How 2014 ACA Insurance Plans Cover Autism William Luvisi, President Senior Consultants Inc.
Introduction to Health Insurance Exchanges. Affordable Care Act (ACA) Insurance Reforms – No...
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Transcript of Introduction to Health Insurance Exchanges. Affordable Care Act (ACA) Insurance Reforms – No...
![Page 1: Introduction to Health Insurance Exchanges. Affordable Care Act (ACA) Insurance Reforms – No lifetime limits, annual limits – Pre-existing conditions.](https://reader035.fdocuments.us/reader035/viewer/2022062421/56649db35503460f94aa3bd9/html5/thumbnails/1.jpg)
Introduction toHealth Insurance Exchanges
Mim Dixon USET Training
Tunica Biloxi Tribe, LAMay 22, 2012
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The Patient Protection and Affordable Care Act (P.L. 111-148) was enactedMarch 23, 2010.
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Affordable Care Act (ACA)
• Insurance Reforms– No lifetime limits, annual limits– Pre-existing conditions
• Medicaid Expansion• Health Insurance Exchanges
– Individuals– Small businesses
• Medicare Part D “donut hole” changes• Quality, Prevention, Innovation • Health Care Workforce • Indian Health Care Improvement Act
– Title X, Subtitle B, Part III, Sec. 10221
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ACA Strategies to Reduce Number of Uninsured in America• Remove barriers
• Insurance reform• Medicaid expansion• Create market structure (Exchanges)• Risk reduction for insurance companies
• Carrots• Federal premium assistance for individuals• Federal tax credits for businesses <25 employees
• Sticks• Tax penalty for uninsured
• “Individual mandate” - AI/AN are exempt• Business with >50 employee
• Fined $2,000/person over 30 people
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What is Health Insurance Exchange?
• Consumers and businesses can compare insurance plans and purchase
• Federal subsidies of premiums• Enrollment in Medicaid, CHIP, Basic Health Plan (if available)• Web based approach• State or federal exchanges • Operational by January 1, 2014
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“Metallic” Plans in Exchange
• All plans: same Essential Health Benefits• Plans may differ:
• Networks of providers• Cost of premiums, co-pays and deductibles
• Actuarial values of plans equal within metallic categories
• Bronze – 60% actuarial value• Silver – 70% actuarial value• Gold – 80% actuarial value• Platinum – 90% actuarial value
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Exchange Functions• Select Qualified Health Plans (QHP)• Enrollment• Determine individual eligibility • Enroll people in QHPs• Contract with Navigators• Call centers
• Financial management• Premiums• Tax Credits• Cost Sharing• Risk adjustments
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Why are Exchanges Important for Indian Health?
• New source of funding• Covers adults < 65• Premium assistance
• Up to 400% FPL
• I/T/U can bill plan • Shift CHS costs to plans
• Medicaid Expansion• Up to 133% FPL• Assets not counted• Covers all adults• Enroll through Exchanges
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AI/AN have special protections and provisionsin ACA related to Exchanges.
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American Indians and Alaska Natives are
• Exempt from penalty for being uninsured• Exempt from most cost sharing in
Exchange Plans• Cost sharing = deductible + co-pay• Federal government pays cost sharing to
Plans• Able to enroll monthly
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Exemptions from Cost Sharingfor AI/AN Enrolled in Exchange Plans
• No deductibles ever• No cost sharing ever for people served in I/T/U• I/T/U collects 100% of charges from plan
• No cost sharing in private sector for AI/AN with referral from I/T/U• CHS does not pay any portion of care covered by plan
• For AI/AN below 300% FPL, no cost sharing in private sector without referral from I/T/U.
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Premium Subsidies
• AI/AN have same premium subsidies as everyone else in Exchanges
• Based on Modified Adjusted Gross Income (MAGI)
• Sliding scale up to 400% FPL (96%-35%)• Silver level is benchmark• Advanced tax credits• Paid to insurance company• Reconciliation at end of year
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2012 Federal Poverty Level2011 HHS Poverty Guidelines
Personsin Family
48 ContiguousStates and D.C. Alaska Hawaii
1 $11,170 $13,970 $12,860
2 15,130 18,920 17,410
3 19,090 23,870 21,960
4 23,050 28,820 26,510
5 27,010 33,770 31,060
6 30,970 38,720 35,610
7 34,930 43,670 40,160
8 38,890 48,620 44,710
For each additionalperson, add
3,960 4,950 4,550
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Annual Federal Subsidy of Health Insurance Premiums by Income Level for Individuals
% FPL Premium Limitas % Income
Individual Premium(Tribal Sponsorship)
138-150 2% < $690
151-200 3-4% $1,037
201-250 4-6.3% $1,875
251-300 6.3-8.05% $2,776
301-400 8.05-9.5% $3,391-$4,099
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Example: Tribe Pays Portion of Premium
• Tribe pays 2% of premium for individual below 150% FPL with high cost medical needs.
• Tribal Sponsorship is $690 per year.
• Tribe collects payments from plan for all visits and medications provided to individual.
• No cost to CHS for specialty medical care and hospital services.
• More money is available to provide more services for all Tribal members.
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With no cost sharing, AI/AN can choose QHPs with lower premiums.
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Barriers to AI/AN Enrollment• Premium• Tribal sponsorship can eliminate barrier• Basic Health Plan can eliminate barrier
• IRS rules and regulations• Advanced tax credits + reconciliation• No enrollment for non-filers• Complex rules• Basic Health Plan can eliminate barrier
• Lack of insurance experience, knowledge • No motivation to enroll• Federal and State Exchange regulations
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Regulations, Design, Plans
Federal
TribalState
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Exchange Federal Regulations
• Regulations issued by two agencies• CMS, Center for Consumer Information and
Insurance Oversight (CCIIO)• Department of Treasury, IRS
• Federal government is deferring to States to give them flexibility.
• National Tribal Participation• NIHB, MMPC, TTAG, NCAI, TSGAC
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Federal Regulations Issued
• Establishment of Exchanges and QHPs• Standards Related to Reinsurance, Risk
Corridors and Risk Adjustment• Health Insurance Premium Tax Credit• Exchange Functions: Eligibility
Determinations, Employer Standards • Medicaid Eligibility Changes under the ACA• Essential Health Benefits• Actuarial Values
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More NPRMs are coming. . .
• Federal payment of cost sharing for AI/AN• Tax penalties for individuals, businesses• Basic Health Program• Standards for Oversight of Quality and
Reporting
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Planning at State Level
• Laws, Executive Orders to Establish Exchanges
• Federal Exchange Establishment Grants
• Health Insurance Commissioners• Medicaid, CHIP, Basic Health Plans• Tribal Consultation
• Letter from HHS Secretary to State Governors
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Planning within your Tribe
• Designate individual or team to become informed about ACA and Exchanges
• Advocacy at State and Federal levels• Participate in Exchange planning for State• Tribal planning and budgeting • Premium payments• Provider contracts• Outreach and enrollment assistance• Communications plan
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Key DatesJanuary 1, 2013 – HHS decides whether
state is ready to operate an ExchangeOctober 15, 2013- First open enrollment
period starts for ExchangesJanuary 1, 2014 – QHPs start offering services
through the Exchange
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Tribal Leaders and I/T/U managementmust devote attention toHealth Exchange decisionsnow through 2013.