introducing ohio’s health marketplace

Introducing Ohio’s Health Marketplace

Presented byJohn Dodd and John McGough

September 17, 2013

So tell me more about that new free health insurance…

Confusion in the market

Starts with the name 85% recognize the name “Obamacare” < 30% recognize “ACA” PPACA ???????

Is the Patient Protection Affordability and Accountability Act a law or bill?

What pieces were delayed and until when? Who is eligible for a subsidy and what does it mean to me? What about those tax credits? What will be available and how much will it cost? If I do nothing now, what is the worst that could happen to me? Will the options be same in NW Ohio, Cleveland, Columbus,

Cincinnati and Youngstown? Ohio will have more volatility than other states

Patient Protection Affordability and Accountability Act – Signed into Law

March 23, 2010

Current Political Dynamic

PPACA/ACA/Obamacare

Since passage the law has never gotten above 50% approval in public opinion polls

The law survived a Supreme Court challenge with only a change to the penalty to states not expanding Medicaid to 133-138% of FPL

The law survived two national elections with one of those re-electing President Obama

Current split government in Congress will not bring any legislative changes. Period.

Even if the Republican controlled House of Representatives is successful in de-funding the law, all the other provisions will go forward. We are past the point of return to pre-2010.

PPACA – what does it look like?

What Is The Health Care Reform Law All About? It is NOT a total takeover of the health care system to create a

single payer Canadian or European style health care system.

It is a MASSIVE new law that brings federal regulation to health insurance as opposed to the traditional state regulation of the insurance industry.

It does include a number of new regulations for healthcare providers, but falls short of total takeover of the entire system.

Citizens will still be dealing with private health care providers and private insurance companies unless covered by Medicaid.

Timeline for Implementation 2010

26 total provisions scheduled to be implemented

26 total provisions implemented

2010 PPACA Scheduled Provisions

Review of Health Plan Premium Increases More scrutiny in premium rate review More justification required

Changes in Medicare Provider Rates Qualifying Therapeutic Discovery Project

CreditMedicaid and CHIP Payment Advisory

Commission

2010 PPACA Scheduled Provisions (cont.)

Comparative Effectiveness Research Prevention and Public Health Fund Medicare Beneficiary Drug Rebate Small Business Tax Credits


Medicaid Drug Rebates Coordinating Care for Dual Eligibles

New efficiencies for those with Medicare and Medicaid

Generic Biologic Drugs New requirements on Non-profit Hospitals

True non-profit??????


Medicaid Coverage for Childless Adults Reinsurance Program for Retiree Coverage

This was a program for plan sponsors to encourage them to continue retiree plans

Pre-existing Condition Insurance Plan High Risk Pool closed earlier in 2013

New Prevention Council Consumer Website


Tax on Indoor Tanning Services Expansion of Drug Discount Program Adult Dependent Coverage to Age 26 Consumer Protections in Insurance

Eliminating lifetime limits on coverages No pre-ex limitation for children

Insurance Plan Appeals Process


Coverage of Preventive Benefits Health Centers and the National Health

Service Corps Health Care Workforce Commission Medicaid Community-Based Services


Minimum Medical Loss Ratio for Insurers Closing the Medicare Drug Coverage Gap

$250 check to those hitting Part D doughnut hole in 2011

Beginning 2012 increased % of prescription drugs paid in doughnut hole until reaching 75% in 2020

Medicare Payments for Primary Care Medicare Prevention Benefits Center for Medicare and Medicaid Innovation

Schedule of Progress--Part DMedicare Beneficiary pays this % for Brand-Name in Gap

Medicare Beneficiary pays this % for Generic in Gap

2012 50% 86%

2013 47.5% 79%

2014 47.5% 72%

2015 45% 65%

2016 45% 58%

2017 40% 51%

2018 35% 44%

2019 30% 37%

2020 25% 25%


Medicare Part B Premium Increase for Higher-Income Beneficiaries

Medicare Advantage Payment Changes Less government payment to Advantage plans

going forward—Will that increase premiums, reduce benefits, or both?

Medicaid Health Homes Chronic Disease Prevention in Medicaid National Quality Strategy


Changes to Tax-Fee Savings Accounts Penalty for ineligible withdrawals increased from

10% to 20% Grants to Establish Wellness Programs * Teaching Health Centers Medical Malpractice Grants Funding for Health Insurance Exchanges

Exploratory grants to states Followed by implementation grants for those states

choosing to implement a state exchange Ohio choose not to establish a state exchange


Nutritional Labeling * Medicaid Payments for Hospital-Acquired

Infections Graduate Medical Education Medicare Independent Payment Advisory

Board An independent board that will begin making

decisions on eligible expenses and amounts paid for eligible expenses

Medicaid Long-Term Care Services


Accountable Care Organizations in Medicare Uniform Coverage Summaries for Consumers

Summary of Benefits and Coverage Medicare Advantage Plan Payments Medicare Independence at Home

Demonstration Medicare Provider Payment Changes


Fraud and Abuse Prevention Annual Fees on the Pharmaceutical Industry Medicaid Payment Demonstration Projects * Data Collection to Reduce Health Care

Disparities


Medicare Value-Based Purchasing Tougher reimbursement rules Proceeding to performance based pay----not

payment per procedure Reduced Medicare Payments for Hospital

Readmissions Changed name of the “Exchange” to

“Marketplace”


Employer Notification to Employees Regarding Exchanges Delayed from March 1, 2013 to October 1,

2013 Employers required to provide notice whether

or not they offer a plan—if subject Fair Labor Standards Act (FLSA)

Medicare Bundled Payment Pilot Program Medicaid Coverage of Preventive Services Medicaid Payment for Primary Care


Itemized Deduction Floor for Medical Expenses Increased from 7.5% to 10% of AGI

Flexible Spending Account Limits Limited to $2500 per year

Medicare Tax Increase

0.9% on income exceeding $200,000 filing single or $250,000 filing jointly

Employee Retiree Coverage Subsidy Tax on Medical Devices-$2.3% on DME


Financial Disclose * CO-OP Health Insurance Plans

One has been approved for Ohio Did not get organized in time to be in the

exchange/marketplace in 2014 Extension of CHIP through 2015 Medicare Disproportionate Share Hospital

Payments * Medicaid Disproportionate Share Hospital

Payments *

Timeline for Implementation 2014 and Beyond



Expanded Medicaid Coverage Not in Ohio—not yet

Presumptive Eligibility for Medicaid Streamlined application process

Individual Requirement to Have Insurance Health Insurance Exchanges/Marketplaces Health Insurance Premium and Cost Sharing Subsidies

Refundable and Advanceable Federal Income Tax Credits to be used as Premium Subsidies on Silver Level Coverage Purchased in the Exchange/Marketplace

Silver Level Coverage Will be Enhanced to Lower MOOP Limits for those with income below 250% of FPL


Guaranteed Availability of Insurance No Risk Rating, No Pre-ex

No Annual Limits on Coverage Essential Health Benefits Package Required

in Small Group and Individual Markets Multi-State Health Plans Temporary Reinsurance Program for Health

Plans


Basic Health Plan Catastrophic plan for those unable to afford coverage

and under age 30 Employer Requirements

Penalty for non-compliance delayed until 2015 Medicare Advantage Plan Loss Ratios Wellness Programs Included in Insurance Plans Fees on Health Insurance Sector

$8 Billion in 2014—looks like about 2.4% of premium Reinsurance pool charge of $5.25 PMPM

Medicare Payments for Hospital-Acquired Infections

2015 and beyond – PPACA Scheduled Provisions

2015 - Increase Federal Match for CHIP 2016 - Health Care Choice Compacts 2018 -Tax on High-Cost Insurance

What Resources Are Available?

We’re here to help you!

What Resources Are Available?

www.NAHU.org www.Healthcare.gov Health and Human Services/Center for

Medicare and Medicaid Services Health Insurance Carriers and Plans Various Professional Organizations (ie. IFEBS,

American College, WEB International, Kaiser Family Foundation, NAIFA, PIA/Big I)

Google.com Googling Your Question Produces a Number of

Qualified Answers From Consultants

Who Will Be Involved In The Exchange/Marketplace Nationally? Agents/brokers

Agents and Brokers are allowed to participate if the state allows agents and brokers to participate

Navigators By law each state must have at least 2

navigators Funded by federal grants in 2014, then by grants

obtained by the exchange/marketplace in 2015 and after

Certified Application Counselors Funded by either state or private grants

Who Can Sell On The Exchange/Marketplace In Ohio? Only licensed agents and brokers may sell,

solicit, or negotiate a contract of health insurance.

Only licensed agents and brokers may recommend a particular product, or option, to a consumer.

Within the Exchange/Marketplace Agents and Brokers are required to provided unbiased information and comparisons of plans

Agents/brokers requirements

Active State of Ohio Health Insurance License Current appointment with all carriers they are

writing Complete Exchange training – available NOW at https://Marketplace.MedicareLearningNetworkLMS.com

Two parts on the individual exchange/marketplace

Part two is now available Agreement is then signed and certification

process begins—all on line SHOP exchange education is optional

Navigators

Under Ohio law (H.B. 3):

Navigator can: (1) conduct public education activities and raise awareness of availability of Qualified Health Plans; (2) distribute fair and impartial general information concerning enrollment in all QHPs and availability of premium tax credits and cost-sharing reductions; (3) Facilitate enrollment in QHPs, without suggesting that an individual select a particular plan; (4) May provide information related to Medicaid eligibility.

Navigator cannot: (1) Sell, solicit or negotiate health insurance; (2) Provide advise concerning substantive benefits, terms or conditions of a plan or offer advice about which plan is better or worse or suitable for a particular individual or entity; (3) Recommend a particular plan or advise consumers about which plan to choose; (4) Provide any information or services related to plans or products not offered in an Exchange; (5) Engage in any unfair method of competition or any fraudulent, deceptive, or dishonest act or practice.

Navigators (cont.)

5 Navigator Grants in Ohio totaling $3,043,868 Ohio Association of Food BanksChildren’s Hospital Medical Center (out)Clermont Recovery Center, IncHelping Hands Community Outreach

CenterNeighborhood Health Association

Navigators (cont.)

Navigators do not receive commissions – their funding mechanism is via the Federal grants in 2014

Structured as a cooperative agreement - Performance period is up to 12 months from the date of the award and future awards funded by the exchange/marketplace

Navigators will be required to annually recertify Navigator includes the organization receiving the grant and

certification plus each person designated to perform navigator duties

Navigators DO NOT carry errors and omissions coverage

Certified Application Counselors

On July 17, 2013 CMS issued a final rule at 45 CFR 155.225 introducing a separate class of Certified Application Counselors (CACs), such as community health centers, health care providers and entities, and community-based organizations, to assist consumers with enrolling in coverage through the Marketplace.

Certified Application Counselors will be designated by the Marketplace to provide the same application assistance that is available from Navigators, but will not be funded through the Marketplace. However, the conflict of interest provisions that apply to navigators do not apply to CACs.

Certified Application Counselors (cont.)

Certified Application Counselors must complete the CMS Exchange Training

Certified Application Counselors do not receive commissions

Certified Application Counselors receive grants from states or other organizations

Certified Application Counselors will be required to annually recertify

Certified Application Counselors DO NOT carry errors and omissions coverage

Other players

Champions for Coverage Carriers E-Enrollment sites (web-based enrollment)

Implementation Time FrameMany Delays

July 2013----Agent/Broker and Navigator Training-running late August 2013----Agent/Broker and Navigator Certification-running late October 1, 2013----Exchange Marketplace open for annual open

enrollment in plans with effective date of 01/01/2014 Applications dated 10/01 through 12/15 get 01/01/14 effective date Applications dated 12/16/13 through 01/15/2014 get 02/01/14 date Applications dated 01/16/13 through 02/15/2014 get 03/01/14 date

Future annual open enrollment will be 10/15 through 12/07 Special enrollment events are recognized during the year

COBRA notices to be changed to proved notice of exchange January 1, 2014----New Premium Rating and Underwriting

Standards begin with renewals on or following this date March 31, 2014----Initial Open Enrollment Period for Exchange

Marketplace ends

How do I get paid on the Exchange?

How Is An Agent/Broker Compensated When Selling Inside the Exchange/Marketplace?

Agents and Brokers Will Continue to Be Paid by the Insurance Company With Whom the Business is Placed—If the Insurance Company Works With Agents and Brokers

The Exchange/Marketplace Has No Desire to Begin Paying Agents and Brokers.

Questions?

The Individual Market

916,000 Ohioans will be eligible for a subsidy – USA Families, March 2013

PPACA – Options for Individuals

Individuals will have options starting in 2014: Keep their employer-based health insurance (if

available) Purchase their health insurance via the

Exchange/Marketplace Purchase their health insurance

off-Exchange/Marketplace Enroll in government program (Medicaid,

Medicare, VA, or other---if qualified) Do not enroll and pay the penalty of $95 or 1%

of their household income (2014 penalty, increases in subsequent years)

Individual Buyers on the Exchange

Individuals may qualify for subsidies and/or benefit enhancements based on income levels From 133% to 400% FPL, various subsidies will be available The subsidies change to 100% to 400% of FPL in states that

do not expand Medicaid Up to 250% FPL, additional benefit enhancements may apply

—called cost sharing reduction Medicaid expansion in Ohio is still unknown; the Ohio

Legislature is still currently holding hearings on both Medicaid reform and possible Medicaid expansion but not for 2014

On September 4, 2013 the Service Employees International and the Ohio Hospital Association formed a coalition named “Healthy Ohioans Work” to start the process of proposing a law to authorize Medicaid expansion through the initiative petition process that could possible lead to a vote on the 2014 General Election ballot.

Federal Poverty Level--2013

Number of persons in household

100%

FPL 48 Contiguous + DC

400%

FPL 48 Contiguous + DC

1 $11,490 $45,960

2 $15,510 $62,040

3 $19,530 $78,120

4 $23,550 $94,200

5 $27,570 $110,280

6 $31,590 $126,360

Federal Poverty Level--2013

FPL % 1 person family

2 person family

3 person family

4 person family

100% $11,490 $15,510 $19,530 $23,550

133% $15,282 $20,628 $25,975 $31,322

150% $17,235 $23,265 $29,295 $35,325

200% $22,980 $31,020 $39,060 $47,100

250% $28,725 $38,775 $48,825 $58,875

300% $34,470 $46,530 $58,590 $70,065

350% $40,215 $54,285 $68,355 $82,425

400% $45,960 $62,040 $78,120 $94,200

Distribution of Population by Federal Poverty Level (2011)Bracket Range FPL

Ohio #

Ohio %

Ohio % of U. S. Total

U. S. #

U. S. %

< 100%

2,213,700

20% 4% 61,319,200

20%

100-138%

803,700

7% 3% 25,051,500

8%

139-250%

2,373,500

21% 4% 60,462,700

20%

251-399%

2,413,500

21% 4% 59,176,200

19%

400% +

3,522,500

31% 3% 101,881,900

33%

Total 11,326,900

100%

4% 307,891,500

100%

Premium subsidies and cost sharing reductions provide powerful incentives for many Americans----------------------Family of Four-------------------------

Annual Household Income % FPL

Annual Household Income Dollars

Individual Responsibility Premium % income

Annual Individual Responsibility Premium $’s

Monthly Premium Equivalent

Average Annual Premium Cost Group Plan ‘12

Amount of Taxpayer Subsidy

100% $23,050 2% $ 461 $ 38 $17,258 $16,797

133% 30,657 3% $ 920 $ 77 $17,258 $16,338

150% $34,575 4% $1,383 $115 $17,258 $15,875

200% $46,100 6.30% $2,904 $242 $17,258 $14,354

250% $57,625 8.05% $4,639 $387 $17,258 $12,619

300% $69,150 9.50% $6,569 $547 $17,258 $10,689

400% $92,200 9.50% $8,759 $730 $17,258 $ 8,499

Individual Buyers on the Exchange/Marketplace

Press Release STATE OF OHIO

DEPARTMENT OF INSURANCE

COMMUNICATIONS OFFICE

8/1/2013

Health Insurance Premiums to Increase 41 Percent

Due to Affordable Care Act

Premiums for Federal Exchange Show Higher Costs for

Ohio Consumers and Small Businesses


For individual health insurance plans, a total of 12 companies offering 200 different plans have been approved by the Department for the exchange.

Based on premiums for the current individual market, plans in Ohio today cost on average $236.29 per month compared to $332.58 in 2014. --- 40.7% increase


The process for buyers They will receive many notices from various

sources telling them they need to buy health insurance

What roll will you play? How will you continue to be a successful

insurance professional?


They need you more than ever!


In assisting consumers in the Exchange/Marketplace agents and brokers may assist the consumer in determining their qualification for Medicaid or premium subsidies as well as cost sharing reductions

Agents and Brokers will be assisting consumers with setting up an account on the Exchange/Marketplace website either directly or through a carrier’s portal to the marketplace site

Agents and Brokers may find that the consumer possibly qualifies for Medicaid or CHIP

These consumers should be referred to the Ohio Department of Jobs and Family Services through the Exchange/Marketplace

Agents and Brokers will not be enrolling consumers in these programs


If the Consumer qualifies for subsidies questions need to be askedDo they have affordable health insurance that meets the minimum value requirement (.60 AV) available through their employer?Does that coverage meet the affordability safe harbor?If both the above are met, the individual will not qualify for subsidized coverage regardless of incomePersonal situation – everyone has different needs; determine what those immediate and long term needs may be, then proceed with best course for the consumer

Individual Buyers on the Exchange/Marketplace Think of family situations Is spouse eligible for group coverage?

If not, the spouse may qualify for subsidized coverage in the exchange/marketplace

Is family eligible for CHIP? If so, CHIP is available even if employer coverage is

available—that is my understanding How will small employers arrange their benefit package?

Perhaps will purposely not meet affordability standard to allow lower paid families to qualify for subsidized individual coverage in the exchange marketplace while still maintaining a plan for higher paid employees.

How will this affect meeting participation rules for the group?


CMS introduction to Healthcare.gov

http://www.youtube.com/watch?v=v5p0u0S_REY&list=PLUslxKz-YuCjD-9VRKOQkd4GHoZDrbMaV

This is a how-to video for an individual using the exchange/marketplace without any assistance.


H.B. 3 requires an Exchange operated in Ohio to make a list available of all agents and navigators authorized to provide services in the Exchange. Includes “any website, software application, or other electronic medium, or Exchange-sanctioned outreach event that enables consumers to determine eligibility for and to purchase a Qualified Health Plan through an Exchange”.


Healthcare.gov – how to quote/enroll

Not yet perfectly clear

What Are the Procedures for Agents/Brokers Enrolling Someone in the Exchange/Marketplace?

As you know Ohio did not create its own state based exchange/marketplace where it could control the entire process.

Ohio has chosen a Federally-facilitated

exchange/marketplace Ohio retains management of the insurance

carriers operating in the Federally Facilitated Exchange/Marketplace (FFM)

Federal government maintains control of all other functions—website, outreach, navigators, etc.


All FFM activities take place on line Individual Marketplace

There will not be Marketplace offices springing up in your city, town, or county seat

The FFM will have two sections Qualification Section

Find out premium tax subsidies and/or cost sharing reduction qualification—tied to IRS, HHS, CMS

Plan Selection Section

Shop for qualified health plans with or without subsidy


Qualification Section Provide Privacy Notice to Consumer Set up account Provide information about members living in household

—name, date of birth, Social Security number Provide income information for members of household Provide employment information of members of

household—employer name, employer tax ID, basic information on employer health plan provided on exchange./marketplace notice


Qualification Section Continued Eligibility to purchase in exchange/marketplace is determined

U. S citizen or Foreign National legally residing in the U.S.

Premium tax subsidy, if any, is determined Subsidy is advanceable refundable federal income tax credit

Advanceable means the credit is available throughout the year rather than awaiting tax return filing to claim credit

Refundable means the tax credit is available even if that amount of tax is not owed for the year’s income

Consumer may choose to have the credit advanced or to be paid out as income tax refund upon filing a tax return

Any miscalculation of tax credit due to incorrect estimate of annual income is reconciled on the federal income tax return


Plan Selection Section Consumer takes tax credit and cost sharing

reduction estimate to this section All plans available on the marketplace are

assessable here and can be compared Credit subsidy is based on silver level plan Cost sharing reduction is made by modifying the

chosen silver level plan benefits to meet the MOOP set for the FPL income level

Enrollment in selected plan may take place here as well


Agents and Brokers may assist consumers in both sections of the process

In the original plans, the FFM was to have a separate broker portal where certified agents and brokers would enter the FFM with user ID, PIN, and agent number

Agent/broker would then open account for consumer—consumer would need to attest to the information provided---and proceed as shown in previous slides

This portal was removed from plans a few months ago due to complexity—may be added later


Procedures have changed, but we still have not seen a list of direct instructions to follow

Here is my best explanation of how things will work for agents and brokers

Entering through the Marketplace website Agent/broker must be certified to work in the

marketplace Agent/broker enters the Marketplace together with

the consumer to open account and verify consumer information

Eligibility for subsidies is determined


Procedures Continued Consumer gives approval to agent/broker assistance Agent/broker provides ID and NPN Proceed to Plan Selection Section

Compare plans Select Plan Enrollment attestation by consumer Enter Agent/Broker ID and NPN again Enroll in plan Send x12-834 to plan issuer Set up payment by consumer


Entering through an issuer website Agent/Broker must be certified to work in

marketplace On issuer website, log into broker portal Issuer website will include an ACA Calculator When Calculator is accessed, will be directed to

FFM website Register consumer with Marketplace Enter Consumer Demographics Eligibility for any assistance will flow for consumer

back to the issuer website


Directed back to issuer website Compare plans Select plan Enrollment Attestation by consumer Submit enrollment Direct back to marketplace website for

acceptance of enrollment Send x12-834 to issuer Arrange payment by consumer


One prominent health insurance carrier in Ohio suggests that a best practice suggestion is to enroll through the carrier website to assure that the agent/broker receives commission for the sale


Other options Web based broker opportunities

Become certified to include link to FFM on your agency website

Final 300 page rule just released Wednesday, September 4, 2013

Work with an “aggregator” web based broker Larger GA type arrangement

Broker may work within an option of relationships May include private exchange capabilities

Private exchange may be linked to FFM Creative ideas are coming forward for agents/brokers to

consider


Carriers offering products on the Individual Exchange/Marketplace

Anthem, Aultcare, Buckeye Community Health Plan, Caresource, Coventry, Healthspan, Humana Health Plan of Ohio, Kaiser, Medical Health Insuring Corporation of Ohio (“MMO”), Molina, Paramount, and SummaCare.

Remember that a market still exists outside the exchange/marketplace that will include other carriers

The FFM carriers may not be working off the FFM


All carriers offering products on the Exchange/Marketplace must:Cover the Essential Health Benefits

Including pediatric dental and vision May be part of health insurance plan or stand alone

Cover Preventive Benefits at 100%Meet one of the Metal Levels of coverage with every plan – Platinum, Gold, Silver or BronzeOffer plans on a Guarantee Issue basisDo not apply pre-existing condition to anyoneMeet all other regulatory mandates set forth by HHS and the Ohio Department of Insurance


Carriers can vary in the following areas:NetworksPharmacy benefitsDeductible/coinsurance/copay differencesProduct design must meet the minimum actuarial values of the metal level of planExtra “value-added” benefitsCost


Sample Silver plans (meet 70% AV requirements)

Carrier A: $2000/$4000 ded – 70% co-ins - $6350/$12,700 MOOP

Carrier B: $500/$1000 ded – 90% co-ins - OV and Rx subject to Ded/Co-ins. $2100/$4200 MOOP

Carrier C:$3000/$6000 ded – 80% co-ins – OV co-pay $10/$50; Rx $10/$35/$70 co-pay-- $6350/$12,700 MOOP


Sample Bronze plans (meet 60% AV requirements)

Carrier A: $4300/$8600 ded – 70% coins - $6350/$12,700 MOOP

Carrier B: $5000/$10,000 ded –70% coins – OV copay $40/$80/$40 up to 3 per year; Rx ded and coins; $6350/$12,700 MOOP

Carrier C: $5000/$10,000 HSA – 70% coins - $6000/$12,000 MOOP


BEST Opportunities for to ensure your success:1.Get your training/certification from the Exchange2.Know your products/carriers3.Be appointed with all carriers you will write4.Decide how to assist current customers through the process of perhaps moving to the new system5.Referrals will be key to success in this initial enrollment period

The Small Employer Market (SHOP)

We’re here to help!

Small Employer on the Exchange

According to Ohio Department of Insurance press release, Premiums Increase 41 Percent:

For small group health insurance plans, 6 companies offering

184 plans have been approved to sell on the exchange.

For the small group market, today’s premiums average is $341.03 per month compared to $401.99 in 2014 (+ 17.9%). An example of the difference between premium and the cost to provide coverage is that premiums do not include cost sharing paid by the consumer, whereas cost includes both the cost to the company to provide the coverage and the cost sharing paid by the consumer.

PPACA – Options for Small Employers

Small Employers (defined in OH as 2-50 FTE for 2014 and 2015, then to 2-99 in 2016) will have options starting in 2014: Renew/start their employer-based health insurance

in 2013 (pre-modified community rating) Convert to modified community rating on first

renewal coincident with or next following 01/01/14 Purchase their health insurance via the

Exchange/Marketplace with community rating beginning 01/01/14

Purchase their health insurance off-exchange with community rating beginning 01/01/14

Do not offer health insurance benefits

Small Employers on the Exchange

Key considerations for employers:Introduce or maintain group health planAttract and retain quality employeesTotal cost considerationsEarly renewal strategy 2013 vs. new plan January 1, 2014Tax implications

Exchange & Subsidies – NO Employer Sponsored Ins.Age 33, $36,000, Family 4137% FPL, No ESIUnsubsidized Premium: $13,026Maximum % income 4.17% Person pays no more than this % of income for coverage Actual required premium $

1,501 Government Tax Credit

$11,525

** Assumes in Higher regional cost, in 2014 dollars & paid with after tax dollars

Age 57, $95,000, Family 4406% FPL, No ESIUnsubsidized Premium:

$25,193Maximum % income

None Person gets no subsidyActual required premium

$25,193 Government Tax Credit $0** Assumes in Higher regional cost,

in 2014 dollars & paid with after tax dollars

Kaiser Family Foundation – Health Reform Subsidy Calculator

Small Employers on the Exchange/Marketplace

How do I quote/enroll my small group client via the SHOP exchange?

At the time of this presentation, the actual screen shots with options are not available; however, a narrative of the process has been provided by CMS.


The process will be somewhat simplified compared with the process in Ohio today.

1.The employer provides their company name, tax ID, and basic census information including number of employees, dates of birth of employees and dependents if dependent coverage will be offered


2. The agent/broker will provide a group plan proposal for the client.

3. The client selects the single plan/carrier to be offered to the employees.

4. The employer enrolls in the SHOP exchange for the appropriate plan and carrier


5. The employees then enroll via the SHOP with their personal information

6. The employer receives one invoice for all enrolled employees and their dependents

7. Change through the year will be made by employer/employee on line.

8. SHOP primarily for employers using the small business tax credit


Carriers offering small employer group products on the Exchange:

Anthem, Aultcare, Healthspan, Kaiser, Medical Health Insuring Corporation of Ohio (“MMO”), and SummaCare.

Like the individual market, a small group market will continue to be offered outside the Exchange/Marketplace. Additional carriers who may not offer coverage in the FFM may offer cover coverage outside the FFM.

Small Employer on the Exchange/Marketplace

All carriers offering products on the Exchange must:Cover the Essential Health Benefits

Including pediatric dental and vision May be included in the health plan or stand alone

Cover Preventive Benefits at 100%Meet one of the Metal Levels of coverage with every plan – Platinum, Gold, Silver or BronzeOffer plans on a Guarantee Issue basisDo not apply pre-existing condition to anyoneMeet all other regulatory mandates set forth by HHS and the Ohio Department of Insurance


Carriers can vary in the following areas:NetworksPharmacy benefitsDeductible/coinsurance/copay differencesProduct design to meet the minimum actuarial valuesExtra “value-added” benefitsCost


Sample Silver plans (meet 70% AV requirements)

Carrier A: $1500/$3000 ded – 80% coins - $6350/$12,700 OOP max

Carrier B

Carrier C: $2000/4000 ded HSA – 80% coins - $3800/$7600 OOP max


Sample Bronze plans (meet 60% AV requirements)

Carrier A: $3500/$7000 ded – 70% coins - $6350/$12,700 OOP max

Carrier B:

Carrier C: $5000/$10,000 ded – 70% coins - $10/$50 OV co-pay; $15 generic/75% coins after ded Rx Card; $6000/$12,000 MOOP

PPACA – Other Options

Additional options for Ohioans Medicaid – status of expansion CHIP VA/Federal Plans Medicare Others?

Continue to Be a Person Bringing Value to the Consumer

We must prepare for what is coming. We must prepare our clients for what is

coming. If we provide value added service we will

always have a place in the marketplace. Opportunities abound!

You’re needed NOW more than EVER!

Introducing Ohio’s Health Marketplace

QUESTIONS?

introducing ohio’s health marketplace

Documents

provisions cont

health care reform law

private health care

fplthe law

massive new law

medicaid coverage

public opinion pollsthe

insurance industry