Virginia medicaid battle


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Virginia medicaid battle

  1. 1. Health Insurance and You Virginia State Corporation Commission Bureau of Insurance This presentation is for general educational purposes only. Nothing in this presentation is intended to be an opinion, legal or otherwise, of the State Corporation Commission or the Bureau of Insurance, nor should it be construed as an endorsement of any product, service, person or organization mentioned in this presentation. 1
  2. 2. Objectives • • • • Overview of Virginia SCC/Bureau of Insurance Describe key provisions of recent health insurance changes Discuss coverage options/changes in 2014 Describe the Bureau’s role in Plan Management functions of the federal exchange (Health Insurance Marketplace in Virginia) • Describe how Bureau of Insurance can provide assistance • Other resources 2
  3. 3. Bureau of Insurance (BOI) The BOI licenses, regulates, reviews forms and rates for approval, investigates and examines insurance companies, agencies and agents on behalf of the citizens of the Commonwealth of Virginia. The BOI Insurance also registers, examines and investigates (title) real estate settlement agents and agencies. 3
  4. 4. BOI’s Regulatory Mission To ensure that citizens of the Commonwealth are provided with access to adequate and reliable insurance protection; that the companies selling insurance are financially sound to support payment of claims; that the agents selling insurance are qualified and conduct their business according to statutory and regulatory requirements, as well as acceptable standards of conduct; and that the insurance policies are of high quality, are understandable and are fairly priced. 4
  5. 5. Affordable Care Act (ACA) • Comprehensive federal health care law enacted on March 23, 2010 • Various provisions effective at differing dates • Various state laws were enacted to conform state law to a number of requirements within the ACA • Other nonconforming areas, such as operating the state’s health benefit exchange in Virginia, remain the sole province of the federal government 5
  6. 6. Current Virginia law • Lifetime dollar limits on essential health benefits (EHB) prohibited • Annual dollar limits on EHB restricted for most plans • Pre-existing condition exclusions for children under age 19 prohibited • Adult children can remain on parents’ health insurance policy until age 26 • Rescissions prohibited • Cost-sharing on preventive care eliminated • Selection of any available participating PCP; direct access to OB/Gyn care • New rules for internal appeals and external review Check for any exclusions and exceptions 6
  7. 7. What happens in 2014 • Generally, insurers must issue and continue in force to the consumer any plan purchased (guaranteed renewability) • Insurers may require the person to enroll during the initial open enrollment period set by the Health Insurance Marketplace or upon a special enrollment period • Pre-existing condition exclusions/denials prohibited • Annual dollar limits on EHB eliminated for most plans • Underwriting in individual and small group markets only by: • • • • Age (3:1) Tobacco Use (Up to 1.5:1) Family Size Geography (12 rating areas within Virginia) Check for any exclusions and exceptions 7
  8. 8. Essential Health Benefits (EHBs) • Virginia EHB Benchmark plan: • Anthem PPO KeyCare 30 • Plan with largest enrollment within product with largest enrollment • Medicaid CHIP (SMILES) plan – pediatric dental • Federal Employee Plan (FEP) Blue Vision plan for pediatric vision (default plan) • For further details on EHB requirements, visit: • Check for any exclusions and exceptions 8
  9. 9. Essential Health Benefits (EHBs) • In 2014, all new individual and small employer plans must cover EHBs, which must include at least these 10 categories: • • • • • • • • • • Ambulatory Patient Services Emergency Services Hospitalization Maternity and Newborn Care Mental Health and Substance Use Service Prescription Drugs Rehabilitative and Habilitative Services & Devices Laboratory Services Preventive & Wellness Services & Chronic Disease Management Pediatric Services (Oral* & Vision Care) • Prior to 2014, limits prohibited or restricted on categories as previously described Check for any exclusions and exceptions 9
  10. 10. Differences from the Benchmark Policy • 2014 market requirements • New preventive services for adults, women and children • Insurer may use different clinical review guidelines or medically necessary criteria • Routine adult vision benefits may be offered, but are not required • Medicaid CHIP (SMILES) plan covers cosmetic orthodontia, but not required for EHB Check for any exclusions and exceptions 10
  11. 11. Minimum Required Services/Visits (EHB) • Skilled nursing facility • 100 days per stay • Mental Health/Substance Use • no stated limit • Habilitative/Rehabilitative Services • 30 visits per calendar year combined for occupational/physical therapy; • 30 visits combined for speech therapy Check for any exclusions and exceptions 11
  12. 12. Minimum Required Services/Visits (EHB) (cont’d) • Private duty nursing • actuarial equivalent of $500 per calendar year or 16 hours per calendar year • Home health care services • 100 visits per calendar year • Chiropractic care/spinal manipulations • 30 visits per calendar year Check for any exclusions and exceptions 12
  13. 13. Minimum Required Services/Visits (EHB) (cont’d) • Pediatric oral and vision • Routine dental exam twice/year • One routine eye exam per year • One pair standard glasses or lenses per year • Early Intervention Services (birth – age 3) • $5,000 limit no longer applicable • Coverage for Prescription Drugs must include coverage of same number of drugs in each category and class as benchmark or 1, whichever is greater Check for any exclusions and exceptions 13
  14. 14. Effect of EHB on Virginia’s Mandated Offers • Section 38.2-3414 Obstetrical services mandated offer • Included in benchmark • Section 38.2-3418.15 Prosthetics mandated offer • Included in benchmark • Section 38.2-3418.3 Coverage for treatment of morbid obesity • Not included in benchmark • Must still be offered with each plan Check for any exclusions and exceptions 14
  15. 15. Out-of-Pocket Costs • There are limitations to the amount of total out-of-pocket expenses consumers must incur for EHBs • There are small group deductible limits for EHBs • All new individual and small group plans must fall into one of the following categories of cost-sharing (deductibles, copays, coinsurance): • • • • Bronze: covers 60% of costs Silver: covers 70% of costs Gold: covers 80% of costs Platinum: covers 90% of costs Check for any exclusions and exceptions 15
  16. 16. Levels of Coverage Metal Level (AV Level) Bronze Silver* Gold* Platinum Premium Cost Lowest Moderate Higher Highest Expected Insurer Cost 60% 70% 80% 90% Expected Consumer Cost 40% 30% 20% 10% Check for any exclusions and exceptions 16
  17. 17. Small Employers • Small Employers are not required to offer health insurance, but if they do they must offer coverage to all full-time employees • In Virginia, the small employer upper limit will remain at 50 employees 2014 and 2015. In 2016, the definition of a small employer will be up to 100 employees 17
  18. 18. Plan Management Review, Monitoring and Oversight Duties Bureau of Insurance Department of Health Licensed and in Good Standing Accreditation Requirements and Timeline Plans and Benefits (variations for cost- Network Adequacy sharing reductions) Essential Health Benefits Essential Community Providers Actuarial Value Standards Service Area Rates (new and increases) Program Attestations Meaningful Difference Marketing 18
  19. 19. Qualified Health Plan Certification • On July 31, the Bureau of Insurance recommended to the Health Insurance Marketplace for certification in Virginia, plans offered by: • 9 individual carriers and 6 small employer carriers • The Bureau also recommended for Exchange Certification Stand-Alone Dental Plans (SADPs) • 8 in the Individual and 13 in the Small Group Market (some for inside and outside the Health Insurance Marketplace; some for outside the Health Insurance Marketplace only) For more information: • aspx 19
  20. 20. Enrollment Periods Inside and Outside the Marketplace • Initial Open Enrollment Period:   October 1, 2013 – March 31, 2014 November 15 – December 15, 2013 (Small employers not meeting minimum participation and/or contribution requirements) • Subsequent Annual Open Enrollment Periods:   October 15 – December 7 November 15 – December 15 (small employer) • Special Enrollment Periods available throughout the year (3060 days) • Small Employer/Employee Enrollment anytime during the year if requirements met • Employer may have 90-day waiting period on eligibility for employee enrollment 20
  21. 21. Remember This • It is not required that you purchase coverage from the Health Insurance Marketplace • Coverage will be available outside the Health Insurance Marketplace • No law requires small employers to provide coverage • No law requires employer-based coverage to end 21
  22. 22. Assistance is Available • The Bureau of Insurance staff can: • Respond to insurance-related questions • Investigate your complaints regarding your insurance coverage • Provide tips to help you appeal a claim denial by your insurance company • Provide information on health care and alternative coverage options • Make appropriate referrals for issues outside our purview 22
  23. 23. Other consumer support • Agents can sell in the Health Insurance Marketplace in Virginia if they are licensed and certified • Agents may sell in the SHOP, but do not need to be certified by the federal government • Navigators receiving grants from each Marketplace will be available to educate consumers about coverage offered through the Health Insurance Marketplace and how to enroll; special requirement to provide information in a culturally and linguistically appropriate manner and accessible to people with disabilities • Other assistance personnel trained to educate consumers and explain the enrollment process • Health Insurance Marketplace and SHOP Call Centers • Website: 23
  24. 24. National Marketplace Toll-Free Call Center • A national call center will be used for all states with a Federally Facilitated or Partnership Marketplace • 1-800-318-2596 (TTY 1-855-889-4325) • Open 24/7 • English and Spanish with Language Line for other languages • SHOP call center for Employers: • 1-800-706-7893 (TTY users: 1-800-706-7915) • Monday through Friday, 9 a.m. to 5 p.m. EST • Also available to Agents and Brokers Questions related to operation of the Health Insurance Marketplace or SHOP 24
  25. 25. Helpful websites Bureau of Insurance Training materials U.S. Department of Labor/EBSA IRS ACA Tax Provisions Homepage U.S. Small Business Administration FAQs on ACA 25
  26. 26. Knowledge is Your Best Policy State Corporation Commission Bureau of Insurance Life & Health Division Mailing address: P.O. Box 1157 Richmond, VA 23218 Street address: 1300 E. Main Street Richmond, VA 23219 (877) 310-6560 Fax: (804) 371-9944 TDD/Voice (804) 371-9206 26