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__________________________________ Lisa Summers, CNM, DrPH Peter McMenamin, PhD Department of Nursing Practice & Policy.

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Presentation on theme: "__________________________________ Lisa Summers, CNM, DrPH Peter McMenamin, PhD Department of Nursing Practice & Policy."— Presentation transcript:

1 __________________________________ Lisa Summers, CNM, DrPH Peter McMenamin, PhD Department of Nursing Practice & Policy

2 THE CRITICAL ROLE OF NURSES & NURSING State Health Insurance Exchanges:

3 Acknowledgement Laura Brennaman, MSN, RN, CEN Doctoral Fellow RWJF Nursing & Health Policy Collaborative University of New Mexico

4 Overview State Health Insurance Exchanges 101 – What are they? – Why should you be engaged? Stories from the States – Colorado – Maryland – Mississippi Questions and Discussion

5 Presidents address June 28, 2012 if youre one of the 30 million Americans who dont yet have health insurance, starting in 2014 this law will offer you an array of quality, affordable, private health insurance plans to choose from. Each state will take the lead in designing their own menu of options…

6 Once states set up these health insurance marketplaces, known as exchanges, insurance companies will no longer be able to discriminate against any American with a preexisting health condition. They wont be able to charge you more just because youre a woman. They wont be able to bill you into bankruptcy. If youre sick, youll finally have the same chance to get quality, affordable health care as everyone else. And if you cant afford the premiums, you'll receive a credit that helps pay for it.

7 What is an Exchange? Portals for individuals & small businesses to buy affordable & qualified health plans. Intended to: – Enhance competition in the health insurance market – Improve choice of affordable health insurance to individuals – Give small businesses the same purchasing clout as large businesses.

8 Timeline for Exchanges Federal government will assess states readiness to operate Exchanges January 2013 Scheduled to start open enrollments in October 2013. Insurance effective dates beginning January 1, 2014.

9 Consumer assistance tools Toll-free call center In plain language That are accessible and timely manner interpretive services for people who have limited English proficiency Up-to-date website standardized comparison of all qualified health plans

10 Essential Health Benefits Package Ambulatory patient services Emergency services Hospitalization Maternity & newborn care Mental health & substance use disorder services, including behavioral health treatment Prescription drugs Rehabilitative & habilitative services & devices Laboratory services Preventive & wellness services & chronic disease management Pediatric services, including oral & vision care

11 Plan Levels & Cost Sharing Insurers contribute 60% of costs of EHBP for Bronze plans 70% of costs of EHBP for Silver plans 80% of costs of EHBP for Gold plans 90% of costs of EHBP for Platinum plans

12 Comparing Plan Value in the Exchange Consumers want it to be easy to compare premiums and benefits covered. Premium costs comparison Standardized actuarial rating (metal level) Quality ratings by accreditation agencies Medical loss ratios Up-to-date provider directories

13 Medical Loss Ratio (MLR) The MLR requirement is 80% for plans sold inside the Exchange

14 Navigators Assist Exchange users to select a health plan Conduct public education activities to raise awareness about the Exchange Refer complaints or problems to appropriate agencies for resolution.

15 Seamless Streamlined Process one-stop shopping where people with lower and moderate incomes can learn if they qualify for - Medicaid CHIP benefits Premium subsidies Tax credits for eligible small benefits

16 ANA Advocacy APRNs should recognized as primary care providers in qualified plans Nurse Managed Health Clinics, School-Based Health Clinics, and Free Standing Birth Centers should be Essential Community Providers APRNs should be team leaders in Patient Centered Medical Homes Nurses should be on the governing boards of State Health Insurance Exchanges

17 Progress on Exchange Development From Kaiser Family Foundation Updated April 13, 2012

18 Network Adequacy Offers sufficient choice of providers in-network and out-of-network while assuring reasonable access to quality primary and specialty care. The National Association of Insurance Commissioners (NAIC) Model Act for network adequacy includes all types of licensed health care professionals, including APRNs. CMS affirms the network must assure that all services will be available without unreasonable delay

19 APRNs Provide Essential Benefits Ambulatory Services Maternity & Newborn Care Services during Hospitalizations Chronic disease management Mental health & substance use disorder services All four APRN roles need to be included in health Exchanges

20 Essential Community Providers Essential community providers are those healthcare delivery providers that serve predominantly low-income, medically underserved individuals. They are to be included in qualified plan networks as long as the provider accepts the generally applicable payment rates of the plan.

21 Essential Community Providers Should include Nurse-managed health centers School-based health centers Freestanding birth centers

22 Provider Directories Should list all credentialed providers Online version Print version

23 ADVOCACY AT THE STATE LEVEL Nurses and state associations will need to monitor the evolvement of Exchanges in their states to deliver the evidence of quality, improved access, and cost saving available through APRN directed primary care

24 Resources ANA Issue Brief, State Insurance Exchanges: The Critical Role of Nurses and Nursing is available on line. exchanges It includes links to good sites for keeping abreast of developments. Upcoming HHS Forums (email invitation 7/17)

25 Stories from the States Colorado Fran Ricker, Executive Director, Policy Director and Lobbyist, Colorado Nurses Association Maryland Robyn Elliot, Lobbyist, Maryland Nurses Association Mississippi Teresa Malone, Executive Director, Mississippi Nurses Association

26 For more information:

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