National Health Council - Preparing for Exchange Enrollment (July 2013)

Preparing Your Staff and Patientsfor Exchange Enrollment

July 17, 2013

Essential Health Benefits: We’ve Only Just Begun

Marc Boutin, JDExecutive Vice President and COO

National Health Council

The mission of the National Health Council is to provide a united voice for people with

chronic diseases and disabilities.

© National Health Council

Putting Patients First®

Cover Everyone

Curb Costs Responsibly

Abolish Exclusions for Pre-existing Conditions

Eliminate Lifetime Caps on Benefits

Ensure Access to Long-tem and End-of-life Care

GOAL: Engage individuals in a nationwide effort to create and implement a modern health care system, based on 5 Principles for Putting Patients First®


Essential Health Benefits

Broad Definition of Covered Services

―Specific List of

Exclusions


Patient Protections

Anti-Descrimination

Medical Necessity

Exceptions and Appeals

Continuity of Care

Prohibition of Specialty Tiers

Limited Cost Sharing

Part D Protected Classes


Patient Community Wins

Drug Formulary must have the same number of prescription drugs in each class as that of the EHB-benchmark plan

States must monitor and identify discriminatory benefit designs

The ability of health plans to substitute benefits is limited.


Tools: Choosing an appropriate plan

Evaluation and Tracking Tool

Patient Advocacy Tools


Public Policymaking Process in the U.S.

Interest Group Preferences, Demographics, Technological Inputs

Policy Modification Phase – Feedback

Policy Formulation

Phase

Development ofLegislation

Policy Implementation

Phase

Rulemaking Application

Based on Health Policymaking in the United States, 2nd Edition, by Beaufort B. Longest Jr.

State Exchangesand Medicaid Expansion:

What do you need to know?

Kelly BrantleySenior Manager

Avalere Health, LLC

© Avalere Health LLC

Agenda

Coverage Expansion

Affordability in Exchanges

Enrollment

Federal and State Consumer Outreach and Enrollment Activity

» Opportunities for NHC Members to Participate

Next Steps

Q&A

Coverage Expansion

The intersection of businessstrategy and public policy


The ACA Is Expected to Reduce Number of Uninsured, Primarily through Enrollment in Medicaid and Exchanges

Source: Avalere Enrollment Model, June 2013. Assumes 26 states opt out of the Medicaid expansion. Avalere assumes that: Arkansas enrolls new Medicaid eligibles into the exchange through premium support, Iowa enrolls new Medicaid eligibles over 100 percent of poverty into the exchange through premium support, and Wisconsin reduces Medicaid eligibility to 100% FPL and moves these individuals in the exchanges.ACA = Affordable Care Act

2013 2014 2015 2016

49 40 35 26

54 59 6162

16 13 12 11

141 140 141 141

5 5 5 5

50 52 53 55

8 12 22

Expected Sources of Coverage (in Millions), 2013-2016

MedicareOther Public ProgramsEmployerNon-Group ExchangesMedicaid and CHIPUninsured


Health Reform Broadens Medicaid Eligibility Substantially

The ACA required states to expand the Medicaid program…» Required states, beginning in 2014, to cover all individuals who are under 65,

do not receive Medicare, and have income below 133% FPL» Largely affects parents and childless adults who are not disabled

…but the Supreme Court rendered the expansion optional» The court ruled that states must be given a choice about whether or not to

move forward with the ACA’s Medicaid expansion» The federal government cannot cut off existing Medicaid funding to states that

choose not to proceed with the expansion

ACA = Affordable Care ActFPL = Federal Poverty Level

Expansion largely will help parents and childless adults who are not disabled. Most states only cover parents at much lower income levels, and very few states cover any childless adults unless they are disabled.


To Date, 23 States & DC Plan to Expand Medicaid Eligibility in 2014, 21 Will Not Expand, and the Remainder Are Undecided

AK

HI

CA

AZ

NV

OR

MT

MN

NE

SD

ND

ID

WY

OK

KSCOUT

TX

NMSC

FL

GAALMS

LA

AR*

MO

IA*

VA

NCTN*

IN

KY

IL

MIWI

PA

NY

WV

VT

ME

RICT

DEMD

NJ

MANH

WA

OH

DC

Will Expand (23 + DC)

State Commitment to Expand Medicaid Eligibility in 2014

Leaning No (6)

Will Not Expand (21)

Source: Avalere State Reform Insights, Updated July 15, 2013* Considering a premium assistance model for expansion using exchange plans for some or all beneficiaries


Exchanges Aim to Offer One-Stop Shopping to Individuals and Small Businesses, Similar to Online Travel Sites

Exchange Governing Body

Individual Exchange

SHOP Exchange

26 M enrollees Majority are subsidized

individuals; No subsidies for those with

ESI*

Unknown number of groups with ≤100

workers

* Individuals with an offer of employer-sponsored insurance (ESI) are not eligible for subsidies unless their individual employer premium exceeds 9.8% of their income or does not provide minimum value.Source: Avalere Health Enrollment Model, June 28, 2013.


By 2019, About 26 Million People Will Gain Health Insurance Coverage through the Exchanges

Projected Number of Exchange Enrollees, 2014-2019

En

roll

men

t (

Mil

lio

ns)

2014 2015 2016 2017 2018 20190

5

10

15

20

25

7

10

1921 21 21

1

2

4

4 4 5

Subsidized Unsubsidized

Source: Avalere Enrollment Model, June 2013. Assumes 26 states opt out of the Medicaid expansion. Avalere assumes that: Arkansas enrolls new Medicaid eligibles into the exchange through premium support, Iowa enrolls new Medicaid eligibles over 100 percent of poverty into the exchange through premium support, and Wisconsin reduces Medicaid eligibility to 100% FPL and moves these individuals in the exchanges.


State-Run Exchange State Partnership Exchange (SPE)

Federally Facilitated Exchange (FFE)*

States Have Three Options with Varying Degrees of State Responsibility for Exchange Functions

States have three options:1) Perform plan

management only2) Perform consumer

assistance only3) Perform both plan

management and consumer assistance

HHS will manage technical functions – eligibility and enrollment, financial management, etc.

Partnership blueprints were due on February 15, 2012

States manage core exchange functions:» Plan management

» Consumer assistance

» Eligibility and enrollment

» Financial management

The ACA appropriates state establishment grants to support these activities through 2014

Exchange blueprints were due on November 16, 2012

ACA requires HHS to run a FFE in any state that does not set up an exchange

States with the FFE will not control key exchange functions, although the federal government is consulting with states on its design

FFE states will retain traditional responsibilities of their insurance departments

HHS = Department of Health and Human Services* HHS has approved eight FFE states—KS, ME, MT, NE, OH, SD, UT and VA—to operate the “Marketplace Plan Management” model in which these states will perform plan management.


16 States and DC Will Run Exchanges in 2014, While 6 States Will Pursue Partnerships, and the Rest Will Rely on the FFE

Source: Avalere State Reform Insights, July 15, 2013.*In addition to the marketplace plan management model for its individual exchange, Utah will rely on its existing small group exchange as its SHOP.**While New Mexico will operate a partnership for its individual exchange, the state will run its own SHOP.*** Although Idaho will operate a state-based exchange, it will rely on HHS for certain functions, such as eligibility and enrollment.

Insurance Exchange Operational Model

AK

HI

CA

AZ

NV

OR

MT

MN

NE

SD

ND

ID***

WY

OK

KSCO

UT*

TX

NM**SC

FL

GAALMS

LA

AR

MO

IA

VA

NCTN

IN

KY

IL

MI

WI

PA

NY

WV

VT

ME

RICT

DEMD

NJ

MANH

WA

OH

D.C.

FFE – Marketplace Plan Management (8)

State-Run (15 + DC)

FFE (20)

Partnership (7)

Affordability in Exchanges



Plans in the Individual and Small Group Market, Including Exchange Plans, Must Offer the Essential Health Benefits1. Essential Health Benefits

» Applies to all individual and small group plans

2. Out-of-Pocket Limits (OOP)

» Applies to all plans – OOP cap is tied to annual HSA limits ($6,350 for an individual in 2014)

3. Actuarial Value

» All individual and small group plans in the exchange must offer Silver and Gold

Ambulatory patient services Prescription drugs

Emergency services Rehabilitative and habilitative services and devices

Hospitalization Laboratory services

Maternity and newborn care Preventive and wellness services and chronic disease management

Mental health and substance abuse services Pediatric services (including oral and vision care)

Bronze Plan covers 60% of healthcare costs

Silver 70% of healthcare costs

Gold 80% of healthcare costs

Platinum 90% of healthcare costs

Actuarial Value = A measure of a benefit generosity that is expressed as percent of expenses paid by the insurerHSA = Health Savings Account


Exchange Plans Will Follow Set Metal Levels & Will Be Less Generous than Employer Coverage

Insurance Plan % of Patient Costs Covered by Plan

Typical Employer Plan (HMO)1 93%

Platinum 90%

FEHBP Blue Cross Blue Shield Standard Option (PPO) 1

87%

Typical Employer Plan (PPO)1 80.0% - 84%

Gold 80%

Medicare Parts A, B and D1 76%

Silver 70%

Bronze 60%

1. Peterson, Chris. “Setting and Valuing Health Insurance Benefits.” Congressional Research Service. (2009)

Most enrollees are expected to select lower-premium Silver and Bronze plans, which will include very high out-of-pocket requirements for patients.

May have very high cost-sharing—enrollees could be

underinsured


Exchanges Will Offer Premium and Cost-Sharing Subsidies

Premium Subsidies: Sliding scale tax credits to limit premium spending as a percent of income for individuals under 400% FPL; Applies to the second lowest cost Silver plan available in the exchange

Cost Sharing Reductions: Provides cost-sharing subsidies for individuals with incomes below 250% FPL

Income Premiums Limited to % of Income

<133% FPL 2.0%

133 – 150% FPL 3.0 - 4.0%

150 – 200% FPL 4.0 – 6.3%

200 – 250% FPL 6.3 – 8.05%

250 – 300% FPL 8.05 – 9.5%

300 – 400% FPL 9.5 %

FPL = Federal Poverty LevelOOP = Out-of-Pocket

Household Income

Reduction in OOP Limit Actuarial Value

100 - 150% FPL 2/3 94%

150 – 200% FPL 2/3 87%

200 – 250% FPL 1/5 73%

250 – 400% FPL None, given AV level 70%


Initial Rate Filings Show Wide Variation in Silver Plan Premiums within and among States

CA (13) CO (10) CT (4) OH (5) OR (12) RI (2) VA (5) VT (2) WA (7) $-

$100

$200

$300

$400

$500

$600

$700

Monthly Silver Plan Premiums for Nonsmoking 40-Year-Olds for Exchange Plans*

Maximum

State (Number of Carriers)

Mo

nth

ly P

rem

ium

* Rates are for plans filed to be offered through exchanges for nonsmoking 40-year-old individual. Data are for the minimum, maximum, and averages across all regions within a state. Source: Avalere Health analysis of health insurance rate filings publicly available as of June 12, 2013.


Case Study: Despite Health Care Reform’s OOP Limit, Patients with Rare Diseases Will Face High Initial Costs for Their Drugs

First Month's Rx Fill Second Month$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

$7,000

Estimated Drug Spending for Rare Disease Patients in Exchange Coverage

Assumes $15,000 Monthly Drug Cost

VT DeductibleCA Silver Coinsurance PlanMA, NY Silver*OR Standard Silver PlanCT Standard Silver

Source: Avalere Health analysis based on states’ 2014 standardized benefit designs for silver-level plans in their exchanges. Calculations are based on a prescription drug with a cost of $15,000 per month that is placed on a plan’s highest-cost formulary tier. Assumes no other drug or medical spending by the patient during the year.* MA and NY each have a standard silver plan design with the same overall deductible amount, tier 3 cost sharing, and OOP maximum, although the benefit designs differ on cost sharing amounts for other services not included in this analysis.


The Affordable Care Act Introduces New Protections Invaluable to Patients with Special Healthcare Needs

• Insurers must cover treatment for conditions patients had prior to obtaining coverage

Pre-existing Condition Exclusions

• Insurers cannot turn down patients based on health status for initial enrollment or renewals

Guarantee Issue

• Insurers may only vary the premium rates for enrollees on the basis of four factors: family size, rating area, age, and tobacco use

Rating Rules

• Insurers must combine the claims experience across all enrollees in each market when setting premiums

Single Risk Pool

Enrollment



Options for Enrollment in Exchange Coverage Will Include an Online Web Portal and In-Person Assistance

Medicaid / CHIP

Apply for Coverage Select Benefit & Health Plan

Platinum (90%)

Gold (80%)

Silver (70%)

Bronze (60%)

United

Humana

CIGNA

Aetna

WellPoint

BC/BS

Regional

Complete Enrollment

Income Verification

Process

Exchange without Subsidy

Exchange with

Subsidy

Exchange portals will allow individuals to determine eligibility for exchanges and subsidies

Consumers will be allowed to select from three to four coverage levels* and from a variety of benefit designs and carriers

In-person assistance will be available to aid consumers in enrollment decisions

* Individuals receiving cost-sharing reductions must purchase silver-level coverage


Patients Can Enroll Beginning in October, with Coverage Effective as Soon as January 1

July August Sept October Nov Dec Jan Feb March April

2013 2014

For enrollments between October 1 and December 15, 2013, coverage will be effective January 1, 2014

After December 15, for enrollments between the 1st and 15th day of the month, coverage will begin the first day of the next month. For enrollments between the 16th and the last day of the month, coverage begins the first day of the second following month.

Patients will be able to enroll outside of the open enrollment period only if they experience qualifying events including:

» Marriage or divorce

» Loss of other insurance coverage (from an employer, for example)

» Become eligible for subsidies due to change in income

October 1: Open Enrollment Begins

January 1: New Coverage Effective

March 31: Open Enrollment Closes


The ACA Requires People Who Do Not Have Health Insurance to Pay a Penalty, Which Phases Up in Later Years

Year Penalty

2014 Greater of $95 or 1% of income (offset by filing threshold)

2015 Greater of $325 or 2% of income (offset by filing threshold)

2016 Greater of $625 or 2.5% of income (offset by filing threshold)

2017Greater of $625 (+ cost of living

adjustment) or 2.5% of income (offset by filing threshold)

Penalty amounts increase in future years, but are capped at bronze premium levels

Source: IRS, Proposed Rule, Shared Responsibility Payment for Not Maintaining Minimum Essential Coverage, January 2013.


State Navigators, Assisters, and Counselors: How to work with them

Purva RawalSenior Manager

Avalere Health, LLC

Consumer Outreach and Enrollment Activity



HHS and States Focused on Consumer Outreach and Enrollment As October 1 Approaches

Exchanges must have fixed, annual open enrollment periods with special enrollment periods for particular circumstances

» Initial open enrollment period will run from October 1, 2013 through March 31, 2014 » In subsequent years, annual enrollment will run from October 15 through December 7

of each year

Major federal, state, and private marketing efforts are expected to begin this summer to draw attention to the coverage expansions and the exchange marketplaces in time for enrollment assistance on October 1, 2013

APR MAY JUN JUL AUG SEPT OCT NOV DEC JAN FEB MAR

October 1, 2013-March 31, 2014: Initial open enrollment in the individual exchange

October 15-December 7: Annual open enrollment

in the individual exchange


Patients Will Need Support across Three Domains•Althoug

h many people will qualify for federal subsidies in the exchanges, individuals may still have trouble affording premiums

•Affordability may vary greatly by state depending on enrollment trends and the payer landscape

Premiums

•Awareness of new coverage options is low and the process for applying will be complex for many to navigate

•Patients will require non-bias, informed support from navigators and non-navigator assisters in order to enroll in the plan that best meets their needs

Enrollment

•Cost sharing for upper tiered medications is expected to be high, ranging from 20-50% on tiers 3 and 4 in states with standardized plan designs

•While some patients will be eligible for cost-sharing subsidies, many will need support accessing medications before they meet the OOP limit

Access to Providers and

Treatments


HHS Has Proposed Three Separate Consumer Assister Entities to Boost Exchange Enrollment

Navigator In-person AssistersCertified Application Counselor

Roles and Responsibilities

Assist and educate individuals to receive eligibility determination from exchange and help with enrollment

Provide similar assistance as Navigator to supplement the Navigator program for the initial years of the exchanges

Assist consumers in completing and gathering information for single streamlined eligibility application for Medicaid, exchanges

Funding Grants from HHS in FFE and SPEs, grants from the state exchange in SBEs

Exchange Establishment Grants

Self-funded; federal and exchange grants not available

States FFE, SPE, SBE SPE, Optional SBE FFE, SPE, SBE

FFE = Federally Facilitated Exchange; SPE = State-Partnership Exchange; SBE = State Based Exchange Source: Centers for Medicare & Medicaid Services. Proposed Rule on Standards for Navigators and Non-Navigator Assistance Personnel. Released April 3, 2013.

The multiple consumer assister options, differing funding streams, and staggered application deadlines –in the absence of final rules - are challenging to those trying

to identify what consumer assister roles they can play and where.


States with RFPs for Navigators, IPAs, or Certified Application Counselors

AK

HI

CA

AZ

NV

OR

MT

MN

NE

SD

ND

ID

WY

OK

KSCO

UT

TX

NMSC

FL

GAALMS

LA

AR

MO

IA

VA

NCTN

IN

KY

IL

MIWI

PA

NY

WV

VT

ME

RICT

DEMD

NJ

MANH

WA

OH

D.C.

RFP Released (12 + DC)

No RFP (40)

To Date, 12 States and DC Have Issued RFPs for Consumer Assistance Programs

Source: Avalere State Reform Insights, July 15, 2013.


States Are Spending on Consumer Assistance More Heavily than HHS

FFE AK CA CO CT DC HI IL MD MN NV VT

54,000,000

$16

43,000,000

17,000,000

4,550,000

10,000,000

$0.43

28,000,000

24,000,000

4,000,000 3,990,000

12,840,000

Spending on Consumer Assistance Programs, in Millions

Avalere analysis based on publicly reported spending on consumer assistance programs, including navigators and IPAs.Source: Avalere State Reform Insights, July 15. 2013


HHS Has Made Steady Progress on Consumer Assistance Programs, But Significant Work Still Must Be Accomplished

Funding Delays Training PlanA

Outstanding Activities

The funding announcement for the Navigator program was delayed until April 9, 2013 and CMS indicated only one round of awards would take place.

The anticipated award date is now August 15, 2013 and CMS expects to make awards to at least two different applicants in each of the 34 FFE states and 33 FF-SHOP states.

Federally funded in-person assisters, including Navigators, must be trained and certified before conducting outreach assistance activities.

CMS plans to complete the development of the Navigator training curriculum and certification exam by August 2013 and will begin training once the curriculum is published.

CMS recommended that in-person outreach activities begin in the summer of 2013 to educate small employers and employees in advance of the open enrollment period.

In addition, HHS is targeting marketing and outreach efforts to specific populations, such as young adults and Hispanics.

Source: GAO Report: Status of Federal and State Efforts to Establish Federally Facilitated Health Insurance Exchanges. June 2013. Available at: http://www.gao.gov/assets/660/655291.pdf

http://www.gao.gov/assets/660/655291.pdf


Navigators and Assisters Must Be Trained Quickly and Prepared to Reach Varied Populations

•Minorities expected to be disproportionately represented—need for consumer assister services in other languages

•Population expected to have lower educational attainment compared to those with ESI requiring materials at appropriate literacy levels, etc.

Population

•Navigators and non-Navigator assistance personnel must obtain certification through the exchange, complete and pass an HHS-approved training, and obtain continuing education and be recertified

•CMS estimates training will take up to 30 hours for certification

Training

•Navigators and non-Navigator assistance personnel must be trained and certified quickly in anticipation of open enrollment October 1

•Interested entities must apply by June 7, with awards made by August 15 (letter of intent due May 1)

Timing

Patient groups and community-based organizations could play a critical role in educating Navigators and IPAs on the benefit design features enrollees with special

needs or chronic health conditions should consider before selecting a plan.


Opportunities for NHC Members to Engage

Patient advocacy groups have a key role to play in educating Navigators and In-Person Assisters in serving exchange enrollees with special needs or chronic conditions

Key considerations in plan design for assisting patients

» Provider Access: Ensure patients’ physician(s), facilities of choice are in-network

» Drug Cost-Sharing and Other Access Limitations: Understand formulary rules for specialty drugs and biologics, including costs and utilization management

NHC members should seek opportunities to partner with other stakeholders who share the goal of maximizing exchange enrollment and promoting high levels of appropriate plan choice

QUESTIONS?

If you have any questions or commentsabout the National Health Counciland its work on behalf of patients,

the essential health benefits, or enrollment in the exchanges,

contact us at [email protected].

mailto:[email protected]

National Health Council - Preparing for Exchange Enrollment (July 2013)

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Transcript of National Health Council - Preparing for Exchange Enrollment (July 2013)