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The Federal Health Insurance Marketplace February 27, 2014 John Rogers Manager, Self-Pay Services RevCare, Inc.

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Presentation on theme: "The Federal Health Insurance Marketplace February 27, 2014 John Rogers Manager, Self-Pay Services RevCare, Inc."— Presentation transcript:

1 The Federal Health Insurance Marketplace February 27, 2014 John Rogers Manager, Self-Pay Services RevCare, Inc.

2 2 Federal Marketplace

3 Ohio’s Federal Health Insurance Marketplace Ohio and 36 other states did not build a state exchange, deferring to the Marketplace for individuals/families, and a Federal Small Group Health Options Program (SHOP) marketplace for employer groups of 50 and under. (SHOP enrollment delayed until November 2014.) These two exchanges will operate separately and with different risk pools. Ohio Marketplace is accessed at Ohio Department of Insurance (ODI) regulates and manages state plan participation. 15 Ohio payer applied to ODI to offer 200+ plans through exchange. ODI reviewed plan rates and readiness in July. 12 plans approved and operating in 2014. FFE Open enrollment: October 1 st, 2013 through March 31, 2014. Plans effective January 1 st, 2014. Next open enrollment is November 15, 2014 through January 15, 2015. Enrollment primarily facilitated by consortia of community organizations called “Navigators”, approved and funded by CMS for 12-month periods. Navigators are responsible for outreach, education, and assistance with plan selection and enrollment. Ohio’s share of Navigator funds was $2.6M ($54M available nationally). “Certified Application Counselors” (CAC), designated and trained by CMS, can also facilitate enrollment. Exchange provides subsidized insurance options from 100-400% of FPL, most coverage begins at 138%. Subsidies in form of advanced tax credits and premium subsidy. 138% and under are assessed Medicaid eligible by Marketplace and application data forwarded to ODM. Per ODM, 106,000 Ohio Medicaid assessments are backlogged in, and are being triaged and distributed to ODJFS offices statewide this week. 3

4 4 Source: Enroll America, 2013

5 Ohio Navigators for 2013-14 Ohio Association of Foodbanks (as“OhioForHeath”) Ohio Association of Free Clinics Cuyahoga Health Access Partnership Carmella Rose Health Foundation Toledo/Lucas County CareNet Community Access Program Corporation Community Action Committee of Pike County Clermont Recovery Center, Inc. Helping Hands Community Outreach Center Neighborhood Health Association Source: Ohio Department of Insurance, 2014. 5

6 Ohio Medicaid Expansion: Legislative Timeline Patient Protection and Affordable Care Act (ACA) signed into law by President Obama on March 23, 2010. Upheld by USSC on June 28, 2012, but mandatory state Medicaid expansion ruled unconstitutional. Governor Kasich backs Medicaid expansion in his proposed budget on February 4, 2013. April 2013: State House strips Medicaid expansion from budget before sending to Senate. May 5, 2013: State legislative subcommittees begin exploring alternatives to expansion, but make little progress. May 7, 2013: Ohio Hospital Association indicates a ballot proposal for expansion is being developed for November 2014. (Current polls show 60% of Ohioans favor expansion.) May 22, 2013: State Representative Barbara Sears (R-Monclova) introduces bill proposing expansion to 138% of FPG, per ACA, but fails to gain party support. June 30, 2013: 2014-2015 State Budget signed by Gov. Kasich, with no provision for Medicaid Expansion after House and Senate fail to bring any bill to a vote. July 30, 2013: State Senator Capri Cafaro (D-Hubbard), introduces expansion/reform bill with input from bipartisan subcommittees; expands Medicaid to 138% FPG, includes workforce development and new oversight body. “Circuit breaker” provision rolls back expansion if federal funding is withdrawn in out-years. October 21, 2013: State Controlling Board votes 5-2 to approve appropriation of $2.56B in additional federal Medicaid funds for expansion of coverage up to 138% of FPG (275,000 individuals). December 20, 2013: Ohio Supreme Court upholds Controlling Board decision to expand Medicaid January 1, 2014: Newly extended Medicaid eligibility guidelines go into effect. 6

7 With expansion, Federal Government to pay 90-100% of benefits for newly eligible Medicaid recipients. Currently pays 63%. 7 Source: Partnership of Regional Economic Models, Inc., the Urban Institute, Ohio State University, and Health Policy Institute of Ohio, 2013

8 Medicaid expansion raises the income limits for these groups to 138% of FPL (MAGI), providing some form of Exchange or Medicaid eligibility for all groups under 400% of FPL. Without expansion, these groups would still have a coverage gap until 100% of FPL, and only qualify for HCAP. 8 Source: Health Policy Institute of Ohio, 2013

9 Eligibility Requirements for Marketplace QHP Enrollment US Citizen, qualified alien, or LPR Not incarcerated No existing access to affordable, minimum essential coverage (affordability defined as 8% max of gross household income) Live in plan area 9

10 Open Enrollment and Qualifying Events Open enrollment: October 1 st, 2013 through March 31, 2014. Plans effective January 1 st, 2014. Next proposed open enrollment is November 15, 2014 through January 15, 2015. Individuals may enroll outside open enrollment within 60 days of qualifying event:  Lost coverage at work (or other) health coverage  Gained or became a dependent through marriage, birth, adoption, or placement for adoption  Contract errors by insurance company  Change in eligibility for financial assistance  Relocation outside coverage area 10

11 Individual Mandate Most American households are required to have minimum essential coverage for all members by March 31, 2014, or face the higher of these two tax penalties. 2014: $95 per person for the year ($47.50 per child under 18). $285 max. 1% of annual household income over the tax filing threshold. 2015: 2% of income or $325 per person (minors assessed at 50%) 2016: 2.5% of income or $695 per person (minors assessed at 50%) 2017: 2.5%, adjusted for inflation (minors assessed at 50%) Max annual household penalty is 300% of the minimum penalty for that year, e.g., max penalty for 2016 would be $695 X 3.0 = $2085. Total penalty for tax year cannot exceed national average of bronze plan annual premiums. If uninsured for part of the year, 1/12 of the yearly penalty applies to each uninsured month. If uninsured for less than 3 months, there is no penalty. Source:; CMS, 2014

12 Exemptions to Individual Mandate and Tax Penalty Hardship (economic or circumstantial) Uninsured less than 3 months of the year Below 133% FPG Below tax filing threshold Lack of Affordable Coverage (8% standard) Religious Conscience Federally recognized tribe or eligible for Indian Health Services Health Care Sharing Ministry Incarceration Not lawfully present Existing plan cancelled due to ACA All told, an estimated 26 million Americans are exempt. Source:; CMS, 2014

13 QHP Premium Grace Period 13 Source: ECG Management Consultants, 2013

14 Requirements for Qualified Health Plans (QHP) Be licensed and in good standing with state Offer plans that fall within the bronze, silver, gold, platinum or catastrophic cost-sharing tiers Offer at least one silver and one gold QHP through the marketplace Meet Essential Health Benefits (EHB) standard by providing comprehensive package of covered services Meet provider network standards: Essential Community Providers (ECP) Limit out-of-pocket to $6,350 (individual) and $12,700 (family) for 2014 CMS guidance of February 7 th indicates hospitals may be able to subsidize patient QHP policies through private not-for-profit foundations. 14

15 QHP Precious Metal Tiers Bronze: 40% consumer cost share (deductibles and other cost shares)* Silver: 30% consumer cost share (deductibles and other cost shares)** Gold: 20% consumer cost share (deductibles and other cost shares) Platinum: 10% consumer cost share (deductibles and other cost shares) Catastrophic: (Under age 30, minimum coverage, no subsidy, does not meet actuarial value standards of “precious metal” tiers) * Average cost share per life ** Silver plans are the Marketplace standard to which subsidy levels are pegged, and cannot exceed 9.5% of gross household income for families under 400% FPG. 15

16 Payers in Ohio’s Federal Marketplace 1)Community (Anthem) 2)AultCare 3)Buckeye Community Health Plan 4)CareSource 5)Coventry 6)HealthSpan 7)Humana Health Plan of Ohio 8)Kaiser 9)Medical Health Insuring Corporation of Ohio 10)Molina 11)Paramount 12)SummaCare Source: Ohio Department of Insurance, 2014. This list comprises Marketplace plans only. There are additional payers offering QHPs outside the marketplace. 16

17 Marketplace Enrollment Trends: 10/1/13 through 2/1/14 53% increase in total Marketplace plan selections in January 62% increase in plan selections for Federally Facilitated Marketplaces 3,299,500 total enrollment to date 3.2M Medicaid/CHIP determinations through Marketplace 55% female,45% male 53% age 45-64 25% age 18-34 82% selected plan with Financial Assistance 72% of FFM enrollees selected silver plan, 93% of FFM silver plan enrollees selected plan with financial assistance 17 Source: CMS, 2014

18 Ohio Enrollment Trends 10/1/13 through 2/1/14 Total Eligible to Enroll in a QHP: 159,694* Total Eligible to Enroll in a QHP with financial assistance: 91,285 Total assessed eligible for Medicaid by Marketplace: 78,575 (Per CMS, as compared to Ohio Department of Medicaid estimate of 106,000) Total number of QHP selections (not Medicaid): 60,122, or 37% of total eligible applicants from 10/1/13 through 2/1/14 *Represents the total number of individuals for whom a completed Marketplace application has been received and who are determined eligible for a plan selection. 18 Source: CMS, 2014

19 Marketplace Enrollment Trends: 10/1/13 through 2/1/14 19 Source: CMS, 2014

20 Marketplace Enrollment Trends: 10/1/13 through 2/1/14 20 Source: CMS, 2014

21 21 Source: CMS, 2014 Marketplace Enrollment Trends: 10/1/13 through 2/1/14

22 QHP Premium Grace Period 22 Source: CMS, 2014

23 23 Source: CMS, 2014 Ohio Metal Selection by Gender: Females: 59% Silver, 21% Bronze Males: 56% Silver, 22% Bronze Total: 58% Silver, 21% Bronze (79%) National: 62% Silver, 19% Bronze (81%)

24 Bronze and Silver Plans in Northeastern Ohio 24 Buckeye: “Ambetter” Anthem: “Direct Access” Aultcare: “Silver”,“Bronze” CareSource: “Just4me” SummaCare: “SummaCare Individual” Kaiser: “KP Silver”,“KP Bronze” Molina: “Molina Marketplace” Paramount”: “Paramount HMO [Silver]” HealthSpan: “HealthSpanOne” HealthAmerica One: “Silver”,“Bronze” Silver and Bronze QHPs in Northeastern Ohio (with Marketplace plan names) Source: CMS/HHS;

25 25 HHS/CMS QHP databases Site search term: QHP landscape

26 Average QHP Premiums (National) 26 Source: HHS, 2014

27 27 Source: CMS, 2014

28 Cost of Coverage, including Financial Assistance: Up to 133% of poverty: 2% of income toward premiums 133 - 150% of poverty: 3 - 4% of income toward premiums 150 - 200% of poverty: 4 - 6.3% of income toward premiums 200 - 250% of poverty: 6.3 - 8.05% of income toward premiums 250 - 300% of poverty: 8.05 - 9.5% of income towards premiums 300 - 400% of poverty: 9.5% of income towards premiums 28 Source: Stack, Shawn; Wexner Medical Center, Ohio State University, 2013

29 Ongoing Enrollment Challenges Initial Marketplace bugs: account creation, datahub issues Capacity issues (CMS intends February capacity increase from 25,000- 50,000 simultaneous users) Medicaid eligibility determination issues: Per ODM, Marketplace assessment data to state has been unreliable Marketplace-to-state data transfer issues Enrollment figures not accounting for unbound coverage (some insurers reporting up to 30% of first month premiums unpaid) Appeals and exemption processing errors Enrollment target of 7 million unlikely to be met, current enrollment at 75% of Month 4 target, 5-6 million likely at current rate. Heightened political pressure: calls for IM delay, ACA repeal 29

30 Learn more about RevCare’s Eligibility Solutions at Get the latest healthcare news at 30 John Rogers Manager, Self-pay Services RevCare, Inc. 3250 West Market St. | Suite 304 | Akron, OH 44333 (office) 330.873.1820| (toll free) 800.837.3328 x153

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