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
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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
Slide2Why the need for health insurance reform?
Part 1
Slide3Slide4Slide5What 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
Slide6The Patient Protection and Affordable Care Act (ACA)
Part 2
Slide7Major 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
Slide8ACA (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
Slide9ACA 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
Slide10ACA 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
Slide11ACA 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
Slide12The Silver State Health Insurance Exchange
Part 3
Slide13Philosophy 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
Slide14SSHIX 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
Slide15Mission 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.
Slide16Values
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
Slide17Levels 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
Slide18SSHIX 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
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Slide19SSHIX Concept of Operations
Slide20SSHIX 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%
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Slide21SSHIX 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)
Slide22SSHIX 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
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Slide23SSHIX Small Employer Option
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Slide24All 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
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One Carrier/One Plan
Carrier
A
B
C
D
Platinum
Gold
Silver
X
Bronze
Slide25ACA
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
Slide26Essential 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
Slide27The 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
Slide28SSHIX 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
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Slide29SHOP 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
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Slide30Navigators
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.
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Slide31Navigators
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
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Slide32Questions? Discussion?
Thank you