Health Insurance ExchangeHIX
Robert E Goff
Before the Exchanges Big Change
2010 2011 2013 2014 2015-2017
• Small business tax credit
• Prohibitions against lifetime benefit caps & rescissions
• Phased-in ban on annual limits
• Annual review of premium increases
• Public reporting by insurers on share of premiums spent on non-medical costs
• Preventive services coverage without cost-sharing
• Young adults on parents’ plans
Source: Commonwealth Fund Analysis of the The Affordable Care Act (Public Law 111-148 and 111-152).
• Insurers must spend at least 85% of premiums (large group) or 80% (small group / individual) on medical costs or provide rebates to enrollees
• HHS must determine if states will have operational exchanges by 2014; if not, HHS will operate them
• State insurance exchanges
• Medicaid expansion• Small business tax
credit increases • Insurance market
reforms including no rating on health
• Essential benefit standard
• Premium and cost sharing credits for exchange plans
• Premium increases a criteria for carrier exchange participation
• Individual requirement to have insurance
• Employer shared responsibility penalties
• Penalty for individual requirement to have insurance phases in (2014-2016)
• Option for state waiver to design alternative coverage programs (2017)
•States adopt exchange legislation and begin implementing exchanges
•Phased-in ban on annual limits
2014 The Year of the Health Insurance Exchanges
What is the HIX?
Simply put: Health Insurance products, different
benefit packages, different plans available for purchase at a single “market”
Two markets▪ Small Business Health Options Program
(SHOP) 50 or less▪ Individual Market
What makes HIX “Game changing”
No pre-existing condition restrictions Subsidies based on income available
Who is offering in the NY HIX?Medical Plans
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http://www.nystateofhealth.ny.gov/PlansMap
Who is offering in the NY HIX?Dental Plans
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http://www.nystateofhealth.ny.gov/PlansMap
Required Ten Essential Health BenefitsPreventive services will be offered at with not patient cost sharing
1. Ambulatory patient services
2. Emergency room services
3. Hospitalization
4. Maternity and newborn care
5. Mental health and substance abuse disorders
6. Prescription drugs
7. Rehabilitation and habilitation services and devices
8. Laboratory services
9. Preventive and wellness services and chronic disease management
10. Pediatric services, including oral and vision
SAMPLE
What is being offeredPlatinum, Gold, Silver,
Bronze
Exchange Responsibilities
Exchange Functions
Operate a toll-free telephone hotline to help users
Enroll applicants in their chosen plan
Maintain a website to sell plans
Work with federal and state agencies regarding subsidies and tax credits
Enroll eligible individuals into Medicaid
Set annual Open Enrollment Period and special Enrollment Periods
Certify and rate plans
Only Available in Exchanges
• Subsidies for individuals from 133%-400% of FPL
• Small employer tax credits
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What is NY State of Health?
Organized marketplace One-stop shopping for subsidized and unsubsidized
coverage Easily compare health plan options The only place to check eligibility and apply for
financial assistance Enroll in qualified health plans
Two programs Individual Marketplace Small Business Marketplace
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Individual Marketplace (58%)
Small Business Marketplace (42%)
Who Will Enroll In NY State Of Health?
Health Plan Marketplace enrollment is estimated to be 1.1 million New Yorkers
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450,000
615,000
NY State of Health Enrollment
Open Enrollment begins on October 1
Individuals may enroll in health plans during open enrollment October 1, 2013 - March 31, 2014) or with a qualifying event
Individuals who qualify for Medicaid/CHP may enroll any month of the year
Small employers may choose open enrollment dates for their employees any month of the year
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Customer Service Call Center
Assistance available in over 170 languages Many staff will be bilingual and oral
interpretation available for remaining languages.
• Will take applications over the phone starting in October
Can refer to in-person assistors
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3 Types of In-Person Assistors
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• Complete Applications• Compensation from DOH grant program• Training and certification required• Serve Individuals and Small Business Marketplace
IPA/Navigators
• Complete Applications• No compensation from Marketplace• Training and certification required
Certified Application Counselors
• Complete Applications• Commission-based compensation• Training and certification required• Choose to certify in Small Business Marketplace, Individual, or
both
Insurance Brokers/Agents
Individual Responsibility
• Jan. 1, 2014: Individuals must enroll in coverage or pay a tax penalty
Penalty amount:
• Greater of $ amount or a % of income– 2014 = $95 or 1%– 2015 = $325 or 2%– 2016 = $695 or 2.5%– Family penalty capped at 300% of the adult flat dollar
penalty or “bronze” level premium
Family Responsibility
Penalty amount:
Greater of $ amount or a % of income– 2014 = $285 or 1%– 2015 = $975 or 2%– 2016 = $2,085 or 2.5%– Family penalty capped at 300% of the adult flat dollar
penalty or “bronze” level premium
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Employer Penalty
Please note that the information in this chart is based on an interpretation of the Patient Protection and Affordable Care Act. This chart is for general information purposes only and is not intended to constitute legal advice or a recommended course of action in any given situation and should not be relied upon in making decisions of a legal nature.
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Subsidies, Tax Credits, Penalties
Individuals may be eligible for premium assistance – 133% to 400% FPL if employer: Doesn’t offer minimum essential coverage or Offers coverage, but premium isn’t affordable However, if employer does offer affordable MEC
and the employee purchases on HIX, not eligible for subsidy
Cost sharing assistance Individuals 133%-250% of FPL Must purchase silver plan
Small employer tax credits Employers < 25 Must purchase on SHOP, other requirements apply
Penalties for not having/offering health insurance
What does this mean to physicians?
1.1 million New Yorker's added to the “insured population” Reduced bad debts Increased access to care Increased demand for services
What they aren’t telling physicians
These “new” patients come with lower reimbursement rates
Most of the HIX offering are paying between 6% and 25% LESS than the commercial rates for the same company
Some plans are making participation mandatory
There “new” patients come with continued risk of bad debts
Federal regulations put the physician at risk of not being paid when patients are late in paying their premiums.
Carriers HIX products must provide a 3 month grace period to enrollees that haven’t paid their premiums. During the first 30 days plans must pay claims, but in the last 60 days, the payer will hold the claims.
If the patient coverage is cancelled after 90 days for failure to pay premiums, plans are not required to pay any claims in those last 60 days. It falls to the practice to go after the patient, for services rendered.
What should a physician do? It Depends
Do you need this volume?
Do you believe increasing your access to patient sis the ‘right” thing to do?
Are you “par” by virtue of your current participation agreements?
Can you limit your participation to x number of HIX plans? X number of enrollees?
Know what you are getting into reimbursement wise.
Verify each patient’s benefit plan at time of 1- appointment scheduling and 2- at time of service.
Require a contingent credit card authorization on all patients
Nystateofhealth website
Stuff you want to ask
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Thank you
Robert E. Goff