I am at the World Health Care Congress Health Plan Innovation Conference.
Check out the agenda here: http://www.worldcongress.com/events/HL10009/
I will be live blogging a number of the sessions so watch out for a stream of posts and tweets. These notes are being taken and published in real time so please forgive spelling errors or information omissions.
Health Plans may be thinking about innovation but that doesn't seem to extend to Twitter. I couldn't find a #hashtag for the conference so I am creating one: #whchpi (World Health Congress Health Plan Innovation)
The workshop is led by Joshua Goldberg of NAIC who is updating attendees on Insurance Exchanges.
Topics to be covered:
- Exchange Functions and Responsibilities
- Benefits packages
Two Exchanges: SHOP - Small Group and Individual.
Non-Profit or Government Agency run.
There will be annual open enrollment and special enrollment (eg. for major change in conditions for individuals)
3/23/11 - HHS Awards planning and establishment grants.
1/1/13 - HHS Certifies State Readiness
1/1/14 - Coverage Effective
We are currently in the Policymaking phase. States are creating legislation and rules
By Mid-2011 Federal and State build outs start.
Mid 2012 Plans will begin certification
In 2013 Marketing and Outreach will start.
End of 2013 Enrollment will start.
Structure & Governance:
- State Agency (existing infrastructure, accountability but procurement could present challenges)
- Non-Profit created by the State (expected to be most popular option - gives flexibility, avoids conflict of interest, insulated from politics, but that brings less accountability)
- Federally Operated (Less work for States, difficulties working with multiple states and agencies, regulatory authority is ceded to Federal Government)
Role of State Agencies
Dept of Insurance will continue licensure, certification and market conduct and enforcement.
Medicaid will determine eligibility and enrollment issues and subsidy administration.
Governor will provide political leadership.
Exchanges: Individual and Small Group (SHOP)
Individual exchange will be sole source of subsidies.
Small Group is 1-100 Employees (can keep 2-50 classification until Jan 1, 2016)
Groups expanded down to include groups of 1 - effective now.
There is an option to combine non-group and small group markets. States will probably wait on that decision.
Employees may have a choice of carrier.
- Employer may choose coverage level
- Employees choose carriers offering the level of coverage approved by employer.
- Employees will be individually rated. Different rates for each employee (based on age etc.)
- States may band together
- May or may not involve risk pooling
multiple subsidiary exchanges. e.g. Geographic coverage. This is an unlikely option.
Basics required by Federal Law. States can exceed requirements.
- Procedures for certification (cert/re-cert/de-cert)
- Toll Free hotline
- Website with standardized information
- Ratings for plans
- Standard format to present coverage options
- Inform individuals of eligibility or Medicaid, CHIP or other state, local or public programs.
- Certify exemptions from individual mandate.
- Provide Calculator to determine actual cost of coverage
- Provide treasury with list of exempt individuals and individuals eligible for tax credits.
- Provide a Navigator program
Additional Optional Functions:
- Selective Contracting (may restrict number of plans allowed to participate in Exchange
- Require price concessions or extra benefits and services
- Single Risk Pool requirement (require same price on and off exchanges)
- Application and Enrollment (can just refer to agents or carriers.)
- Premium Collection (Could be important service in SHOP program to reduce complications for small businesses - reduce number of payments made)
This is not covered in current legislation because premium collection would be classed as Federal Revenue - adversely boosting the apparent cost of legislation - even though all monies collected would be passed through to carriers.
Qualified Health Plans:
- Licensed and providing essential benefits
- 1 Silver and 1 gold plan
- Same price on and off the exchange
Bronze: 60% of actuarial value of benefits
Only Silver and Gold mandated.
Qualifying as a Certified Health Plan:
- Meet Marketing requirements
- Meet network adequacy Requirements
- Be accredited by an org recognized by HHS
- Implement Quality Improvement Strategies
- Utilize uniform enrollment form and standardized format to present plan options
Form design has been delegated to national association of Insurance Commissioners.
- Bidding to reduce premiums
- Standardized cost sharing
- Mandate Bronze and Platinum plans
- More Quality Improvement activity
- More disclosures
- Provider Quality information disclosure
- More benefits
- Feds to foster creation of qualified nonprofit insurers.
-- Loans for Startyp costs
-- Grants to meet solvency requirements (grants to be repaid)
-- $6B available
- Governed by majority vote of members
- US Office of Personnel Management (OPM) 2 plans in all 50 states
- Similar to FEHBP process
- Insurers must be licensed in every state
- Benefits uniform across states (but states may require additional benefits)
- States may require plans to meet rating requirements
[Ed: ie. all the same but different]
Roles exist for Agents
States need to examine agent compensation mechanisms
Navigators should not fill Agent role
Navigators are people/organizations that assist people in selecting appropriate plans.
- Funded by State grants
- (Trade, industry, chambers of commerce, unions, licensed brokers) can advise
- Conduct public education and distribute information
- Facilitate enrollment
- Provider Referrals to consumer assistance offices
- HHS to develop standards to ensure that navigators are qualified and licensed if appropriate.
- Navigators may not receive direct or indirect compensation from insurers for enrollment.
Department of Insurance
See previous post: http://ekivemark.posterous.com/insurance-exchange-market-oversight for graphic.
- Insurance Law
- If state doesn't enforce then HHS will.
Challenges: Adverse Selection
Plans not in the exchange could cause adverse selection by offering non-standard or minimum benefits.
- Young and Healthy are uncovered (penalties are low - start at $95)
- Small group market expansion (groups of one and expansion from max of 50 to up to 100 employees.
Addressing Adverse Selection:
2014-16 Reinsurance entity will be established. Plans will pay fee in to this entity. $10B to be collected. 15% of premium collection in individual market.
- IT Systems and Interoperability
-- Medicaid eligibility
-- Income Verification
-- Legal Residency status
- Legacy systems require revamping.
- Other Reforms
-- NAIC American Health Benefit Exchange Model Act.
--- Adopted Dec 2010
--- Provides framework for States to begin development of exchanges
--- 19 States are adopting the NAIC model.
--- 9 using another model
--- 2 existing exchanges
- Public Expectations
- Politics and plenty of it (e.g. Election in 2012)