Robert E Goff
• Small business
tax credit
• Prohibitions
against lifetime
benefit caps &
rescissions
• Phased-in ban
on annual limits
• Annual review of
premium
increases
• Public reporting
by insurers on
share of
premiums spent
on non-medical
costs
• Preventive
services
coverage without
cost-sharing
• Young adults on
parents’ plans
2010
• State insurance
exchanges
• Medicaid expansion
• Small business tax
•Phased-in ban on annual limits
credit increases
• Insurance market
reforms including no
•States adopt exchange legislation and
rating on health
begin implementing exchanges
• Essential benefit
standard
• Premium and cost
• Penalty for individual
• Insurers must
sharing credits for
requirement to have
spend at least 85% • HHS must
exchange plans
insurance phases in
determine if
of premiums (large
•
Premium
increases
a
(2014-2016)
states will have
group) or 80%
criteria
for
carrier
• Option for state
operational
(small group /
exchange
waiver to design
exchanges by
individual) on
participation
alternative coverage
2014; if not,
medical costs or
programs (2017)
HHS will operate • Individual requirement
provide rebates to
to
have
insurance
them
enrollees
• Employer shared
responsibility
penalties
2011
2013
2014
Source: Commonwealth Fund Analysis of the The Affordable Care Act (Public Law 111-148 and 111-152).
2015-2017
2014
The Year of the Health Insurance
Exchanges

Simply put:
 Health Insurance products, different benefit
packages, different plans available for purchase at
a single “market”
 Two markets
▪ Small Business Health Options Program (SHOP) 50 or
less
▪ Individual Market


No pre-existing condition restrictions
Subsidies based on income available
http://www.nystateofhealth.ny.gov/PlansMap
6
Who is offering in the NY HIX?
Dental Plans
http://www.nystateofhealth.ny.gov/PlansMap
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1.
Ambulatory patient services
2.
Emergency room services
3.
Hospitalization
4.
Maternity and newborn care
5.
Mental health and substance abuse disorders
6.
Prescription drugs
7.
Rehabilitation and habilitation services and devices
8.
Laboratory services
9.
Preventive and wellness services and chronic disease management
10.
Pediatric services, including oral and vision
SAMPL
E
What is being offered
Platinum, Gold, Silver,
Bronze
Exchange Responsibilities
Only Available in Exchanges
• Subsidies for individuals from 133%-400% of FPL
• Small employer tax credits
Exchange Functions
Operate a toll-free telephone hotline to help users
Enroll applicants in their chosen plan
Maintain a website to sell plans
Work with federal and state agencies regarding subsidies
and tax credits
Enroll eligible individuals into Medicaid
Set annual Open Enrollment Period and special Enrollment Periods
Certify and rate plans
11

Organized marketplace
 One-stop shopping for subsidized and unsubsidized coverage
 Easily compare health plan options
 The only place to check eligibility and apply for financial
assistance
 Enroll in qualified health plans

Two programs
 Individual Marketplace
 Small Business Marketplace
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Health Plan Marketplace enrollment is estimated to be
1.1 million New Yorkers
Individual Marketplace
(58%)
450,000
615,000
Small Business
Marketplace (42%)
13

Open Enrollment begins on October 1

Individuals may enroll in health plans during open
enrollment October 1, 2013 - March 31, 2014) or
with a qualifying event

Individuals who qualify for Medicaid/CHP may enroll
any month of the year

Small employers may choose open enrollment dates
for their employees any month of the year
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
Assistance available in over 170 languages
 Many staff will be bilingual and oral interpretation
available for remaining languages.
•

Will take applications over the phone starting in October
Can refer to in-person assistors
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IPA/Navigators
• Complete Applications
• Compensation from DOH grant program
• Training and certification required
• Serve Individuals and Small Business Marketplace
Insurance
Brokers/Agents
• Complete Applications
• Commission-based compensation
• Training and certification required
• Choose to certify in Small Business Marketplace, Individual, or
both
Certified
Application
Counselors
• Complete Applications
• No compensation from Marketplace
• Training and certification required
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Individual Responsibility
•
Jan. 1, 2014: Individuals must enroll in
coverage or pay a tax penalty
Penalty amount:
•
Greater of $ amount or a % of income
– 2014 = $95 or 1%
– 2015 = $325 or 2%
– 2016 = $695 or 2.5%
– Family penalty capped at 300% of the adult flat dollar
penalty or “bronze” level premium
Family Responsibility
Penalty amount:
Greater of $ amount or a % of income
– 2014 = $285 or 1%
– 2015 = $975 or 2%
– 2016 = $2,085 or 2.5%
– Family penalty capped at 300% of the adult flat dollar
penalty or “bronze” level premium
Please note that the
information in this chart is
based on an interpretation of
the Patient Protection and
Affordable Care Act. This chart
is for general information
purposes only and is not
intended to constitute legal
advice or a recommended
course of action in any given
situation and should not be
relied upon in making decisions
of a legal nature.
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
Individuals may be eligible for premium assistance – 133% to 400%
FPL if employer:
 Doesn’t offer minimum essential coverage or
 Offers coverage, but premium isn’t affordable
 However, if employer does offer affordable MEC and
the employee purchases on HIX, not eligible for
subsidy

Cost sharing assistance
 Individuals 133%-250% of FPL
 Must purchase silver plan

Small employer tax credits
 Employers < 25
 Must purchase on SHOP, other requirements apply

Penalties for not having/offering health insurance
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
1.1 million New Yorker's added to the “insured
population”
 Reduced bad debts
 Increased access to care
 Increased demand for services



These “new” patients
come with lower
reimbursement rates

There “new” patients come with
continued risk of bad debts

Most of the HIX offering
are paying between 6%
and 25% LESS than the
commercial rates for the
same company
Some plans are making
participation mandatory

Federal regulations put the physician at
risk of not being paid when patients are
late in paying their premiums.
Carriers HIX products must provide a 3
month grace period to enrollees that
haven’t paid their premiums. During the
first 30 days plans must pay claims, but
in the last 60 days, the payer will hold
the claims.
If the patient coverage is cancelled after
90 days for failure to pay premiums,
plans are not required to pay any claims
in those last 60 days. It falls to the
practice to go after the patient, for
services rendered.




Do you need this
volume?
Do you believe
increasing your access to
patient sis the ‘right”
thing to do?

Are you “par” by virtue
of your current
participation
agreements?



Can you limit your
participation to x number
of HIX plans? X number
of enrollees?
Know what you are
getting into
reimbursement wise.
Verify each patient’s
benefit plan at time of 1appointment scheduling
and 2- at time of service.
Require a contingent
credit card authorization
on all patients
Stuff you want to ask
Thank you
Robert E. Goff
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