National Health Council - Preparing for Exchange Enrollment (July 2013)


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What patient advocacy organizations need to know as they help people with chronic conditions understand the essential health benefits provided under the Affordable Care Act and assist people in enrolling in state exchanges

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  • Electronic 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.
  • Laws pertaining to health typically come about when diverse health problems reach a critical mass. Problems rise to the forefront because they apply to a large number of people – such as the need for health care delivery reform – or because the problem sharply focuses on a small but powerful group – for example, funding of nursing or medical education programs.  Problems that actually lead to policy solutions emerge because they reach unacceptable levels. For the AIDS community, it was the tragic number of people dying. In response to the community outcry, policymakers draft policies. We can think of these policies as potential solutions to the problems. In the legislative development phase, the public influences the crafting of the solution, as shown at the top of the diagram.  At the far right, you’ll see that passage of the legislation is not the end of the process. Patient advocacy organizations also provide input and feedback in the rulemaking process. As the legislation is implemented, the need for changes in the law may come to light. New problems will arise – and we are back at the policy formulation phase.  It’s an ongoing, circular process.
  • The Affordable Care Act (ACA) requires states to establish exchanges by 2014Exchanges will function as new marketplaces where individuals and small businesses can purchase health insuranceStates may establish and operate their own exchanges, otherwise the federal government will establish an exchangeBoth state-run and federal exchanges must be up and running by January 1, 2014 Each state will have two exchanges: one for individuals to purchase insurance, and another for qualifying small businesses to purchase insurance for their employees
  • National Health Council - Preparing for Exchange Enrollment (July 2013)

    1. 1. Preparing Your Staff and Patients for Exchange Enrollment July 17, 2013
    2. 2. Essential Health Benefits: We’ve Only Just Begun Marc Boutin, JD Executive Vice President and COO National Health Council
    3. 3. The mission of the National Health Council is to provide a united voice for people with chronic diseases and disabilities.
    4. 4. © National Health Council Putting Patients First®  Cover Everyone  Curb Costs Responsibly  Abolish Exclusions for Pre-existing Conditions  Eliminate Lifetime Caps on Benefits  Ensure Access to Long-tem and End-of-life Care GOAL: Engage individuals in a nationwide effort to create and implement a modern health care system, based on 5 Principles for Putting Patients First®
    5. 5. © National Health Council
    6. 6. © National Health Council Essential Health Benefits Broad Definition of Covered Services ― Specific List of Exclusions
    7. 7. © National Health Council Patient Protections  Anti-Descrimination  Medical Necessity  Exceptions and Appeals  Continuity of Care  Prohibition of Specialty Tiers  Limited Cost Sharing  Part D Protected Classes
    8. 8. © National Health Council Patient Community Wins  Drug Formulary must have the same number of prescription drugs in each class as that of the EHB- benchmark plan  States must monitor and identify discriminatory benefit designs  The ability of health plans to substitute benefits is limited.
    9. 9. © National Health Council Tools:  Choosing an appropriate plan  Evaluation and Tracking Tool Patient Advocacy Tools
    10. 10. © National Health Council Public Policymaking Process in the U.S. Interest Group Preferences, Demographics, Technological Inputs Policy Modification Phase – Feedback Policy Formulation Phase Development of Legislation Policy Implementation Phase Rulemaking Application Based on Health Policymaking in the United States, 2nd Edition, by Beaufort B. Longest Jr.
    11. 11. State Exchanges and Medicaid Expansion: What do you need to know? Kelly Brantley Senior Manager Avalere Health, LLC
    12. 12. © Avalere Health LLC Page 13 Agenda  Coverage Expansion  Affordability in Exchanges  Enrollment  Federal and State Consumer Outreach and Enrollment Activity » Opportunities for NHC Members to Participate  Next Steps  Q&A
    13. 13. Coverage Expansion The intersection of business strategy and public policy
    14. 14. © Avalere Health LLC Page 15 The ACA Is Expected to Reduce Number of Uninsured, Primarily through Enrollment in Medicaid and Exchanges Source: Avalere Enrollment Model, June 2013. Assumes 26 states opt out of the Medicaid expansion. Avalere assumes that: Arkansas enrolls new Medicaid eligibles into the exchange through premium support, Iowa enrolls new Medicaid eligibles over 100 percent of poverty into the exchange through premium support, and Wisconsin reduces Medicaid eligibility to 100% FPL and moves these individuals in the exchanges. ACA = Affordable Care Act 49 40 35 26 54 59 61 62 8 12 22 16 13 12 11 141 140 141 141 5 5 5 5 50 52 53 55 2013 2014 2015 2016 Expected Sources of Coverage (in Millions), 2013-2016 Medicare Other Public Programs Employer Non-Group Exchanges Medicaid and CHIP Uninsured
    15. 15. © Avalere Health LLC Page 16 Health Reform Broadens Medicaid Eligibility Substantially  The ACA required states to expand the Medicaid program… » Required states, beginning in 2014, to cover all individuals who are under 65, do not receive Medicare, and have income below 133% FPL » Largely affects parents and childless adults who are not disabled  …but the Supreme Court rendered the expansion optional » The court ruled that states must be given a choice about whether or not to move forward with the ACA’s Medicaid expansion » The federal government cannot cut off existing Medicaid funding to states that choose not to proceed with the expansion ACA = Affordable Care Act FPL = Federal Poverty Level Expansion largely will help parents and childless adults who are not disabled. Most states only cover parents at much lower income levels, and very few states cover any childless adults unless they are disabled.
    16. 16. © Avalere Health LLC To Date, 23 States & DC Plan to Expand Medicaid Eligibility in 2014, 21 Will Not Expand, and the Remainder Are Undecided 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 Will Expand (23 + DC) State Commitment to Expand Medicaid Eligibility in 2014 Leaning No (6) Will Not Expand (21) Source: Avalere State Reform Insights, Updated July 15, 2013 * Considering a premium assistance model for expansion using exchange plans for some or all beneficiaries
    17. 17. © Avalere Health LLC Page 18 Exchanges Aim to Offer One-Stop Shopping to Individuals and Small Businesses, Similar to Online Travel Sites Exchange Governing Body Individual Exchange SHOP Exchange 26 M enrollees Majority are subsidized individuals; No subsidies for those with ESI* Unknown number of groups with ≤100 workers * Individuals with an offer of employer-sponsored insurance (ESI) are not eligible for subsidies unless their individual employer premium exceeds 9.8% of their income or does not provide minimum value. Source: Avalere Health Enrollment Model, June 28, 2013.
    18. 18. © Avalere Health LLC Page 19 By 2019, About 26 Million People Will Gain Health Insurance Coverage through the Exchanges Projected Number of Exchange Enrollees, 2014-2019 Enrollment(Millions) 7 10 19 21 21 21 1 2 4 4 4 5 0 5 10 15 20 25 2014 2015 2016 2017 2018 2019 Subsidized Unsubsidized Source: Avalere Enrollment Model, June 2013. Assumes 26 states opt out of the Medicaid expansion. Avalere assumes that: Arkansas enrolls new Medicaid eligibles into the exchange through premium support, Iowa enrolls new Medicaid eligibles over 100 percent of poverty into the exchange through premium support, and Wisconsin reduces Medicaid eligibility to 100% FPL and moves these individuals in the exchanges.
    19. 19. © Avalere Health LLC Page 20 State-Run Exchange State Partnership Exchange (SPE) Federally Facilitated Exchange (FFE)* States Have Three Options with Varying Degrees of State Responsibility for Exchange Functions  States have three options: 1) Perform plan management only 2) Perform consumer assistance only 3) Perform both plan management and consumer assistance HHS will manage technical functions – eligibility and enrollment, financial management, etc. Partnership blueprints were due on February 15, 2012  States manage core exchange functions: » Plan management » Consumer assistance » Eligibility and enrollment » Financial management The ACA appropriates state establishment grants to support these activities through 2014 Exchange blueprints were due on November 16, 2012 ACA requires HHS to run a FFE in any state that does not set up an exchange States with the FFE will not control key exchange functions, although the federal government is consulting with states on its design FFE states will retain traditional responsibilities of their insurance departments HHS = Department of Health and Human Services * HHS has approved eight FFE states—KS, ME, MT, NE, OH, SD, UT and VA—to operate the ―Marketplace Plan Management‖ model in which these states will perform plan management.
    20. 20. © Avalere Health LLC Page 21 16 States and DC Will Run Exchanges in 2014, While 6 States Will Pursue Partnerships, and the Rest Will Rely on the FFE Source: Avalere State Reform Insights, July 15, 2013. *In addition to the marketplace plan management model for its individual exchange, Utah will rely on its existing small group exchange as its SHOP. **While New Mexico will operate a partnership for its individual exchange, the state will run its own SHOP. *** Although Idaho will operate a state-based exchange, it will rely on HHS for certain functions, such as eligibility and enrollment. Insurance Exchange Operational Model 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 – Marketplace Plan Management (8) State-Run (15 + DC) FFE (20) Partnership (7)
    21. 21. Affordability in Exchanges The intersection of business strategy and public policy
    22. 22. © Avalere Health LLC Page 23 Plans in the Individual and Small Group Market, Including Exchange Plans, Must Offer the Essential Health Benefits 1. Essential Health Benefits » Applies to all individual and small group plans 2. Out-of-Pocket Limits (OOP) » Applies to all plans – OOP cap is tied to annual HSA limits ($6,350 for an individual in 2014) 3. Actuarial Value » All individual and small group plans in the exchange must offer Silver and Gold Ambulatory patient services Prescription drugs Emergency services Rehabilitative and habilitative services and devices Hospitalization Laboratory services Maternity and newborn care Preventive and wellness services and chronic disease management Mental health and substance abuse services Pediatric services (including oral and vision care) Bronze Plan covers 60% of healthcare costs Silver 70% of healthcare costs Gold 80% of healthcare costs Platinum 90% of healthcare costs Actuarial Value = A measure of a benefit generosity that is expressed as percent of expenses paid by the insurer HSA = Health Savings Account
    23. 23. © Avalere Health LLC Page 24 Exchange Plans Will Follow Set Metal Levels & Will Be Less Generous than Employer Coverage Insurance Plan % of Patient Costs Covered by Plan Typical Employer Plan (HMO)1 93% Platinum 90% FEHBP Blue Cross Blue Shield Standard Option (PPO) 1 87% Typical Employer Plan (PPO)1 80.0% - 84% Gold 80% Medicare Parts A, B and D1 76% Silver 70% Bronze 60% 1. Peterson, Chris. ―Setting and Valuing Health Insurance Benefits.‖ Congressional Research Service. (2009) Most enrollees are expected to select lower-premium Silver and Bronze plans, which will include very high out-of-pocket requirements for patients. May have very high cost- sharing—enrollees could be underinsured
    24. 24. © Avalere Health LLC Page 25 Exchanges Will Offer Premium and Cost-Sharing Subsidies Premium Subsidies: Sliding scale tax credits to limit premium spending as a percent of income for individuals under 400% FPL; Applies to the second lowest cost Silver plan available in the exchange Cost Sharing Reductions: Provides cost-sharing subsidies for individuals with incomes below 250% FPL Income Premiums Limited to % of Income <133% FPL 2.0% 133 – 150% FPL 3.0 - 4.0% 150 – 200% FPL 4.0 – 6.3% 200 – 250% FPL 6.3 – 8.05% 250 – 300% FPL 8.05 – 9.5% 300 – 400% FPL 9.5 % FPL = Federal Poverty Level OOP = Out-of-Pocket Household Income Reduction in OOP Limit Actuarial Value 100 - 150% FPL 2/3 94% 150 – 200% FPL 2/3 87% 200 – 250% FPL 1/5 73% 250 – 400% FPL None, given AV level 70%
    25. 25. © Avalere Health LLC Page 26 Initial Rate Filings Show Wide Variation in Silver Plan Premiums within and among States $222 $233 $300 $232 $197 $286 $201 $400 $264 $326 $370 $362 $314 $291 $310 $299 $432 $311 $476 $659 $441 $429 $549 $332 $436 $454 $359 $- $100 $200 $300 $400 $500 $600 $700 CA (13) CO (10) CT (4) OH (5) OR (12) RI (2) VA (5) VT (2) WA (7) MonthlyPremium State (Number of Carriers) Monthly Silver Plan Premiums for Nonsmoking 40-Year-Olds for Exchange Plans* Minimum Average Maximum * Rates are for plans filed to be offered through exchanges for nonsmoking 40-year-old individual. Data are for the minimum, maximum, and averages across all regions within a state. Source: Avalere Health analysis of health insurance rate filings publicly available as of June 12, 2013.
    26. 26. © Avalere Health LLC Page 27 Case Study: Despite Health Care Reform’s OOP Limit, Patients with Rare Diseases Will Face High Initial Costs for Their Drugs $0 $1,000 $2,000 $3,000 $4,000 $5,000 $6,000 $7,000 First Month's Rx Fill Second Month Estimated Drug Spending for Rare Disease Patients in Exchange Coverage Assumes $15,000 Monthly Drug Cost VT Deductible CA Silver Coinsurance Plan MA, NY Silver* OR Standard Silver Plan CT Standard Silver Source: Avalere Health analysis based on states’ 2014 standardized benefit designs for silver-level plans in their exchanges. Calculations are based on a prescription drug with a cost of $15,000 per month that is placed on a plan’s highest-cost formulary tier. Assumes no other drug or medical spending by the patient during the year. * MA and NY each have a standard silver plan design with the same overall deductible amount, tier 3 cost sharing, and OOP maximum, although the benefit designs differ on cost sharing amounts for other services not included in this analysis.
    27. 27. © Avalere Health LLC Page 28 The Affordable Care Act Introduces New Protections Invaluable to Patients with Special Healthcare Needs • Insurers must cover treatment for conditions patients had prior to obtaining coverage Pre-existing Condition Exclusions • Insurers cannot turn down patients based on health status for initial enrollment or renewals Guarantee Issue • Insurers may only vary the premium rates for enrollees on the basis of four factors: family size, rating area, age, and tobacco use Rating Rules • Insurers must combine the claims experience across all enrollees in each market when setting premiums Single Risk Pool
    28. 28. Enrollment The intersection of business strategy and public policy
    29. 29. © Avalere Health LLC Page 30 Options for Enrollment in Exchange Coverage Will Include an Online Web Portal and In-Person Assistance Medicaid / CHIP Apply for Coverage Select Benefit & Health Plan Platinum (90%) Gold (80%) Silver (70%) Bronze (60%) United Humana CIGNA Aetna WellPoint BC/BS Regional Complete Enrollment Income Verification Process Exchange without Subsidy Exchange with Subsidy   Exchange portals will allow individuals to determine eligibility for exchanges and subsidies  Consumers will be allowed to select from three to four coverage levels* and from a variety of benefit designs and carriers  In-person assistance will be available to aid consumers in enrollment decisions * Individuals receiving cost-sharing reductions must purchase silver-level coverage
    30. 30. © Avalere Health LLC Page 31 Patients Can Enroll Beginning in October, with Coverage Effective as Soon as January 1 July August Sept October Nov Dec Jan Feb March April 2013 2014  For enrollments between October 1 and December 15, 2013, coverage will be effective January 1, 2014  After December 15, for enrollments between the 1st and 15th day of the month, coverage will begin the first day of the next month. For enrollments between the 16th and the last day of the month, coverage begins the first day of the second following month.  Patients will be able to enroll outside of the open enrollment period only if they experience qualifying events including: » Marriage or divorce » Loss of other insurance coverage (from an employer, for example) » Become eligible for subsidies due to change in income October 1: Open Enrollment Begins January 1: New Coverage Effective March 31: Open Enrollment Closes
    31. 31. © Avalere Health LLC Page 32 The ACA Requires People Who Do Not Have Health Insurance to Pay a Penalty, Which Phases Up in Later Years Year Penalty 2014 Greater of $95 or 1% of income (offset by filing threshold) 2015 Greater of $325 or 2% of income (offset by filing threshold) 2016 Greater of $625 or 2.5% of income (offset by filing threshold) 2017 Greater of $625 (+ cost of living adjustment) or 2.5% of income (offset by filing threshold) Penalty amounts increase in future years, but are capped at bronze premium levels Source: IRS, Proposed Rule, Shared Responsibility Payment for Not Maintaining Minimum Essential Coverage, January 2013.
    32. 32. © National Health Council State Navigators, Assisters, and Counselors: How to work with them Purva Rawal Senior Manager Avalere Health, LLC
    33. 33. Consumer Outreach and Enrollment Activity The intersection of business strategy and public policy
    34. 34. © Avalere Health LLC Page 35 HHS and States Focused on Consumer Outreach and Enrollment As October 1 Approaches  Exchanges must have fixed, annual open enrollment periods with special enrollment periods for particular circumstances » Initial open enrollment period will run from October 1, 2013 through March 31, 2014 » In subsequent years, annual enrollment will run from October 15 through December 7 of each year  Major federal, state, and private marketing efforts are expected to begin this summer to draw attention to the coverage expansions and the exchange marketplaces in time for enrollment assistance on October 1, 2013 APR MAY JUN JUL AUG SEPT OCT NOV DEC JAN FEB MAR October 1, 2013-March 31, 2014: Initial open enrollment in the individual exchange October 15-December 7: Annual open enrollment in the individual exchange
    35. 35. © Avalere Health LLC Page 36 Patients Will Need Support across Three Domains • Although many people will qualify for federal subsidies in the exchanges, individuals may still have trouble affording premiums • Affordability may vary greatly by state depending on enrollment trends and the payer landscape Premiums • Awareness of new coverage options is low and the process for applying will be complex for many to navigate • Patients will require non-bias, informed support from navigators and non-navigator assisters in order to enroll in the plan that best meets their needs Enrollment • Cost sharing for upper tiered medications is expected to be high, ranging from 20-50% on tiers 3 and 4 in states with standardized plan designs • While some patients will be eligible for cost-sharing subsidies, many will need support accessing medications before they meet the OOP limit Access to Providers and Treatments
    36. 36. © Avalere Health LLC Page 37 HHS Has Proposed Three Separate Consumer Assister Entities to Boost Exchange Enrollment Navigator In-person Assisters Certified Application Counselor Roles and Responsibilities Assist and educate individuals to receive eligibility determination from exchange and help with enrollment Provide similar assistance as Navigator to supplement the Navigator program for the initial years of the exchanges Assist consumers in completing and gathering information for single streamlined eligibility application for Medicaid, exchanges Funding Grants from HHS in FFE and SPEs, grants from the state exchange in SBEs Exchange Establishment Grants Self-funded; federal and exchange grants not available States FFE, SPE, SBE SPE, Optional SBE FFE, SPE, SBE FFE = Federally Facilitated Exchange; SPE = State-Partnership Exchange; SBE = State Based Exchange Source: Centers for Medicare & Medicaid Services. Proposed Rule on Standards for Navigators and Non- Navigator Assistance Personnel. Released April 3, 2013. The multiple consumer assister options, differing funding streams, and staggered application deadlines –in the absence of final rules - are challenging to those trying to identify what consumer assister roles they can play and where.
    37. 37. © Avalere Health LLC Page 38 States with RFPs for Navigators, IPAs, or Certified Application Counselors 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. RFP Released (12 + DC) No RFP (40) To Date, 12 States and DC Have Issued RFPs for Consumer Assistance Programs Source: Avalere State Reform Insights, July 15, 2013.
    38. 38. © Avalere Health LLC Page 39 States Are Spending on Consumer Assistance More Heavily than HHS $54 $16 $43 $17 $5 $10 $0.43 $28 $24 $4 $4 $13 FFE AK CA CO CT DC HI IL MD MN NV VT Spending on Consumer Assistance Programs, in Millions Avalere analysis based on publicly reported spending on consumer assistance programs, including navigators and IPAs. Source: Avalere State Reform Insights, July 15. 2013
    39. 39. © Avalere Health LLC Page 40 HHS Has Made Steady Progress on Consumer Assistance Programs, But Significant Work Still Must Be Accomplished Funding Delays Training Plan A Outstanding Activities  The funding announcement for the Navigator program was delayed until April 9, 2013 and CMS indicated only one round of awards would take place.  The anticipated award date is now August 15, 2013 and CMS expects to make awards to at least two different applicants in each of the 34 FFE states and 33 FF- SHOP states.  Federally funded in-person assisters, including Navigators, must be trained and certified before conducting outreach assistance activities.  CMS plans to complete the development of the Navigator training curriculum and certification exam by August 2013 and will begin training once the curriculum is published.  CMS recommended that in- person outreach activities begin in the summer of 2013 to educate small employers and employees in advance of the open enrollment period.  In addition, HHS is targeting marketing and outreach efforts to specific populations, such as young adults and Hispanics. Source: GAO Report: Status of Federal and State Efforts to Establish Federally Facilitated Health Insurance Exchanges. June 2013. Available at:
    40. 40. © Avalere Health LLC Page 41 Navigators and Assisters Must Be Trained Quickly and Prepared to Reach Varied Populations • Minorities expected to be disproportionately represented—need for consumer assister services in other languages • Population expected to have lower educational attainment compared to those with ESI requiring materials at appropriate literacy levels, etc. Population • Navigators and non-Navigator assistance personnel must obtain certification through the exchange, complete and pass an HHS- approved training, and obtain continuing education and be recertified • CMS estimates training will take up to 30 hours for certification Training • Navigators and non-Navigator assistance personnel must be trained and certified quickly in anticipation of open enrollment October 1 • Interested entities must apply by June 7, with awards made by August 15 (letter of intent due May 1) Timing Patient groups and community-based organizations could play a critical role in educating Navigators and IPAs on the benefit design features enrollees with special needs or chronic health conditions should consider before selecting a plan.
    41. 41. © Avalere Health LLC Page 42 Opportunities for NHC Members to Engage  Patient advocacy groups have a key role to play in educating Navigators and In- Person Assisters in serving exchange enrollees with special needs or chronic conditions  Key considerations in plan design for assisting patients » Provider Access: Ensure patients’ physician(s), facilities of choice are in- network » Drug Cost-Sharing and Other Access Limitations: Understand formulary rules for specialty drugs and biologics, including costs and utilization management  NHC members should seek opportunities to partner with other stakeholders who share the goal of maximizing exchange enrollment and promoting high levels of appropriate plan choice
    42. 42. QUESTIONS?
    43. 43. If you have any questions or comments about the National Health Council and its work on behalf of patients, the essential health benefits, or enrollment in the exchanges, contact us at