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Missouri Health Exchange

Missouri Health Exchange. Health Insurance Exchanges - HIEx. HIEx – A government regulated standardized health care plan from which individuals may purchased insurance State Exchange Operated by the state Federally-Facilitated Exchange Operated in partnership with the state or

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Missouri Health Exchange

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  1. Missouri Health Exchange

  2. Health Insurance Exchanges - HIEx • HIEx – A government regulatedstandardized health care plan from which individuals may purchased insurance State Exchange • Operated by the state Federally-Facilitated Exchange • Operated in partnership with the state or • Operated solely by the federal government • Cornerstone of PPACA’s “individual mandate” • Required to be Certified & Operational by 01/2014

  3. States Position on Health Exchanges April 2013

  4. HIEx – Key Features • Guaranteed Issuance • Limited Price variation • Age 3:1 • Smoking Status 1.5:1 • Four Premium Tiers (Bronze to Platinum) w/ Coverage Ranges of 60%, 70%, 80%, & 90% • No Lifetime or Annual Limits

  5. HIEx – Key Features (cont) • Out-of-Pocket Limits • Individual - $6,350 • Family - $12,700 • Insurance Purchase Tax Credits for Individuals up to 400% Poverty • Requirements To Purchase Exchange Insurance • Must Live In US • US Citizen or Legal National • Not Currently Incarcerated • Employers w/ Fewer Than 100 Employees* * Prior to 2016 States can limit Exchange access to Employers with <= 50 employees, and starting in 2017 States can open Exchanges to Employers with > 100 employees.

  6. HIEx Coverage Clarification (Guaranteed Issuance) • This does not mean individuals can opt-in at any point • Enrollment is closed after March 31, 2014 except for individuals with a “Qualifying Event” • Loss of essential health coverage • Change in family structure • Change in citizen status • Government error with previous enrollment • Change in subsidy eligibility • Relocation to a new coverage area • Reaching Lifetime Limit on all benefits in grandfathered plan • Indian Heritage (entitled to monthly special enrollment) • Exceptional circumstance determined by HIEx or HHS (e.g. natural disasters)

  7. 2011 MO EMPLOYER MARKET

  8. Missouri Healthcare Market 1Excludes 151,200 Uninsured 0-18 • Outpatient Care • Emergency Room Visits • Hospitalization • Maternal & Newborn Care • Mental Health & Substance Use Treatments • Prescription Drugs • Rehabilitative & Habilitation Services & Devices • Lab Test • Preventive Services & Chronic Disease Care • Pediatric Services • PediatricDental • Pediatric Vision • In addition to the individual mandate for the uninsured, Obamacare will require individuals and employers enrolled in a non-grandfatheredhealthcare plan to replace their coverage with a plan that meets minimum new coverage standards. • Grandfathering requires that nothing in prior insurance plan changed since 3/2010 including co-pays

  9. Missouri HIEx Potential Impact WUSM B/E • 139% Medicare if All Payors Shift • 170% Medicare if All Payors Except Medicare & Medicaid Shift BJC B/E • 135% Medicare if All Payors Shift • 163% Medicare if All Payors Except Medicare & Medicaid Shift

  10. Key HIEx Plans

  11. Coventry – Missouri HIEx

  12. Coventry – Illinois HIEx

  13. HIEx Cost-Sharing Subsidies *Income Cap is subtracted from the premium of second lowest cost Silver plan and the resulting difference is the actual dollar subsidy.

  14. HIEx Individual Mandate(Non-Enrollment Penalty) Limited to individuals at 133% FPL + 2014 2015 2016 2017 3% Taxable IncomeModified AGI1 2% 1% Penalty Increases by: Rate of Inflation or 2.5% of Income GREATER OF OR OR OR Penalty Per Adult & Child2 Adult $95.00Child $47.50 Adult $325.00Child $162.50 Adult $695.00Child $347.50 Maximum Per Family3 3x Lessor of Above 3x Lessor of Above 3x Lessor of Above CAP • 1Income defined as total income in excess of filing threshold ($10,000 per Individual//$20,000 per family in 2013) • 2Child defined as individual under 18 • 3Penalty is pro-rated for the number of months individual is without insurance, though there is no penalty for a single gap in coverage of less than 3 months in a year. Penalty cannot exceed national average for Bronze-level premium.

  15. Example(Non-Enrollment Penalty 2014) Greater of = $500.00 Lessor of 3 x $190 = $570.00 = $500.00 Greater of = $1,000 Lessor of 3 x $237.50 = $712.50 = $712.50

  16. Family Deductibles for St. Louis

  17. Example Cost Liability for St. Louis (Least Costly Family Plan w/o HSA) * Cost sharing for individuals that select Silver Plan – 100%- <200% 2/3 reduction; 200%-250% = ½ reduction and 250%+-400% = 1/3 reduction.

  18. Monthly Premium Family w/ Subsidy  $2,100 Annual incremental cost to enroll in a plan where BJC & WUSM are PAR

  19. Proposed WUSM Charity Care Policy(For The New Market Dynamic) • Policy should be: • Politically & PR Sound • Fair & Equitable to All Patients (i.e. Uninsured & Insured) • Individuals with access to health insurance should be encouraged to purchase coverage, including: • Low income unemployed persons • Employed individuals without access to employer sponsored insurance • Self-employed individuals • The expected collection rate should be based solely on an individual’s FPL Underlying Principles

  20. Proposed Charity Care PolicyPercent of Charge Sought While BJC and WUSM utilized the same discount structure for Charity Care, implementation differed. BJC based its decision solely on a patients AGI. WUSM evaluated AGI and all known assets e.g. property holdings.

  21. Proposed Charity Care PolicyPercent of Charge Sought +30 +15 0 -10 -30 0 0 Point-of-Reference 50% ≈ WUSM’s contracted HMO/PPO Allowable

  22. Proposed Charity Care PolicyPercent of Charge Sought EXAMPLE Expected Purchase Level Bronze60/40 Silver70/30

  23. Proposed Charity Care PolicyPercent of Charge Sought EXAMPLE Expected Purchase Level Bronze60/40 Silver70/30 Rounded

  24. Proposed Policy Regarding Non-PAR Patients • Be Politically & PR Sound • Minimize alienation of referring providers • Look reasonable to WUSM providers • Look reasonable to patients caught in the middle • Play well if addressed in the local media • Mitigate legal exposure to the extent possible • Discourage Plan Carve-Out Initiatives Underlying Principles Policy should:

  25. Proposed Policy Regarding Non-PAR Patients Non-PAR (insured) patients will not be scheduled for an office appointment until an SPA is executed with the patient’s health insurance carrier: • SPA shall require 100% payment due from the carrier • SPA shall require payment within 30 days of bill date • SPA shall require payment at a charge recover level comparable to WUSM’s terms with similar payors. • Commercial HMO/PPO – 75% Charge. (Note: This is equivalent to WUSM’s rate with contracted out-of-area payors that primarily refer tertiary level patients) • Federal HIEx – 50% Charge. (Note: this is comparable to WUSM’s contracted Federal HIEx rate and WUSM’s rate with contracted in-area Commercial HMO/PPO payors)

  26. Proposed Non-PAR Patient PolicyCommercial HMO/PPO/Private Exchange REMAINS UNCHANGED FROM CURRENT APPROACH

  27. Proposed Non-PAR Patient PolicyFederal Exchange

  28. Providing Guidance to HIEx Eligible Patients • Three BJC employees have received Certified Application Counselor status • WUSM has been approved as a Certified Application Counselor site • Currently in the process of securing certification for 4 financial counselors (2 located at CAM, 2 at West Campus) • Goal is to counsel qualified patients on how to secure HIEx coverage and what plans will allow access to Medical Center resources • BJC seeking Broker community interest in signing patients up for HIEx(s)[low/marginal commission business] • WU including HIEx information in pre-65 retiree mailing

  29. Feedback From Local Broker Community

  30. Broker Feedback • We should expect employers to react to the changing market dynamic • Expect employers that had previously resisted discontinuing spouse/dependent coverage, due to lack of insurance options for spouses/dependents with a pre-existing medical condition, to move spouses/dependents to an Exchange • Currently seeing large employers moving to fully insured while medium sized groups tend to be moving to ASO relationships. • Do not expect the Massachusetts’ results to occur in our market, the market dynamics are very different in terms of distribution of medical resources and patient social/demographic variables. • At least one Broker indicated their company was looking at establishing a private exchange. • Brokers, as a group,  appeared lukewarm to assigning agents to assist individuals with signing up with the Exchanges.  Viewed as a low margin commission business.

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