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Introduction to Health Insurance Exchanges. Affordable Care Act (ACA) Insurance Reforms – No lifetime limits, annual limits – Pre-existing conditions.

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Presentation on theme: "Introduction to Health Insurance Exchanges. Affordable Care Act (ACA) Insurance Reforms – No lifetime limits, annual limits – Pre-existing conditions."— Presentation transcript:

1 Introduction to Health Insurance Exchanges


3 Affordable Care Act (ACA) Insurance Reforms – No lifetime limits, annual limits – Pre-existing conditions Medicaid Expansion Health Insurance Exchanges – Individuals – Small businesses Medicare Part D “donut hole” changes Quality, Prevention, Innovation Health Care Workforce Indian Health Care Improvement Act – Title X, Subtitle B, Part III, Sec. 10221

4 Remove barriers Insurance reform Medicaid expansion Create market structure (Exchanges) Risk reduction for insurance companies Carrots Federal premium assistance for individuals Federal tax credits for businesses <25 employees Sticks Tax penalty for uninsured “Individual mandate” - AI/AN are exempt Business with >50 employee Fined $2,000/person over 30 people

5 What is Health Insurance Exchange? Consumers and businesses can compare insurance plans and purchase Federal subsidies of premiums Enrollment in Medicaid, CHIP, Basic Health Plan (if available) Web based approach State or federal exchanges Operational by January 1, 2014

6 All plans: same Essential Health Benefits Plans may differ: Networks of providers Cost of premiums, co-pays and deductibles Actuarial values of plans equal within metallic categories Bronze – 60% actuarial value Silver – 70% actuarial value Gold – 80% actuarial value Platinum – 90% actuarial value

7 Select Qualified Health Plans (QHP) Enrollment Determine individual eligibility Enroll people in QHPs Contract with Navigators Call centers Financial management Premiums Tax Credits Cost Sharing Risk adjustments

8 New source of funding Covers adults < 65 Premium assistance Up to 400% FPL I/T/U can bill plan Shift CHS costs to plans Medicaid Expansion Up to 133% FPL Assets not counted Covers all adults Enroll through Exchanges


10 Exempt from penalty for being uninsured Exempt from most cost sharing in Exchange Plans Cost sharing = deductible + co-pay Federal government pays cost sharing to Plans Able to enroll monthly

11 No deductibles ever No cost sharing ever for people served in I/T/U I/T/U collects 100% of charges from plan No cost sharing in private sector for AI/AN with referral from I/T/U CHS does not pay any portion of care covered by plan For AI/AN below 300% FPL, no cost sharing in private sector without referral from I/T/U.

12 AI/AN have same premium subsidies as everyone else in Exchanges Based on Modified Adjusted Gross Income (MAGI) Sliding scale up to 400% FPL (96%-35%) Silver level is benchmark Advanced tax credits Paid to insurance company Reconciliation at end of year

13 2011 HHS Poverty Guidelines Persons in Family 48 Contiguous States and D.C.AlaskaHawaii 1$11,170$13,970$12,860 2 15,130 18,920 17,410 3 19,090 23,870 21,960 4 23,050 28,820 26,510 5 27,010 33,770 31,060 6 30,970 38,720 35,610 7 34,930 43,670 40,160 8 38,890 48,620 44,710 For each additional person, add 3,960 4,950 4,550

14 Annual Federal Subsidy of Health Insurance Premiums by Income Level for Individuals % FPL Premium Limit as % Income Individual Premium (Tribal Sponsorship) 138-1502%< $690 151-2003-4%$1,037 201-2504-6.3%$1,875 251-3006.3-8.05%$2,776 301-4008.05-9.5%$3,391-$4,099

15 Tribe pays 2% of premium for individual below 150% FPL with high cost medical needs. Tribal Sponsorship is $690 per year. Tribe collects payments from plan for all visits and medications provided to individual. No cost to CHS for specialty medical care and hospital services. More money is available to provide more services for all Tribal members.


17 Premium Tribal sponsorship can eliminate barrier Basic Health Plan can eliminate barrier IRS rules and regulations Advanced tax credits + reconciliation No enrollment for non-filers Complex rules Basic Health Plan can eliminate barrier Lack of insurance experience, knowledge No motivation to enroll Federal and State Exchange regulations

18 Federal TribalState

19 Regulations issued by two agencies CMS, Center for Consumer Information and Insurance Oversight (CCIIO) Department of Treasury, IRS Federal government is deferring to States to give them flexibility. National Tribal Participation NIHB, MMPC, TTAG, NCAI, TSGAC

20 Establishment of Exchanges and QHPs Standards Related to Reinsurance, Risk Corridors and Risk Adjustment Health Insurance Premium Tax Credit Exchange Functions: Eligibility Determinations, Employer Standards Medicaid Eligibility Changes under the ACA Essential Health Benefits Actuarial Values

21 Federal payment of cost sharing for AI/AN Tax penalties for individuals, businesses Basic Health Program Standards for Oversight of Quality and Reporting

22 Laws, Executive Orders to Establish Exchanges Federal Exchange Establishment Grants Health Insurance Commissioners Medicaid, CHIP, Basic Health Plans Tribal Consultation Letter from HHS Secretary to State Governors

23 Designate individual or team to become informed about ACA and Exchanges Advocacy at State and Federal levels Participate in Exchange planning for State Tribal planning and budgeting Premium payments Provider contracts Outreach and enrollment assistance Communications plan

24 Key Dates January 1, 2013 – HHS decides whether state is ready to operate an Exchange October 15, 2013- First open enrollment period starts for Exchanges January 1, 2014 – QHPs start offering services through the Exchange


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