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The Affordable Care Act and New Hampshire
- 1. Health Reform and HealthInsurance Markets 2014 Changes in New Hampshire New Hampshire Insurance Department Tyler Brannen – Health Policy Analyst October 17, 2013 1
- 2. The ACA andNH • Federal law vs. state laws • Health insurance rules • Expanding health insurance coverage • “Exchanges” and the individual mandate 2
- 3. NH’s Health Commercial InsuranceMarkets • About 55% of “insured” people covered by selffunded employers • 76% of people covered by large employers • Of those people, 29% are regulated as insured (140,000) • 24% of people in small employers or individual market • 110,000 small employer members • 40,000 individual members 3
- 4. Health Insurance Carrier/TPA MemberDistribution by Funding Golden Rule American Republic Celtic NovaSys_Health United HealthMarkets Assurant Usable MVP Aetna Harvard Pilgrim CIGNA Anthem 4 - 50,000 100,000 Fully-Insured Members 150,000 200,000 Self-Insured Members 250,000 300,000
- 5. Factors in InsuranceCompany Competition Main Factors: • Medical claims costs • Provider contracts • Insured population health status • Other Factors: • Membership • Underwritten & self-funded • Organizational efficiency • Return on Investments • Customer service 5
- 6. RSA 420-J:7 Network Adequacy(Ins 2700) • • • • • Anthem’s Pathways Network Complied with NH Network Adequacy requirements Does not apply to most of Anthem’s members Anthem indicates premium savings of at least 25% Primary issue – 10 of 26 hospitals in NH not included • Anthem only medical carrier on the exchange/Marketplace • Significance - only place to access subsidies • Why only Anthem? • Will there be a legislative solution? • How involved should the government be? 6
- 7. What is happeningin the delivery system? • Investment in Community Health Centers • Increased use of mid-level providers (NPs, PAs), health coaches, and community health workers • Telemedicine • Hospitalists • Urgent care centers and walk in clinics • Accountable Care Organizations and medical homes • Hospital services provided in non-traditional settings • Incentives exist for restructuring the delivery system with a lower cost structure 7
- 8.
- 9. What’s New in2014? • Individual mandate • New rules for individual and small group markets • Essential health benefits – 10 Categories • Emergency services, hospitalization, Maternity & newborn care • Guaranteed issue • New rating factors for calculating premiums • PAST: age, health status, group size, industry, tobacco • FUTURE: Age, tobacco, geographic (not used in NH) • Metal levels • Requirements for large employers (2015) 9
- 10. “The Marketplace” andSHOP Exchange • Individuals and small employers ONLY • NOT Medicare • Federal –state partnership model • https://www.healthcare.gov/ • • • • Medicaid Subsidies for individuals Tax credits for small employers Online Oct 1, 2013 for coverage Jan 1, 2014 • Annual Open Enrollment Periods after that start October 15 and end December 7 • Special Enrollment Periods • You can still buy insurance outside the Marketplace 10
- 11. Subsidy Availability • Substantialsubsidies are available through the Marketplace for those at 100%-400% of federal poverty (FPL) • Individuals: $11,490 - $45,960 • Family of 4: $23,550 - $94,200 • Those under 100% FPL are not eligible for subsidies • Assumed to be covered by Medicaid 11
- 12. Sliding Scale forEligible Individuals Percentage of poverty line Annual dollar amount (2013) Premium contribution as % of income Monthly premium contribution 100 – 133% $11,490 - $15,282 2% $19 - $25 133 – 150% $15,282 - $17,235 3 – 4% $38 - $57 150 – 200% $17,235 - $22,980 4 – 6.3% $57 - $121 200 – 250% $22,980 - $28,725 6.3 – 8.05% $121 - $193 250 – 300% $28,725 - $34,470 8.05 – 9.5% $193 - $272 300 – 350% $34,470 - $40,215 9.5% $272 - $318 350 – 400% $40,215 - $45,960 9.5% $318 - $364 12
- 13. The Individual Mandate •In 2014: • Every individual must have health insurance • Employer coverage, individual coverage, Medicaid, Medicare • Limited exemptions to penalty requirement (e.g., low income) • Administered and enforced by IRS • Penalty amounts: • 2014: $95 per household member (up to $285) or 1% of income (whichever is higher). • 2015: $325 per household member (up to $975) or 2% of income (whichever is higher). • 2016: $695 per household member (up to $2095) or 2.5% of income (whichever is higher). • After 2016 – cost of living adjustments 13
- 14. Consumer Assistance • • • • • • • • • • Federal website(HealthCare.gov) and toll free call center Navigators Certified Application Counselors Small Business Administration NH Health Plan Agents and brokers Health insurance companies IRS Department of Labor Consumer advocates 14
- 15. Federal Resources U.S. Departmentof Health and Human Services Health Reform Website/Marketplace http://www.healthcare.gov Help Center: 800-318-2596 (24/7) Small Business Administration (Employer information) http://www.sba.gov/healthcare http://business.usa.gov/healthcare SBA Hotline: 800-706-7893 (M - F, 9-5) 15
- 16. New Hampshire Resources NHInsurance Department (603) 271-2261 Consumer Hotline: 800-852-3416 http://www.nh.gov/insurance NH Department of Health and Human Services http://www.dhhs.nh.gov Medicaid – Client Services: (800) 852-3345, ext. 4344 NH Health Plan http://www.nhhp.org/nhhp/ consumerassistance.asp 16