Georgia’s Healthcare Exchange
Experience
Robert Threlkeld, Partner
Morris, Manning & Martin, LLP
rthrelkeld@mmmlaw.com
(404) 233-7000
Agenda
 Overview of Affordable Care Act
 Georgia Exchange (focus on Individual plans)
 Year 1 Overview
 Year 2 Projections
 How to Help Navigate Members
2
OVERVIEW OF THE
AFFORDABLE CARE ACT
3
Affordable Care Act
 The Patient Protection and Affordable Care Act (Pub. L.
No. 111-148) was enacted on March 23, 2010; the Health
Care and Education Reconciliation Act (Pub. L. No. 111-152)
was enacted on March 30, 2010. These laws are collectively
known as the Affordable Care Act (“ACA”).
 The primary goals of the ACA are to decrease the number
of uninsured Americans and reduce the overall costs of
health care.
4
Health Insurance Exchange
 ACA created the ability for states to establish a state-operated
Exchange entity or elect (default) to a federally-operated
Exchange
 The primary functions of the Exchange include:






Eligibility and enrollment for Medicaid
Eligibility and enrollment for Individuals
Eligibility and enrollment for Small Business Health Options Program (SHOP)
Plan Management
Financial Management
Consumer Assistance for the Exchange
SOURCE: https://www.healthcare.gov/get-covered-a-1-page-guide-to-the-health-insurance-marketplace/
5
State versus Federal Exchange
 Federally-facilitated Exchange Model (FFE)– All core
functions of the Exchange are operated by the United
States Department of Health and Human Services (HHS) on
behalf of a state. 27 states (including Georgia)
 State-based Exchange Model (SBE) – All core functions of
the Exchange are operated by the state. 16 states and
District of Columbia
 State Partnership Exchange Model (SPE)—States can elect
to participate in the Federally Facilitated Exchange model
but retain and operate either Plan Management or
Consumer Assistance OR both Plan Management and
Consumer Assistance. 7 states
SOURCE: http://kff.org/health-reform/state-indicator/state-decisions-for-creating-health-insurance-exchanges-and-expanding-medicaid/
6
Medicaid Expansion
 The Medicaid expansion is a core component of ACA and
was designed to fill longstanding gaps in health coverage
for adults.
 As enacted, the ACA created a continuum of health
coverage options, with Medicaid expanding to cover all
low-income adults with income up to 138% of poverty
(about $16,000 for an individual) and tax credits to
purchase private coverage in new Health Insurance
Marketplaces available to people with moderate incomes.
SOURCE: www.kff.com and The Henry J. Kaiser Family Foundation
7
Medicaid Expansion
 However, the July 2012 Supreme Court ruling on the
Affordable Care Act effectively made the Medicaid
expansion a state option, and as of August 2014, 21 states,
including Georgia, are not moving forward with the
Medicaid expansion at this time (see next slide).
 In states that do not implement the Medicaid expansion,
millions of low-income adults that could have gained
Medicaid will remain ineligible for the program. A small
number of these people may be eligible for tax credits to
purchase private coverage, but the majority will be left
without an affordable coverage option.
SOURCE: www.kff.com and The Henry J. Kaiser Family Foundation
8
Current Status of Medicaid Expansion
VT
WA
MT
ME
ND
NH*
MN
OR
SD
ID
MI*
WY
PA*
IA*
NE
NV
IL
UT
CO
CA
OH
IN*
WV
KS
MO
KY
NM
OK
TX
AK
AL
DC
SC
AR*
MS
VA
CT RI
NJ
DE
MD
NC
TN
AZ
MA
NY
WI*
GA
LA
FL
HI
NOTES: Data are as of August 28, 2014.
SOURCES: Current status for each state is based on data from the Centers for
Medicare and Medicaid Services
Slide courtesy of the Henry J. Kaiser Family Foundation
Implementing the Medicaid Expansion
(28 States including DC)
Open Debate (2 States)
Not Moving Forward at this Time (21 States)
9
GEORGIA EXCHANGE
10
Georgia Plans Generally
 Georgia follows the Federally-facilitated Exchange (FFE) Model
under which all core functions of the Exchange are operated by
the United States Department of Health and Human Services
(HHS) on behalf of a state.
 Georgians wishing to enroll in the Exchange must visit
www.healthcare.gov
 Insurers are prohibited from denying coverage based on preexisting conditions.
 Tobacco Surcharge: Georgia allows insurance companies to
charge tobacco users 50% more than non-tobacco users.
SOURCES: http://www.webmd.com/health-insurance/20130716/how-affordable-care-act-affects-smokers
11
Georgia Plan Benefits
 All approved plans in the state must cover the same package of benefits, called essential
health benefits. In Georgia, the benefits include:
 Outpatient services, such as doctor visits or tests done outside a hospital,
including chiropractic care and the diagnosis and treatment of conditions that cause
infertility
 Emergency services
 Hospital stays
 Pregnancy and baby care
 Mental health and substance abuse services, including behavioral health treatment
 Prescription drugs, including generic and certain brand-name drugs
 Rehab and habilitative services, those that help people recover from an accident or
injury and those that help people with developmental issues. In Georgia, this includes up
to 20 visits for physical or occupational therapy and 20 visits for speech therapy.
Coverage for autism services is also required.
 Lab services
 Preventive and wellness services, along with those that help people manage chronic
conditions
 Services for children, including dental and eye care
 Some services not included: hearing aids, cosmetic surgery, long-term care, and private
nursing.
SOURCE: http://www.cms.gov/CCIIO/Resources/Data-Resources/Downloads/georgia-ehb-benchmark-plan.pdf
12
“Metal” Plans
 Insurers must cover a minimum set of essential health benefits and must organize
their plan offerings into five levels of patient cost-sharing (below, ranging from
most to least protective). These “metal” plans are offered in each state.
 Plans in each category pay different amounts of the total costs of an average
person’s care. This takes into account the plans’ monthly premiums, deductibles,
copayments, coinsurance, and out-of-pocket maximums. The actual percentage an
insured pays will depend on the services he or she uses during the year.
 Bronze Plan: Insureds pay 40% and the plan pays 60%.
 Silver Plan: Insureds pay 30% and the plan pays 70%.
 Gold Plan: Insureds pay 20% and the plan pays 80%.
 Platinum Plan: Insureds pay 10% and the plan pays 90%.
 Catastrophic Plan: plans pay less than 60% of the total average cost of care on
average. They’re available only to people who are under 30 years old or have
a hardship exemption.
SOURCE: https://www.healthcare.gov/how-do-i-choose-marketplace-insurance/plans-categories/
13
“Metal” Plans Continued
 Bronze plans (which cover 60 percent of health care costs
when averaged across all enrollees) have the most costsharing and represent the lowest level of coverage
generally available through exchanges. As a consequence,
they typically have the lowest premiums.
 Silver plans have lower cost-sharing than bronze plans
(covering an average of 70 percent of enrollees’ health
care costs on average), and will therefore generally have
higher premiums.
SOURCE: http://kaiserfamilyfoundation.files.wordpress.com/2013/09/early-look-at-premiums-and-participation-in-marketplaces.pdf
14
Georgia and Medicaid Expansion
 Georgia has not expanded Medicaid.
 As of July 2014, only 204,051 Georgians have gained Medicaid or
CHIP coverage since the beginning of the Health Insurance
Marketplace’s first open enrollment period in October, 2013.
 According to HHS, if Georgia expanded Medicaid, an additional
478,000 uninsured individuals would gain coverage. The
expansion would be paid 100% by federal funds for the first three
years and federal funds would never fall below 90% of costs
thereafter.
 Across the nation, 8 million more Americans are now enrolled in
Medicaid and CHIP.
SOURCE: Health and Human Services, http://www.hhs.gov/healthcare/facts/bystate/ga.html
15
Georgia Enrollment Numbers: 2014
 316,543 individuals selected a Marketplace plan
between October 1, 2013 and March 31, 2014
(including additional special enrollment period
activity through April 19, 2014).
 57% are female and 43% are male.
 36% are under age 35.
 31% are between the ages of 18 and 34.
 87% selected a plan with financial assistance.
SOURCE: U.S. Department of Health and Human Services, http://www.hhs.gov/healthcare/facts/bystate/ga.html
16
Enrollment Numbers: 2014
17
Enrollee Plan Selections: 2014
 Bronze Plan: 11% of Georgians selected (20% nationally)
 Insured pays 40% and plan pays 60%
 Silver Plan: 71% of Georgians selected (65% nationally)
 Insured pays 30% and the plan pays 70%.
 Gold Plan: 6.5% of Georgians selected (8% nationally)
 Insured pays 20% and the plan pays 80%.
 Platinum Plan: 9.5% of Georgians selected (5% nationally)
 Insured pays 10% and the plan pays 90%.
 Catastrophic Plan: 2% of Georgians selected (2% nationally)
 Thirty-one percent of Georgia enrollees were between the ages
of 18 and 34.
SOURCE: ASPE Marketplace Summary Enrollment Report and CMS March Medicaid/CHIP Enrollment Report
18
Insurers Selling in Georgia
Marketplace: 2014
 Participating insurers generally will offer a number of
plans at various tiers of coverage (“metals”), and
they also typically offer more than one plan option
within a given coverage tier. As a result, the number
of plans available to consumers will be significantly
greater than the number of insurers participating.
 In 2014, only five carriers participated:
 BlueCross BlueShield (BCBS) of Georgia, Alliant, Humana,
Kaiser Foundation Health Plan, and Peach State
SOURCE: Georgia Office of Insurance and Safety Fire Commissioner
19
Georgia Market Rating Areas
 The Market Rules and Rate Review Final Rule (45 CFR Part 147)
provides that each state will have a set number of geographic rating
areas that all issuers in the state must uniformly use as part of their
rate setting.
 In Georgia, the Market Rating Areas are based on counties and
there are currently 16 regions. The carriers were split into regions
throughout the state to identify what areas each participated.
 In 2014, BCBS was the only carrier that was offered in all 16 regions
in the state.
 Not all counties within a particular rating area are actually served by
each carrier in every case. A carrier is noted as serving a named
Market Rating Area if they serve in at least one county within a
particular rating area.
SOURCE: Georgia Office of Insurance and Safety Fire Commissioner
20
Georgia Market Rating Areas
21
Insurers By Market Rating Area: 2014
Name of Market Rating Area
Albany
Athens
Atlanta
W. Atlanta
Augusta
Brunswick
Chattanooga
Columbus
Dalton
Atlanta Outer NE
South. Cental Georgia
Macon-Warner Robins
N.W. Atlanta
Savannah
Valdosta
East Macon
Area
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
Carriers Serving the Market Rating Area
BCBS
Humana
Alliant
BCBS
Humana
Peach St
Alliant
BCBS
Humana Kaiser
Peach St
Alliant
BCBS
Humana
BCBS
Humana
BCBS
Humana
Alliant
BCBS
BCBS
Humana
Peach St
Alliant
BCBS
Humana
Alliant
BCBS
Humana
BCBS
Humana
BCBS
Humana
Alliant
BCBS
Humana
BCBS
Humana
BCBS
Humana
BCBS
Humana
SOURCE: Georgia Office of Insurance and Safety Fire Commissioner
22
Premium Variables
 Exchange premiums reflect insurers’ estimates of the cost of
offering the new benefits to the people who are expected to
enroll.
 Insurers will be able to vary premiums only by age (to a limited
extent), tobacco status, geographic region, and family size.
 In general, lowest premiums for 2014 were in Region 8:
Columbus.
 In general, highest premiums for 2014 were in Region 1:
Albany.
SOURCE: http://kaiserfamilyfoundation.files.wordpress.com/2013/09/early-look-at-premiums-and-participation-in-marketplaces.pdf
and Georgia Office of Insurance and Safety Fire Commissioner
23
Premium Variables
 Unsubsidized exchange premiums vary due to several
factors, such as differences in the underlying cost of health
care, market competition, and the effectiveness of state
rate review programs at lowering premiums.
 Exchanges also vary in their authority to negotiate
premiums with insurers or exclude plans.
 Within a given rating area for a given insurer, premiums
will vary by the age of an individual, as well as family
income and household size, which determine eligibility for
tax credits.
SOURCE: http://kaiserfamilyfoundation.files.wordpress.com/2013/09/early-look-at-premiums-and-participation-in-marketplaces.pdf
and Georgia Office of Insurance and Safety Fire Commissioner
24
Premiums* Based on Rating Area: 2014
RATING
AREA
SILVER**
1 $
2 $
3 $
4 $
5 $
6 $
7 $
8 $
9 $
10 $
11 $
12 $
13 $
14 $
15 $
16 $
460.86
283.04
269.59
312.88
284.17
321.44
344.39
265.78
331.14
278.85
306.32
303.28
312.55
290.78
422.42
280.72
BRONZE**
$
405.43
$
250.90
$
240.26
$
278.48
$
249.45
$
281.54
$
306.25
$
232.40
$
294.61
$
248.65
$
268.44
$
266.19
$
278.31
$
254.88
$
371.97
$
254.54
*Premiums are based on average rate for all insurers per Rating Area for a 40 year old individual
**Based on lowest-price Silver or Bronze plan per insurer
SOURCE: Data provided by Georgia Office of Insurance and Safety Fire Commissioner
25
Premiums Based on Rating Area:
2014
$500.00
$400.00
$300.00
Silver
$200.00
Bronze
$100.00
$1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
26
Premiums* Based on Insurer: 2014
INSURER
SILVER**
BRONZE**
Alliant
$337.65
$302.54
BCBS
$352.96
$312.32
Humana
$250.50
$217.76
Kaiser
$254.00
$232.00
Peach State
$239.71
$199.55
*Premiums are based on average rate per insurer across all Georgia Rating Areas for a 40 year old individual.
Insurers do not all offer plans n same rating areas, which may affect an insurer’s average premium price.
**Based on lowest-price Silver or Bronze plan per insurer
SOURCE: Data provided by Georgia Office of Insurance and Safety Fire Commissioner
27
Premiums Based on Insurer: 2014
$450.00
$400.00
$350.00
$300.00
$250.00
$200.00
$150.00
$100.00
$50.00
$-
Silver
Bronze
Alliant
BCBS
Humana
Kaiser
Peach
State
28
Premiums* Based on Age: 2014
AGE
SILVER
BRONZE
21
$240.11
$193.56
30
$272.68
$220.74
40
$307.32
$248.57
50
$428.79
$351.36
60
$651.41
$527.98
*Premiums based on average of lowest cost premiums across all insurers
SOURCE: Data provided by Georgia Office of Insurance and Safety Fire Commissioner
29
Premiums Based on Age: 2014
700
600
500
400
Silver
300
Bronze
200
100
0
21
30
40
50
60
30
Tax Credits
 Enrollees with family incomes from one to four times the federal
poverty level (about $24,000 to $94,000 for a family of four) may
qualify for tax credits that will lower the cost of coverage
through reduced premiums and, in some cases, also be eligible
for subsidies to reduce their out-of-pocket costs.
 Among Georgia residents selecting a QHP, 87 percent qualified
for financial assistance, compared to 85 percent nationally.
 A report released in June by the U.S. Department of Health and
Human Services showed the average monthly premium, after
tax credits, for Georgia consumers was $54. Sixty percent of
enrollees pay $50 or less per month after subsidies. Georgia’s
$54 average is second only to Mississippi, where the average
monthly premium after subsidies is just $23.
SOURCES: http://www.healthinsurance.org/georgia-state-health-insurance-exchange/
and http://aspe.hhs.gov/health/reports/2014/Premiums/2014MktPlacePremBrf.pdf .
31
Tax Credit Calculation
 Exchange subsidies limit the percent of one’s income that he or she
must spend on a silver premium. The cap depends on the enrollee’s
income range.
 Maximum Amount Enrollee Pays for Benchmark Silver Premium = Cap (%) *
Income
 If the enrollee’s unsubsidized premium is already less than their cap,
he or she would not receive a subsidy.
 Tax Credit = Unsubsidized Benchmark Silver Premium – Maximum Amount
Enrollee Pays for Silver Premium
 Subsidized enrollees can apply their tax credit toward the purchase
of other levels of coverage, such as bronze plans.
 Amount Enrollee Pays for Bronze Premium = Unsubsidized Bronze Premium –
Tax Credit
SOURCE: http://kaiserfamilyfoundation.files.wordpress.com/2013/09/early-look-at-premiums-and-participation-in-marketplaces.pdf
32
Subsidy Study 1: 2014
 Blake is a 25 year-old non-smoker and resides in Atlanta, Fulton
County (Rating Area 3).
 Blake is single, has no children, has no employer coverage.
 Blake’s household income in 2014: $25,000 (218% of poverty level of
$11,670 for family of 1).
 Maximum % of income Blake will have to pay for the premium, if eligible for a
subsidy: 6.92%
 Health Insurance premium in 2014 (for a silver plan, before tax credit): $2,362
per year ($197 per month)
 Blake could receive a government tax credit subsidy of up to: $633 per year
(which covers 27% of the overall premium)
 Amount Blake pays for the premium: $1,729 per year ($144 per month) (which
equals 6.92% of Blake’s household income and covers 73% of the overall
premium)
SOURCE: http://kff.org/interactive/subsidy-calculator/
33
Subsidy Study 2: 2014
 Jay and his wife Jenn are 40 year-old non-smokers and reside in Athens,
Clarke County (Rating Area 2).
 Jay and Jenn have 2 children, both under 21 and non-smokers who will
also enroll in exchange coverage
 Neither Jay nor Jenn has employer coverage.
 Jay and Jenn’s household income in 2014: $60,000 (255% of poverty level
of $23,850 for a family of 4).
 Maximum % of income Jay and Jenn have to pay for the premium, if eligible for a
subsidy: 8.19%
 Health Insurance premium in 2014 (for a silver plan, before tax credit): $8,721 per
year ($727 per month)
 Jay and Jenn could receive a government tax credit subsidy of up to: $3,808 per
year (which covers 44% of the overall premium)
 Amount Jay and Jenn pay for the premium: $4,913 per year ($659 per month)
(which equals 8.19% of their household income and covers 56% of the overall
premium)
SOURCE: http://kff.org/interactive/subsidy-calculator/
34
Subsidy Study 3: 2014
 Bill and his wife Jan are 60 year-old non-smokers and reside in
Savannah, Chatham County (Rating Area 14).
 Bill and Jan have 3 children, all non-dependents and who are
enrolling separately in exchange coverage
 Neither Bill nor Jan has employer coverage.
 Bill and Jan’s household income in 2014: $45,000 (290% of poverty
level of $15,730 for a family of 2).
 Maximum % of income Bill and Jan have to pay for the premium, if
eligible for a subsidy: 9.21%
 Health Insurance premium in 2014 (for a silver plan, before tax credit):
$17,435 per year ($1,453 per month)
 Bill and Jan could receive a government tax credit subsidy of up to:
$13,289 per year (which covers 76% of the overall premium)
 Amount Bill and Jan will pay for the premium: $4,416 per year ($368 per
month) (which equals 9.21% of their household income and covers 24% of
the overall premium)
SOURCE: http://kff.org/interactive/subsidy-calculator/
35
GEORGIA EXCHANGE:
YEAR 2 PROJECTIONS
36
2015 Enrollment Period
 The next open enrollment period will be from November 15,
2014, to February 15, 2015.
 If an individual has a life-changing event -- such as the birth of a
child, losing a job, or moving to a new state – such individual is
not required to wait for the next enrollment period and can sign
up or change coverage within 60 days of the event.
 In the Marketplace, you qualify for a special enrollment period
60 days following certain life events that involve a change in
family status (for example, marriage or birth of a child) or loss of
other health coverage. Job-based plans must provide a special
enrollment period of 30 days.
SOURCES: https://www.healthcare.gov/glossary/open-enrollment-period/ and https://www.healthcare.gov/glossary/special-enrollment-period/
37
Insurers Selling in Georgia
Marketplace: 2015
• In 2015, the following carriers will be added to the
Georgia marketplace (to add to BCBS, Alliant,
Humana, and Peach State):
‒ Cigna, Coventry, Kaiser, Time Insurance, and United
Healthcare
 The carriers will still be split according to the Georgia
Market Rating Areas, but along with BCBS, Coventry,
Humana, and United Healthcare will most likely be
available in all 16 areas.
 Note that even if a carrier provides service in an area,
the carrier does not necessarily provide service in
every county in that area.
SOURCE: Georgia Office of Insurance and Safety Fire Commissioner
38
Proposed Georgia Market Rating
Areas: 2015
(new insurers in each area are in red)
Name of Market Rating Area
Albany
Athens
Atlanta
W. Atlanta
Augusta
Brunswick
Chattanooga
Columbus
Dalton
Atlanta Outer NE
South. Cental Georgia
Macon-Warner Robins
N.W. Atlanta
Savannah
Valdosta
East Macon
Area
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
Alliant
Alliant
Alliant
Alliant
Alliant
Alliant
Alliant
BCBS
BCBS
BCBS
BCBS
BCBS
BCBS
BCBS
BCBS
BCBS
BCBS
BCBS
BCBS
BCBS
BCBS
BCBS
BCBS
Carriers Serving the Market Rating Area
Coventry Humana
CIGNA Coventry Humana Kaiser
Peach St
CIGNA Coventry Humana Kaiser
Peach St
Coventry Humana Kaiser
Coventry Humana
Coventry Humana
Coventry Humana
Coventry Humana
Peach St
Coventry Humana
Coventry Humana Kaiser
CIGNA Coventry Humana
CIGNA Coventry Humana
CIGNA Coventry Humana Kaiser
Coventry Humana
Coventry Humana
Coventry Humana
Time
Time
Time
Time
Time
Time
Time
Time
Time
Time
Time
Time
Time
Time
United HC
United HC
United HC
United HC
United HC
United HC
United HC
United HC
United HC
United HC
United HC
United HC
United HC
United HC
United HC
United HC
NOTE: Not all counties within a particular service area are actually served by each carrier in every case.
A carrier is noted as serving a named Geo Service Area if they serve in at least one county within a particular service area.
SOURCE: Georgia Office of Insurance and Safety Fire Commissioner
39
Projected Premiums* Based on Insurer: 2015
INSURER
SILVER**
BRONZE**
Alliant
$318.91
$271.15
BCBS
$324.83
$248.40
Cigna
$371.90
$317.14
Coventry
$346.39
$279.98
Humana
$383.31
$333.32
Kaiser
$323.00
$232.00
Peach State
$227.52
$182.71
Time
$392.84
$329.72
United Healthcare
Information not
accessible
Information not
accessible
*Premiums are based on average rate per insurer across all Georgia Rating Areas for a 40 year old individual. Insurers do not all offer plans in same areas
**Based on lowest-price Silver or Bronze plan per insurer
SOURCE: Data provided by Georgia Office of Insurance and Safety Fire Commissioner
40
Projected Premiums Based on Insurer: 2015
$450.00
$400.00
$350.00
$300.00
$250.00
$200.00
$150.00
$100.00
$50.00
$-
Silver
Bronze
41
Projected Premiums* Based on
Rating Area: 2015
RATING
AREA
SILVER**
1 $
2 $
3 $
4 $
5 $
6 $
7 $
8 $
9 $
10 $
11 $
12 $
13 $
14 $
15 $
16 $
394.45
305.81
305.80
340.72
312.02
363.23
333.88
304.57
332.08
319.39
356.94
337.63
347.09
323.65
375.43
322.09
BRONZE**
$
324.13
$
260.24
$
261.08
$
272.40
$
252.74
$
299.14
$
276.61
$
268.45
$
275.79
$
259.41
$
296.33
$
281.08
$
284.18
$
266.89
$
305.93
$
265.13
*Premiums are based on average rate for all insurers per Rating Area for a 40 year old individual
**Based on lowest-price Silver or Bronze plan per insurer
SOURCE: Data provided by Georgia Office of
Insurance and Safety Fire Commissioner
42
Projected Premiums* Based on
Rating Area: 2015
$450.00
$400.00
$350.00
$300.00
$250.00
SILVER**
$200.00
BRONZE**
$150.00
$100.00
$50.00
$1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
43
Change in Silver Premiums Based on
Rating Area
RATING
AREA
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
2014
$ 460.86
$ 283.04
$ 269.59
$ 312.88
$ 284.17
$ 321.44
$ 344.39
$ 265.78
$ 331.14
$ 278.85
$ 306.32
$ 303.28
$ 312.55
$ 290.78
$ 422.42
$ 280.72
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
2015 % CHANGE
394.45
-14.41%
305.81
8.04%
305.80
13.43%
340.72
8.90%
312.02
9.80%
363.23
13.00%
333.88
-3.05%
304.57
14.59%
332.08
0.28%
318.39
14.18%
356.94
16.53%
337.63
11.33%
347.09
11.05%
323.65
11.30%
375.43
-11.12%
322.09
14.74%
SOURCE: Data provided by Georgia Office of Insurance and Safety Fire Commissioner
44
Change in Silver Premiums Based on
Rating Area
$500.00
$450.00
$400.00
$350.00
$300.00
$250.00
$200.00
$150.00
$100.00
$50.00
$-
2014
2015
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
45
Change in Bronze Premiums Based
on Rating Area
RATING
AREA
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
2014
$ 405.43
$ 250.90
$ 240.26
$ 278.48
$ 249.45
$ 281.54
$ 306.25
$ 232.40
$ 294.61
$ 248.65
$ 268.44
$ 266.19
$ 278.31
$ 254.88
$ 371.97
$ 254.54
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
2015 % CHANGE
324.13
-20.05%
260.24
3.72%
261.08
8.67%
272.40
-2.18%
252.74
1.32%
299.14
6.25%
276.61
-9.68%
268.45
15.51%
275.79
-6.39%
259.41
4.33%
296.33
10.39%
281.08
5.59%
284.18
2.11%
266.89
4.71%
305.93
-17.75%
265.13
4.16%
SOURCE: Data provided by Georgia Office of Insurance and Safety Fire Commissioner
46
Change in Bronze Premiums Based
on Rating Area
$450.00
$400.00
$350.00
$300.00
$250.00
$200.00
$150.00
$100.00
$50.00
$-
2014
2015
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
47
Projected Premiums* Based on Age: 2015
AGE
SILVER
BRONZE
21
$263.02
$185.12
30
$298.50
$244.36
40
$336.09
$274.30
50
$469.93
$383.31
60
$713.74
$582.43
*Projected premiums based on average of lowest cost premiums for a 40 yearold individual across all insurers
SOURCE: Data provided by Georgia Office of Insurance and Safety Fire Commissioner
48
Projected Premiums Based on Age: 2015
$800.00
$700.00
$600.00
$500.00
$400.00
$300.00
$200.00
$100.00
$-
Silver
Bronze
21
30
40
50
60
49
Change in Silver Premiums
AGE
2014
2015
% CHANGE
21
$240.11
$263.02
9.54%
30
$272.68
$298.50
9.47%
40
$307.32
$336.04
9.36%
50
$428.79
$469.93
9.53%
60
$651.41
$713.74
9.57%
SOURCE: Data provided by Georgia Office of Insurance and Safety Fire Commissioner
50
Average Projected Silver Premiums
$800.00
$700.00
$600.00
$500.00
$400.00
$300.00
$200.00
$100.00
$-
2014
2015
21
30
40
50
60
51
Change in Bronze Premiums
AGE
2014
2015
% CHANGE
21
$193.56
$185.12
-4.36%
30
$220.74
$244.36
10.70%
40
$248.57
$274.30
10.35%
50
$351.36
$383.31
9.09%
60
$527.98
$582.43
10.31%
SOURCE: Data provided by Georgia Office of Insurance and Safety Fire Commissioner
52
Average Projected Bronze Premiums
$700.00
$600.00
$500.00
$400.00
2014
$300.00
2015
$200.00
$100.00
$21
30
40
50
60
53
HOW TO HELP
NAVIGATE MEMBERS
54
Assistance with Navigation
 The ACA requires state exchanges to establish a “navigator” program
(Section 1311(i)) that will help people who are eligible to purchase
coverage through the exchange learn about their new coverage options
and enroll.
 The Act lists brokers and agents as among the many types of entities
that could receive navigator grants.
 Navigators, brokers, and agents are a key resource to individuals in
regard to navigation. They have more in-depth capabilities as they may
provide advice rather than just “navigation “ on how to use the
site. There is a robust process they must follow to get certified to help
individuals in the public marketplace.
SOURCE: https://www.cms.gov/CCIIO/Resources/Training-Resources/Downloads/navigators-and-assistance.pdf
55
Navigators
 Navigators are funded by the federal government to help individuals
apply for public assistance programs and compare health insurance
plans sold on the exchange.
 Health insurance exchange / marketplace navigators are not individuals they are organizations, described as follows: "trade, industry, and
professional associations, commercial fishing industry organizations,
ranching and farming organizations, community and consumer-focused
nonprofit groups, chambers of commerce, unions, resource partners of
the Small Business Administration, other licensed insurance agents and
brokers....”
 On September 8, 2014, CMS awarded $60 million in Navigator
Cooperative Agreements to entities to serve in the 34 Federallyfacilitated and State Partnership Marketplaces.
SOURCE: http://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-Marketplaces/assistance.html
56
Navigator Duties
Under the law, navigators have the following five duties:
 To conduct public education about the availability of qualified health plans.
(Qualified health plans must meet certain standards, and they are certified to sell
in the exchange. Some qualified plans may be sold both inside and outside of an
exchange, depending on state law.)
 To distribute fair, impartial information about enrollment in qualified plans and
about the availability of premium tax credits and cost-sharing assistance in the
exchange.
 To facilitate enrollment in qualified plans.
 To refer people who need help resolving a problem with their health plan or with
their premium assistance to a consumer assistance or ombudsman program or
to another appropriate agency that can help with a grievance or appeal.
 To provide information in a culturally and linguistically appropriate manner to the
population being served by an exchange.
SOURCE: 42 U.S. Code § 18031 - Affordable choices of health benefit plans
57
What Navigators Cannot Do
 Navigators may not work for a health insurance provider.
 Navigators do not have to be licensed to sell insurance.
 Navigators will not be paid based on the advice they give. In no way can
payment for their services be tied to the decisions made by the people they
advise. Put another way, no navigator will be paid a commission, finder's
fee, or any other form of compensation because someone they worked with
made any specific choice of insurance plans.
 Navigators will not make decisions for the people they advise. They will
simply walk their advisees through a series of questions and decisionmaking tools to help those people make their own insurance plan choices.
 Navigators will not be able or be expected to qualify the people they advise
for any specific plan.
SOURCE: 42 U.S. Code § 18031 - Affordable choices of health benefit plans
58
Certified Application Counselors
 FFMs like Georgia’s will designate organizations to certify application
counselors who perform many of the same functions as Navigators
including educating consumers and helping them complete an
application for coverage.
 Certified application counselors and Marketplace-designated
organizations won’t receive new federal grant money through the
Marketplace. The counselors and organizations could, however, receive
federal funding through other grant programs or Medicaid to help
support their consumer assistance and enrollment activities.
 Examples of possible certified application counselors include staff at
community health centers, hospitals, other health care providers, or
social service agencies.
 All certified application counselors are required to complete
comprehensive training.
SOURCE: https://www.cms.gov/cciio/resources/files/downloads/marketplace-ways-to-help.pdf
59
Agents and Brokers
 An exchange may allow agents and brokers to be
Navigators, provided they otherwise meet the Navigator
eligibility criteria.
 An exchange may also allow agents and brokers to enroll
individuals and employers in QHPs offered through an
exchange if the agents and brokers meet certain
requirements.
 Unlike navigators, licensed agents are permitted to
provide advice in helping individuals assess which health
plan best suits their needs.
SOURCE: https://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-Marketplaces/Downloads/agent-broker-ffm-training-summary.pdf
60
Agent/Broker Role in the FFMs
To participate in the FFMs, agents/broker must:
 Adhere to all state requirements for licensure,
appointment, and market conduct
 Complete Marketplace on-line training
 Complete the applicable Marketplace Agreement(s)
 Complete security authentication steps for FFM
registration
 Agents must attend ongoing education
classes/certifications every year
SOURCE: https://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-Marketplaces/Downloads/agent-broker-ffm-training-summary.pdf
61
Selling and Maintaining FFM Policies
 Agents/Brokers will be able to help client apply for
coverage and select a health plan.
 Agents obtain and hold Errors and Omissions
Insurance, unlike Navigators.
 Agents and brokers can work with consumers in
either of two ways:
 Directly accessing the FFM website through the issuer’s
connection
 Assisting consumers who are accessing the FFM website
SOURCE: https://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-Marketplaces/Downloads/agent-broker-ffm-training-summary.pdf
62
Hospitals Helping to Navigate Members
 In many markets, hospitals are not involved in helping
to navigate members mostly due to the lack of Errors
& Omissions Insurance or qualified personnel.
 For example, a small regional facility in West Georgia
provides all questions to a local agent that is CMS and
FFM qualified. He is a NAHU/GAHU member and is a
licensed agent. That may not be the case with all
hospitals.
63
SUMMARY
 316,543 individuals selected a Marketplace plan
between October 1, 2013 and March 31, 2014
 71% of Georgians who enrolled in a Marketplace plan
chose a Silver Plan
 Four additional insurers will be providing plans in
Georgia in 2015
 Premiums are expected to increase between 2014 and
2015
 Navigators, agents, and brokers can provide
assistance with the Exchange
64
Thank You!
 Special Thank You to Ms. Jodie Braner, President of
the Georgia Association of Health Underwriters, for
her assistance.
 Special Thank You to Ms. Susan Fairley of the Georgia
Office of Insurance and Safety Fire Commissioner for
her assistance.
65