Key Aspects for Employers
 2015
 Will Arkansas be operating as a State Partnership
Marketplace or will Arkansas become a StateBased Marketplace?
 Implications for the Small Group Market and
Small Employer Health Options Program (SHOP):
 Employer or employee choice model
 Active purchaser or market based
Known Changes to the Market
beyond 2015
 New definition of Small Group moves to 100 employees
in 2016
 Rating rules apply to 50-100 groups
 Essential Health Benefits (EHB) package applies to 50-100
groups
 New way rates are built for 50-100 groups
 HHS has reserved the right to define “Essential Health
Benefits” Package for 2016
 May result in a standardized EHB in all 50 States
 State waiver for private option ends in 2016
New Rating Methodology for 50100 in 2016
 Gender rating removed
 Industry rating removed
 Common geographic rating established by regulators
 Tobacco load nationally 50% (Arkansas 20%)
 Health status and pre-existing conditions no longer considered
 Age rating reduced from 6:1 ratio oldest to youngest to 3:1
Essential Health Benefits
Non-grandfathered small group health plans – offered on or off the SHOP, must provide these
government-mandated essential health benefits
Essential health benefits include services in the following 10 categories:
1
Ambulatory patient services
6
Prescription drugs
2
Emergency services
7
3
Hospitalization
Rehabilitative and “habilitative”
services and devices
4
Maternity and newborn care
8
Laboratory services
9
Preventive and wellness services
and chronic disease management
10
Pediatric services, including dental
and vision care
5
Mental health and substance
use disorder services,
including behavioral health
treatment
Premium Rate Calculation
 Unique rate calculation for every member
 Member-level, rather than employee-level, census
required to comply
 Every member on an employee contract has a
unique rate
 Rates developed for up to 3 minor children
 4th minor child (and any additional) is free
 Children age 21+ must be rated as adults
2017 Marketplace
 Marketplace can allow
large groups (100+) to
purchase through online
marketplaces similar to
SHOP for small employer
groups.
 Implications
“Large Group” Purchasing
on Marketplace
 Essential Health Benefits Package
 Employee Choice Model
 Employer Open Enrollment Period
Employer Strategies to Stay
“Outside Marketplace”
 Self-Funding
 Grandfathering
 Defined contribution
through private
exchanges
ACA Impact on Employer Group
Coverage Cost
Employer Strategies to
Control Costs
 Employee/Incentives to drive engagement
(Wellness and Health Management
Incentives/Programs)
 Medical Home Models
 Health Improvement Tools
Employer Strategies to Stay
“Off Exchange” and Control Costs
 Management of “pre-crisis” chronic conditions –
new models of Case Management
 Focused Provider Panels
 Home Monitoring, Electronic Health
 Reference-based pricing
 Onsite health care
 New payment mechanism
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