1. Health Reform 2010: R OLE OF H EALTH I NSURANCE E XCHANGES December 9, 2010 Jennifer Cooper Legislative Director, National Indian Health Board (JCooper@NIHB.org) Doneg McDonough Consultant to National Indian Health Board (DMcDonough@NIHB.org)

2. NIHB Comments to OCIIO on Exchanges The National Indian Health Board (NIHB) submitted detailed comments to the HHS Office of Consumer Information and Insurance Oversight (OCIIO) on October 4, 2010  http://www.nihb.org/indianhealthreform/docs/12082010/4_6_NIHB%20response_Exchange.pdf http://www.nihb.org/indianhealthreform/docs/12082010/4_6_NIHB%20response_Exchange.pdf In response to the OCIIO / Indian Health Service (IHS) November 12 letter initiating Tribal consultation on Exchange standards, NIHB is preparing additional comments to OCIIO/IHS Tribes and other organizations are encouraged to provide comments to OCIIO/IHS by December 31, 2010 2

3. Key Exchange-related Issues for AI/AN Need for on-going Tribal consultations by Federal and State governments on Exchange standards and operations Need uniform definition of “Indian” to effectively implement the AI/AN cost-sharing protections and the exemption from the requirement to purchase coverage Establish standards for “qualified” health plans requiring I/T/U inclusion in health plan provider networks Establish mechanism to permit group payment of premiums by Tribal sponsors to health plans offered through an Exchange Create a mechanism (such as an “Indian Addendum”) to inform and enforce Federal requirements specific to Indian Country 3

4. Key AI/AN-specific provisions Indian-Specific Exchange Provisions AI/AN Enrollees: AI/AN at or below 300% FPL will have no cost-sharing under a plan offered through an Exchange Providers Serving AI/AN: Providers serving AI/AN will receive full payment (including cost-sharing amount) from Exchange-offered plans Plans Serving AI/AN: Health plans serving AI/AN and offered through an Exchange will receive an additional payment from HHS to compensate for the elimination of cost-sharing by AI/AN enrollees Indian-Specific Provisions under All Plans I/T/U Clients: No cost-sharing by AI/AN clients for services provided by IHS, Tribal or urban Indian program, or CHS I/T/U Providers: All I/T/U providers are able to bill all health plans for reimbursement for services rendered to AI/AN 4

5. Primary Functions of Exchanges Section 1311(d)(2) of ACA*  IN GENERAL.—An Exchange shall make available qualified health plans to qualified individuals and qualified employers. Functions of Exchanges  Certify health plans that are available through an Exchange  Provide information on health plan options to enrollees  Facilitate selection and enrollment in a health plan  Determine eligibility for the premium and cost-sharing assistance for enrollees  Conduct risk adjustment function across plans *ACA refers to the Patient Protection and Affordable Care Act of 2010 5

6. Why is accessing an Exchange important? As with the general population, under the ACA premium and cost-sharing protections for AI/AN are available only for AI/AN –  who are enrolled in the individual market (i.e., non-employer sponsored coverage) in an Exchange  who have household income of not more than 400 percent of the federal poverty level For AI/AN with household income of not more than 300 percent of the federal poverty level, “the issuer of the plan shall eliminate any cost-sharing under the plan” Also, Exchanges hold out a potential for greater competition and choice in the health insurance market 6

7. Eligibility Thresholds for Assistance through an Exchange Federal poverty level thresholds 7

8. Premium Protections through an Exchange 8 General enrollee premium protections (annual)

9. Cost-sharing Protections through an Exchange 9 General enrollee cost-sharing protections (annual)

10. Value of Premium and Cost-sharing Assistance through an Exchange 10

11. Only “Qualified” Health Plans to be Offered through an Exchange The Secretary of HHS is to establish criteria for the certification of qualified health plans Three of the requirements for “qualified” health plans to be offered through an Exchange (under ACA Section 1311(c)(1)) are --  (A) meet marketing requirements  (B) ensure sufficient choice of providers  (C) include within health insurance plan networks those essential community providers, where available, that serve predominantly low-income medically- underserved individuals Access to I/T/U (Indian Health Service, Tribes and Tribal Organizations, and urban Indian organization) providers through health plans offered through an Exchange is essential  The NIHB recommends that health plans be required as a condition of being certified as a “qualified” health plan to include I/T/U providers in networks 11

12. Access to an Exchange by “Qualified” Individuals Individuals without access to “affordable” employer-sponsored coverage may enroll in an Exchange  “Unaffordable” is defined as requiring an individual to spend more than 9.5% of income on premiums for employer-sponsored coverage –Employer-sponsored health plan to have at least a 60 percent actuarial value (i.e., plan covers at least 60 percent of average health care costs)  These individuals would be eligible for premium and cost-sharing assistance through an Exchange Wyden Provision: Individuals with income below 400% of poverty level can enroll through an Exchange if they would have to spend more than 8% of income on premiums for an employer-sponsored plan  These individuals would NOT be eligible for premium and cost-sharing assistance in Exchange 12

13. “Qualified” Employers Can Purchase Coverage for Employees through an Exchange Access to the Exchanges is phased-in for employers, beginning with employers with up to 100 employees (or 50 employees at state option) in 2014 States may operate a separate “SHOP” Exchange for employers or combine it with the individual market For Tribal employers, the new Section 409 of the Indian Health Care Improvement Act provides a pre-2014 Exchange-like option through the Federal Employees Health Benefits Program 13

14. Requirements on Employers Tribal governments are NOT exempt from the employer requirements  Most of the employer requirements take effect Jan. 1, 2014 Employers with fewer than 50 full-time equivalent (FTE) employees are exempt from most requirements Employers with more than 50 FTE are required to either --  Offer “affordable” coverage or  Make per employee payments to an Exchange –No payments are required for part-time employees (average < 30 hours per week) 14

15. Employer’s Decision Impacts an Individuals Access to an Exchange For employers subject to employer requirements (50+ FTE) – Employer offers “affordable” coverage  Plan covers at least 60% of expected costs (60% actuarial value)  Employee’s share of premium is not more than 9.5% of income Employer does not offer coverage  Pays $2,000 to Exchange for every full-time employee beyond the first 30 full-time employees Employer offers coverage deemed “unaffordable” to some  Plan does not cover 60% of expected costs and/or employee’s share of premium is more than 9.5% of income  Employer pays $3,000 per employee enrolling through Exchange 15

16. Exchange is Anticipated to Play a Central Role in Reducing Number of Uninsured Nationally, number of uninsured to drop by more than half 16

17. For AI/AN today, roughly 1/3 do not have comprehensive health insurance coverage For AI/AN, 16% have no insurance and another 16% have only IHS * Source: Race, Ethnicity and Health Care, “A Profile of American Indians and Alaska Natives and Their Health Coverage”, Kaiser Family Foundation, September 2009. Figures may exceed 100% due to rounding. 17

18. Most Uninsured AI/AN to Benefit from Premium and Cost-Sharing Protections Uninsured AI/AN are primarily lower-income 18 * Source: Race, Ethnicity and Health Care, “A Profile of American Indians and Alaska Natives and Their Health Coverage”, Kaiser Family Foundation, September 2009