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Health Insurance Marketplaces: Opportunities and Challenges
Barbara Eyman Principal, Eyman Associates
General Counsel, America’s Essential Hospitals
Xiaoyi Huang Assistant Vice President for Policy, America’s Essential Hospitals
October 1, 2013
PATCHWORK OF COVERAGE PROGRAMS:
STATE VARIATIONS
MARKETPLACE IN AN EXPANSION STATE
FPL
400%
300%
200%
100%
Children Undocumented
Immigrants
Adults w/o
Children
People with
Disabilities
Parents Pregnant
Women
0%
250%
Exchange
Subsidized
Unsubsidized
133%
63% 75%
185%
Legal
Immigrants
5-year bar
Medicaid Medicaid Expansion
Modified from slides originally developed by the Center for Budget Policy & Priorities
MARKETPLACE IN AN EXPANSION STATE: SHIFT OVER TIME
FPL
400%
300%
200%
100%
Children Undocumented
Immigrants
Adults w/o
Children
People with
Disabilities
Parents Pregnant
Women
0%
250%
Exchange
Subsidized
Unsubsidized
133% 185%
Legal
Immigrants
5-year bar
Medicaid Expansion Medicaid
63% 75%
Modified from slides originally developed by the Center for Budget Policy & Priorities
MARKETPLACE IN AN EXPANSION STATE WITH BASIC HEALTH PROGRAM
FPL
400%
300%
200%
100%
Children Undocumented
Immigrants
Adults w/o
Children
People with
Disabilities
Parents Pregnant
Women
0%
250%
Exchange
Subsidized
Unsubsidized
133% 185%
Legal
Immigrants
5-year bar
0%
Medicaid Expansion Medicaid
63% 75%
Basic Health Plan
Modified from slides originally developed by the Center for Budget Policy & Priorities
MARKETPLACE IN ARKANSAS
FPL
400%
300%
200%
100%
Children Undocumented
Immigrants
Adults w/o
Children
People with
Disabilities Parents Pregnant
Women
0%
250%
Exchange
Subsidized
Unsubsidized
133%
63% 75%
185%
0%
Legal
Immigrants
5-year bar
Medicaid Medicaid Private Option
Modified from slides originally developed by the Center for Budget Policy & Priorities
MARKETPLACE IN ARKANSAS: SHIFT OVER TIME
FPL
400%
300%
200%
100%
Children Undocumented
Immigrants
Adults w/o
Children
People with
Disabilities
Parents Pregnant
Women
0%
250%
Exchange
Subsidized
Unsubsidized
133%
63% 75% 0%
Legal
Immigrants
5-year bar
63% 75%
185%
Medicaid Medicaid Private Option
Modified from slides originally developed by the Center for Budget Policy & Priorities
MARKETPLACE IN NON-EXPANSION STATE
FPL
400%
300%
200%
100%
Children Undocumented
Immigrants
Adults w/o
Children
People with
Disabilities
Parents Pregnant
Women
0%
250%
Exchange
Subsidized
Unsubsidized
133%
63% 75%
185%
0%
Legal
Immigrants
5-year bar
Medicaid
Modified from slides originally developed by the Center for Budget Policy & Priorities
THEMES ACROSS COVERAGE PROGRAMS
Eligibility vs. enrollment
Churning
Scope of coverage
Cost-sharing affordability
Premium affordability
Continuous coverage?
Churning
Available providers
Payment rates
Inclusion in networks
Bad debt
Supplemental payments
Continuity of care
POS enrollment Innovation across populations
PATIENTS PROVIDERS
FOCUS ON EXCHANGES
ENROLLMENT OPENS OCT. 1
TOP OF MIND MARKETPLACE ISSUES
America’s Essential Hospitals
Essential Community Providers
• Are you an ECP? • State vs. Federal
standards • Inclusion in plan
networks? • Rates?
Premiums • Affordability? • Continuity of
coverage
Cost Sharing • Affordability? • Bad debt • Charity care
Other challenges/issues/opportunities/successes?
Enrollment and
Outreach
Implications of Delays • Employer Mandate • Drug costs
TIMELINE FOR IMPLEMENTATION
Delayed On Time
ACA Provision New Date
Single out-of-pocket spending limit for medical services/drugs
2015
Employer mandate (penalties) and reporting
Jan. 1, 2015
SHOP exchange enrollment Nov. 1, 2013
Income verification state-based exchanges
2015 (sampling permitted)
Basic Health Plan 2015
State technical delays (DC, OR, CO, others)
?
ACA Provision Date
Enrollment in individual exchanges
Oct. 1, 2013
Exchange coverage begins Jan. 1, 2014
Medicaid Expansion (opting states)
Jan. 1, 2014
Individual mandate Jan. 1, 2014
Insurance reforms Jan. 1, 2014
Income verification federal exchanges
Jan. 1, 2014
Medicaid coverage preventive services
Jan. 1, 2013
Medicaid PC payments Jan. 1, 2013
VARIATION IN EXCHANGE PREMIUMS
$-
$50
$100
$150
$200
$250
$300
AZ FL GA IA IL MI MO NJ NM OH PA TN TX VA WV
Catastrophic
Bronze
Silver
Gold
(Lowest Monthly Premium by Metal Category)
(60% AV)
(70% AV)
(80% AV)
VARIATION IN EXCHANGE PREMIUMS
$-
$50
$100
$150
$200
$250
$300
AZ FL GA IA IL MI MO NJ NM OH PA TN TX VA WV
Bronze
(Lowest Monthly Premium by Metal Category)
$209
$104
NJ TX
(60% AV)
VARIATION IN EXCHANGE PREMIUMS
$-
$50
$100
$150
$200
$250
$300
AZ FL GA IA IL MI MO NJ NM OH PA TN TX VA WV
Silver
(Lowest Monthly Premium by Metal Category)
$241
$128
NJ PA
(70% AV)
PREMIUM AFTER TAX CREDIT
Example 27-Year-Old with an Income of $25,000
AZ
FL
GA
IA
IL
MI
MO
NJ
NM
OH
PA
TN
TX
VA
WV After TaxCredit
LowestBronze
AZ
FL
GA
IA
IL
MI
M…
NJ
N…
OH
PA
TN
TX
VA
WV After TaxCredit
2nd lowestSilver
$145 $80
$120
VA
AZ
MARKETPLACE COST-SHARING ASSISTANCE
• Cost-sharing subsidies available for individuals with incomes between 100% and 250% of FPL
• Requires enrollment in a silver plan (actuarial value 70%) • Effectively increases the actuarial value of the plan
• Out-of-pocket limits also lower between 100% and 400% FPL
Income Level Actuarial Value
100-150% FPL 94%
150-200% FPL 87%
200-250% FPL 73%
Income Level Reduction in Out-of-Pocket Liability
100-200% FPL 2/3 of maximum ($2,117 in 2014)
200-300% FPL 1/2 of maximum ($3,175 in 2014)
300-400% FPL 1/3 of maximum (4,233 in 2014)
TOP OF MIND MARKETPLACE ISSUES
America’s Essential Hospitals
Essential Community Providers
• Are you an ECP? • State vs. Federal
standards • Inclusion in plan
networks? • Rates?
Premiums • Affordability? • Continuity of
coverage
Cost Sharing • Affordability? • Bad debt • Charity care
Other challenges/issues/opportunities/successes?
Enrollment and
Outreach
Implications of Delays • Employer Mandate • Drug costs
