Introducing Ohio’s Health Marketplace

1. Introducing Ohio’s Health Marketplace Presented by John Dodd and John McGough September 17, 2013

2. So tell me more about that new free health insurance…

3. Confusion in the market • Starts with the name • 85% recognize the name “Obamacare” • < 30% recognize “ACA” • PPACA ??????? • Is the Patient Protection Affordability and Accountability Act a law or bill? • What pieces were delayed and until when? • Who is eligible for a subsidy and what does it mean to me? • What about those tax credits? • What will be available and how much will it cost? • If I do nothing now, what is the worst that could happen to me? • Will the options be same in NW Ohio, Cleveland, Columbus, Cincinnati and Youngstown? • Ohio will have more volatility than other states

4. Patient Protection Affordability and Accountability Act – Signed into Law March 23, 2010

5. Current Political Dynamic

6. PPACA/ACA/Obamacare • Since passage the law has never gotten above 50% approval in public opinion polls • The law survived a Supreme Court challenge with only a change to the penalty to states not expanding Medicaid to 133-138% of FPL • The law survived two national elections with one of those re-electing President Obama • Current split government in Congress will not bring any legislative changes. Period. • Even if the Republican controlled House of Representatives is successful in de-funding the law, all the other provisions will go forward. We are past the point of return to pre-2010.

7. PPACA – what does it look like?

8. What Is The Health Care Reform Law All About? • It is NOT a total takeover of the health care system to create a single payer Canadian or European style health care system. • It is a MASSIVE new law that brings federal regulation to health insurance as opposed to the traditional state regulation of the insurance industry. • It does include a number of new regulations for healthcare providers, but falls short of total takeover of the entire system. • Citizens will still be dealing with private health care providers and private insurance companies unless covered by Medicaid.

9. Timeline for Implementation 2010 • 26 total provisions scheduled to be implemented • 26 total provisions implemented

10. 2010 PPACA Scheduled Provisions • Review of Health Plan Premium Increases • More scrutiny in premium rate review • More justification required • Changes in Medicare Provider Rates • Qualifying Therapeutic Discovery Project Credit • Medicaid and CHIP Payment Advisory Commission

11. 2010 PPACA Scheduled Provisions (cont.) • Comparative Effectiveness Research • Prevention and Public Health Fund • Medicare Beneficiary Drug Rebate • Small Business Tax Credits

12. 2010 PPACA Scheduled Provisions (cont.) • Medicaid Drug Rebates • Coordinating Care for Dual Eligibles • New efficiencies for those with Medicare and Medicaid • Generic Biologic Drugs • New requirements on Non-profit Hospitals • True non-profit??????

13. 2010 PPACA Scheduled Provisions (cont.) • Medicaid Coverage for Childless Adults • Reinsurance Program for Retiree Coverage • This was a program for plan sponsors to encourage them to continue retiree plans • Pre-existing Condition Insurance Plan • High Risk Pool closed earlier in 2013 • New Prevention Council • Consumer Website

14. 2010 PPACA Scheduled Provisions (cont.) • Tax on Indoor Tanning Services • Expansion of Drug Discount Program • Adult Dependent Coverage to Age 26 • Consumer Protections in Insurance • Eliminating lifetime limits on coverages • No pre-ex limitation for children • Insurance Plan Appeals Process

15. 2010 PPACA Scheduled Provisions (cont.) • Coverage of Preventive Benefits • Health Centers and the National Health Service Corps • Health Care Workforce Commission • Medicaid Community-Based Services

16. Timeline for Implementation 2011 • 20 total provisions scheduled to be implemented • 18 total provisions implemented

17. 2011 PPACA Scheduled Provisions • Minimum Medical Loss Ratio for Insurers • Closing the Medicare Drug Coverage Gap $250 check to those hitting Part D doughnut hole in 2011 Beginning 2012 increased % of prescription drugs paid in doughnut hole until reaching 75% in 2020 • Medicare Payments for Primary Care • Medicare Prevention Benefits • Center for Medicare and Medicaid Innovation

18. Schedule of Progress--Part D

19. 2011 PPACA Scheduled Provisions (cont.) • Medicare Part B Premium Increase for Higher-Income Beneficiaries • Medicare Advantage Payment Changes • Less government payment to Advantage plans going forward—Will that increase premiums, reduce benefits, or both? • Medicaid Health Homes • Chronic Disease Prevention in Medicaid • National Quality Strategy

20. 2011 PPACA Scheduled Provisions (cont.) • Changes to Tax-Fee Savings Accounts • Penalty for ineligible withdrawals increased from 10% to 20% • Grants to Establish Wellness Programs * • Teaching Health Centers • Medical Malpractice Grants • Funding for Health Insurance Exchanges • Exploratory grants to states • Followed by implementation grants for those states choosing to implement a state exchange • Ohio choose not to establish a state exchange

21. 2011 PPACA Scheduled Provisions (cont.) • Nutritional Labeling * • Medicaid Payments for Hospital-Acquired Infections • Graduate Medical Education • Medicare Independent Payment Advisory Board • An independent board that will begin making decisions on eligible expenses and amounts paid for eligible expenses • Medicaid Long-Term Care Services

22. Timeline for Implementation 2012 • 11 total provisions scheduled to be implemented • 10 total provisions implemented

23. 2012 PPACA Scheduled Provisions • Accountable Care Organizations in Medicare • Uniform Coverage Summaries for Consumers • Summary of Benefits and Coverage • Medicare Advantage Plan Payments • Medicare Independence at Home Demonstration • Medicare Provider Payment Changes

24. 2012 PPACA Scheduled Provisions (cont.) • Fraud and Abuse Prevention • Annual Fees on the Pharmaceutical Industry • Medicaid Payment Demonstration Projects * • Data Collection to Reduce Health Care Disparities

25. 2012 PPACA Scheduled Provisions (cont.) • Medicare Value-Based Purchasing • Tougher reimbursement rules • Proceeding to performance based pay----not payment per procedure • Reduced Medicare Payments for Hospital Readmissions • Changed name of the “Exchange” to “Marketplace”

26. Timeline for Implementation 2013 • 14 total provisions scheduled to be implemented • 11 total provisions implemented

27. 2013 PPACA Scheduled Provisions • Employer Notification to Employees Regarding Exchanges • Delayed from March 1, 2013 to October 1, 2013 • Employers required to provide notice whether or not they offer a plan—if subject Fair Labor Standards Act (FLSA) • Medicare Bundled Payment Pilot Program • Medicaid Coverage of Preventive Services • Medicaid Payment for Primary Care

28. 2013 PPACA Scheduled Provisions (cont.) • Itemized Deduction Floor for Medical Expenses • Increased from 7.5% to 10% of AGI • Flexible Spending Account Limits • Limited to $2500 per year • Medicare Tax Increase 0.9% on income exceeding $200,000 filing single or $250,000 filing jointly • Employee Retiree Coverage Subsidy • Tax on Medical Devices-$2.3% on DME

29. 2013 PPACA Scheduled Provisions (cont.) • Financial Disclose * • CO-OP Health Insurance Plans • One has been approved for Ohio • Did not get organized in time to be in the exchange/marketplace in 2014 • Extension of CHIP through 2015 • Medicare Disproportionate Share Hospital Payments * • Medicaid Disproportionate Share Hospital Payments *

30. Timeline for Implementation 2014 and Beyond • 19 total provisions scheduled to be implemented

31. 2014 PPACA Scheduled Provisions • Expanded Medicaid Coverage • Not in Ohio—not yet • Presumptive Eligibility for Medicaid • Streamlined application process • Individual Requirement to Have Insurance • Health Insurance Exchanges/Marketplaces • Health Insurance Premium and Cost Sharing Subsidies • Refundable and Advanceable Federal Income Tax Credits to be used as Premium Subsidies on Silver Level Coverage Purchased in the Exchange/Marketplace • Silver Level Coverage Will be Enhanced to Lower MOOP Limits for those with income below 250% of FPL

32. 2014 PPACA Scheduled Provisions (cont.) • Guaranteed Availability of Insurance • No Risk Rating, No Pre-ex • No Annual Limits on Coverage • Essential Health Benefits Package Required in Small Group and Individual Markets • Multi-State Health Plans • Temporary Reinsurance Program for Health Plans

33. 2014 PPACA Scheduled Provisions (cont.) • Basic Health Plan • Catastrophic plan for those unable to afford coverage and under age 30 • Employer Requirements • Penalty for non-compliance delayed until 2015 • Medicare Advantage Plan Loss Ratios • Wellness Programs Included in Insurance Plans • Fees on Health Insurance Sector • $8 Billion in 2014—looks like about 2.4% of premium • Reinsurance pool charge of $5.25 PMPM • Medicare Payments for Hospital-Acquired Infections

34. 2015 and beyond – PPACA Scheduled Provisions • 2015 - Increase Federal Match for CHIP • 2016 - Health Care Choice Compacts • 2018 -Tax on High-Cost Insurance

35. What Resources Are Available? • We’re here to help you!

36. What Resources Are Available? • www.NAHU.org • www.Healthcare.gov • Health and Human Services/Center for Medicare and Medicaid Services • Health Insurance Carriers and Plans • Various Professional Organizations (ie. IFEBS, American College, WEB International, Kaiser Family Foundation, NAIFA, PIA/Big I) • Google.com • Googling Your Question Produces a Number of Qualified Answers From Consultants

37. Who Will Be Involved In The Exchange/Marketplace Nationally? • Agents/brokers • Agents and Brokers are allowed to participate if the state allows agents and brokers to participate • Navigators • By law each state must have at least 2 navigators • Funded by federal grants in 2014, then by grants obtained by the exchange/marketplace in 2015 and after • Certified Application Counselors • Funded by either state or private grants

38. Who Can Sell On The Exchange/Marketplace In Ohio? • Only licensed agents and brokers may sell, solicit, or negotiate a contract of health insurance. • Only licensed agents and brokers may recommend a particular product, or option, to a consumer. • Within the Exchange/Marketplace Agents and Brokers are required to provided unbiased information and comparisons of plans

39. Agents/brokers requirements • Active State of Ohio Health Insurance License • Current appointment with all carriers they are writing • Complete Exchange training – available NOW at https://Marketplace.MedicareLearningNetworkLMS.com • Two parts on the individual exchange/marketplace • Part two is now available • Agreement is then signed and certification process begins—all on line • SHOP exchange education is optional

40. Navigators • Under Ohio law (H.B. 3): • Navigator can: (1) conduct public education activities and raise awareness of availability of Qualified Health Plans; (2) distribute fair and impartial general information concerning enrollment in all QHPs and availability of premium tax credits and cost-sharing reductions; (3) Facilitate enrollment in QHPs, without suggesting that an individual select a particular plan; (4) May provide information related to Medicaid eligibility. • Navigator cannot: (1) Sell, solicit or negotiate health insurance; (2) Provide advise concerning substantive benefits, terms or conditions of a plan or offer advice about which plan is better or worse or suitable for a particular individual or entity; (3) Recommend a particular plan or advise consumers about which plan to choose; (4) Provide any information or services related to plans or products not offered in an Exchange; (5) Engage in any unfair method of competition or any fraudulent, deceptive, or dishonest act or practice.

41. Navigators (cont.) • 5 Navigator Grants in Ohio totaling $3,043,868 • Ohio Association of Food Banks • Children’s Hospital Medical Center (out) • Clermont Recovery Center, Inc • Helping Hands Community Outreach Center • Neighborhood Health Association

42. Navigators (cont.) • Navigators do not receive commissions – their funding mechanism is via the Federal grants in 2014 • Structured as a cooperative agreement - Performance period is up to 12 months from the date of the award and future awards funded by the exchange/marketplace • Navigators will be required to annually recertify • Navigator includes the organization receiving the grant and certification plus each person designated to perform navigator duties • Navigators DO NOT carry errors and omissions coverage

43. Certified Application Counselors • On July 17, 2013 CMS issued a final rule at 45 CFR 155.225 introducing a separate class of Certified Application Counselors (CACs), such as community health centers, health care providers and entities, and community-based organizations, to assist consumers with enrolling in coverage through the Marketplace. • Certified Application Counselors will be designated by the Marketplace to provide the same application assistance that is available from Navigators, but will not be funded through the Marketplace. However, the conflict of interest provisions that apply to navigators do not apply to CACs.

44. Certified Application Counselors (cont.) • Certified Application Counselors must complete the CMS Exchange Training • Certified Application Counselors do not receive commissions • Certified Application Counselors receive grants from states or other organizations • Certified Application Counselors will be required to annually recertify • Certified Application Counselors DO NOT carry errors and omissions coverage

45. Other players • Champions for Coverage • Carriers • E-Enrollment sites (web-based enrollment)

46. Implementation Time FrameMany Delays • July 2013----Agent/Broker and Navigator Training-running late • August 2013----Agent/Broker and Navigator Certification-running late • October 1, 2013----Exchange Marketplace open for annual open enrollment in plans with effective date of 01/01/2014 • Applications dated 10/01 through 12/15 get 01/01/14 effective date • Applications dated 12/16/13 through 01/15/2014 get 02/01/14 date • Applications dated 01/16/13 through 02/15/2014 get 03/01/14 date • Future annual open enrollment will be 10/15 through 12/07 • Special enrollment events are recognized during the year • COBRA notices to be changed to proved notice of exchange • January 1, 2014----New Premium Rating and Underwriting Standards begin with renewals on or following this date • March 31, 2014----Initial Open Enrollment Period for Exchange Marketplace ends

47. How do I get paid on the Exchange?

48. How Is An Agent/Broker Compensated When Selling Inside the Exchange/Marketplace? • Agents and Brokers Will Continue to Be Paid by the Insurance Company With Whom the Business is Placed—If the Insurance Company Works With Agents and Brokers • The Exchange/Marketplace Has No Desire to Begin Paying Agents and Brokers.

49. Questions?

50. The Individual Market 916,000 Ohioans will be eligible for a subsidy – USA Families, March 2013