Cara Henley
Associate Director, Insurance & Managed Care
•August 23, 2013
Healthcare Association of New York State
www.hanys.org
Health Insurance Exchanges
• An organized marketplace where consumers can easily compare
health plan options and enroll in qualified health coverage
• Seeks to increase competition while providing benefit
standardization and potentially lower costs
• Public and private exchanges may co-exist
Healthcare Association of New York State
www.hanys.org
Public Exchanges
Individual
SHOP
• Federally mandated for January 2014
• Individual exchange will target uninsured and
self-insured population
• SHOP (Small Business Health Options Program)
will target small group employers early on; may
incorporate large group employers in 2017
• Community adjusted premiums with limited risk
adjustment
• Small business tax credits and individual
subsidies will be offered
Healthcare Association of New York State
Private Exchanges
• Will not exist in all states
• Targeted to large and midsize employers
• Less regulated than public
exchanges
• Will support defined
contribution models
• May facilitate shift to selfinsured products
www.hanys.org
COVERAGE REQUIREMENTS
• An exchange must offer a plan choice in each category
• A participating payor must offer at least one gold or one platinum
plan
• The plans must provide the 10 EHB categories; states can require
higher level of benefits
Healthcare Association of New York State
www.hanys.org
Individual Requirement
2014
• Penalty is $95
per adult and
$47.50 per
child (up to
$285 per
family) or 1%
of family
income,
whichever is
greater
2015
• Penalty is
$325 per
adult and
$162.50 per
child (up to
$975 per
family) or 2%
of family
income,
whichever is
greater
2016
• Penalty is
$695 per
adult and
$347.50 per
child (up to
$2,085 per
family) or
2.5% of family
income,
whichever is
greater
The penalty is pro-rated by the number of months without coverage, though there is no
penalty for a single gap in coverage of less than 3 months in a year. The penalty cannot be
greater than the national average premium for Bronze level coverage in an Exchange. After
2016, penalty amounts are increased annually by the cost of living.
Healthcare Association of New York State
www.hanys.org
Employer Coverage
Fewer than 25 Employees
Businesses with fewer than 25 FTEs and an average annual wage of less than $50K that
pay at least 50% of the cost of health coverage are eligible for a tax credit.
Fewer than 50 Employees
Businesses with fewer than 50 FTEs are not eligible for a tax credit and are exempt from
penalties faced by larger employers that do not offer coverage.
Healthcare Association of New York State
www.hanys.org
Employer Requirement - Delayed
Large Group Employers
Larger employers that do not provide coverage will be assessed a penalty beginning 2014 if
any one worker receives a tax credit when buying insurance on their own in the Exchange.
The employer penalty is equal to $2,000 multiplied by the number of workers in the
business in excess of 30 workers (with the penalty increasing over time).
Large employers that offer coverage may also be subject to penalties. If the coverage
offered does not have an actuarial value of at least 60% or the premium for coverage
exceeds 9.5% of the worker’s income, then the worker is eligible to purchase insurance on
the Exchange and any available tax credits.
For each worker receiving a tax credit, the employer will pay a minimum penalty of $3,000
per worker that receives a tax credit and a maximum penalty of $2,000 multiplied by the
number of workers in excess of 30 workers.
Healthcare Association of New York State
www.hanys.org
COMPARING THE MAPS
Healthcare Association of New York State
www.hanys.org
Healthcare Association of New York State
www.hanys.org
Federal Repositioning?
• Basic Health Program – delayed
• Federal SHOP – delayed
• Employer Mandate – delayed
Healthcare Association of New York State
www.hanys.org
New York’s Investment
• Committed by Executive Order to create
a state-based Exchange
• Received $368 million in federal grant
awards
• Retained several consultants to conduct
more than 15 policy studies
• In the process of hiring individuals to
staff the Exchange
Healthcare Association of New York State
www.hanys.org
Projected Enrollment
• The State of New York anticipates that
about 1.1 million individuals will
participate in the Health Benefit
Exchange statewide by 2017:
– 615,000 in the individual, non-group
market, and
– 450,000 in the Small Business Health
Options (SHOP) market.
Healthcare Association of New York State
www.hanys.org
Health Benefit Exchange Timeline
July 2013
• Final network
submission due, if
needed, by 6/21
• Plan certification
process complete
by 7/15
August 2013
• Navigator awards
announced
October 2013
January 2014
March 2014
January 2015
• Navigator
training and
education
scheduled
• Open
enrollment
begins 10/1
• First policies
sold take
effect 1/1
• Extended first
year open
enrollment
ends 3/31
• Financial self
sufficiency
required by
1/1
• Media outreach
begins
Healthcare Association of New York State
www.hanys.org
Essential Health Benefits
Outpatient Services
PCP Office Visits
Specialty Visits
Outpatient Facility Fee
Outpatient Surgery
Hospice Services
Home Health Care Services
Preventive, Wellness &
Chronic Disease
Management
Mental Health and
Substance Abuse
Disorder Services
Preventive Care/Screening
Immunization
MH Outpatient and
Inpatient Services
Gym Membership
Substance Use Disorder
Outpatient and Inpatient
Services
Prenatal and Postnatal Care
Hospitalization
Emergency Services
Inpatient Hospital Services
Emergency Room Services
Inpatient Physician and Surgical Services
Urgent Care Centers or Facilities
Skilled Nursing Facility
Emergency
Transportation/Ambulance
Delivery and All Inpatient Services for
Maternity Care
Healthcare Association of New York State
www.hanys.org
Essential Health Benefits
Prescription Drugs
Generic Drugs
Preferred Brand Drugs
Non-Preferred Brand Drugs
Specialty Drugs
Off Label Cancer Drugs
Rehabilitative and Habilitative
Services and Devices
Inpatient Rehabilitation Services
Outpatient Rehabilitation Services
Habilitation Services
Chiropractic Care
Durable Medical Equipment
Laboratory and Imaging
Services
Hearing Aids
Prosthetic Devices
Diagnostic Tests
Imaging
Healthcare Association of New York State
www.hanys.org
Essential Health Benefits
Other
Pediatric Dental
Emergency Dental Care
Infertility Treatment
Checkup for Children
Family Planning
Autism Spectrum
Disorder
Basic Dental Care
Chemotherapy
Bariatric Surgery
Major Dental Care
Mastectomy
Care/Breast
reconstructive
surgery
Transplants
Orthodontia
Pediatric Vision
Vision examinations
Prescription Lenses
Frames
Contact Lenses
Healthcare Association of New York State
Oral Surgery
Diabetic equipment,
supplies, education
and self-management
Reconstructive and
Corrective Surgery
Surgical Second
Opinion
www.hanys.org
Enrollment in Public Programs
New Adult Category
138%
200%
300%
200%
300%
400%
FPL
0%
1
100%
400%
500%
Medicaid
2
CHIP
3
BHP
(state option)
4
Premium Tax Credits and Cost Sharing
Reductions for Qualified Health Plans
5
Qualified Health Plans
Healthcare Association of New York State
www.hanys.org
Other Changes
Family Health Plus
Healthy New York
• Repealed December 31, 2014
• Nearly all FHP enrollees are
subsumed under the new Medicaid
adult category
• Buy-In Program is repealed December
31, 2014
• No new applications will be taken
after December 31, 2013
• FHP enrollees between 133% and
150% of FPL who enroll in commercial
Exchange coverage will have their
premiums paid by the State
• Repealed December 31, 2014, in time
for beneficiaries to enroll in qualified
health plans offered on the Exchange
Healthcare Association of New York State
www.hanys.org
Potential
Subsidized
Exchange
Coverage
Medicaid
Coverage
Churning
Healthcare Association of New York State
www.hanys.org
Individual and Small Group Premium Rates
• The Department of Financial Services (DFS) has
approved 2014 individual and small group premium
rates for products offered on the Exchange
• Rates have been released based on seven different
rating regions:
– Albany, Buffalo, Mid Hudson, New York, Rochester,
Syracuse, Utica, and Long Island
Healthcare Association of New York State
www.hanys.org
Decreased Rates. . .
But Unanswered Questions
• Individual premium rates are approximately
50% lower than the average cost of available
plans today
• Premiums did not drop as steeply in the small
group market compared to the individual
market
• Details on provider networks, out-of-network
coverage, and patient financial responsibility
are not yet available
Healthcare Association of New York State
www.hanys.org
Rebranding and Marketing
Healthcare Association of New York State
www.hanys.org
Qualified Health Plans
Qualified Dental Plans
Affinity Health Plan
BlueCross BlueShield of Western NY
Today’s Options of NY, Inc.
BlueShield of Northeastern NY
BlueCross BlueShield of Western NY
Delta Dental
BlueShield of Northeastern NY
DentCare Delivery Systems, Inc.
CDPHP
Dentegra
Emblem Health
EmblemHealth
Empire
Empire
Excellus
Guardian
Fidelis Care
HealthPlex
HealthFirst
MetLife
Health Republic (Freelancers Union)
Solstice
Independent Health
Market Plus
MVP Health Care
North Shore LIJ Care Connect
Oscar
United HealthCare/Oxford
Univera
Healthcare Association of New York State
www.hanys.org
Open Enrollment
• Initial open enrollment period:
October 1, 2013 - March 31, 2014
–
–
–
–
–
If enrolled on or before Dec. 15, coverage effective Jan. 1
If enrolled Dec. 16 to Jan. 15, coverage effective Feb. 1
If enrolled Jan. 16 to Feb. 15, coverage effective March 1
If enrolled Feb. 16 to March 15, coverage effective April 1
If enrolled March 16 to March 31, coverage effective May 1
• For future years (2015 and beyond) annual open enrollment period:
October 15 – December 7
– Coverage effective January 1
Healthcare Association of New York State
www.hanys.org
Triggering Events for Special
Enrollment
• The special enrollment period will be 60 days from the date of
a triggering event
Losing other minimum essential coverage.
Gaining or becoming a dependent through marriage, birth, adoption, or
placement for adoption.
Gaining status as a citizen, national, or lawfully present in the U.S.
An error in enrollment
A QHP has substantially violated a material provision of a member’s contract
Becoming newly eligible or newly ineligible for advance payments of the premium
tax credit or experiencing a change in eligibility for cost-sharing reductions
A permanent move
The individual is an Indian
Other exceptional circumstance, as determined by Exchange or HHS.
Healthcare Association of New York State
www.hanys.org
Certified Application Counselors
• CMS established CACs as a type of assistance
available to provide information and to help
facilitate enrollment into qualified health plans
available on the Exchange, in addition to
Medicaid and Child Health Plus coverage.
• CACs will complement the existing Navigator/InPerson Assistor program.
• No grant funding for CACs; the CAC program is
intended to dovetail with existing enrollment
activities.
Healthcare Association of New York State
www.hanys.org
Grace Period Coverage
• A QHP must provide a grace period of three consecutive
months if an enrollee receiving advance payments of the
premium tax credit has previously paid at least one full
month's premium during the benefit year.
• During the grace period, the QHP must:
– Pay all appropriate claims for services rendered to the
enrollee during the first month of the grace period and may
pend claims for services rendered to the enrollee in the
second and third months of the grace period;
– Notify HHS of such non-payment; and,
– Notify providers of the possibility for denied claims when an
enrollee is in the second and third months of the grace
period
Healthcare Association of New York State
www.hanys.org
Basic Health Program
Delayed Until 2015
• ACA allows states to offer one or more “Basic Health”
insurance plans to low- to moderate-income individuals
• Plans must provide at least the essential health benefits,
and individual premiums may be no greater than the
second least expensive Silver plan offered on the Exchange
• In a state that offers Basic Health, residents under age 65
with income above 133% and up to 200% of the FPL would
be eligible, as well as lawfully present aliens with income
below 133% and ineligible for Medicaid
• Moreover, in a state electing the Basic Health Program,
eligible individuals may not purchase other available
coverage through the Exchange
Healthcare Association of New York State
www.hanys.org
Basic Health Program
Delayed Until 2015
• The federal government will give states
95% of what would have been spent on
advance premium tax credits for eligible
individuals in the Exchange
• The state is examining two approaches
to provider reimbursement
– Current Family Health Plus rates
– Family Health Plus rates plus 25%
Healthcare Association of New York State
www.hanys.org
STRATEGIC CONSIDERATIONS
Healthcare Association of New York State
www.hanys.org
Strategic Considerations
Possibilities
•
•
•
•
More insured lives
Comparison shopping
Simplified and centralized enrollment
Private exchanges
Risks
•
•
•
•
•
•
Rate pressure
Market migration
Adverse selection
Churning
Government pressure and political climate
Self sufficiency
Healthcare Association of New York State
www.hanys.org
Provider Financial Impact
Uninsured
Individuals
Join
Medicaid
Healthcare Association of New York State
Existing
Insured
Commercial
Patients Shift
to Exchange
Plans
Small
Employers
With No
Insurance
Coverage
Join
Exchange
Self-Pay
Individuals
Join
Exchange
Plans
ECG Management Consultants
www.hanys.org
Balancing Threats and Opportunities
Existing Commercial Lives
Moving to the Exchange =
Lost Revenue
Uninsured Moving to
the Exchange =
New Revenue
Healthcare Association of New York State
www.hanys.org
PRIVATE EXCHANGES
Healthcare Association of New York State
www.hanys.org
SHOP EXCHANGE IMPLICATIONS
Healthcare Association of New York State
www.hanys.org
Healthcare Association of New York State
www.hanys.org
MEDICAID MANAGED CARE
UPDATE
Healthcare Association of New York State
www.hanys.org
Medicaid Managed Care
• New York State is moving toward “Care
Management for All”
• Care Management for All enrollment will
rise from 77% to 95% of the Medicaid
population
• Fee-for-service spending will drop to only
4% of Medicaid spending
Healthcare Association of New York State
www.hanys.org
Transition from Medicaid to
Managed Care
• Long Term Care population
• Behavioral Health population
Healthcare Association of New York State
www.hanys.org
Current MLTC Enrollment
• 45 Managed Long Term Care (MLTC)
plans
• Over 111,000 enrollees statewide
• Over 101,000 in New York City
• Increasing enrollment outside of the
city
Source: http://www.health.ny.gov/health_care/managed_care/reports/enrollment/monthly/
Healthcare Association of New York State
www.hanys.org
Community Based Long Term Care
• July 2012 – began enrollment in NYC
– Mandatory Population: Dual eligibles, 21
and older, requiring more than 120 days of
community based LTC services
– Voluntary Population:
• Dual eligibles, 18-21, requiring more than
120 days
• Non-duals, 18 and older, nursing home
eligible
Healthcare Association of New York State
www.hanys.org
Community Based Long Term Care
• January 2013 – Nassau, Suffolk, and
Westchester counties
• August 2013 – Orange and Rockland
counties (pending CMS approval)
• December 2013 – Albany, Erie, Monroe
and Onondaga counties
• April 2014 – other counties with
capacity
Healthcare Association of New York State
www.hanys.org
Facility Based Long Term Care
• October 2013 — permanent nursing home
benefit carved in (MMC)
• DOH Proposal — new permanently placed
nursing home residents age 21 and older
required to enroll in managed care plan (MMC
or MLTC)
• January 2014 —NYC, Westchester, Nassau, Suffolk
• April 2014 — Rest of State
• Residents already permanently placed by
mandatory dates can remain in FFS
Healthcare Association of New York State
www.hanys.org
Behavioral Health Transition
• January 2012: regional BHOs began working with
providers to monitor and review inpatient behavioral
health services and discharge plans for stays not
"covered" under the state's various Medicaid
Managed Care plans.
• The state is delaying the transition of behavioral
health services into managed care until January 1,
2015.
• The state continues to develop the model and is also
awaiting federal approval for the new services and
design.
Healthcare Association of New York State
www.hanys.org
Behavioral Health Transition
• The revised implementation dates are:
– January 1, 2015: Behavioral health adults
in New York City; (HARP and Non-HARP)
– July 1, 2015: Behavioral health adults in
the rest of the state; (HARP and Non
HARP) and
– January 1, 2016: Behavioral health
children statewide.
Healthcare Association of New York State
www.hanys.org
Healthcare Association of New York State
www.hanys.org
Questions?
Cara Henley
(518) 431-7827
chenley@hanys.org
Healthcare Association of New York State
www.hanys.org