HEALTH CARE REFORM MAKING THE TRANSITION FROM …€¦ · HEALTH CARE REFORM MAKING THE TRANSITION FROM PREMIERHEALTH July 23 and 25, 2013 PLEASE NOTE: This presentation is for general

HEALTH CARE REFORM MAKING THE TRANSITION FROM PREMIERHEALTH

July 23 and 25, 2013

PLEASE NOTE: This presentation is for general information purposes only. While MMBB has attempted to provide current

and accurate information, this information is provided “as is” and MMBB makes no representation or warranties regarding its

accuracy or completeness. The information provided should not be construed as legal or tax advice or as a recommendation

of any kind.

Real planning, real solutions. That’s our calling. |

What we are going to cover

Why We Are Closing the PremierHealth Plan

Basic Overview of PPACA

What You Can Do To Get Ready

Plan Termination Considerations

What MMBB Will Do

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PATIENT PROTECTION AND AFFORDABLE CARE ACT


PremierHealth Key Findings

Catastrophic claims largest driver of increased plan spend

5% of members drive 58.3% of total claim payments

Aging population

Average member age higher than the norm

MMBB 51 vs. Norm of 45

Chronic conditions increasing

53% of population representing 82% of total plan spend

Decreasing enrollment

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Real planning, real solutions. That’s our calling. | 4

PATIENT PROTECTION AND

AFFORDABLE CARE ACT

OVERVIEW


ACA/Health Insurance Reform

Signed into law March 23, 2010

Legal Challenges – Supreme Court Decision

Goals – provide affordable health insurance coverage, significantly

reduce number of uninsured, and improve the quality of coverage

available

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Major Provisions Implemented in 2011

Restricted annual and no lifetime dollar limits with respect to

essential health benefits

Limitation on cancellation of coverage of plan participants

(rescission)

No pre-existing condition limitation for enrollees under 19 years old

Coverage for adult-dependent children up to age 26

No cost sharing for certain medical preventive care services

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2014 Key Provisions

Pre-existing conditions exclusion eliminated

Individual Mandate

Expanded Medicaid Eligibility

Health Insurance Marketplace

Employer Mandate – Delayed until 2015



Pre-existing Conditions Exclusion Eliminated

Health plans will not be able to deny or charge

more for coverage because of an individual’s

pre-existing condition



Individual Mandate

Most legal residents will be required to have health insurance or

pay a penalty

Limited Exemptions

Penalty is indexed:

2014 – Greater of $95 per adult/$47.50 per child or 1% of income

2015 – Greater of $325 per adult/$162.50 per child or 2% of income

2016 – Greater of $695 per adult/$347.50 per child or 2.5% of income

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Expanded Medicaid Eligibility

ACA expands state Medicaid programs to cover nearly all

individuals under age 65 with incomes up to 133% of the federal

poverty level

States decide if they want to expand eligibility

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1. The Advisory Board Company, Where each state stands on ACA’s Medicaid Expansion,

http://www.advisory.com/Daily-Briefing/2012/11/09/MedicaidMap (June 2013).

1.

http://www.advisory.com/Daily-Briefing/2012/11/09/MedicaidMap June 14






Health Insurance Marketplace Previously called Public Exchanges

Available January 1, 2014

Connects buyers and sellers of health insurance

A marketplace that offers a choice of standardized,

affordable health insurance plans



Health Insurance Marketplace (Public Exchanges)

State-based Marketplace

Partnership Marketplace

Federally Facilitated Marketplace

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2. The Kaiser Family Foundation, States decisions for creating health insurance marketplaces,

http://money.usnews.com/money/blogs/the-best-life/2013/05/10/the-real-obstacle-of-health-insurance-exchanges-american-consumers, (May2013).

2.

http://money.usnews.com/money/blogs/the-best-life/2013/05/10/the-real-obstacle-of-health-insurance-exchanges-american-consumers
























Individuals and Small Businesses (SHOP)

“Metal-Level” Plan Offerings

Subsidies available

Reduced cost sharing to lower out-of-pocket services

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Essential Health Benefits

“Metal-Level” Plan Offerings

Platinum, Gold, Silver, Bronze

Differentiated by actuarial value

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0%

20%

40%

60%

80%

100%

Bronze Silver Gold Plat

Metal Levels

$ Out of

Pocket


Individual Health Insurance Marketplace (Public

Exchanges)

Subsidies

Tax credits available in the individual exchange to lower

monthly premiums

Eligibility

o Based on household income and family size

o Ineligible for other health benefits coverage other than the individual

insurance market

o Income between 100% to 400% of the Federal Poverty Level

($23,500 - $94,200 for a family of four in 2013)

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Individual Health Insurance Marketplace (Public

Exchanges)

Cost Sharing

Incomes at or below 250% of the Federal Poverty Level ($58,875

annually for a family of four in 2013)

Must enroll in a silver-level plan

Must receive a subsidy

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Small Business Health Insurance Marketplace

(Public Exchange)

Small Business Health Options Program (SHOP)

Eligibility

100 or few employees, states can limit to fewer than 50

Single Qualified Health Plan

Subsidies are not available

Eligible for Small Business Healthcare Tax Credit

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Small Business Healthcare Tax Credit

Eligible if you have fewer than 25 full-time equivalent employees

making an average of $50,000 a year or less

Starting in 2014, the tax credit is worth up to 35% of employer’s

contribution toward employee premium costs

Beginning in 2014, the Small Business Healthcare Tax Credit is

available only if you get coverage through SHOP

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Open enrollment October 1, 2013 through March 31, 2014

Consumer Assistance

Navigators

Certified application counselors

In person assistors

Certified licensed brokers

Call Center, 800.318.2596

Online Assistance

www.healthcare.gov

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Employee Notice of Coverage Options

Employers must provide notice to all employees prior to October 1

Department of Labor models available

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Private Marketplace

No federal subsidies or cost sharing available

Operated by for profit private companies or non-profit

Vary in structure

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Employer Mandate (Delayed to 2015)

Applicable to large employers

Play or Pay/Shared Responsibility

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What You Can Do To Get Ready -- Employees

Speak with your employer and find out what your organization’s

plan of action is

Next, identify what PremierHealth covers so that you can compare

other plans to it -- a Benefit Summary is available

Put together a list of your doctors to determine whether they will

participate in the health care network you want to use

Gather basic information about your household income

Go to www.healthcare.gov to view a checklist

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What You Can Do To Get Ready -- Employers

Decide on how you will provide health care coverage for your

employees

Review current PremierHealth coverage so that you can compare it

to other options available – a Benefit Summary is available

Go to www.healthcare.gov to view a “Checklist for Businesses”

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Plan Termination Considerations Medical claims handling

Claims submission

Care in process

Access to Account information/claims history

Prescriptions Mail order claims

Retail pharmacy




Plan Termination Considerations - Cigna

Medical claims handling

Claims submission

Care in process


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Plan Termination Considerations – Express Scripts

Prescriptions

Mail order claims

Retail pharmacy


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Plan Termination Considerations

MMBB Communication Program

Staff Training

www.mmbb.org/healthcarereform

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To contact MMBB Financial Services call 800.986.6222 or

email [email protected].

For the latest information on Health Care Reform, please visit

www.mmbb.org/healthcarereform.

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QUESTIONS?

mailto:[email protected]

http://www.mmbb.org/healthcarereform

Documents

HEALTH CARE REFORM MAKING THE TRANSITION FROM …€¦ · HEALTH CARE REFORM MAKING THE TRANSITION FROM PREMIERHEALTH July 23 and 25, 2013 PLEASE NOTE: This presentation is for general