Racing to New Coverage Opportunities:Final Steps to Help You Prepare for Enrollment
September 11, 2013
Educating Patients About The New Health Insurance Exchanges
Marc Boutin Executive Vice President & Chief Operating Officer
National Health Council
© National Health Council
Helping VHAs Educate Patients About Exchanges
Training and EducationThrough education, NHC will lay a foundation for VHAs on insurance marketplaces and Medicaid expansion
1
Patient Advocacy ToolsTools will help advocates assist patients through implementation activities
2
Key MessagesKey messages will launch each month and build off messages tested by national partners
3
© National Health Council
Training and Education
Webinars: July 2013: Explain the exchanges,
discuss role of patient organizations in educating people with chronic conditions
August 2013: Discuss tools NHC is developing, hear from three VHAs about their initiatives
September 11, 2013: Update on exchanges and NHC tools, discuss information patients need when they enroll
© National Health Council
Tools: Customizable resources, such as fact sheets
and one-pagers (e.g., enrollment assistance programs, financial protections)
Infographics
Assistance in choosing an appropriate plan, capturing feedback on any problems, cataloging patient stories
Patient Advocacy Tools
© National Health Council
Key Messages
Samples: There will be new, affordable insurance options
available for people without insurance.
All insurance plans will have to cover doctor visits, hospitalizations, maternity care, emergency room care, and prescriptions.
Financial help is available so you can find a plan that fits your budget.
If you have a pre-existing condition, insurance plans cannot deny you coverage.
Help will be available online, by phone, and in person to find the plan that works best for you.
State Exchanges and Medicaid Expansion:
What do you need to know?
Corey FordSenior Manager
Avalere Health, LLC
The ACA Is Expected to Reduce Number of Uninsured, Primarily through Enrollment in Medicaid and Exchanges
10
2013 2014 2015 2016 2017
49 40 35 26 24
50 55 57 58 59
16 13 12 11 10
144 144 145 146 147
5 5 5 5 5
50 52 53 55 56
314 317 319 322 325
8 12 22 24
EXPECTED SOURCES OF COVERAGE (IN MILLIONS), 2013-2017
TotalMedicareOther Public ProgramsEmployerNon-Group ExchangesMedicaid & CHIP
Source: Avalere Enrollment Model, August 2013, Scenario 2 (assumes 26 states opt out of the Medicaid expansion)ACA: Affordable Care Act
To Date, 24 States & DC Plan to Expand Medicaid Eligibility in 2014, 23 Will Not Expand, and the Remainder Are Undecided
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Source: Avalere State Reform Insights, Updated September 6, 2013*AR and IA have submitted waivers to use premium assistance models with exchange plans for parts of their expansion populations; TN is considering a similar model for expansion beneficiaries**MI’s expansion will likely take effect in March or April 2014 and will require waiver approval from CMS for a number of provisions, including the use of HSAs.
AK
HI
CA
AZ
NV
OR
MT
MN
NE
SD
ND
ID
WY
OK
KSCO
UT
TX
NMSC
FL
GAALMS
LA
AR*
MO
IA*
VA
NCTN*
IN
KY
IL
MI**
WI
PA
NY
WV
VT
ME
RICT
DEMD
NJ
MANH
WA
OH
DC
Will Expand (24 + DC)
Will Not Expand (23)
STATE COMMITMENT TO EXPAND MEDICAID ELIGIBILITY IN 2014
Leaning No (3)
States That Expand Will Face a Significant Influx of New Medicaid Enrollees
12
AK
HI
CA
AZ
NV
OR
MT
MN
NE
SD
ND
ID
WY
OK
KSCOUT
TX
NMSC
FL
GAALMS
LA
AR*
MO
IA
VA
NCTN*
IN
KY
IL
MIWI
PA
NY
WV
VT
ME
RICT
DEMD
NJ
MANH
WA
OH
DC
PERCENT INCREASE IN MEDICAID ENROLLMENT AS COMPARED TO BASELINE COVERAGE, 2022
Opting Out (26)
≥ 50.1% (7)
25.1-50.0% (10)
≤ 25.0% (7 + DC)
*AR will offer premium assistance to Medicaid beneficiaries; thus, new Medicaid enrollment is low as these individuals are captured in exchange enrollment.Source: Avalere Enrollment Model, August 2013, Scenario 2 (assumes 26 states opt out of the Medicaid expansion).
Newly Eligible Enrollees Will Have Different Characteristics Than Current Medicaid Beneficiaries
13
1. Avalere Enrollment Model, August 2013, Scenario 2 (assumes 26 states opt out of the Medicaid expansion).2. All figures except condition information from U.S. Census Bureau, Current Population Survey, Annual Social and Economic Supplement, 2012. Percentages based on demographics of uninsured individuals with incomes under 125% FPL. CPS data is for coverage in 2011. Figures may not sum due to rounding. Condition information from 2010 Medical Expenditure Panel Survey (MEPS).
CHARACTERISTICS OF NEWLY ELIGIBLE MEDICAID ENROLLEES COMPARED TO
CURRENT ENROLLEES2
● ~83% previously uninsured
● 83% of newly eligible Medicaid enrollees will be adults age 19-64
o Compared to 42% of the current population—reflecting a large portion of children in current program
● Better reported self-health than current enrollees
o 87% of newly eligibles compared to 72% of current enrollees report good to excellent health, which may be due to representation of the disabled among current enrollees
● Lower incidence of common chronic conditions than adults (18-64) currently enrolled and spend less per capita, than current enrollees
o May have undiagnosed conditions
2013 2014 2015 -
5
10
15
20
25
30
35
40
45
50
55
60
65
5055 57
MEDICAID AND CHIP ENROLLEES, 2013, 2014, 2015 (IN MILLIONS)1
NU
MB
ER
OF
EN
RO
LLE
ES
(M
ILLI
ON
S)
15 States and DC Will Run Exchanges, 7 States Approved for Partnership, 8 states scheduled for Marketplace Plan Management
14
Source: Avalere State Reform Insights, August 15, 2013* Utah will operate a marketplace plan management model for its individual exchange and rely on its existing small group exchange for the SHOP exchange. ** New Mexico will operate a partnership for its individual exchange, but run its own SHOP exchange. *** Although Idaho will operate a state-based exchange, it will rely on HHS for certain functions, such as eligibility and enrollment .
AK
HI
CA
AZ
NV
OR
MT
MN
NE
SD
ND
ID***
WY
OK
KSCO
UT*
TX
NM**SC
FL
GAALMS
LA
AR
MO
IA
VA
NCTN
IN
KY
IL
MI
WI
PA
NY
WV
VT
ME
RICT
DEMD
NJ
MANH
WA
OH
D.C.
FFE – MPM (8)
State-Run (15 + DC)
FFE (20)
Partnership (7)
2014 INSURANCE EXCHANGE OPERATIONAL MODEL
Approximately 26 Million Are Expected to Enroll in Coverage through Exchanges
15
AK
HI
CA
AZ
NV
OR
MT
MN
NE
SD
ND
ID
WY
OK
KSCO
UT
TX
NM
SC
FL
GAALMS
LA
AR
MO
IA
VA
NC
TN
IN
KY
IL
MIWI
PA
NY
WV
VT
ME
RICT
DEMD
NJ
MANH
WA
OH
D.C.
≤ 100,000 (8 + DC)
≥ 501,000 (17)
251,000-500,000 (14)
101,000-250,000 (11)
TOTAL ENROLLMENT IN EXCHANGE COVERAGE, 2022
Source: Avalere Enrollment Model, August 2013, Scenario 2 (assumes 26 states opt out of the Medicaid expansion ).
EXCHANGE ENROLLEES, 2014 (MILLIONS)1
NU
MB
ER
OF
E
NR
OLL
EE
S(M
ILLI
ON
S)
1. Avalere Enrollment Model, August 2013, Scenario 2 (assumes 26 states opt out of the Medicaid expansion ).2. All figures except condition information from U.S. Census Bureau, Current Population Survey, Annual Social and Economic Supplement, 2012. Percentages based on demographics of uninsured individuals with incomes between125%-400% FPL. CPS data is for coverage in 2011. Condition information from 2010 Medical Expenditure Panel Survey (MEPS).
About 8 Million Will Enter the Exchange in 2014 with Different Health Profile Than the Currently Insured
16
20141
2
3
4
5
6
7
8
9
10
7
1
Subsidized Unsubsidized
Characteristics of Subsidized Exchange Enrollees Compared to Employer Population2
~65% previously uninsured
58% of enrollees are adults < age 45
» Compared to 43% of employer population
45% White, 34% Hispanic and 13% Black
» Percentage of Hispanic enrollees is double that of employer population
Worse reported self-health than individuals with employer coverage
» Over 90% still report good to excellent health
Lower incidence of common chronic conditions than adults (18-64) with employer coverage
» May have undiagnosed conditions
Spend less per capita, than individuals with employer coverage
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ISSUER COMPETITION BY STATE, INDIVIDUAL MARKET
A Majority of States Will Operate with a Lower Number of Issuer Competition in the Individual Exchange Market
AK
HI
CA
AZ
NV
OR
MT
MN
NE
SD
ND
ID
WY
OK
KSCOUT
TX
NMSC
FL
GAALMS
LA
AR
MO
IA
VA
NCTN
IN
KY
IL
MIWI
PA
NY
WV
VT
ME
RICT
DEMD
NJ
MANH
WA
OH
DC
1-3 Issuers (14 + DC)
4-6 Issuers (15)
7-9 Issuers (4)
10+ Issuers (8)
Source: Avalere State Reform Insights, Updated September 5, 2013
Information Undisclosed (9)
StateEnrollment
Number Rank
Expected lives in 2016
Aetna* Cigna HumanaUnited
HealthcareWellPoint
CA 1 2,601,000 X
FL 3 1,719,000 X X X
OH 6 783,000 X X X
NC 7 780,000 X
GA 9 724,000 X
MI 11 653,000 X X
NY 4 1,079,000 X X
VA 13 541,000 X X
National Carriers Are Participating in Markets Where They Have Experience—Not Where Most Enrollment Will Likely Be
Source: State Reform Insights, August 23, 2013*Includes participation of Coventry, given the acquisition was finalized on May 3, 2013. Given the timing of the acquisition, there will likely be QHPs under the Aetna and Coventry name. Note: The following states have not yet announced what carriers are participating in their state: TX, IL, NJ, PA, WI. 19
NATIONAL CARRIERS ARE RELYING ON EXPERIENCE AND PROVIDER NETWORKS TO DESIGN COMPETITIVE PRODUCTS
Regional and Local Players Likely to Dominate Exchange Markets in Early Years
20
National players (e.g., United, Aetna)
● Strategically deciding which state exchanges they choose to participate
Regional players (e.g., Blues, Kaiser)
● Less flexibility to decide whether to play, likely to be key participants, to maintain market share
Medicaid-only plans (e.g., Centene, Molina)
● Uniquely positioned to provide health care for individuals churning from Medicaid into exchanges
Source: Avalere Research based on 41 states plus DC that have released data about carrier participation, August 2013. *Regional plans include any Blues plans and Kaiser plans. ** Provider Sponsored plans include plans with a relationship with physician groups or part of an ACO.
Carrier by Plan Type (% of number of plans)
22%
31%12%
11%
15%
9%
RegionalLocal
Medicaid MCO
National
Provider Sponsored
CO-OP
It will be critical to identify top enrollment plans in key markets as targets for engagement. These plans are likely to be distinct from major commercial players today
Average Monthly Plan Premiums Across All Metal Tiers for Nonsmoking 40-year olds for Exchange Plans
Rates are for plans filed to be offered through exchanges for nonsmoking 40-year-old individual. Data are for the averages across all regions within a state. Based on rate filings, CT, IN, and WA do not appear to have any platinum plans available on the exchange. MD only provided rate filings for bronze and silver products. Source: Avalere Health analysis of health insurance rate filings publicly available as of August 30, 2013.
CA (12) CT (3) IN (5) MD (4) NY (16) OH (12) SD (3) VT (2) VA (8) WA (4) $200
$250
$300
$350
$400
$450
$500
$550
$600
$650
Platinum
STATE (NUMBER OF CARRIERS)
MO
NT
HL
Y P
RE
MIU
M
21
Six States Will Go Beyond Federal EHB to Require Standardized Benefits in their Exchanges
22
COST-SHARING IN SELECT STANDARDIZED SILVER PLANS
Source: State Reform Insights, July 15, 2013*Benefit cost-sharing parameters are specific to individuals. Deductibles and OOP max may be higher for family coverage. **All plans must comply with the annual limitation on OOP maximums for medical and drug benefits ($6,350 in 2014). †California’s silver copay and coinsurance plan designs vary in cost sharing for advanced imaging and home health care services as well as in the accumulation of certain cost sharing towards the deductible. ‡For brand drugs only §Parameters vary for mail-order pharmacies
State Plan Type Benefit Cost-Sharing Parameters*
Overall Deductible
Drug Deductible
Drug Formulary
Inpatient
Emergency Room
Primary Care Physician
Specialist
OOP Max for Drugs
Tier 1
Tier 2
Tier 3
Tier 4
CA
Silver Copay† Medical:$2,000 $250‡ $25 $50 $70 20% 20% $250 $45 $65 N/A
Silver Coinsurance†
Medical:$2,000 $250‡ $25 $50 $70 20% 20% $250 $45 $65 N/A
Silver HSA $1,500 N/A 20% 20% 20% 20% 20% 20% 20% 20% N/A
CT Standard Silver Medical:$3,000 $400 $10 $25 $40 40% $500 $150 $30 $45 N/A
MA Silver $2,000 N/A $20§ $35§ $70§ N/A $1,000 $250 $30 $50 N/A
NY Silver $2,000 N/A $10§ $35§ $70§ N/A $1,500 $150 $30 $50 N/A
OR Silver $2,500 $0 $15 $50 50% 50% 30% 30% $35 $70 N/A
VT
Silver Deductible $1,900 $100‡ $12 $50 50% N/A 40% $250 $20 $40 $1,250
Silver- HDHP $1,550 $1,250 $10 $40 50% N/A 20% 20% 10% 20% $1,250
Patients Meeting the OOP Cap Expected to be Underinsured
23
A study of families receiving unsubsidized insurance through the Massachusetts exchange — established in 2006 — indicates that those on the lower end of the income spectrum, those with fair to poor health, and those with more children, often faced high levels of financial burden due to out-of-pocket costs for care.2
100% FPL 150% FPL 200% FPL 250% FPL 300% FPL 400% FPL 500% FPL0%
5%
10%
15%
20%
25%OUT-OF-POCKET CAP AS A PERCENT OF INCOME1
OOP cap as a % of income Underinsured threshold
1. Based on CWF definition: out-of-pocket expenses equaled 10% or more of income; out-of-pocket expenses equaled 5% or more of income if low income (<200% of poverty); or deductibles equaled 5% or more of income. Available at: http://www.commonwealthfund.org/~/media/Files/Publications/Fund%20Report/2013/Apr/1681_Collins_insuring_future_biennial_survey_2012_FINAL.pdf 2. Health Affairs, Some Families Who Purchased Health Coverage Through The Massachusetts Connector Wound Up With High Financial Burdens, April 2013. Available at: http://content.healthaffairs.org/content/early/2013/04/15/hlthaff.2012.0864.full.pdf+html
Lives Served by Market Today
Anticipated Future Market
Less Generous More GenerousBenefit Design Generosity
Commercial
Exchange
MedicaidCatastrophic
Exchange Plans May Have Spillover Effects by Setting a New Low Standard for Coverage Generosity
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© National Health Council
Choosing the Best Plan for You: Tips to Navigate Exchange Websites
Kelly BrantleySenior Manager
Avalere Health, LLC
The Federally Facilitated Marketplace Consumer Hotline and Additional Resources Are Available Now
28
LIVE CHAT
RESOURCES INCLUDE: CALL CENTER, LIVE CHAT, AND FAQ GUIDE
CALL CENTER
Federally Facilitated Website Currently Operating A Tool to Help People Determine Possible Coverage Options Prior to Oct. 1
29
A SERIES OF QUESTIONS WILL HELP YOU DETERMINE IF YOU WILL LIKELY BE ELIGIBLE FOR EXCHANGES, MEDICAID, AND/OR FINANCIAL ASSISTANCE
Applying for Coverage on Healthcare.gov Includes a Set of Required Application Information
30
Applicants must enter:
• Contact information, including
address, phone number, preferred
language, and preferred method of
contact.
• Social security number, federal tax
information, status of dependents,
and race
• Household, dependent, and spousal
information
• Income information using pay stubs
and W-2 forms.
The Site Then Calculates an Eligibility Determination for Financial Assistance
31
APPLICANTS ARE NOTIFIED IN REAL TIME IF THEY ARE ELIGIBILE FOR ADVANCE PREMIUM TAX CREDITS, COST SHARING REDUCTIONS, AND/OR MEDICAID
Real time eligibility
notification
Educational Slides Prior to Metal Tier and Plan Comparison
32
HEALTHCARE.GOV ATTEMPTS TO INCREASE HEALTH LITERACY AMONGST CONSUMERS
Before the applicant reviews metal tier options and plans, they will review three slides that briefly explain: Essential Health Benefits, actuarial value of the five metal tiers, and general cost-sharing information (i.e., “the lower the premium, the higher the out-of-pocket costs
when you need care”)
How to Navigate Metal Tiers, Comparing Health Plans as well as Key Information Available for Direct Comparison
• The applicant is provided information
about the number of plans in each
level, the high and low monthly
premiums, average co-pay, average
deductible, and out-of-pocket
maximum. Applicants may select one
or more metal tiers.
• After selecting the tier, applicants are
brought to a list of available plans.
Applicants have the option to sort plans
by: maximum out-of-pocket, premium,
and deductible
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Using Expected Healthcare Needs to Select a Plan: Formularies, Provider Networks, and Out-of-Pocket Costs
35
● FORMULARIES
− Applicants will access plan formularies by expanding the “Prescription Drug Coverage” section and clicking on a link that will take the applicant to the issuer’s website
● PROVIDER NETWORKS
− Applicants will access the plan’s provider network by clicking on the “Provider Directory” link that is part of the initial information displayed for each plan
● OUT-OF-POCKET COSTS
− It is important to note that the out-of-pocket calculator and information available on the website may not accommodate personal health care needs
Applicants may find it difficult to quickly and accurately compare provider networks and formularies from different issuers due to the lack of standardization for formatting and the separate search function
Keep in Mind the Following Strategies for Protection against Fraud in the Marketplace
● BE INFORMED. Learn about the basics of health care at healthcare.gov and compare insurance plans in order to make an informed final decision
● PROTECT YOUR PERSONAL INFORMATION. Do not give out any personal health information. Do not give your Social Security number or credit card or banking information to companies you didn’t contact or in response to unsolicited advertisements.
● ASK QUESTIONS, VERIFY ANSWERS. The Marketplace has trained and certified assisters available to help if the information is unclear. Keep the contact information of any salesperson that assists you. Contact healthcare.gov to utilize the live chat options or the call center if you need to verify answers
● REPORT SUSPICIOUS ACTIVITY. Any suspected fraud can be reported to the Health Insurance Marketplace consumer call center at 1-800-318-2596
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