Temporary High Risk Insurance Pool Program Section 1101 of the Patient Protection and Affordable Care Act Troy Oechsner Deputy Superintendent New York State Insurance Department United Hospital Fund Roundtable April 23, 2010

High Risk Pool Timetable Establishment. The Secretary of HHS must establish a high risk pool program within 90 days of enactment (June 21). Establishment. The Secretary of HHS must establish a high risk pool program within 90 days of enactment (June 21). Letter of Intent. States must submit a letter of intent to the Secretary of HHS by April 30th to be eligible to receive federal funding. Letter of Intent. States must submit a letter of intent to the Secretary of HHS by April 30th to be eligible to receive federal funding.

High Risk Pool Timetable (continued) RFP. HHS will set out a request for proposals detailing specific requirements for state high risk pools (about May 1). RFP. HHS will set out a request for proposals detailing specific requirements for state high risk pools (about May 1). State Proposal. In response to RFP, states will submit a specific proposal (flexible deadline, first come first serve, through summer). State Proposal. In response to RFP, states will submit a specific proposal (flexible deadline, first come first serve, through summer).

HHS Guidance Letter to states (April 2) Letter to states (April 2) Call with NY Dept. of Insurance (April 13) Call with NY Dept. of Insurance (April 13) s (ongoing) s (ongoing) Call with all states (April 22) Call with all states (April 22)

Other Outreach NY State Agencies NY State Agencies Other States Other States Stakeholders Stakeholders

Implementation Considerations The Secretary may contract with states or nonprofits. If a state is not going to establish a high risk pool, the Secretary must establish a high risk pool within the state. The Secretary may contract with states or nonprofits. If a state is not going to establish a high risk pool, the Secretary must establish a high risk pool within the state. States must maintain the current levels of funding (if any) for established high risk pools. States must maintain the current levels of funding (if any) for established high risk pools.

Considerations Purpose Purpose Insure the uninsured Insure the uninsured Insure high risk people in need Insure high risk people in need Statewide or Regional Statewide or Regional Risk: At Risk or Not Risk: At Risk or Not

Considerations Care Management Features Care Management Features Provider network Provider network Medical management Medical management Benefit Package Benefit Package One or more One or more Comprehensiveness/actuarial value Comprehensiveness/actuarial value Reach the uninsured Reach the uninsured Do no harm to existing markets Do no harm to existing markets

Considerations Pricing Lower rates Lower rates Better risk pool/reach more people? Better risk pool/reach more people? More funding per head/hit enrollment cap More funding per head/hit enrollment cap Higher rates Higher rates Impact on risk pool Impact on risk pool Affordability Affordability Less funds per head/ensure availability of program Less funds per head/ensure availability of program

Considerations Eligibility: How Flexible on Criteria? Pre-existing condition Pre-existing condition Strict vs. expansive Strict vs. expansive Crowd out Crowd out Purpose Purpose Exceptions? Exceptions? Migration of DP risk? Migration of DP risk? Citizenship: What does “legally present” mean? Citizenship: What does “legally present” mean? Standard Standard Proofs Proofs

Considerations Funding Funding Must strike balance Helping the most people Helping the most people Helping those most in need Helping those most in need Reallocation of Funds in Two Years Reallocation of Funds in Two Years Unspent funds at risk Transition to Insurance Exchange Transition to Insurance Exchange

Some Basic Options (with many variations) 1. Existing DP: Apply funds to existing Direct Pay market 2. New HRP: Develop a new state-run risk pool for eligible New Yorkers 3. New DP Product. Apply funds to new direct- pay product for eligible individuals 4. FHP. Put funds into Family Health Plus Buy-In 5. Do Nothing. Let HHS establish