/
The Affordable Care Act (ACA) and Health Insurance Exchanges The Affordable Care Act (ACA) and Health Insurance Exchanges

The Affordable Care Act (ACA) and Health Insurance Exchanges - PowerPoint Presentation

bikerssurebig
bikerssurebig . @bikerssurebig
Follow
342 views
Uploaded On 2020-08-29

The Affordable Care Act (ACA) and Health Insurance Exchanges - PPT Presentation

Ronald Kline MD FAAP Medical Director Pediatric Division Comprehensive Cancer Centers of Nevada Gubernatorial Appointee Silver State Health Insurance Exchange Vice Chair Plan Certification and Management Committee ID: 810741

plan health state insurance health plan insurance state sshix plans small aca care exchange carrier services enrollment silver group

Share:

Link:

Embed:

Download Presentation from below link

Download The PPT/PDF document "The Affordable Care Act (ACA) and Health..." is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.


Presentation Transcript

Slide1

The Affordable Care Act (ACA) and Health Insurance Exchanges

Ronald Kline, MD, FAAP

Medical Director, Pediatric Division

Comprehensive Cancer Centers of Nevada

Gubernatorial Appointee, Silver State Health Insurance Exchange

Vice Chair, Plan Certification and Management Committee

Slide2

Why the need for health insurance reform?

Part 1

Slide3

Slide4

Slide5

What will happen to health care costs?

Thank God for cars

In 1894, the Times of London predicted that by 1950, every street in London would be buried in nine feet of horse manure

Stein

s Law

If something cannot go on forever, it will stop

Trends that can’t continue, won’t

Herbert Stein, (1916-99) Chairman, President’s Council of Economic Advisors

Slide6

The Patient Protection and Affordable Care Act (ACA)

Part 2

Slide7

Major features of ACA

(Affordable Care Act)

Guaranteed Issue (No pre-existing condition exclusions)

Individual mandate (or an IRS penalty)

Limits on insurance company Medical Loss Ratios (MLR)

85% for large group plans

80% for small group plans

Slide8

ACA (2)

Expansion of Medicaid (State Decision)

100% of costs paid by the Federal government from 2014-2016

95% paid from 2017-2020

90% paid from 2020 onwards

Health Insurance Exchanges

Alternative Health Care Delivery Systems

Accountable Care Organizations

Cooperatives

Children up to age 26 may remain on their parents policies

Coverage for clinical trials

Slide9

ACA Concerns

Independent Payment Advisory Board

15 members appointed by the President to 6 year terms

Recommendations must be voted on by Congress with a straight up or down vote (no amendments

Medicare chief actuary is concerned that physicians will not be able to remain profitable with these cuts and will leave Medicare

Slide10

ACA Concerns (2)

(the conspiracy theory)

Requirement to buy insurance (individual mandate) vs. penalty/tax

Will large numbers of people simply pay the penalty and purchase insurance only when they are sick

Thus bankrupting insurance companies and ultimately resulting in a single payer system

Slide11

ACA Concerns (3)

800 billion dollar 10 year price tag assumes no fix in the Sustainable Growth Rate (which envisions 30% cuts in Medicare in Jan 2013)

If SGR is fixed (as most assume it will be), actual cost of ACA increases

Slide12

The Silver State Health Insurance Exchange

Part 3

Slide13

Philosophy of Exchanges

Group Purchasing Organization (GPO) that aggregates individuals and small businesses into a large group to enhance purchasing power (Alain Einthoven originated idea and

Heritage Foundation has supported the concept in the past

)

Federal government subsidy is layered on top of this free market concept

Active vs. Passive Purchasers

Slide14

SSHIX Concept of Operations

“Expedia” for health insurance:

Organized commercial health insurance marketplace for individuals and small employers

Enables consumers to review benefits, compare plans, and enroll in coverage

Slide15

Mission and Vision

Vision:

Access to health insurance for all Nevadans

Mission:

To increase the number of insured Nevadans by facilitating the purchase and sale of health insurance that provides quality health care through the creation of a transparent, simplified marketplace of qualified health plans.

Slide16

Values

Consumer-Focused

: At the center of the Exchange’s efforts are the people it serves, including patients and their families, and small business owners and their employees

Innovative

: The Exchange strives to be an innovative and forward thinking

organization

Diversity

: Diverse stakeholder involvement is vital to a successful implementation of the

Exchange

Business Friendly

: The Exchange is committed to creating a business friendly environment for the simple purchase of health insurance

Slide17

Levels of Coverage

Platinum Plan Covers 90% of actuarial value

Gold Plan Covers 80% of actuarial value

Silver Plan Covers 70% of actuarial value

Bronze Plan Covers 60% of actuarial value

Catastrophic Plan for young adults

Actuarial values can be achieved by offering different levels of coverage for different services

Slide18

SSHIX User Experience

Shopping Experience

Enter demographic information (age, zip code, income, American Indian Status)

ELIGIBILITY ENGINE

Select metal tier of coverage

Select health plan (subsidized cost provided based on demographic information)

Select other products (dental, vision)

Enroll

18

Slide19

SSHIX Concept of Operations

Slide20

SSHIX Eligibility

SSHIX Eligibility

Individual (non-group) coverage:

Legal US resident (and resident of Nevada)

Not eligible for Medicaid or Medicare

Not offered employer-sponsored insurance that is:

Affordable (i.e., does not exceed 9.5% of person’s income), and

meets minimum actuarial value standard of 60%

20

Slide21

SSHIX Eligibility (2)

Subsidies available to individuals and families with income up to 400% of the federal poverty level (FPL)

$44,680 for single person (2012)

$92,200 for family of four (2012)

Slide22

SSHIX for Small Employers

Small Employers:

Employers with up to

50 full-time employees (FTEs) in 2014 (state option to expand to 100 FTEs)

100 FTEs in 2016 (required by ACA)

Large employees in 2017 (state option)

Tax credits (in 2014 & 2015) for employers with:

25 or fewer employees

Firm’s average wages $50,000 or less

22

Slide23

SSHIX Small Employer Option

23

Slide24

All Carriers/One Plan Level

Carrier

A

B

C

D

Platinum

Gold

Silver

X

X

X

X

Bronze

One Carrier/Multiple Plans

Carrier

A

B

C

D

Platinum

X

Gold

X

Silver

X

Bronze

X

All Carriers/All Plans

Carrier

A

B

C

D

Platinum

X

X

X

X

Gold

X

X

X

X

Silver

X

X

X

X

Bronze

X

X

X

X

One Carrier/One Package

Carrier

A

B

CDPlatinum Gold XSilver XBronze

SSHIX Small Employer Options

24

One Carrier/One Plan

Carrier

A

B

C

D

Platinum

Gold

Silver

X

Bronze

Slide25

ACA

r

equirements for all health plans

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 and chronic disease management

10. Pediatric services, including oral and vision care

Slide26

Essential Health Benefits (EHB)

The “Benchmark” Approach

Rather than defining one EHB package that would apply to all states, HHS has proposed that each state choose its own benchmark plan to act as the EHB for that state. HHS provided four benchmark options from which a state can choose:

One of the three largest small group plans in the State by enrollment

One of the three largest State employee health plans by enrollment

One of the three largest federal employee health plan options by enrollment

The largest HMO plan offered in the State’s commercial market by enrollment

Slide27

The Players

HPN HMO E25 Benefit Schedule

Sierra D-XX-1000-1500 Benefit Schedule

Anthem PPO $45 Gen Rx Benefit Schedule

NV PEBP PY 2012 MPD

State of Nevada HPN 15 Benefit Schedule

HHP Benefit Summary

GEHA 2010 Plan

FEHBP – HPN Plan

FEHBP – Blues Plan

HPN CCSD Option I Benefit Schedule

Slide28

SSHIX Advisory Committees

SSHIX Board created 5 advisory

committees:

Finance and Sustainability

Plan Certification and Management

Small Business Health Options Program (SHOP) Exchange

Reinsurance and Risk Adjustment

Consumer Assistance

28

Slide29

SHOP Exchange

Determine:

Number of QHP issuers and number of health plans available at each of the four plan levels

Extent to which plan benefits may be standardized (i.e. point of service cost sharing)

Plan designs in SHOP compared to individual exchange

Employer purchasing model and flexibility in offering employee choice

Risk mitigation across plans and tiers

Minimum contribution and participation requirements

29

Slide30

Navigators

Roles of Navigators

Conduct public education activities; raise awareness; distribute information regarding enrollment in QHPs

Facilitate enrollment in QHPs

Refer people to the appropriate agency if they have questions, complaints, or grievances

Provide information in a culturally and linguistically appropriate manner.

30

Slide31

Navigators

Entities that have established, or can readily establish, relationships with employers, employees, consumers, and/or self-employed individuals, including, but limited to:

Trade, industry, unions and professional associations;

Chambers of commerce;

Community-based non-profits; and

Faith-based organizations.

Navigators are prohibited, by law, from receiving “direct or indirect payments” in connection with the enrollment of an individual or an employee in a health plan

31

Slide32

Questions? Discussion?

Thank you