Patient Protection and Affordable Care Act (PPACA): Understanding Health Insurance Exchange

1. Patient Protection and Affordable Care Act (PPACA): Understanding Health Insurance Exchange Center for Healthy Communities Annual Meeting July 10, 2013 presented by Kate Cauley

2. Two major components of PPACA 1. Enrollment Mandate • Health Insurance Exchange/Health Insurance Marketplace • Federally facilitated marketplace • Qualified Health Plans (QHPs) • Essential Health Benefits (EHBs) • Enrollment process

3. Federally Facilitated Marketplace The on-line site for Ohio, called the Health Insurance Marketplace, will be operated through the US Department of Health and Human Services. The Ohio Department of Insurance will perform “plan management” for insurance companies offering services in Ohio.

4. Qualified Health Plans Health Insurers who are QHPs must: • be licensed and in good standing • include a sufficient choice of providers including at least 20% of “essential community providers” • include a comprehensive package of covered items known as essential health benefits • agree to abide by all regulations regarding marketing, premium rating and prohibitions on pre-existing conditions

5. Qualified Health Plans, cont. Health Insurers who are QHPs must: • offer multiple tiers of plans: bronze, silver, gold, platinum, or catastrophic cost sharing • use standard format for presenting health benefit plan options • use standardized single application form • limit out-of-pocket spending

6. Qualified Health Plans, cont. Ohio Department of Insurance also requires: • no annual or lifetime dollar limit permitted on EHBs and services • Coverage must be substantially equal to Ohio EHB Benchmark Plan (Anthem’s Blue 6.0 – Blue Access PPO-Medical Option #D4/Rx Option G) • Except for Rx, if a plan substitutes benefits it must be in accordance with Ohio EHB Benchmark Plan use standardized single application form

7. Essential Health Benefits • Ambulatory patient services • Emergency services • Hospitalization • Maternity and newborn care • Mental health and substance abuse treatment • Prescription drugs

8. Essential Health Benefits, cont. • Rehabilitative and habilitative services and devices • Laboratory services • Preventive and wellness services and chronic disease management • Pediatric services, including oral and vision care

9. Enrollment Process On-line application process provides: • one application for all plans • on-line comparison of all plans re: premiums, benefits packages, ratings • electronic calculator to process costs of various premiums, deductibles, etc. State will provide federally funded/trained Navigators

10. FAQs • If I have health insurance through my employer can I shop in the Marketplace? • I can’t afford the premiums how do I get subsidies? • What if I can’t apply on line?

11. Resources • https://www.healthcare.gov/what-is-the-health-insurance-marketplace#state=ohio • http://www.healthpolicyreview.org/daily_review/2013/06/hpio-releases-brief-detailing-aca-health-insurance-marketplaces.html?utm_source=feedburner&utm_medium=feed&utm_campaign=Feed%3A+typepad%2Fhealthpolicyreview+%28Ohio+Health+Policy+Review%29