
Utah launched its health insurance exchangeDesigned for small employers only; represents a market-driven solution
2010Democrats borrowed the Exchange concept and inserted it into PPACARepublicans hated it
In Mississippi:The concept of an exchange is accepted across party lines as good public
policyGovernor Haley Barbour advocated for a market-based, consumer-oriented
exchange for 3 years prior to the passage of the Affordable Care ActWe are trying to fulfill that vision by creating a state-based market-driven
solutionOnly 7 - 11% of Mississippians have a good understanding of what services
an exchange actually provides 3
What is an Exchange?Essentially, an Exchange is a marketplace for major
medical insurance.
A one-stop shop for health insurance -- similar to Travelocity, Expedia, and Priceline.
This is perhaps an underestimate in that the Exchange:Will be a massive undertaking;Will provide many services beyond simply offering different
insurance products for sale;The web portal comparison piece is just the “tip of the
iceberg.”4
Two Types of Exchanges
Individual Health Insurance Exchange
5
Small Employer Health Insurance Exchange
Individuals & families may purchase qualified coverage through Qualified Health Plans
Purchaser may be eligible for premium subsidies—based on income level
Small businesses with up to 100 employees may purchase qualified coverage
Premium subsidies are not available through the SHOP exchange (tax credits are available for qualified employers)
States may choose to operate two separate exchanges or combine into a single mechanism
Exchange FunctionsCertify and decertify plans to be sold on the ExchangeOperate a toll-free customer service hotlineMaintain a website to provide standardized information on plansUse a standardized format for presenting coverage options Inform individuals of eligibility for Medicaid, CHIP, etc.Make available a calculator to determine the actual cost of coverageProvide a rating system for plans available through the ExchangeCollect premiums for plans sold through the Exchange and forward those
premiums to the carrierOperate separate Exchanges for individuals and for small employersManage the movement of individuals inside and outside the Exchange and
between the individual and small employer ExchangeEstablish a “Navigator” program to assist consumers in enrollmentDevelop a risk adjustment program to appropriately distribute among
carriers the costs associated with high-risk individuals 6
Mandated Exchange Functions
77
Portal / Web sitePortal / Web site
Enrollment and
Eligibility Interface
Enrollment and
Eligibility Interface
Carrier1
Carrier1
Carrier2
Carrier2
Carrier3
Carrier3
HealthPlan#1
HealthPlan#1
Plan Comparison InterfacePlan Comparison Interface
HealthPlan#2
HealthPlan#2
HealthPlan#3
HealthPlan#3
Administration InterfaceAdministration Interface
Communication InterfaceCommunication Interface
TREASURYTREASURY
HOMELANDSECURITY
HOMELANDSECURITY
IRSIRS
HHSHHS
SOCIALSECURITY
SOCIALSECURITY
Verify CitizenshipVerify Citizenship
Verify IncomeVerify Income
Tax CreditsTax Credits
Verify ResidencyVerify Residency
STATEMedicaid
STATEMedicaid
EligibilityEligibility
ReportingReporting
SubsidiesSubsidies
Cost ReductionCost Reduction
CUSTOMERSERVICE
CUSTOMERSERVICE
NotificationsNotifications
Pay PremiumsPay Premiums
Employeeor
Consumer
Employeeor
Consumer
Billing or InvoicesBilling or Invoices
Employeeor
Consumer
Employeeor
ConsumerAdmin, Life Events, etc.Admin, Life Events, etc.
Customer ServiceCustomer Service
ONLINECALCULATO
RDisplay Total
Costs
ONLINECALCULATO
RDisplay Total
Costs
HealthPlan#4
HealthPlan#4
Carrier4
Carrier4
StateInsurance
Agency
Certify, RecertifyDecertify
Health Plans
StateInsurance
Agency
Certify, RecertifyDecertify
Health Plans
NavigatorNavigatorGuidanceGuidance
DataService
Hub
DataService
Hub
FISCALAGENTFISCALAGENT
RISK ADJUSTMENTRISK ADJUSTMENT
Minimum Requirements for the Exchange
By January 1, 2014, each state shall have in place an operational health insurance exchange to sell individual and small group major medical policies.
By January 1, 2013, the Secretary of Health & Human Services (HHS) will determine whether each state will have an effective mechanism in place to run an Exchange by January 1, 2014, and if not, then the Federal government will step in to run the Exchange for the state.
Only qualified health plans certified by the Exchange may be offered through the Exchange.
8
What Will a Federal Exchange Look Like?Medicare.govWill not be tailored to the specific needs of Mississippians
“Cookie cutter” exchange for all states that fail to create their own ExchangeFederal government may pick two to three national carriers for the
Federal Exchange.The Federal government will have sole authority to regulate the
insurance plans sold through the exchange to the exclusion of each state’s traditional role in insurance regulation. The Federal government may utilize existing state regulatory agencies to
implement law without additional funding or opportunity for input; States will still pay for the Federal exchange.
Federal government will regulate health insurance in Mississippi.Federal government will determine eligibility for Medicaid and may
withhold funding if a State refuses to enroll individuals that the Federal Exchange deems eligible.
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Likely State Scenarios in 2014Three Primary Categories
States making significant progress (5-10 states)Will be certified as “approved”Will likely still rely on Federal processes for some
functionality
States making some progress (30-35 states)Will be certified as “conditionally approved”Will be considered state-federal “hybrid”
States making little or no progress (5-10 states)Will have a Federally-facilitated ExchangeMay continue to work toward a state-facilitated exchange 10
Mississippi Based Exchange
States have the right of first refusal to operate an Exchange.
Federal Exchange is the fallback.
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Mississippi Comprehensive Health Insurance Risk Pool Association
The enabling legislation for the Risk Pool is found in Mississippi Code Annotated 83-9-203 et seq., 1972 as amended.
Subsection 83-9-213(2)(p) specifically states: (2) The association may:
(p) Serve as a mechanism to provide health and accident insurance coverage to citizens of this state under any state or federal program designed to enable persons to obtain or maintain health insurance coverage.
Section 83-9-213(3) states: (3) The commissioner may, by rule, establish additional powers and duties
of the board and may adopt such rules as are necessary and proper to implement Sections 83-9-201 through 83-9-222.
14
Mississippi Comprehensive Health Insurance Risk Pool Association
The Association is operated by a nine-member board of directors, as stated in Section 83-9-211(2)(a).
The board of directors consists of:Four (4) members appointed by the Insurance Commissioner. Two (2) of
the commissioner’s appointees shall be chosen from the general public and shall not be associated with the medical profession, a hospital, or an insurer. One (1) appointee shall be representative of medical providers. One (1) appointee shall be representative of health insurance agents.
Three (3) members appointed by the participating insurers, at least one (1) of whom is a domestic insurer.
The Chair of the Senate Insurance Committee and the Chair of the House Insurance Committee, or their designees, who shall be nonvoting, ex officio members of the board.
15
Exchange Advisory Board & SubcommitteesThe Commissioner of Insurance issued Bulletin 2011-9 on
October 18, 2011, which established an Exchange Advisory Board & Advisory Subcommittees.
The Advisory Board will assist the Department of Insurance as it develops rules, regulations, and policy governing the Exchange.
The Advisory Board and Subcommittees consist of members representing the following stakeholder groups:
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A) Educated health care consumers B)Individuals & entities with enrollment experience C) Advocates for hard-to-reach populations D) Small businesses & self-employed individuals E) State government agencies F) Federally-recognized tribes within the State
G) Public health experts H) Health care providers I) Large employers J) Health insurance issuers K) Health insurance agents & brokers holding current licenses
17
Exchange Advisory Board & Subcommittees MembershipEDUCATED
HEALTH CARE CONSUMERS
EXPERIENCE IN ENROLLMENT
HARD TO REACH
POPULATIONS
SMALL BUSINESSES & SELF-EMPLOYED
INDIVIDUALS
PUBLIC HEALTH EXPERTS
HEALTH CARE PROVIDERS
HEALTH INSURANCE
ISSUERS
HEALTH INSURANCE AGENTS & BROKERS
LARGE EMPLOYERSSTATE GOVERNMENT AGENCIES/DIVISIONS
FEDERALLY-RECOGNIZED
TRIBESGeroldean Dyse Sherry Abraham Michael Jones Linda Dixon Rigsby Dr. James P. Almas Bucky Murphy Susan Martindale Signe Jones
Roy Mitchell Sannie Snell Nancy Stewart Corey Wigging Tammy Bullock Scott Stanford Bryan Lagg Keri Abernathy
Therese Hanna Kimberly Hughes Katrina Reynolds Kim Stonecypher Dr. Margaret Gray Dr. Grayson Norquist Kim Hancock Kurt Hellmann Angela Ladner Rims Barber Debbie Ferguson
Mary Werner Kay Trapp Jill Bishop Dr. Philip Marler John Reed Marilyn Douglas Thomas Montgomery Sandi Munden
Robert Pugh Lee Ann Griffin* Kristy Simms Dr. Morris Hamilton Robert Morris Dr. Jasmine Chapman Beth Dickson Myrtis Small Mitch Morris Dr. Joe Files
Gary Ben
Bill Oliver Stephanie Barnes Taylor* Dr. Richard Conn Dr. Kristi Henderson Mary Mixon Dr. Lenito Sinay Dr. Frank Reese Keith Heartsill David Elliott Michael Neuendorf Dr. Gail Megason Ann Bishop Dr. Thomas Joiner Dr. Owen EvansDr. Donald Seago Larry Walker Dr. R.A. Foxworth Stephen Nichols Dr. Tammy Sims Mike Birdsong Dr. Marc Mitchell Dr. W. R. Webb
Dr. Claude Brunson Dr. Richard deShazo J. Michael Estes Lorraine Washington Terry Trigg Daniel M. Harrison Emily Lewis Mike Carney Patty Collins Wally Davis
Joel Jasper Dudley Wooley Steve Armstrong Doug Henley Cindy Hamman Preston Francis Scott Bingham Dan Gibson
Lawrence Kissner Charles Pace Michael Bailey Kyle Godfrey Jeff Album Clinton Mayes
Teresa Planch Elizabeth C. O’Keeffe Dr. Michael Patterson John T. Newsome Jerri Avery Dr. Randy EasterlingRita Rutland
Federal Funding Opportunities Through 2014
Level I:Single-year funding only
Period of performance is up to one year post-award
Available only through 2012 States may apply through June 29, 2012
Level II:Multi-year funding
Period of performance is from date of award through December 31, 2014
Available through 2014 States may apply through June 29, 2012
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Barriers To ImplementationOverall lack of certainty
2012 ElectionsConstitutional challenges
Lack of timely guidance from HHS1,968 new or expanded powers given to the Secretary of HHSLots of red tape
Heavy technology liftSystems developmentStrained public/private sector resources—not enough vendors
Tough statutory timelinesAgreement among state officialsStakeholder buy-in
24
United States Supreme Court
Individual mandate is upheld as constitutionalThe penalty for noncompliance with the mandate is
a tax
Medicaid expansion is coercive to states and therefore unconstitutional
25
Essential Health BenefitsOnly qualified health plans offering Essential
Health Benefits and certified by the Exchange may be offered through the Exchange.
HHS issued guidance on Essential Health Benefits on December 16, 2011.
MID will review plans and determine whether they meet the requirements set for qualified health plans.
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Essential Health BenefitsThe guidance released on December 16, 2011, sets forth the
intended regulatory approach of HHS, which allows states to select an existing health plan to set the “benchmark” for the items & services to be included in the Essential Health Benefits package.
The four benchmark plans are:One of the three largest small group plans in the state;One of the three largest state employee health plans;One of the three largest Federal employee health plan options;The largest HMO plan offered in the state’s commercial market.
HHS intends to require that a health plan offer benefits that are “substantially equal” to the benchmark plan selected by the state and modified as necessary to reflect the 10 categories of coverage listed by PPACA.
27
EHB: Ten Categories of CoveragePPACA Section 1302 sets out ten categories of coverage that must
be included in the Essential Health Benefits package:1) Ambulatory patient services;
2) Emergency Services;
3) Hospitalization;
4) Maternity and newborn care;
5) Mental health and substance use disorder services, including behavioral health treatment;
6) Prescription drugs;
7) Rehabilitative and habilitative services and devices;
8) Laboratory services;
9) Preventive and wellness services & chronic disease management;
10) Pediatric services, including oral & vision care.28
2014 ReformsProhibition of pre-existing condition exclusionsGuaranteed issueRating rules:
No health status3:1 maximum age rating1.5:1 tobacco use
Single risk pools in individual and small group markets
Individual mandateEmployer responsibilities
29
The Future of the Law: 2012 Elections
Who will occupy the White House? Is “effective” repeal by Executive Order possible? If President Obama is re-elected then PPACA will be implemented by using
all means necessary
Who controls the House and Senate and to what degrees? Is actual repeal possible?Will statutory timelines remain? If Republicans get Senate, House & Presidency, then through “reconciliation”
process (same process used in the Senate to pass PPACA) the funding for many PPACA programs can be stopped. This will do nothing to stop some major reforms (such as guaranteed issue &
community rating) from going into effect and this could cause major problems. 30
Mississippi Insurance DepartmentCommissioner Mike Chaney
Aaron Sisk · (601) 359-2012 31