Montana Health Insurance Updates
Montana HealthCare Forum
Presented by
Commissioner Monica J. Lindeen
Commissioner of Securities and Insurance
Montana State Auditor
November 4, 2013
1
2013 Montana Health
Insurance Legislation
• Rate Review for Health Insurance—HB 87
• Patient-Centered Medical Home Program—SB
84
• Cancer Clinical Trials—SB 55
• Network Adequacy for PPO’s—HB 544
• Navigator/assister/producer training and
certification—HB 250
2
State-based Rate Review – HB87
• The CSI introduced a bill to the 2013 legislature to
create effective rate review authority for Montana.
• House Bill 87 (sponsored by Rep. Welborn) passed
and is now law.
• For the first time, the Montana insurance
commissioner has rate review authority.
• Montana has taken back rate review authority from
the federal government.
3
Rate Review
• In 2014, the ACA requires that adjusted community
rating apply to the individual and small employer group
markets
• Issuers may not vary rates for individuals or small groups
based on health status or claims history
• Issuers must maintain a single risk pool and may vary
rates based on:
 Age (3:1 maximum)
 Tobacco use (1:5:1 maximum)
 4 geographic areas in Montana
5
Benefits of Rate Review
• Montana consumers have already benefited:
– One company lowered rates by 7 percent.
– A second lowered rates by 22 percent.
– A third company lowered rates by 66
percent.
6
Patient-Centered Medical Homes – SB84
• A Patient-Centered Medical Home (PCMH) is a
model of health care delivery that emphasizes
primary health care, coordinated care and
prevention.
• In the PCMH model, insurers pay an incentive based
on quality of care, rather than quantity.
• SB 84 establishes standards and structure for a
statewide PCMH program.
• SB 84 requires CSI to adopt rules to implement
provisions of the law.
7
Implementing the
Montana PCMH Act
• Administrative rules were published at the end of
September.
• Appoint the stakeholder council on November 8.
• Establish a process for recognizing which accrediting
organizations meet Montana’s standards.
• Begin qualifying practices and payers who meet the
decided standards in December.
• Educate the public and promote PCMH across
Montana.
• Working now to incorporate Montana specific
standards.
8
Cancer Clinical Trials
Senate Bill 55
• Passed by the 2013 Montana legislature to clarify
coverage of routine costs for patients in approved clinical
trials must be covered.
• Went into effect immediately upon passage.
• Helps remove insurance uncertainties for doctors and
patients, allowing them to focus on fighting the disease
instead of coverage for routine costs.
• Addresses confusion and inconsistency in coverage of
routine care patients receive when undergoing a clinical
trial.
SB55 Implementation
• Note that the state law covers cancer only, but the ACA has a
similar provision that covers “all life threatening diseases.”
(effective 1-1-14)
• CSI is still noticing insurance denials of routine care claims. When
we explain the law to the company, they pay the claim.
• CSI will be issuing guidance to insurers soon to remind them of
the law.
• The advisory council developed an Oncology Clinical Trial
Treatment Notification Form.
– The form is being finalized and is intended to be set as a statewide
standard for communication on trials between providers and payers.
– CSI will continue education like today to the provider and payer community
to ensure the greatest benefit of the law to Montanans.
10
Network Adequacy – HB544
• A new network adequacy law in Montana was effective October 1,
2013. Most “network-type” health insurance plans, including
dental and vision, sold in Montana are “PPO” plans.
– The consumer’s cost-sharing is increased if he/she seeks
coverage from “out-of-network” healthcare
providers. Consumer cost-sharing is substantially reduced or
even eliminated if that consumer seeks healthcare services “innetwork.”
• The new law says that a provider network is deemed adequate if
it includes 90 % of the hospitals and 80 % of the healthcare
providers in the state.
• Below that threshold percentage, the commissioner
may “determine” a network to be adequate.
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Network Adequacy cont.
• Below that level, a maximum differential is applied: no more
than 25 % cost-sharing difference that the consumer pays for
out-of-network services.
• The commissioner will disapprove a network plan as
“misleading” if there is no viable network.
• Cost-sharing differences between in and out-of-network are
significant—as much as four times higher. Consumers should
always check the insurer’s list of in-network providers before
they choose a health plan.
• Many of the benefits of the ACA are based on “in-network”
costs only.
12
Assistor State Certification– HB250
• All navigators, Certified Application Counselors
(CACs), and Certified Exchange Producers (CEPs)
must complete federal and Montana-specific
training be certified.
• CEPs must complete federal and state training to
sell products through the marketplace.
• CSI developed state-specific training materials.
Navigators must pass a background check and
take a test.
• CSI has a list of all certified navigators, CACs, and
agents on www.montanahealthanswers.com.
Navigators and CACs
The ACA allows for two new consumer
assistance roles
• Navigators – contracted through grants from
HHS, responsible for performing outreach and
education, as well as enrollment assistance
• Certified Application Counselors – not paid by
exchange or federal grants—only offering
enrollment assistance
• Intended for current employees of medical providers and
community groups
Navigators and Agents
Similarities and Differences
• Both navigators and agents help consumers by
providing marketplace enrollment assistance.
• Navigators operate only within the
Marketplace.
• Unlike agents, navigators cannot be
compensated in any way by insurers.
• States cannot require that navigators be
licensed producers, but they do need state
certification and training.
• Navigators and CACs may NOT recommend
specific insurance products.
HB250 Implementation
• In addition to their federal training, CSI
required an online state training for all 3 types
of assistors.
• CSI created to 90 minute webinars, both were
required for CACs; one was required for
Navigators.
• Weekly calls with Navigator groups.
• CSI is a continuous resource for CACs and
Navigators.
• Ongoing regulation of all 3 roles.
16
Certified Assistors
as of October 25, 2013
• Certified Application Assistors: 69
• Navigators: 26
• Certified Exchange Producers: 291
17
Montana Specific Training Included:
• Montana specific information on Medicaid and Healthy Montana Kids
eligibility
• American Indian ACA benefits
• Montana specific privacy laws
• Unlicensed producer activity and the consequences
• Background information on plan design structure and how to choose a
plan
• Deductibles and other cost-sharing
• Financial and health considerations
• Network Adequacy
• Prescription drug formulary
• Summary of Benefits and Coverage
• Multi-State Plans
• Autism and Mental Health Parity
• Stand-alone dental plans
• How to help people who aren’t eligible
Affordable Care Act
Marketplace
• Montana’s federally built, federally maintained
Marketplace website is not working properly.
• www.montanahealthanswers.com, visited by
more than 11,000 individual Montanans.
• We’ve answered nearly 1,000 questions from our
Ask Away site.
• Our office has hosted dozens of town hall events
to explain the law.
19
Adjusting to Marketplace
Problems
• Continue to do outreach and education.
• Work with assistors to adapt to problems and help
consumers.
• Answer questions through the website.
• Montana website made more shopper friendly with a
calculator and charts on plan structure and cost
break down for people to view without having to go
to healthcare.gov.
• I met with an HHS official just last week to tell my
concerns and find out when a fix is expected.
20
Montana is a Plan Management State
for the Marketplace
• The CSI works with the federally facilitated
marketplace to alleviate duplication and save
consumers time and money.
• This coordination helps preserve the state regulation
of health insurance.
• CSI’s plan management duties includes:
– Recommending qualified health plans to the federally
facilitated marketplace.
– Using rate review authority to review health insurance
rates and their benefits.
– Monitoring insurance companies for compliance with state
and federal law.
Questions?
Call my office 1-800-332-6148
Or visit www.csi.mt.gov
www.montanahealthanswers.com