Georgia’s Healthcare Exchange Experience

Robert Threlkeld, PartnerMorris, Manning & Martin, LLP

rthrelkeld@mmmlaw.com(404) 233-7000

Overview of Affordable Care Act Georgia Exchange (focus on Individual plans)

Year 1 Overview Year 2 Projections

How to Help Navigate Members

Agenda

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OVERVIEW OF THE AFFORDABLE CARE ACT

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The Patient Protection and Affordable Care Act (Pub. L. No. 111-148) was enacted on March 23, 2010; the Health Care and Education Reconciliation Act (Pub. L. No. 111-152) was enacted on March 30, 2010. These laws are collectively known as the Affordable Care Act (“ACA”).

The primary goals of the ACA are to decrease the number of uninsured Americans and reduce the overall costs of health care.

Affordable Care Act

ACA created the ability for states to establish a state-operated Exchange entity or elect (default) to a federally-operated Exchange

The primary functions of the Exchange include: Eligibility and enrollment for Medicaid Eligibility and enrollment for Individuals Eligibility and enrollment for Small Business Health Options

Program (SHOP) Plan Management Financial Management Consumer Assistance for the Exchange

Health Insurance Exchange

SOURCE: https://www.healthcare.gov/get-covered-a-1-page-guide-to-the-health-insurance-marketplace/

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Federally-facilitated Exchange Model (FFE)– All core functions of the Exchange are operated by the United States Department of Health and Human Services (HHS) on behalf of a state. 27 states (including Georgia)

State-based Exchange Model (SBE) – All core functions of the Exchange are operated by the state. 16 states and District of Columbia

State Partnership Exchange Model (SPE)—States can elect to participate in the Federally Facilitated Exchange model but retain and operate either Plan Management or Consumer Assistance OR both Plan Management and Consumer Assistance. 7 states

State versus Federal Exchange

SOURCE: http://kff.org/health-reform/state-indicator/state-decisions-for-creating-health-insurance-exchanges-and-expanding-medicaid/

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The Medicaid expansion is a core component of ACA and was designed to fill longstanding gaps in health coverage for adults. 

As enacted, the ACA created a continuum of health coverage options, with Medicaid expanding to cover all low-income adults with income up to 138% of poverty (about $16,000 for an individual) and tax credits to purchase private coverage in new Health Insurance Marketplaces available to people with moderate incomes.

Medicaid Expansion

SOURCE: www.kff.com and The Henry J. Kaiser Family Foundation7

However, the July 2012 Supreme Court ruling on the Affordable Care Act effectively made the Medicaid expansion a state option, and as of August 2014, 21 states, including Georgia, are not moving forward with the Medicaid expansion at this time (see next slide).

In states that do not implement the Medicaid expansion, millions of low-income adults that could have gained Medicaid will remain ineligible for the program. A small number of these people may be eligible for tax credits to purchase private coverage, but the majority will be left without an affordable coverage option.

Medicaid Expansion

SOURCE: www.kff.com and The Henry J. Kaiser Family Foundation

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Current Status of Medicaid Expansion

WY

WI*

WV

WA

VA

VT

UT

TX

TN

SD

SC

RI PA*

OR

OK

OH

ND

NC

NY

NM

NJ

NH*

NV NE

MT

MO

MS

MN

MI*

MA

MD

ME

LA

KY KS

IA*

IN* IL

ID

HI

GA

FL

DC

DE

CT

CO CA

AR*AZ

AK

AL

Implementing the Medicaid Expansion (28 States including DC)

Open Debate (2 States)Not Moving Forward at this Time (21 States)

NOTES: Data are as of August 28, 2014.SOURCES: Current status for each state is based on data from the Centers for Medicare and Medicaid ServicesSlide courtesy of the Henry J. Kaiser Family Foundation

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GEORGIA EXCHANGE

Georgia follows the Federally-facilitated Exchange (FFE) Model under which all core functions of the Exchange are operated by the United States Department of Health and Human Services (HHS) on behalf of a state.

Georgians wishing to enroll in the Exchange must visit www.healthcare.gov

Insurers are prohibited from denying coverage based on pre-existing conditions.

Tobacco Surcharge: Georgia allows insurance companies to charge tobacco users 50% more than non-tobacco users. 

Georgia Plans Generally

SOURCES: http://www.webmd.com/health-insurance/20130716/how-affordable-care-act-affects-smokers

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All approved plans in the state must cover the same package of benefits, called essential health benefits. In Georgia, the benefits include: Outpatient services, such as doctor visits or tests done outside a hospital,

including chiropractic care and the diagnosis and treatment of conditions that cause infertility

Emergency services Hospital stays Pregnancy and baby care Mental health and substance abuse services, including behavioral health treatment Prescription drugs, including generic and certain brand-name drugs Rehab and habilitative services, those that help people recover from an accident or injury

and those that help people with developmental issues. In Georgia, this includes up to 20 visits for physical or occupational therapy and 20 visits for speech therapy. Coverage for autism services is also required.

Lab services Preventive and wellness services, along with those that help people manage chronic

conditions Services for children, including dental and eye care

Some services not included: hearing aids, cosmetic surgery, long-term care, and private nursing.

Georgia Plan Benefits

SOURCE: http://www.cms.gov/CCIIO/Resources/Data-Resources/Downloads/georgia-ehb-benchmark-plan.pdf 12

Insurers must cover a minimum set of essential health benefits and must organize their plan offerings into five levels of patient cost-sharing (below, ranging from most to least protective). These “metal” plans are offered in each state.

Plans in each category pay different amounts of the total costs of an average person’s care. This takes into account the plans’ monthly premiums, deductibles, copayments, coinsurance, and out-of-pocket maximums. The actual percentage an insured pays will depend on the services he or she uses during the year.

Bronze Plan: Insureds pay 40% and the plan pays 60%. Silver Plan: Insureds pay 30% and the plan pays 70%. Gold Plan: Insureds pay 20% and the plan pays 80%. Platinum Plan: Insureds pay 10% and the plan pays 90%. Catastrophic Plan: plans pay less than 60% of the total average

cost of care on average. They’re available only to people who are under 30 years old or have a hardship exemption.

“Metal” Plans

SOURCE: https://www.healthcare.gov/how-do-i-choose-marketplace-insurance/plans-categories/

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Bronze plans (which cover 60 percent of health care costs when averaged across all enrollees) have the most cost-sharing and represent the lowest level of coverage generally available through exchanges. As a consequence, they typically have the lowest premiums.

Silver plans have lower cost-sharing than bronze plans (covering an average of 70 percent of enrollees’ health care costs on average), and will therefore generally have higher premiums.

“Metal” Plans Continued

SOURCE: http://kaiserfamilyfoundation.files.wordpress.com/2013/09/early-look-at-premiums-and-participation-in-marketplaces.pdf

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Georgia has not expanded Medicaid. As of July 2014, only 204,051 Georgians have gained

Medicaid or CHIP coverage since the beginning of the Health Insurance Marketplace’s first open enrollment period in October, 2013.

According to HHS, if Georgia expanded Medicaid, an additional 478,000 uninsured individuals would gain coverage. The expansion would be paid 100% by federal funds for the first three years and federal funds would never fall below 90% of costs thereafter.

Across the nation, 8 million more Americans are now enrolled in Medicaid and CHIP.

Georgia and Medicaid Expansion

SOURCE: Health and Human Services, http://www.hhs.gov/healthcare/facts/bystate/ga.html

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316,543 individuals selected a Marketplace plan between October 1, 2013 and March 31, 2014 (including additional special enrollment period activity through April 19, 2014).

57% are female and 43% are male. 36% are under age 35. 31% are between the ages of 18 and 34. 87% selected a plan with financial assistance.

Georgia Enrollment Numbers: 2014

SOURCE: U.S. Department of Health and Human Services, http://www.hhs.gov/healthcare/facts/bystate/ga.html

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Enrollment Numbers: 2014

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Bronze Plan: 11% of Georgians selected (20% nationally) Insured pays 40% and plan pays 60%

Silver Plan: 71% of Georgians selected (65% nationally) Insured pays 30% and the plan pays 70%.

Gold Plan: 6.5% of Georgians selected (8% nationally) Insured pays 20% and the plan pays 80%.

Platinum Plan: 9.5% of Georgians selected (5% nationally) Insured pays 10% and the plan pays 90%.

Catastrophic Plan: 2% of Georgians selected (2% nationally)

Thirty-one percent of Georgia enrollees were between the ages of 18 and 34.

Enrollee Plan Selections: 2014

SOURCE: ASPE Marketplace Summary Enrollment Report and CMS March Medicaid/CHIP Enrollment Report

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Participating insurers generally will offer a number of plans at various tiers of coverage (“metals”), and they also typically offer more than one plan option within a given coverage tier. As a result, the number of plans available to consumers will be significantly greater than the number of insurers participating.

In 2014, only five carriers participated: BlueCross BlueShield (BCBS) of Georgia, Alliant,

Humana, Kaiser Foundation Health Plan, and Peach State

Insurers Selling in Georgia Marketplace: 2014

SOURCE: Georgia Office of Insurance and Safety Fire Commissioner

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The Market Rules and Rate Review Final Rule (45 CFR Part 147) provides that each state will have a set number of geographic rating areas that all issuers in the state must uniformly use as part of their rate setting.

In Georgia, the Market Rating Areas are based on counties and there are currently 16 regions. The carriers were split into regions throughout the state to identify what areas each participated.

In 2014, BCBS was the only carrier that was offered in all 16 regions in the state. 

Not all counties within a particular rating area are actually served by each carrier in every case. A carrier is noted as serving a named Market Rating Area if they serve in at least one county within a particular rating area.

Georgia Market Rating Areas

SOURCE: Georgia Office of Insurance and Safety Fire Commissioner

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Georgia Market Rating Areas

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Insurers By Market Rating Area: 2014

Name of Market Rating Area AreaAlbany 1 BCBS HumanaAthens 2 Alliant BCBS Humana Peach StAtlanta 3 Alliant BCBS Humana Kaiser Peach St

W. Atlanta 4 Alliant BCBS HumanaAugusta 5 BCBS Humana

Brunswick 6 BCBS HumanaChattanooga 7 Alliant BCBS Columbus 8 BCBS Humana Peach St

Dalton 9 Alliant BCBS HumanaAtlanta Outer NE 10 Alliant BCBS Humana

South. Cental Georgia 11 BCBS HumanaMacon-Warner Robins 12 BCBS Humana

N.W. Atlanta 13 Alliant BCBS HumanaSavannah 14 BCBS HumanaValdosta 15 BCBS Humana

East Macon 16 BCBS Humana

Carriers Serving the Market Rating Area

SOURCE: Georgia Office of Insurance and Safety Fire Commissioner

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Exchange premiums reflect insurers’ estimates of the cost of offering the new benefits to the people who are expected to enroll.

Insurers will be able to vary premiums only by age (to a limited extent), tobacco status, geographic region, and family size.

In general, lowest premiums for 2014 were in Region 8: Columbus.

In general, highest premiums for 2014 were in Region 1: Albany.

Premium Variables

SOURCE: http://kaiserfamilyfoundation.files.wordpress.com/2013/09/early-look-at-premiums-and-participation-in-marketplaces.pdf and Georgia Office of Insurance and Safety Fire Commissioner

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Unsubsidized exchange premiums vary due to several factors, such as differences in the underlying cost of health care, market competition, and the effectiveness of state rate review programs at lowering premiums.

Exchanges also vary in their authority to negotiate premiums with insurers or exclude plans.

Within a given rating area for a given insurer, premiums will vary by the age of an individual, as well as family income and household size, which determine eligibility for tax credits.

Premium Variables

SOURCE: http://kaiserfamilyfoundation.files.wordpress.com/2013/09/early-look-at-premiums-and-participation-in-marketplaces.pdf and Georgia Office of Insurance and Safety Fire Commissioner

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Premiums* Based on Rating Area: 2014

*Premiums are based on average rate for all insurers per Rating Area for a 40 year old individual**Based on lowest-price Silver or Bronze plan per insurerSOURCE: Data provided by Georgia Office of Insurance and Safety Fire Commissioner

RATING AREA SILVER** BRONZE**

1 460.86$ 405.43$ 2 283.04$ 250.90$ 3 269.59$ 240.26$ 4 312.88$ 278.48$ 5 284.17$ 249.45$ 6 321.44$ 281.54$ 7 344.39$ 306.25$ 8 265.78$ 232.40$ 9 331.14$ 294.61$ 10 278.85$ 248.65$ 11 306.32$ 268.44$ 12 303.28$ 266.19$ 13 312.55$ 278.31$ 14 290.78$ 254.88$ 15 422.42$ 371.97$ 16 280.72$ 254.54$

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1 3 5 7 9 11 13 15 $-

$50.00 $100.00 $150.00 $200.00 $250.00 $300.00 $350.00 $400.00 $450.00 $500.00

SilverBronze

Premiums Based on Rating Area: 2014

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INSURER SILVER** BRONZE**

Alliant $337.65 $302.54

BCBS $352.96 $312.32

Humana $250.50 $217.76

Kaiser $254.00 $232.00

Peach State $239.71 $199.55

Premiums* Based on Insurer: 2014

*Premiums are based on average rate per insurer across all Georgia Rating Areas for a 40 year old individual. Insurers do not all offer plans n same rating areas, which may affect an insurer’s average premium price.**Based on lowest-price Silver or Bronze plan per insurerSOURCE: Data provided by Georgia Office of Insurance and Safety Fire Commissioner

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Allia

nt

BCBS

Human

a

Kaiser

Peac

h St

ate

$-

$100.00

$200.00

$300.00

$400.00

SilverBronze

Premiums Based on Insurer: 2014

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AGE SILVER BRONZE

21 $240.11 $193.56

30 $272.68 $220.74

40 $307.32 $248.57

50 $428.79 $351.36

60 $651.41 $527.98

Premiums* Based on Age: 2014

*Premiums based on average of lowest cost premiums across all insurersSOURCE: Data provided by Georgia Office of Insurance and Safety Fire Commissioner

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21 30 40 50 600

100

200

300

400

500

600

700

SilverBronze

Premiums Based on Age: 2014

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Enrollees with family incomes from one to four times the federal poverty level (about $24,000 to $94,000 for a family of four) may qualify for tax credits that will lower the cost of coverage through reduced premiums and, in some cases, also be eligible for subsidies to reduce their out-of-pocket costs.

Among Georgia residents selecting a QHP, 87 percent qualified for financial assistance, compared to 85 percent nationally.

A report released in June by the U.S. Department of Health and Human Services showed the average monthly premium, after tax credits, for Georgia consumers was $54. Sixty percent of enrollees pay $50 or less per month after subsidies. Georgia’s $54 average is second only to Mississippi, where the average monthly premium after subsidies is just $23.

Tax Credits

SOURCES: http://www.healthinsurance.org/georgia-state-health-insurance-exchange/ and http://aspe.hhs.gov/health/reports/2014/Premiums/2014MktPlacePremBrf.pdf .

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Exchange subsidies limit the percent of one’s income that he or she must spend on a silver premium. The cap depends on the enrollee’s income range. Maximum Amount Enrollee Pays for Benchmark Silver Premium = Cap

(%) * Income If the enrollee’s unsubsidized premium is already less than

their cap, he or she would not receive a subsidy. Tax Credit = Unsubsidized Benchmark Silver Premium – Maximum

Amount Enrollee Pays for Silver Premium Subsidized enrollees can apply their tax credit toward the

purchase of other levels of coverage, such as bronze plans. Amount Enrollee Pays for Bronze Premium = Unsubsidized Bronze

Premium – Tax Credit

Tax Credit Calculation

SOURCE: http://kaiserfamilyfoundation.files.wordpress.com/2013/09/early-look-at-premiums-and-participation-in-marketplaces.pdf

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Blake is a 25 year-old non-smoker and resides in Atlanta, Fulton County (Rating Area 3).

Blake is single, has no children, has no employer coverage. Blake’s household income in 2014: $25,000 (218% of poverty

level of $11,670 for family of 1). Maximum % of income Blake will have to pay for the premium, if

eligible for a subsidy: 6.92% Health Insurance premium in 2014 (for a silver plan, before tax credit):

$2,362 per year ($197 per month) Blake could receive a government tax credit subsidy of up to:

$633 per year (which covers 27% of the overall premium) Amount Blake pays for the premium: $1,729 per year ($144 per

month) (which equals 6.92% of Blake’s household income and covers 73% of the overall premium)

Subsidy Study 1: 2014

SOURCE: http://kff.org/interactive/subsidy-calculator/

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Jay and his wife Jenn are 40 year-old non-smokers and reside in Athens, Clarke County (Rating Area 2).

Jay and Jenn have 2 children, both under 21 and non-smokers who will also enroll in exchange coverage

Neither Jay nor Jenn has employer coverage. Jay and Jenn’s household income in 2014: $60,000 (255% of

poverty level of $23,850 for a family of 4). Maximum % of income Jay and Jenn have to pay for the premium, if

eligible for a subsidy: 8.19% Health Insurance premium in 2014 (for a silver plan, before tax credit):

$8,721 per year ($727 per month) Jay and Jenn could receive a government tax credit subsidy of up to:

$3,808 per year (which covers 44% of the overall premium) Amount Jay and Jenn pay for the premium: $4,913 per year ($659 per

month) (which equals 8.19% of their household income and covers 56% of the overall premium)

Subsidy Study 2: 2014

SOURCE: http://kff.org/interactive/subsidy-calculator/

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Bill and his wife Jan are 60 year-old non-smokers and reside in Savannah, Chatham County (Rating Area 14).

Bill and Jan have 3 children, all non-dependents and who are enrolling separately in exchange coverage

Neither Bill nor Jan has employer coverage. Bill and Jan’s household income in 2014: $45,000 (290% of poverty

level of $15,730 for a family of 2). Maximum % of income Bill and Jan have to pay for the premium, if

eligible for a subsidy: 9.21% Health Insurance premium in 2014 (for a silver plan, before tax credit):

$17,435 per year ($1,453 per month) Bill and Jan could receive a government tax credit subsidy of up to:

$13,289 per year (which covers 76% of the overall premium) Amount Bill and Jan will pay for the premium: $4,416 per year ($368

per month) (which equals 9.21% of their household income and covers 24% of the overall premium)

Subsidy Study 3: 2014

SOURCE: http://kff.org/interactive/subsidy-calculator/ 35

GEORGIA EXCHANGE: YEAR 2 PROJECTIONS

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The next open enrollment period will be from November 15, 2014, to February 15, 2015.

If an individual has a life-changing event -- such as the birth of a child, losing a job, or moving to a new state – such individual is not required to wait for the next enrollment period and can sign up or change coverage within 60 days of the event.

 In the Marketplace, you qualify for a special enrollment period 60 days following certain life events that involve a change in family status (for example, marriage or birth of a child) or loss of other health coverage. Job-based plans must provide a special enrollment period of 30 days.

2015 Enrollment Period

SOURCES: https://www.healthcare.gov/glossary/open-enrollment-period/ and https://www.healthcare.gov/glossary/special-enrollment-period/

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• In 2015, the following carriers will be added to the Georgia marketplace (to add to BCBS, Alliant, Humana, and Peach State):‒ Cigna, Coventry, Kaiser, Time Insurance, and United

Healthcare The carriers will still be split according to the

Georgia Market Rating Areas, but along with BCBS, Coventry, Humana, and United Healthcare will most likely be available in all 16 areas.

Note that even if a carrier provides service in an area, the carrier does not necessarily provide service in every county in that area.

Insurers Selling in Georgia Marketplace: 2015

SOURCE: Georgia Office of Insurance and Safety Fire Commissioner

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Proposed Georgia Market Rating Areas: 2015

(new insurers in each area are in red)

NOTE: Not all counties within a particular service area are actually served by each carrier in every case. A carrier is noted as serving a named Geo Service Area if they serve in at least one county within a particular service area.SOURCE: Georgia Office of Insurance and Safety Fire Commissioner

Name of Market Rating Area AreaAlbany 1 BCBS Coventry Humana Time United HCAthens 2 Alliant BCBS CIGNA Coventry Humana Kaiser Peach St Time United HCAtlanta 3 Alliant BCBS CIGNA Coventry Humana Kaiser Peach St Time United HC

W. Atlanta 4 Alliant BCBS Coventry Humana Kaiser Time United HCAugusta 5 BCBS Coventry Humana Time United HC

Brunswick 6 BCBS Coventry Humana Time United HCChattanooga 7 Alliant BCBS Coventry Humana Time United HCColumbus 8 BCBS Coventry Humana Peach St Time United HC

Dalton 9 Alliant BCBS Coventry Humana Time United HCAtlanta Outer NE 10 Alliant BCBS Coventry Humana Kaiser Time United HC

South. Cental Georgia 11 BCBS CIGNA Coventry Humana Time United HCMacon-Warner Robins 12 BCBS CIGNA Coventry Humana Time United HC

N.W. Atlanta 13 Alliant BCBS CIGNA Coventry Humana Kaiser Time United HCSavannah 14 BCBS Coventry Humana Time United HCValdosta 15 BCBS Coventry Humana United HC

East Macon 16 BCBS Coventry Humana United HC

Carriers Serving the Market Rating Area

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INSURER SILVER** BRONZE**

Alliant $318.91 $271.15

BCBS $324.83 $248.40

Cigna $371.90 $317.14

Coventry $346.39 $279.98

Humana $383.31 $333.32

Kaiser $323.00 $232.00

Peach State $227.52 $182.71

Time $392.84 $329.72

United Healthcare Information not accessible

Information not accessible

Projected Premiums* Based on Insurer: 2015

*Premiums are based on average rate per insurer across all Georgia Rating Areas for a 40 year old individual. Insurers do not all offer plans in same areas**Based on lowest-price Silver or Bronze plan per insurerSOURCE: Data provided by Georgia Office of Insurance and Safety Fire Commissioner 40

Allia

nt

BCBS

Cigna

Coven

try

Human

a

Kaiser

Peac

h St

ate

Tim

e $-

$100.00

$200.00

$300.00

$400.00

SilverBronze

Projected Premiums Based on Insurer: 2015

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Projected Premiums* Based on Rating Area: 2015

*Premiums are based on average rate for all insurers per Rating Area for a 40 year old individual**Based on lowest-price Silver or Bronze plan per insurerSOURCE: Data provided by Georgia Office of Insurance and Safety Fire Commissioner

RATING AREA SILVER** BRONZE**

1 394.45$ 324.13$ 2 305.81$ 260.24$ 3 305.80$ 261.08$ 4 340.72$ 272.40$ 5 312.02$ 252.74$ 6 363.23$ 299.14$ 7 333.88$ 276.61$ 8 304.57$ 268.45$ 9 332.08$ 275.79$ 10 319.39$ 259.41$ 11 356.94$ 296.33$ 12 337.63$ 281.08$ 13 347.09$ 284.18$ 14 323.65$ 266.89$ 15 375.43$ 305.93$ 16 322.09$ 265.13$

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Projected Premiums* Based on Rating Area: 2015

1 3 5 7 9 11 13 15 $-

$50.00

$100.00

$150.00

$200.00

$250.00

$300.00

$350.00

$400.00

$450.00

SILVER**BRONZE**

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Change in Silver Premiums Based on Rating Area

RATING AREA 2014 2015% CHANGE

1 460.86$ 394.45$ -14.41%2 283.04$ 305.81$ 8.04%3 269.59$ 305.80$ 13.43%4 312.88$ 340.72$ 8.90%5 284.17$ 312.02$ 9.80%6 321.44$ 363.23$ 13.00%7 344.39$ 333.88$ -3.05%8 265.78$ 304.57$ 14.59%9 331.14$ 332.08$ 0.28%10 278.85$ 318.39$ 14.18%11 306.32$ 356.94$ 16.53%12 303.28$ 337.63$ 11.33%13 312.55$ 347.09$ 11.05%14 290.78$ 323.65$ 11.30%15 422.42$ 375.43$ -11.12%16 280.72$ 322.09$ 14.74%

SOURCE: Data provided by Georgia Office of Insurance and Safety Fire Commissioner44

Change in Silver Premiums Based on Rating Area

1 3 5 7 9 11 13 15 $-

$50.00 $100.00 $150.00 $200.00 $250.00 $300.00 $350.00 $400.00 $450.00 $500.00

20142015

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Change in Bronze Premiums Based on Rating Area

RATING AREA 2014 2015% CHANGE

1 405.43$ 324.13$ -20.05%2 250.90$ 260.24$ 3.72%3 240.26$ 261.08$ 8.67%4 278.48$ 272.40$ -2.18%5 249.45$ 252.74$ 1.32%6 281.54$ 299.14$ 6.25%7 306.25$ 276.61$ -9.68%8 232.40$ 268.45$ 15.51%9 294.61$ 275.79$ -6.39%10 248.65$ 259.41$ 4.33%11 268.44$ 296.33$ 10.39%12 266.19$ 281.08$ 5.59%13 278.31$ 284.18$ 2.11%14 254.88$ 266.89$ 4.71%15 371.97$ 305.93$ -17.75%16 254.54$ 265.13$ 4.16%

SOURCE: Data provided by Georgia Office of Insurance and Safety Fire Commissioner46

Change in Bronze Premiums Based on Rating Area

1 3 5 7 9 11 13 15 $-

$50.00 $100.00 $150.00 $200.00 $250.00 $300.00 $350.00 $400.00 $450.00

20142015

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AGE SILVER BRONZE

21 $263.02 $185.12

30 $298.50 $244.36

40 $336.09 $274.30

50 $469.93 $383.31

60 $713.74 $582.43

Projected Premiums* Based on Age: 2015

*Projected premiums based on average of lowest cost premiums for a 40 yearold individual across all insurersSOURCE: Data provided by Georgia Office of Insurance and Safety Fire Commissioner

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21 30 40 50 60 $-

$100.00

$200.00

$300.00

$400.00

$500.00

$600.00

$700.00

$800.00

SilverBronze

Projected Premiums Based on Age: 2015

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AGE 2014 2015 % CHANGE

21 $240.11 $263.02 9.54%

30 $272.68 $298.50 9.47%

40 $307.32 $336.04 9.36%

50 $428.79 $469.93 9.53%

60 $651.41 $713.74 9.57%

Change in Silver Premiums

SOURCE: Data provided by Georgia Office of Insurance and Safety Fire Commissioner

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21 30 40 50 60 $-

$100.00

$200.00

$300.00

$400.00

$500.00

$600.00

$700.00

$800.00

20142015

Average Projected Silver Premiums

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AGE 2014 2015 % CHANGE

21 $193.56 $185.12 -4.36%

30 $220.74 $244.36 10.70%

40 $248.57 $274.30 10.35%

50 $351.36 $383.31 9.09%

60 $527.98 $582.43 10.31%

Change in Bronze Premiums

SOURCE: Data provided by Georgia Office of Insurance and Safety Fire Commissioner

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21 30 40 50 60 $-

$100.00

$200.00

$300.00

$400.00

$500.00

$600.00

$700.00

20142015

Average Projected Bronze Premiums

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HOW TO HELP NAVIGATE MEMBERS

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The ACA requires state exchanges to establish a “navigator” program (Section 1311(i)) that will help people who are eligible to purchase coverage through the exchange learn about their new coverage options and enroll.

The Act lists brokers and agents as among the many types of entities that could receive navigator grants.

Navigators, brokers, and agents are a key resource to individuals in regard to navigation.  They have more in-depth capabilities as they may provide advice rather than just “navigation “ on how to use the site.  There is a robust process they must follow to get certified to help individuals in the public marketplace. 

Assistance with Navigation

SOURCE: https://www.cms.gov/CCIIO/Resources/Training-Resources/Downloads/navigators-and-assistance.pdf

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Navigators are funded by the federal government to help individuals apply for public assistance programs and compare health insurance plans sold on the exchange.

Health insurance exchange / marketplace navigators are not individuals - they are organizations, described as follows: "trade, industry, and professional associations, commercial fishing industry organizations, ranching and farming organizations, community and consumer-focused nonprofit groups, chambers of commerce, unions, resource partners of the Small Business Administration, other licensed insurance agents and brokers....”

On September 8, 2014, CMS awarded $60 million in Navigator Cooperative Agreements to entities to serve in the 34 Federally-facilitated and State Partnership Marketplaces.

Navigators

SOURCE: http://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-Marketplaces/assistance.html

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Under the law, navigators have the following five duties: To conduct public education about the availability of qualified health plans.

(Qualified health plans must meet certain standards, and they are certified to sell in the exchange. Some qualified plans may be sold both inside and outside of an exchange, depending on state law.)

To distribute fair, impartial information about enrollment in qualified plans and about the availability of premium tax credits and cost-sharing assistance in the exchange.

To facilitate enrollment in qualified plans. To refer people who need help resolving a problem with their health plan or

with their premium assistance to a consumer assistance or ombudsman program or to another appropriate agency that can help with a grievance or appeal.

To provide information in a culturally and linguistically appropriate manner to the population being served by an exchange.

Navigator Duties

SOURCE: 42 U.S. Code § 18031 - Affordable choices of health benefit plans57

Navigators may not work for a health insurance provider. Navigators do not have to be licensed to sell insurance. Navigators will not be paid based on the advice they give. In no way

can payment for their services be tied to the decisions made by the people they advise. Put another way, no navigator will be paid a commission, finder's fee, or any other form of compensation because someone they worked with made any specific choice of insurance plans.

Navigators will not make decisions for the people they advise. They will simply walk their advisees through a series of questions and decision-making tools to help those people make their own insurance plan choices.

Navigators will not be able or be expected to qualify the people they advise for any specific plan.

What Navigators Cannot Do

SOURCE: 42 U.S. Code § 18031 - Affordable choices of health benefit plans

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FFMs like Georgia’s will designate organizations to certify application counselors who perform many of the same functions as Navigators including educating consumers and helping them complete an application for coverage.

Certified application counselors and Marketplace-designated organizations won’t receive new federal grant money through the Marketplace. The counselors and organizations could, however, receive federal funding through other grant programs or Medicaid to help support their consumer assistance and enrollment activities.

Examples of possible certified application counselors include staff at community health centers, hospitals, other health care providers, or social service agencies.

All certified application counselors are required to complete comprehensive training.

Certified Application Counselors

SOURCE: https://www.cms.gov/cciio/resources/files/downloads/marketplace-ways-to-help.pdf 59

An exchange may allow agents and brokers to be Navigators, provided they otherwise meet the Navigator eligibility criteria.

An exchange may also allow agents and brokers to enroll individuals and employers in QHPs offered through an exchange if the agents and brokers meet certain requirements.

Unlike navigators, licensed agents are permitted to provide advice in helping individuals assess which health plan best suits their needs.

Agents and Brokers

SOURCE: https://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-Marketplaces/Downloads/agent-broker-ffm-training-summary.pdf

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To participate in the FFMs, agents/broker must: Adhere to all state requirements for licensure,

appointment, and market conduct Complete Marketplace on-line training Complete the applicable Marketplace

Agreement(s) Complete security authentication steps for FFM

registration Agents must attend ongoing education

classes/certifications every year

Agent/Broker Role in the FFMs

SOURCE: https://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-Marketplaces/Downloads/agent-broker-ffm-training-summary.pdf

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Agents/Brokers will be able to help client apply for coverage and select a health plan.

Agents obtain and hold Errors and Omissions Insurance, unlike Navigators.

Agents and brokers can work with consumers in either of two ways: Directly accessing the FFM website through the

issuer’s connection Assisting consumers who are accessing the FFM

website

Selling and Maintaining FFM Policies

SOURCE: https://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-Marketplaces/Downloads/agent-broker-ffm-training-summary.pdf

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In many markets, hospitals are not involved in helping to navigate members mostly due to the lack of Errors & Omissions Insurance or qualified personnel. 

For example, a small regional facility in West Georgia provides all questions to a local agent that is CMS and FFM qualified.  He is a NAHU/GAHU member and is a licensed agent.  That may not be the case with all hospitals.

Hospitals Helping to Navigate Members

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316,543 individuals selected a Marketplace plan between October 1, 2013 and March 31, 2014

71% of Georgians who enrolled in a Marketplace plan chose a Silver Plan

Four additional insurers will be providing plans in Georgia in 2015

Premiums are expected to increase between 2014 and 2015

Navigators, agents, and brokers can provide assistance with the Exchange

SUMMARY

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Special Thank You to Ms. Jodie Braner, President of the Georgia Association of Health Underwriters, for her assistance.

Special Thank You to Ms. Susan Fairley of the Georgia Office of Insurance and Safety Fire Commissioner for her assistance.

Thank You!

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