Robert E Goff Health Insurance ExchangeHIX
Small business tax credit • Prohibitions against lifetime benefit caps & rescissions • Phased-in ban on annual limits • Annual review of premium increases • Public reporting by insurers on share of premiums spent on non-medical costs • Preventive services coverage without cost-sharing • Young adults on parents’ plans Before the Exchanges Big Change • State insurance exchanges • Medicaid expansion • Small business tax credit increases • Insurance market reforms including no rating on health • Essential benefit standard • Premium and cost sharing credits for exchange plans • Premium increases a criteria for carrier exchange participation • Individual requirement to have insurance • Employer shared responsibility penalties • Phased-in ban on annual limits • States adopt exchange legislation and begin implementing exchanges • Penalty for individual requirement to have insurance phases in (2014-2016) • Option for state waiver to design alternative coverage programs (2017) • Insurers must spend at least 85% of premiums (large group) or 80% (small group / individual) on medical costs or provide rebates to enrollees • HHS must determine if states will have operational exchanges by 2014; if not, HHS will operate them Source: Commonwealth Fund Analysis of the The Affordable Care Act (Public Law 111-148 and 111-152).
2014 The Year of the Health Insurance Exchanges
What is the HIX? • Simply put: • Health Insurance products, different benefit packages, different plans available for purchase at a single “market” • Two markets • Small Business Health Options Program (SHOP) 50 or less • Individual Market
What makes HIX “Game changing” • No pre-existing condition restrictions • Subsidies based on income available
Who is offering in the NY HIX?Medical Plans http://www.nystateofhealth.ny.gov/PlansMap
Who is offering in the NY HIX?Dental Plans http://www.nystateofhealth.ny.gov/PlansMap
Required Ten Essential Health BenefitsPreventive services will be offered at with not patient cost sharing • Ambulatory patient services • Emergency room services • Hospitalization • Maternity and newborn care • Mental health and substance abuse disorders • Prescription drugs • Rehabilitation and habilitation services and devices • Laboratory services • Preventive and wellness services and chronic disease management • Pediatric services, including oral and vision
What is being offered Platinum, Gold, Silver, Bronze SAMPLE
Exchange Responsibilities • Only Available in Exchanges • Subsidies for individuals from 133%-400% of FPL • Small employer tax credits
What is NY State of Health? • Organized marketplace • One-stop shopping for subsidized and unsubsidized coverage • Easily compare health plan options • The only place to check eligibility and apply for financial assistance • Enroll in qualified health plans • Two programs • Individual Marketplace • Small Business Marketplace
Who Will Enroll In NY State Of Health? Health Plan Marketplace enrollment is estimated to be 1.1 million New Yorkers 450,000 615,000
NY State of Health Enrollment • Open Enrollment begins on October 1 • Individuals may enroll in health plans during open enrollment October 1, 2013 - March 31, 2014) or with a qualifying event • Individuals who qualify for Medicaid/CHP may enroll any month of the year • Small employers may choose open enrollment dates for their employees any month of the year
Customer Service Call Center • Assistance available in over 170 languages • Many staff will be bilingual and oral interpretation available for remaining languages. • Will take applications over the phone starting in October • Can refer to in-person assistors
Individual Responsibility • Jan. 1, 2014: Individuals must enroll in coverage or pay a tax penalty • Penalty amount: • Greater of $ amount or a % of income • 2014 = $95 or 1% • 2015 = $325 or 2% • 2016 = $695 or 2.5% • Family penalty capped at 300% of the adult flat dollar penalty or “bronze” level premium
Family Responsibility • Penalty amount: • Greater of $ amount or a % of income • 2014 = $285 or 1% • 2015 = $975 or 2% • 2016 = $2,085 or 2.5% • Family penalty capped at 300% of the adult flat dollar penalty or “bronze” level premium
Employer Penalty Please note that the information in this chart is based on an interpretation of the Patient Protection and Affordable Care Act. This chart is for general information purposes only and is not intended to constitute legal advice or a recommended course of action in any given situation and should not be relied upon in making decisions of a legal nature.
Subsidies, Tax Credits, Penalties • Individuals may be eligible for premium assistance – 133% to 400% FPL if employer: • Doesn’t offer minimum essential coverage or • Offers coverage, but premium isn’t affordable • However, if employer does offer affordable MEC and the employee purchases on HIX, not eligible for subsidy • Cost sharing assistance • Individuals 133%-250% of FPL • Must purchase silver plan • Small employer tax credits • Employers < 25 • Must purchase on SHOP, other requirements apply • Penalties for not having/offering health insurance
What does this mean to physicians? • 1.1 million New Yorker's added to the “insured population” • Reduced bad debts • Increased access to care • Increased demand for services
What they aren’t telling physicians • These “new” patients come with lower reimbursement rates • Most of the HIX offering are paying between 6% and 25% LESS than the commercial rates for the same company • Some plans are making participation mandatory • There “new” patients come with continued risk of bad debts • Federal regulations put the physician at risk of not being paid when patients are late in paying their premiums. • Carriers HIX products must provide a 3 month grace period to enrollees that haven’t paid their premiums. During the first 30 days plans must pay claims, but in the last 60 days, the payer will hold the claims. • If the patient coverage is cancelled after 90 days for failure to pay premiums, plans are not required to pay any claims in those last 60 days. It falls to the practice to go after the patient, for services rendered.
What should a physician do? It Depends • Do you need this volume? • Do you believe increasing your access to patient sis the ‘right” thing to do? • Are you “par” by virtue of your current participation agreements? • Can you limit your participation to x number of HIX plans? X number of enrollees? • Know what you are getting into reimbursement wise. • Verify each patient’s benefit plan at time of 1- appointment scheduling and 2- at time of service. • Require a contingent credit card authorization on all patients
Stuff you want to ask ? Thank you Robert E. Goff 25