The document discusses health insurance exchanges being established under the Affordable Care Act. It provides information on state implementation of the exchanges and Medicaid expansion. The summary is: 1) 26 million people are expected to enroll in coverage through exchanges by 2022, with 8 million enrolling in 2014, many receiving subsidies. 2) Exchange enrollment will include those previously uninsured as well as those with different health profiles than those currently insured. 3) States are taking different approaches to running exchanges, with many partnering with or defaulting to the federal government. Exchange competition will vary significantly across states.

1. Racing to New Coverage Opportunities:
Final Steps to Help You
Prepare for Enrollment
September 11, 2013

2. Educating Patients About
The New Health Insurance Exchanges
Marc Boutin
Executive Vice President & Chief Operating Officer
National Health Council

3. © National Health Council
Helping VHAs Educate Patients About Exchanges
Training and Education
Through education, NHC will lay a foundation for VHAs on
insurance marketplaces and Medicaid expansion
1
Patient Advocacy Tools
Tools will help advocates assist patients through
implementation activities
2
Key Messages
Key messages will launch each month and build off messages
tested by national partners
3

4. © National Health Council
Training and Education
Webinars:
 July 2013: Explain the exchanges,
discuss role of patient organizations in
educating people with chronic
conditions
 August 2013: Discuss tools NHC is
developing, hear from three VHAs
about their initiatives
 September 11, 2013: Update on
exchanges and NHC tools, discuss
information patients need when they
enroll

5. © National Health Council
Tools:
 Customizable resources, such as fact sheets
and one-pagers (e.g., enrollment assistance
programs, financial protections)
 Infographics
 Assistance in choosing an appropriate plan,
capturing feedback on any problems,
cataloging patient stories
Patient Advocacy Tools

7. © National Health Council
Key Messages
Samples:
 There will be new, affordable insurance options
available for people without insurance.
 All insurance plans will have to cover doctor
visits, hospitalizations, maternity care,
emergency room care, and prescriptions.
 Financial help is available so you can find a plan
that fits your budget.
 If you have a pre-existing condition, insurance
plans cannot deny you coverage.
 Help will be available online, by phone, and in
person to find the plan that works best for you.

8. State Exchanges and
Medicaid Expansion:
What do you need to know?
Corey Ford
Senior Manager
Avalere Health, LLC

9. State Implementation Activities Update

10. The ACA Is Expected to Reduce Number of Uninsured, Primarily
through Enrollment in Medicaid and Exchanges
10
49 40 35 26 24
50
55 57
58 59
8 12 22 24
16 13 12 11 10
144 144 145 146 147
5 5 5 5 5
50 52 53 55 56
314 317 319 322 325
2013 2014 2015 2016 2017
EXPECTED SOURCES OF COVERAGE (IN MILLIONS), 2013-2017
Medicare
Other Public Programs
Employer
Non-Group
Exchanges
Medicaid & CHIP
Uninsured
Source: Avalere Enrollment Model, August 2013, Scenario 2 (assumes 26 states opt out of the Medicaid expansion)
ACA: Affordable Care Act

11. To Date, 24 States & DC Plan to Expand Medicaid Eligibility in
2014, 23 Will Not Expand, and the Remainder Are Undecided
11
Source: Avalere State Reform Insights, Updated September 6, 2013
*AR and IA have submitted waivers to use premium assistance models with exchange plans for parts of their expansion populations; TN is
considering a similar model for expansion beneficiaries
**MI’s expansion will likely take effect in March or April 2014 and will require waiver approval from CMS for a number of provisions, including
the use of HSAs
.
AK
HI
CA
AZ
NV
OR
MT
MN
NE
SD
ND
ID
WY
OK
KS
CO
UT
TX
NM
SC
FL
GA
ALMS
LA
AR*
MO
IA*
VA
NC
TN*
IN
KY
IL
MI**
WI
PA
NY
WV
VT
ME
RICT
DE
MD
NJ
MA
NH
WA
OH
DC
Will Expand (24 + DC)
Will Not Expand (23)
STATE COMMITMENT TO EXPAND MEDICAID ELIGIBILITY IN 2014
Leaning No (3)

12. States That Expand Will Face a Significant Influx of New
Medicaid Enrollees
12
AK
HI
CA
AZ
NV
OR
MT
MN
NE
SD
ND
ID
WY
OK
KS
COUT
TX
NM
SC
FL
GAALMS
LA
AR*
MO
IA
VA
NC
TN*
IN
KY
IL
MI
WI
PA
NY
WV
VT
ME
RICT
DE
MD
NJ
MA
NH
WA
OH
DC
PERCENT INCREASE IN MEDICAID ENROLLMENT AS COMPARED
TO BASELINE COVERAGE, 2022
Opting Out (26)
≥ 50.1% (7)
25.1-50.0% (10)
≤ 25.0% (7 + DC)
*AR will offer premium assistance to Medicaid beneficiaries; thus, new Medicaid enrollment is low as these individuals are
captured in exchange enrollment.
Source: Avalere Enrollment Model, August 2013, Scenario 2 (assumes 26 states opt out of the Medicaid expansion).

13. Newly Eligible Enrollees Will Have Different Characteristics Than
Current Medicaid Beneficiaries
13
1. Avalere Enrollment Model, August 2013, Scenario 2 (assumes 26 states opt out of the Medicaid expansion).
2. All figures except condition information from U.S. Census Bureau, Current Population Survey, Annual Social and Economic
Supplement, 2012. Percentages based on demographics of uninsured individuals with incomes under 125% FPL. CPS data is for
coverage in 2011. Figures may not sum due to rounding. Condition information from 2010 Medical Expenditure Panel Survey (MEPS).
CHARACTERISTICS OF NEWLY ELIGIBLE
MEDICAID ENROLLEES COMPARED TO
CURRENT ENROLLEES2
● ~83% previously uninsured
● 83% of newly eligible Medicaid enrollees will be
adults age 19-64
o Compared to 42% of the current population—
reflecting a large portion of children in current
program
● Better reported self-health than current enrollees
o 87% of newly eligibles compared to 72% of
current enrollees report good to excellent
health, which may be due to representation of
the disabled among current enrollees
● Lower incidence of common chronic conditions
than adults (18-64) currently enrolled and spend
less per capita, than current enrollees
o May have undiagnosed conditions
50
55 57
-
5
10
15
20
25
30
35
40
45
50
55
60
65
2013 2014 2015
MEDICAID AND CHIP ENROLLEES,
2013, 2014, 2015 (IN MILLIONS)1
NUMBEROFENROLLEES(MILLIONS)

14. 15 States and DC Will Run Exchanges, 7 States Approved for
Partnership, 8 states scheduled for Marketplace Plan Management
14
Source: Avalere State Reform Insights, August 15, 2013
* Utah will operate a marketplace plan management model for its individual exchange and rely on its existing small group exchange for the
SHOP exchange.
** New Mexico will operate a partnership for its individual exchange, but run its own SHOP exchange.
*** Although Idaho will operate a state-based exchange, it will rely on HHS for certain functions, such as eligibility and enrollment.
AK
HI
CA
AZ
NV
OR
MT
MN
NE
SD
ND
ID***
WY
OK
KS
CO
UT*
TX
NM**
SC
FL
GA
ALMS
LA
AR
MO
IA
VA
NC
TN
IN
KY
IL
MI
WI
PA
NY
WV
VT
ME
RICT
DE
MD
NJ
MA
NH
WA
OH
D.C.
FFE – MPM (8)
State-Run (15 + DC)
FFE (20)
Partnership (7)
2014 INSURANCE EXCHANGE OPERATIONAL MODEL

15. Approximately 26 Million Are Expected to Enroll in Coverage
through Exchanges
15
AK
HI
CA
AZ
NV
OR
MT
MN
NE
SD
ND
ID
WY
OK
KS
CO
UT
TX
NM
SC
FL
GAALMS
LA
AR
MO
IA
VA
NC
TN
IN
KY
IL
MI
WI
PA
NY
WV
VT
ME
RICT
DE
MD
NJ
MA
NH
WA
OH
D.C.
≤ 100,000 (8 + DC)
≥ 501,000 (17)
251,000-500,000 (14)
101,000-250,000 (11)
TOTAL ENROLLMENT IN EXCHANGE COVERAGE, 2022
Source: Avalere Enrollment Model, August 2013, Scenario 2 (assumes 26 states opt out of the Medicaid expansion).

16. EXCHANGE ENROLLEES, 2014
(MILLIONS)1
NUMBEROF
ENROLLEES(MILLIONS)
1. Avalere Enrollment Model, August 2013, Scenario 2 (assumes 26 states opt out of the Medicaid expansion).
2. All figures except condition information from U.S. Census Bureau, Current Population Survey, Annual Social and Economic Supplement,
2012. Percentages based on demographics of uninsured individuals with incomes between125%-400% FPL. CPS data is for coverage in 2011.
Condition information from 2010 Medical Expenditure Panel Survey (MEPS).
About 8 Million Will Enter the Exchange in 2014 with Different
Health Profile Than the Currently Insured
16
7
1
1
2
3
4
5
6
7
8
9
10
2014
Subsidized Unsubsidized
Characteristics of Subsidized Exchange Enrollees
Compared to Employer Population2
 ~65% previously uninsured
 58% of enrollees are adults < age 45
» Compared to 43% of employer population
 45% White, 34% Hispanic and 13% Black
» Percentage of Hispanic enrollees is double that
of employer population
 Worse reported self-health than individuals with
employer coverage
» Over 90% still report good to excellent health
 Lower incidence of common chronic conditions than
adults (18-64) with employer coverage
» May have undiagnosed conditions
 Spend less per capita, than individuals with employer
coverage

17. Snapshot of Exchange Landscape

18. 18
ISSUER COMPETITION BY STATE, INDIVIDUAL MARKET
A Majority of States Will Operate with a Lower Number of Issuer
Competition in the Individual Exchange Market
AK
HI
CA
AZ
NV
OR
MT
MN
NE
SD
ND
ID
WY
OK
KS
COUT
TX
NM
SC
FL
GAALMS
LA
AR
MO
IA
VA
NC
TN
IN
KY
IL
MI
WI
PA
NY
WV
VT
ME
RICT
DE
MD
NJ
MA
NH
WA
OH
DC
1-3 Issuers (14 + DC)
4-6 Issuers (15)
7-9 Issuers (4)
10+ Issuers (8)
Source: Avalere State Reform Insights, Updated September 5, 2013
Information Undisclosed (9)

19. State
Enrollment
Number
Rank
Expected lives
in 2016
Aetna* Cigna Humana
United
Healthcare
WellPoint
CA 1 2,601,000 X
FL 3 1,719,000 X X X
OH 6 783,000 X X X
NC 7 780,000 X
GA 9 724,000 X
MI 11 653,000 X X
NY 4 1,079,000 X X
VA 13 541,000 X X
National Carriers Are Participating in Markets Where They Have
Experience—Not Where Most Enrollment Will Likely Be
Source: State Reform Insights, August 23, 2013
*Includes participation of Coventry, given the acquisition was finalized on May 3, 2013. Given the timing of the acquisition, there will likely be
QHPs under the Aetna and Coventry name.
Note: The following states have not yet announced what carriers are participating in their state: TX, IL, NJ, PA, WI.
19
NATIONAL CARRIERS ARE RELYING ON EXPERIENCE AND PROVIDER NETWORKS TO
DESIGN COMPETITIVE PRODUCTS

20. Regional and Local Players Likely to Dominate Exchange
Markets in Early Years
20
National players (e.g., United, Aetna)
● Strategically deciding which state exchanges
they choose to participate
Regional players (e.g., Blues, Kaiser)
● Less flexibility to decide whether to play, likely to
be key participants, to maintain market share
Medicaid-only plans (e.g., Centene, Molina)
● Uniquely positioned to provide health care for
individuals churning from Medicaid into
exchanges
Source: Avalere Research based on 41 states plus DC that have released data about carrier participation, August 2013.
*Regional plans include any Blues plans and Kaiser plans.
** Provider Sponsored plans include plans with a relationship with physician groups or part of an ACO.
Carrier by Plan Type (% of number of plans)
22%
31%
12%
11%
15%
9%
Regional
Local
Medicaid MCO
National
Provider
Sponsored
CO-OP
It will be critical to identify top enrollment plans in key markets as targets for engagement.
These plans are likely to be distinct from major commercial players today

21. Average Monthly Plan Premiums Across All Metal Tiers for
Nonsmoking 40-year olds for Exchange Plans
Rates are for plans filed to be offered through exchanges for nonsmoking 40-year-old individual. Data are for the averages across all regions within
a state. Based on rate filings, CT, IN, and WA do not appear to have any platinum plans available on the exchange. MD only provided rate filings for
bronze and silver products.
Source: Avalere Health analysis of health insurance rate filings publicly available as of August 30, 2013.
$263 $272 $270
$211
$364
$258 $263
$345
$254
$236
$326
$358
$334
$260
$444
$326
$300
$411
$299 $299
$391 $396
$436
$521
$376
$353
$446
$353 $350
$440
$608
$370
$386
$609
$484
$200
$250
$300
$350
$400
$450
$500
$550
$600
$650
CA (12) CT (3) IN (5) MD (4) NY (16) OH (12) SD (3) VT (2) VA (8) WA (4)
MONTHLYPREMIUM
STATE (NUMBER OF CARRIERS)
Bronze Silver Gold Platinum
21

22. Six States Will Go Beyond Federal EHB to Require Standardized
Benefits in their Exchanges
22
COST-SHARING IN SELECT STANDARDIZED SILVER PLANS
Source: State Reform Insights, July 15, 2013
*Benefit cost-sharing parameters are specific to individuals. Deductibles and OOP max may be higher for family coverage.
**All plans must comply with the annual limitation on OOP maximums for medical and drug benefits ($6,350 in 2014).
†California’s silver copay and coinsurance plan designs vary in cost sharing for advanced imaging and home health care services as well as in
the accumulation of certain cost sharing towards the deductible.
‡For brand drugs only §Parameters vary for mail-order pharmacies
State Plan Type Benefit Cost-Sharing Parameters*
Overall
Deductible
Drug
Deductible
Drug Formulary
Inpatient
Emergency
Room
Primary
Care
Physician
Specialist
OOPMax
forDrugs
Tier1
Tier2
Tier3
Tier4
CA
Silver Copay†
Medical:
$2,000
$250‡ $25 $50 $70 20% 20% $250 $45 $65 N/A
Silver
Coinsurance†
Medical:
$2,000
$250‡ $25 $50 $70 20% 20% $250 $45 $65 N/A
Silver HSA $1,500 N/A 20% 20% 20% 20% 20% 20% 20% 20% N/A
CT Standard Silver
Medical:
$3,000
$400 $10 $25 $40 40% $500 $150 $30 $45 N/A
MA Silver $2,000 N/A $20§ $35§ $70§ N/A $1,000 $250 $30 $50 N/A
NY Silver $2,000 N/A $10§ $35§ $70§ N/A $1,500 $150 $30 $50 N/A
OR Silver $2,500 $0 $15 $50 50% 50% 30% 30% $35 $70 N/A
VT
Silver
Deductible
$1,900 $100‡ $12 $50 50% N/A 40% $250 $20 $40 $1,250
Silver- HDHP $1,550 $1,250 $10 $40 50% N/A 20% 20% 10% 20% $1,250

23. Patients Meeting the OOP Cap Expected to be Underinsured
23
A study of families receiving unsubsidized insurance through the Massachusetts exchange —
established in 2006 — indicates that those on the lower end of the income spectrum, those with fair to
poor health, and those with more children, often faced high levels of financial burden due to out-of-
pocket costs for care.2
0%
5%
10%
15%
20%
25%
100% FPL 150% FPL 200% FPL 250% FPL 300% FPL 400% FPL 500% FPL
OUT-OF-POCKET CAP AS A PERCENT OF INCOME1
OOP cap as a % of income Underinsured threshold
1. Based on CWF definition: out-of-pocket expenses equaled 10% or more of income; out-of-pocket expenses equaled 5% or more of
income if low income (<200% of poverty); or deductibles equaled 5% or more of income. Available at:
http://www.commonwealthfund.org/~/media/Files/Publications/Fund%20Report/2013/Apr/1681_Collins_insuring_future_biennial_surv
ey_2012_FINAL.pdf
2. Health Affairs, Some Families Who Purchased Health Coverage Through The Massachusetts Connector Wound Up With High
Financial Burdens, April 2013. Available at: http://content.healthaffairs.org/content/early/2013/04/15/hlthaff.2012.0864.full.pdf+html

24. Lives Served by Market Today
Anticipated Future Market
Less Generous More Generous
Benefit Design Generosity
Commercial
Exchange
Medicaid
Catastrophic
Exchange Plans May Have Spillover Effects by Setting a
New Low Standard for Coverage Generosity
24

25. © National Health Council
Choosing the Best Plan for You:
Tips to Navigate Exchange Websites
Kelly Brantley
Senior Manager
Avalere Health, LLC

26. Tips for Navigating Exchange Websites

27. Applicant Welcome Page for the Federally Facilitated
Marketplace Simplifies Consumer Options
27

28. The Federally Facilitated Marketplace Consumer Hotline and
Additional Resources Are Available Now
28
LIVE CHAT
RESOURCES INCLUDE: CALL CENTER, LIVE CHAT, AND FAQ GUIDE
CALL CENTER

29. Federally Facilitated Website Currently Operating A Tool to Help
People Determine Possible Coverage Options Prior to Oct. 1
29
A SERIES OF QUESTIONS WILL HELP YOU DETERMINE IF YOU WILL LIKELY BE ELIGIBLE FOR
EXCHANGES, MEDICAID, AND/OR FINANCIAL ASSISTANCE

30. Applying for Coverage on Healthcare.gov Includes a Set of
Required Application Information
30
Applicants must enter:
• Contact information, including
address, phone number, preferred
language, and preferred method of
contact.
• Social security number, federal tax
information, status of
dependents, and race
• Household, dependent, and spousal
information
• Income information using pay stubs
and W-2 forms.

31. The Site Then Calculates an Eligibility Determination for
Financial Assistance
31
APPLICANTS ARE NOTIFIED IN REAL TIME IF THEY ARE ELIGIBILE FOR ADVANCE PREMIUM
TAX CREDITS, COST SHARING REDUCTIONS, AND/OR MEDICAID
Real time
eligibility
notification

32. Educational Slides Prior to Metal Tier and Plan Comparison
32
HEALTHCARE.GOV ATTEMPTS TO INCREASE HEALTH LITERACY AMONGST CONSUMERS
Before the applicant reviews metal tier options and plans, they will review three slides that
briefly explain: Essential Health Benefits, actuarial value of the five metal tiers, and general
cost-sharing information (i.e., “the lower the premium, the higher the out-of-pocket costs
when you need care”)

33. How to Navigate Metal Tiers, Comparing Health Plans as well as
Key Information Available for Direct Comparison
• The applicant is provided information
about the number of plans in each
level, the high and low monthly
premiums, average co-pay, average
deductible, and out-of-pocket
maximum. Applicants may select one or
more metal tiers.
• After selecting the tier, applicants are
brought to a list of available plans.
Applicants have the option to sort plans
by: maximum out-of-
pocket, premium, and deductible
33

34. 34

35. Using Expected Healthcare Needs to Select a Plan:
Formularies, Provider Networks, and Out-of-Pocket Costs
35
● FORMULARIES
− Applicants will access plan formularies by expanding the ―Prescription Drug
Coverage‖ section and clicking on a link that will take the applicant to the
issuer’s website
● PROVIDER NETWORKS
− Applicants will access the plan’s provider network by clicking on the ―Provider
Directory‖ link that is part of the initial information displayed for each plan
● OUT-OF-POCKET COSTS
− It is important to note that the out-of-pocket calculator and information
available on the website may not accommodate personal health care needs
Applicants may find it difficult to quickly and accurately compare provider
networks and formularies from different issuers due to the lack of
standardization for formatting and the separate search function

36. Keep in Mind the Following Strategies for Protection against
Fraud in the Marketplace
● BE INFORMED. Learn about the basics of health care at healthcare.gov and
compare insurance plans in order to make an informed final decision
● PROTECT YOUR PERSONAL INFORMATION. Do not give out any personal health
information. Do not give your Social Security number or credit card or banking
information to companies you didn’t contact or in response to unsolicited
advertisements.
● ASK QUESTIONS, VERIFY ANSWERS. The Marketplace has trained and certified
assisters available to help if the information is unclear. Keep the contact information
of any salesperson that assists you. Contact healthcare.gov to utilize the live chat
options or the call center if you need to verify answers
● REPORT SUSPICIOUS ACTIVITY. Any suspected fraud can be reported to the
Health Insurance Marketplace consumer call center at 1-800-318-2596
36

37. QUESTIONS?

38. Racing to New Coverage Opportunities:
Final Steps to Help You
Prepare for Enrollment
September 11, 2013
www.nationalhealthcouncil.org