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Final Steps to Help You Prepare for Exchange Enrollment

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The National Health Council presented a webinar for patient advocacy organizations on September 11, 2013, to review the current status of state health exchanges and provide information on what …

The National Health Council presented a webinar for patient advocacy organizations on September 11, 2013, to review the current status of state health exchanges and provide information on what patients need to know before they enroll.


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  • Through Education, NHC Will Lay a Foundation for VHAs on Insurance Marketplaces and Medicaid ExpansionTwo webinars will deliver background on health insurance marketplaces and Medicaid expansionTarget audience will be federal and state staff of VHA member organizationsEarly summer webinar will focus on status of implementation activities in states and the role that patient advocacy organizations can playAutumn webinar will aim to address more details about specific plan availability, assistance programs in operation, and methods for data collection to inform future federal and state policy updates
  • Tools Will Help Advocates Assist Patients through Implementation Activities Advocacy tools will focus on the patient perspective of newhealth insurance coverage options rather than the general approachexpected by most organizations and agencies focused on enrollment.Answers to common questions to educate staff and volunteers on new insurance marketplaces, Medicaid expansion, and the timeline for implementation activitiesCustomizable resources, such as fact sheets and one-pagers, on direct patient assistance activitiesTopics could include applying for coverage, choosing an appropriate plan, and navigating a new health insurance plan, etc.
  • Key Messages Will Launch Each Month and Build Off Messages Tested by National PartnersOutreach using key messages will focus on themes that resonate mostwith patients concerned about coverage and affordability.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.
  • There has been significant speculation about what level of benefit consumers will want to purchase in the exchanges. The ACA requires that plans meet one of four actuarial value (AV) tier levels—bronze, silver, gold and platinum, all with varying degrees of generosity, in terms of the percentage of medical costs that the plan covers. Bronze plans will cover 60 percent of medical costs, silver plans will cover 70 percent, gold plans will cover 80 percent and platinum plans will cover 90 percent. Across all states reviewed, the average monthly Bronze plan premium is $274, while the average Silver plan is $336. Although the subsidies are tied to the second lowest Silver plan that’s available to an individual, a $62 difference in monthly premiums ($744 annually) could result in consumers deciding to “buy-down” to a Bronze plan. “Bronze plans are offering a significant reduction in monthly costs relative to Silver products, which is likely to entice healthier enrollees to opt for a less generous benefit package,” said Pearson. It is important to note, that for individuals who are between 100 percent and 250 percent of the federal poverty line (FPL), the only way they can receive the cost-sharing reductions that increase the actuarial value of their plan is by enrolling in a Silver plan. This means that most individuals below 250 percent FPL would find it beneficial to pay more in premiums in exchange for better benefits and lower out of-pocket costs.
  • Income information note: Questions include asking whether the applicant expects his/her yearly income for 2014 to be the same as what was reported on his/her 2012 federal income tax return.
  • Applicants are then provided general educational information on their available tax credits and given the opportunity to choose what percentage of the available credits they wish to use. Finally, applicants are provided a series of brief educational graphics that inform them about the metal tiers, essential health benefits, and cost sharing
  • Transcript

    • 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
    • 6. © 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.
    • 7. State Exchanges and Medicaid Expansion: What do you need to know? Corey Ford Senior Manager Avalere Health, LLC
    • 8. State Implementation Activities Update
    • 9. 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
    • 10. 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)
    • 11. 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).
    • 12. 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)
    • 13. 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
    • 14. 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).
    • 15. 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
    • 16. Snapshot of Exchange Landscape
    • 17. 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)
    • 18. 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
    • 19. 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
    • 20. 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
    • 21. 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
    • 22. 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
    • 23. 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
    • 24. © National Health Council Choosing the Best Plan for You: Tips to Navigate Exchange Websites Kelly Brantley Senior Manager Avalere Health, LLC
    • 25. Tips for Navigating Exchange Websites
    • 26. Applicant Welcome Page for the Federally Facilitated Marketplace Simplifies Consumer Options 27
    • 27. 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
    • 28. 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
    • 29. 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.
    • 30. 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
    • 31. 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”)
    • 32. 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
    • 33. 34
    • 34. 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
    • 35. 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
    • 36. QUESTIONS?
    • 37. Racing to New Coverage Opportunities: Final Steps to Help You Prepare for Enrollment September 11, 2013 www.nationalhealthcouncil.org