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Health Insurance Exchanges under the Affordable Care Act Health Insurance Exchanges under the Affordable Care Act

Health Insurance Exchanges under the Affordable Care Act - PowerPoint Presentation

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Uploaded On 2017-04-19

Health Insurance Exchanges under the Affordable Care Act - PPT Presentation

Deborah Chollet PhD Senior Fellow Individual Exchanges and Small Business Health Options Programs SHOP Exchanges Exchange design and implementation occur in the context of significant market reforms ID: 539365

individual exchange health exchanges exchange individual exchanges health plans qualified state consumer coverage enrollment information cost shop premium small

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Slide1

Health Insurance Exchanges under the Affordable Care Act

Deborah Chollet, Ph.D.

Senior FellowSlide2

Individual Exchanges and Small Business Health Options Programs (“SHOP” Exchanges)

Exchange design and implementation occur in the context of significant market reforms

Required duties of the individual Exchange:Enrollment and consumer assistanceEligibility determinations for public programs and subsidiesOversight of Qualified Health PlansAdministration of the ExchangeState flexibility

Overview

2Slide3

Facilitate the individual purchase of coverage

Consumer information and assistance

Facilitate use of income-based subsidies to buy coverageFacilitate enrollment in public coverage, when eligibleAssist small employers that offer coverageEncourage the development of qualified health plans that compete on price and qualityWhy Exchanges?

3Slide4

Market reforms

No preexisting condition

exclusions for childrenNo lifetime benefit caps

Limited recissions

Guaranteed issue

Limits on rating:

No rating on health status

Limited age rating

Essential benefit standardIndividual coverage requirementEmployer shared responsibilityBan on annual benefit caps phases inPenalty phases in for failing to meet individual coverage requirement (2014-2016) Annual review of premium increasesPublic reporting of medical loss ratioInsurers must spend a minimum percent of premium on medical costs in small group (85%) and individual (80%) products, or rebate the excessExchangesFederal regulations expected for individual and SHOP ExchangesStates adopt individual and SHOP Exchange legislation, and start implementation State individual exchanges begin operationPremium and cost sharing credits for Exchange plansState option to: Expand SHOP Exchanges to mid-sized groups (2016) Design alternative coverage program (2017)HHS determines whether states will have working individual Exchanges by 2014, or HHS will operate them20102011201320142015-2017

Market Reform and Exchange Implementation Timeline

4Slide5

Facilitate initial, annual, and special open enrollment periods

Maintain internet web site with standardized information to help consumers compare plans and calculate their cost of coverage

Maintain a toll-free consumer hotlineMake eligibility determinations and enroll eligible Exchange applicants in Medicaid & CHIPWork with the IRS to determine eligibility for and amount of individual premium or cost-sharing subsidies, if no qualified employer offer Certify exemptions from the individual coverage requirement and notify employers and the Treasury of exemptions and individual terminations of coverage during the yearEstablish a Navigator program, awarding grants to eligible entities to conduct Exchange education and enrollment

Requirements for Insurance Exchanges:

Enrollment and Consumer Assistance

5Slide6

Certify qualified health plans and assign ratings based on relative quality and price

Present plan options to consumers in a standardized format with information about benefits and consumer satisfaction

Review premium increases and post carriers’ justifications on the Exchange websiteUse authority to exclude plans from the Exchange if premium increases are deemed excessiveRequirements for Insurance Exchanges: Qualified health plan administration

6Slide7

Marketing that does not deter high-need individuals

Sufficient choice of providers—including essential community providers serving low-income, medically underserved individuals

Accredited with respect to local performance onClinical quality measures (e.g., HEDIS)Patient experience ratings (e.g., CAPS)Consumer accessUtilization managementQuality assurance

Provider credentialingComplaints and appeals

Network adequacy and access

Patient information programs

Quality improvement strategy

Uniform enrollment form, standard presentation of health benefits, and consumer information about quality

What is a Qualified Health Plan?7Slide8

Individual Exchanges must be self-sustaining by Jan. 1, 2015

Consult with stakeholders—consumers, small business, self-employed, Medicaid, advocates for hard-to-reach populations

Account for all activities, receipts, and expenditures, and report annually to HHSPublish on an Internet website average costs of licensing, regulatory fees and required payments, administrative costReport on all operations annually to the Exchange board, Governor, legislature, and State AuditorRequirements for Insurance Exchanges:

Exchange Administration

8Slide9

What entity to administer the Exchange? Contract functions?

Exclusive, statewide, sub-state, or multi-state Exchanges?

Merge individual and SHOP Exchanges?Extend SHOP to groups with 51-100 employees and (in 2017) larger groups?Allow all qualified health plans to participate in the Exchange, or only selected plans?Allow Exchange plans to vary cost sharing, care management, other provisions consistent with federal guidelines?Apply existing state mandates at state cost?What entity will do risk adjustment in/outside the Exchange?What role for agents and brokers, per federal guidelines? What Exchange surcharge to support operations?

State flexibility

9