The Health Insurance Marketplace: What Does It Mean For My Practice? Captain Eugene Freund, MD, MSPH Medical Officer Center for Consumer Information and Insurance Oversight, HHS, CMS Baltimore, Maryland Developed as part of a Medscape education activity “The Health Insurance Marketplace: What Does It Mean For My Practice?,” supported by the US Department of Health and Human Services
Program Goals • Describe the changes to US health care expected in 2014 as the Health Insurance Marketplace takes effect • Describe strategies employed by CMS to improve patient-clinician interactions related to the Affordable Care Act
Historic Expansion of Coverage • Increased Availability of Private Coverage • The Health Insurance Marketplace • Enrollment open on October 1, 2013 • Coverage starting as soon as January 1, 2014 • Expansion of Medicaid Eligibility • Starting January 1, 2014 • Coverage for individuals under 133% of federal poverty level • States that participate receive additional federal funding • 100% funding for first 3 years • 90% funding subsequent years a.HealthCare.gov.
Health Insurance Marketplace • State-Based Marketplace • Mandated by the Affordable Care Act • Clearinghouse where eligible individuals and businesses can compare and purchase private insurance • State has primary responsibility for operation • Federal funds available to support states during planning and implementation during the first year of operation a. Henry J. Kaiser Family Foundation.
Health Insurance Marketplace • Establishment • A Marketplace can be a: • State-Based Marketplace • State Partnership Marketplace • Federal-Facilitated Marketplace • Created by HHS when: • States decide not to establish their own marketplaces • The state Marketplace does not meet minimum federal standards http://www.kff.org/healthreform/upload/8213-2.pdf
Health Insurance Marketplace Timeline 2012 DEC 2014 JAN 2013 JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC Partnership Marketplace blueprint due State-based Marketplace blueprint due Marketplace enrollment begins in all states HHS approval or conditional approval The Marketplace is operational Final approval of state marketplaces Review of insurance plan applications a. Henry J. Kaiser Family Foundation.
Who Is Eligible? • Americans purchasing their own health insurance • Requirements • Must reside in the United States • Must be citizen or lawful resident • Must not be currently incarcerated • Small Businesses • Up to 100 employees • In some states up to 50 employees (2014 and 2015) a. HealthCare.gov website; b. Henry J. Kaiser Family Foundation; c. CMS website.
Requirements for Qualified Health Plans • Qualified health plans must: • Ensure access to care for plan participants • Offer an adequate network of healthcare providers • Offer a sufficient number and geographic distribution of community providers • Provide comprehensive coverage • Including benefits identified as essential to health a. HealthCare.gov website; b. CMS website.
Requirements for Qualified Health Plans (cont) • Essential Health Benefits • Ambulatory patient services • Emergency services • Hospitalization • Maternity and newborn care • Mental health and substance use disorder • Prescription drugs • Rehabilitative and habilitative services and devices • Laboratory services • Preventive and wellness services and chronic disease management • Pediatric services, including oral and vision care a. CMS website.
Information for You and Your Patients • Learn About Your State Marketplace • Visit the HealthCare.gov website for links to information about your state’s Marketplace • Share sources of information with front office staff and others interacting with patients • Become aware of additional services offered by your state to assist individuals and small businesses a. HealthCare.gov website; b. CMS website.
Health Insurance Marketplace Support • Navigator Program • Health Marketplace requirement • Conduct public awareness activities • Assist individuals and small employers in reviewing health insurance options • Facilitate the enrollment process • Additional Support • In-person assistance • Federally funded, optional state program • Designed for communities with poor access to Navigator services a. HealthCare.gov; b. CMS website.
Changes in Healthcare Access = More Patients • Increased Number of Insured Americans • One-stop shopping assistance • Financial assistance based on eligibility • Tax credits to offset cost • Cost sharing subsidies • Increased Public Program Enrollment • Expanded eligibility • Marketplaces to determine eligibility and initiate enrollment • Electronic transmission of eligibility and relevant information to state agencies • New Emphasis on Preventive Care • Affordable Care Act removes cost barriers to basic preventive services a. HealthCare.gov website; b. CMS website; c. HealthCare.gov website.
Projected Increase in Demand for Services: More Payors Marketplace network adequacy requirement • Potential new contractual opportunities • Insurance plans • Federally Qualified Health Centers • Other essential community providers a. Hofer AN, et al. Millbank Quart. 2011;89:69-89.
Planning for Capacity • Building a sufficient healthcare workforce • Multiple federal initiatives to address shortages • Additional primary care residency slots • Support for additional physician assistants • Educational support for nursing students • Establishment of nurse-practitioner-led clinics • Encouraging states to plan and implement innovative workforce expansion strategies • Grants to assist low-income individuals in training for jobs in healthcare a. HHS website.
Relationships With Insurers • Marketplaces require no changes to how practices currently contract with insurers • Potential changes to plans that could affect practices • Changes to offerings • Changes to the number or size of plan networks • Plan networks to include Essential Community Providers a. Clinic Services website; b. CMS website.
Medical Practices as Small Businesses • Affordable Healthcare Coverage for Employees • Access to the Marketplace • Small Business Health Options Program • Simplifies finding health insurance in the small group market • Choose level of coverage offered • Define employee contributions to premiums • Small business tax credit • Currently could cover 35% of costs for qualifying businesses • In 2014 could cover up to 50% a. HealthCare.gov website; b. HealthCare.gov website.
Increased Contact Opportunity via Preventive Services • Preventive Services Under the Affordable Care Act • Viewed as vital to mitigating high costs of preventable conditions • New health insurance plans now required to cover recommended services without cost sharing (September 23, 2010) • Annual wellness visits • Other regularly scheduled recommended checks • No cost sharing for preventive services under Medicare (January 1, 2011) • No or low-cost preventive services for Medicaid beneficiaries (January 1, 2013) a. HealthCare.gov.website.
Medicaid Payment Rate Increases • Pay for primary care physicians no less than 100% of Medicare payment rates • Fully funded by the federal government • For primary care services rendered in 2013 and 2014 • Allows primary care physicians to provide services to those without prior access to basic care a. HealthCare.gov website.
Additional Support • Increased Information Sharing • Financial incentives for healthcare providers for EHR implementation • Healthcare plans required to adopt rules for secure, confidential electronic information exchange • Decreased Administrative Costs • Leveraging technology for administrative tasks • Standardization of billing a. HealthCare.gov website.; b.HealthIT.gov website.
Conclusion • The Health Insurance Marketplace • Mandated by the Affordable Care Act • Provides a new avenue to coverage for individuals and small businesses • Expands opportunity to provide primary care • More people will be enrolled in private and public plans • Increased access to preventive services for patients • Protects physician ability to deliver essential care across patient populations
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