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Missouri Health Exchange. Health Insurance Exchanges - HIEx. HIEx – A government regulated standardized health care plan from which individuals may purchased insurance State Exchange Operated by the state Federally-Facilitated Exchange Operated in partnership with the state or - PowerPoint PPT Presentation

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Page 1: Missouri Health Exchange

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Missouri Health Exchange

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• HIEx – A government regulated standardized health care plan from which individuals may purchased insurance

State Exchange

• Operated by the state

Federally-Facilitated Exchange

• Operated in partnership with the state or

• Operated solely by the federal government

• Cornerstone of PPACA’s “individual mandate”

• Required to be Certified & Operational by 01/2014

Health Insurance Exchanges - HIEx

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States Position on Health ExchangesApril 2013

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1) Guaranteed Issuance

2) Limited Price variation• Age 3:1• Smoking Status 1.5:1

3) Four Premium Tiers (Bronze to Platinum) w/ Coverage Ranges of 60%, 70%, 80%, & 90%

4) No Lifetime or Annual Limits

HIEx – Key Features

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5) Out-of-Pocket Limits• Individual - $6,350• Family - $12,700

6) Insurance Purchase Tax Credits for Individuals up to 400% Poverty

7) Requirements To Purchase Exchange Insurance• Must Live In US• US Citizen or Legal National• Not Currently Incarcerated• Employers w/ Fewer Than 100 Employees*

HIEx – Key Features (cont)

* Prior to 2016 States can limit Exchange access to Employers with <= 50 employees, and starting in 2017 States can open Exchanges to Employers with > 100 employees.

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• This does not mean individuals can opt-in at any point

• Enrollment is closed after March 31, 2014 except for individuals with a “Qualifying Event”

• Loss of essential health coverage• Change in family structure• Change in citizen status• Government error with previous enrollment• Change in subsidy eligibility • Relocation to a new coverage area• Reaching Lifetime Limit on all benefits in grandfathered plan• Indian Heritage (entitled to monthly special enrollment)• Exceptional circumstance determined by HIEx or HHS (e.g. natural disasters)

HIEx Coverage Clarification (Guaranteed Issuance)

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2011 MO EMPLOYER MARKET

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Missouri Healthcare Market

Employer Sponsored 2,971,600 52%

Government Sponsored 1,739,300 30%

Individual Policy 351,000 6%

Uninsured1 (HIEx Eligible for Subsidies) 350,000 6%

Uninsured1 (HIEx Non-Eligible for Subsidies) 350,000 6%

• In addition to the individual mandate for the uninsured, Obamacare will require individuals and employers enrolled in a non-grandfathered

healthcare plan to replace their coverage with a plan that meets minimum new coverage standards.

• Grandfathering requires that nothing in prior insurance plan changed since 3/2010 including co-pays

1) Outpatient Care2) Emergency Room Visits3) Hospitalization4) Maternal & Newborn Care5) Mental Health & Substance Use

Treatments6) Prescription Drugs7) Rehabilitative & Habilitation

Services & Devices8) Lab Test9) Preventive Services & Chronic

Disease Care10) Pediatric Services11) Pediatric Dental12) Pediatric Vision

1Excludes 151,200 Uninsured 0-18

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WUSM B/E• 139% Medicare if All Payors Shift

• 170% Medicare if All Payors Except Medicare & Medicaid Shift

BJC B/E• 135% Medicare if All Payors Shift

• 163% Medicare if All Payors Except Medicare & Medicaid Shift

Missouri HIEx Potential Impact

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HIEx NetworkBronze 60/40

Silver70/30

Gold80/20

Platinum90/10

WUSM PAR

MISSOURI

BCBSMO SSM/Mercy

Coventry-2 SSM/Mercy

Coventry-1 PPO

ILLINOIS

BCBSIL PPO

Coventry-2 PPO (Limited Co.s)

Coventry-1 PPO (Limited Co.s)

Mutual HealthLink PPO

Health Alliance

HealthLink PPO

Key HIEx Plans

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Coventry – Missouri HIEx

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Coventry – Illinois HIEx

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Income LevelPremium Cap as Percent of Income*

For Silver Plan Only Reduction in Actuarial Value OOP Liability

100%- <133% 2% 94% 2/3 of Maximum

133%- <150% 3%-4% 94% 2/3 of Maximum

150%- <200% 4%-6.3% 87% 2/3 of Maximum

200%- <250% 6.3%-8.05% 73% 1/2 of Maximum

250%- <300% 8.05%-9.5% 70% 1/2 of Maximum

300%-400% 9.5% 70% 1/3 of Maximum

HIEx Cost-Sharing Subsidies

*Income Cap is subtracted from the premium of second lowest cost Silver plan and the resulting difference is the actual dollar subsidy.

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Limited to individuals at 133% FPL +

HIEx Individual Mandate(Non-Enrollment Penalty)

1% 2% 3%

Adult $95.00Child $47.50

Adult $325.00Child $162.50

Adult $695.00Child $347.50

3x Lessor of Above

2014 2015 2016

3x Lessor of Above

3x Lessor of Above

OR OR OR

Taxable IncomeModified AGI1

Penalty Per Adult & Child2

Maximum Per Family3

GR

EA

TE

R O

FC

AP

Penalty

Increases by:

Rate of Inflation

or

2.5% of Income

2017

1Income defined as total income in excess of filing threshold ($10,000 per Individual//$20,000 per family in 2013)2Child defined as individual under 183Penalty is pro-rated for the number of months individual is without insurance, though there is no penalty for a single gap in coverage of less than 3 months in a year. Penalty cannot exceed national average for Bronze-level premium.

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Example(Non-Enrollment Penalty 2014)

SCENARIO #1

$50,000 $50,000 x 1% = $500.00

2 Adults 95.00 x 2 = $190.00

3 x $190 = $570.00

$500.00

INCOME

FAMILY SIZE

PENALTY CAP

PENALTY

Greater of = $500.00

SCENARIO #2

$100,000 $100,000 x 1% = $1,000

2 Adults1 Child

95.00 x 2 = $190.0047.50 x 1 = $ 47.50 $237.50

3 x $237.50 = $712.50

$712.50

INCOME

FAMILY SIZE

PENALTY CAP

PENALTY

Greater of = $1,000

Lessor of

=

Lessor of

=

$500.00

$712.50

3 x $190 = $570.00

3 x $237.50 = $712.50

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Family Deductibles for St. Louis

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Example Cost Liability for St. Louis (Least Costly Family Plan w/o HSA)

* Cost sharing for individuals that select Silver Plan – 100%- <200% 2/3 reduction; 200%-250% = ½ reduction and 250%+-400% = 1/3 reduction.

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Monthly Premium Family w/ Subsidy

$2,100 Annual incremental cost to enroll in a plan where BJC & WUSM are PAR

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1) Policy should be: • Politically & PR Sound• Fair & Equitable to All Patients (i.e. Uninsured & Insured)

2) Individuals with access to health insurance should be encouraged to purchase coverage, including:

• Low income unemployed persons• Employed individuals without access to employer sponsored insurance• Self-employed individuals

3) The expected collection rate should be based solely on an individual’s FPL

Proposed WUSM Charity Care Policy (For The New Market Dynamic)

Underlying Principles

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FPLHISTORIC

WUSM/BJC

< 100% 0%

100%-200% 0%

201%-250% 20%

251%-300% 40%

301%-350% 55%

351%-400% 80%

> 400% 100%After Insurance

75%Uninsured/Self-Pay

Proposed Charity Care PolicyPercent of Charge Sought

While BJC and WUSM utilized the same discount structure for Charity Care, implementation differed.

BJC based its decision solely on a patients AGI.

WUSM evaluated AGI and all known assets e.g. property holdings.

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FPLHISTORIC

WUSM/BJCPROPOSED

WUSM

< 100% 0% 0%

100%-200% 0% 30%

201%-250% 20% 35%

251%-300% 40% 40%

301%-350% 55% 45%

351%-400% 80% 50%

> 400% 100%After Insurance

75%Uninsured/Self-Pay

100%After Insurance

75%Uninsured/Self-Pay

Discount Applies After

Lessor of $50 Office Co-Pay or Plan Co-Pay

+30

+15

0

-10

-30

0

0

Proposed Charity Care PolicyPercent of Charge Sought

Point-of-Reference50% ≈ WUSM’s contracted HMO/PPO Allowable

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FPLHISTORIC

WUSM/BJCPROPOSED

WUSM

< 100% 0% 0%

100%-200% 0% 30%

201%-250% 20% 35%

251%-300% 40% 40%

301%-350% 55% 45%

351%-400% 80% 50%

> 400% 100%After Insurance

75%Self-Pay

100%After Insurance

75%Self-Pay

Discount Applies After

Lessor of $50 Office Co-Pay or Plan Co-Pay

Bro

nze

60

/40

Sil

ve

r7

0/3

0

Expecte

d

Purchase

Level HIEx Allowable

Charge $1,000

Rate @ 50% $ 500

ResponsibilityPlan @ 60% $ 300

Pt. @ 40% $ 200

Calculation of Charity DiscountPlan Portion $ 300

Pt. Portion(Historic Discount x Pt. Portion)$200 x 20%

$ 40

EXAMPLE

Proposed Charity Care PolicyPercent of Charge Sought

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FPLHISTORIC

WUSM/BJCPROPOSED

WUSM

< 100% 0% 0%

100%-200% 0% 30%

201%-250% 20% 35%

251%-300% 40% 40%

301%-350% 55% 45%

351%-400% 80% 50%

> 400% 100%After Insurance

75%Self-Pay

100%After Insurance

75%Self-Pay

Discount Applies After

Lessor of $50 Office Co-Pay or Plan Co-Pay

Bro

nze

60

/40

Sil

ve

r7

0/3

0

Expecte

d

Purchase

Level HIEx Allowable

Charge $1,000

Rate @ 50% $ 500

ResponsibilityPlan @ 60% $ 300

Pt. @ 40% $ 200

Calculation of Charity DiscountPlan Portion $ 300

Pt. Portion(Historic Discount x Pt. Portion)$200 x 20%

$ 40

Net Expected $ 340

% Charge 34%

Rounded

EXAMPLE

Proposed Charity Care PolicyPercent of Charge Sought

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1) Be Politically & PR Sound• Minimize alienation of referring providers• Look reasonable to WUSM providers• Look reasonable to patients caught in the middle• Play well if addressed in the local media

2) Mitigate legal exposure to the extent possible

3) Discourage Plan Carve-Out Initiatives

Proposed Policy Regarding Non-PAR Patients

Underlying Principles

Policy should:

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Non-PAR (insured) patients will not be scheduled for an office appointment until an SPA is executed with the patient’s health insurance carrier:

• SPA shall require 100% payment due from the carrier

• SPA shall require payment within 30 days of bill date

• SPA shall require payment at a charge recover level comparable to WUSM’s terms with similar payors.

Commercial HMO/PPO – 75% Charge. (Note: This is equivalent to WUSM’s rate with contracted out-of-area payors that primarily refer tertiary level patients)

Federal HIEx – 50% Charge. (Note: this is comparable to WUSM’s contracted Federal HIEx rate and WUSM’s rate with contracted in-area Commercial HMO/PPO payors)

Proposed Policy Regarding Non-PAR Patients

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Carrier Political/PR Sound Carve Out Disincentive

Commercial HMO/PPO/ Private Exchange

75% Charge

1) Out-of-Network patients likely seeking tertiary care or care not readily available in-network. Extending contracted tertiary care rates likely appears reasonable to:

• Referring Providers• WUSM Providers• Patients• Neutral 3rd Parties

2) WUSM not denying patient access to Medical Center resources.

1) SPA rate equivalent to 150% of the contracted local in-network commercial HMO/PPO rate. (i.e. 50% Charge vs 75% Charge)

2) Plan’s medical management policies/protocols not in play:

• Denials• Recodes• Bundling

3) All payments due from carrier. Carrier bears entire financial risk insulating WUSM from bad debt and patient from financial exposure associated with Co-Pays, Co-insurance and Deductibles.

4) Payment based on Charge not fixed fee schedule, accordingly WUSM controls entire payment.

5) Payment due in 30 days.

6) Decision to approve of deny access falls to carrier.

Proposed Non-PAR Patient PolicyCommercial HMO/PPO/Private Exchange

REMAINS UNCHANGED FROM

CURRENT APPROACH

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Carrier Political/PR Sound Carve Out Disincentive

Federal HIEx

50% Charge

1) Out-of-Network patients likely seeking tertiary care or care not readily available in-network. Extending contracted Federal HIEx rates likely appears reasonable to:

• Referring Providers• WUSM Providers• Patients• Neutral 3rd Parties

2) WUSM not denying patents access to required Medical Center Resources

1) SPA rate equivalent to 190% of what we believe is the contracted specialist rate associated with par providers (i.e. Medicare vs 50% Charge).

2) Plan’s medical management policies/protocols not in play:

• Denials• Recodes• Bundling

3) All payments due from carrier. Carrier bears entire financial risk insulating WUSM from bad debt and patient from financial exposure associated with Co-insurance, deductibles and annual deductible limits.

4) Payment based on Charge not fixed fee schedule accordingly WUSM controls entire payment.

5) Payment due in 30 days.6) WUSM can change required reimbursement at

any time since SPA is linked to only one patient.

7) Decision to approve or deny access falls to carrier.

Proposed Non-PAR Patient PolicyFederal Exchange

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Providing Guidance to HIEx Eligible Patients

• Three BJC employees have received Certified Application Counselor status

• WUSM has been approved as a Certified Application Counselor siteCurrently in the process of securing certification for 4 financial counselors (2

located at CAM, 2 at West Campus)

• Goal is to counsel qualified patients on how to secure HIEx coverage and what plans will allow access to Medical Center resources

• BJC seeking Broker community interest in signing patients up for HIEx(s) [low/marginal commission business]

• WU including HIEx information in pre-65 retiree mailing

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Feedback From Local Broker Community

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• We should expect employers to react to the changing market dynamic

• Expect employers that had previously resisted discontinuing spouse/dependent coverage, due to lack of insurance options for spouses/dependents with a pre-existing medical condition, to move spouses/dependents to an Exchange

• Currently seeing large employers moving to fully insured while medium sized groups tend to be moving to ASO relationships.

• Do not expect the Massachusetts’ results to occur in our market, the market dynamics are very different in terms of distribution of medical resources and patient social/demographic variables.

• At least one Broker indicated their company was looking at establishing a private exchange.

• Brokers, as a group, appeared lukewarm to assigning agents to assist individuals with signing up with the Exchanges. Viewed as a low margin commission business.

Broker Feedback