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Affordable Care Act AMERICAN HEALTH BENEFIT EXCHANGES. Delaware Health Care Commission October 7, 2010. EXCHANGE BASICS. State Based Individuals and small business employees find and compare insurance options Small Business Health Options (SHOP) Individuals May be combined

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Affordable care act american health benefit exchanges l.jpg

Affordable Care ActAMERICAN HEALTH BENEFIT EXCHANGES

Delaware Health Care Commission

October 7, 2010


Exchange basics l.jpg
EXCHANGE BASICS

  • State Based

  • Individuals and small business employees find and compare insurance options

    • Small Business Health Options (SHOP)

    • Individuals

    • May be combined

  • Help comply with individual mandate

  • Must be up and running Jan. 1, 2014


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EXCHANGES MUST

  • Certify “qualified health plans

  • Toll free telephone number

  • Web site with standardized, comparative information on health plan options

  • Provide employees choice of plan options

  • Electronic calculator to determine cost and amount of any premium tax credit


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EXCHANGES MUST

  • Provide initial and annual open enrollment periods

  • Assign ratings to plans on relative quality and price

  • Inform consumers of Medicaid/CHIP eligibility and enroll if eligible

  • Use uniform enrollment form


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EXCHANGES MUST

  • Certify any exemption from individual mandate

  • Notify US Treasury of those exempt

  • Information to employers on employees who cease coverage in qualified health plan

  • Publish costs of licensing, admin costs, money lost to fraud/abuse


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EXCHANGE MUST

  • Establish Navigator program

    • Educate consumers

    • Facilitate enrollment

    • Referrals to consumer assistance program

  • Consult with stakeholders, including

    • Educated health care consumers

    • Entities w/ experience in facilitating enrollment

    • Small business & self-employed

    • Medicaid

    • Advocates for enrolling hard to reach populations


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STATES DECIDE

  • Establish a state-based Exchange

  • Join in a regional Exchange with other states

  • Allow US DHHS to operate an Exchange within a state

  • How to manage insurance markets

    • Merge non-group and small group?

    • Plan conduct in and out of the Exchange


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STATES DECIDE

  • Where the Exchange resides

    • Within existing state agency?

    • A new separate state agency?

    • Quasi-state agency?

    • Private non-profit

    • More on this later…..


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STATES DECIDE

  • How Exchange is governed

    • State Employees of existing or new state agency? (Utah)

    • Overseen by an independent board? (Mass)

      • Who appoints Board

      • Relevant experience of Board

      • Transparency of activities

    • Relationship and applicability of state administrative processes


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STATE CONSIDERSATIONS

  • Roles of various state agencies in the Exchange

    • IT needs and IT agencies

    • Medicaid/CHIP eligibility/enrollment

    • Insurance information and Dept. of Insurance

  • How goods and services will be procured

  • How intersection between Exchange products and public programs operate


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IT CONSIDERATIONS

  • Interface with Medicaid/CHIP

  • Ability to enroll those eligible into Medicaid/CHIP

  • Ability to identify subsidies for consumers who qualify

  • Web portal design

  • Standard format to compare price & quality

  • Data transfer to IRS


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SCOPE AND FINANCING

  • How many lives will enroll in the Exchange?

  • How many plans will be offered in the Exchange?

  • What is the real nature of small group and non-group markets in DE?

  • How should the Exchange finance itself?

    • Must be self-sufficient by 1/1/15


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KEY DATES

  • Sept. 2010 Award of planning grant

  • Spring 2011 Notice – Implementation

  • Jan.1, 2013 States inform; Sec’y HHS decides if will be ready 1/1/14

  • Jan. 1, 2014 State Exchanges become operational


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EXCHANGE GOVERNANCE OPTIONS

  • Affordable Care Act says very little:

  • “An Exchange shall be a governmental agency or nonprofit entity that is established by a State.”

  • Options to be weighed through planning process; DHCC decisions important


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STATE AGENCYExisting or new

  • What the Exchange will do may help drive decision

    • “Market organizer”

    • Active purchaser

    • Use purchasing to drive system change

      • E.g. Transform how plans reimburse providers


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STATE AGENCYADVANTAGES

  • Direct link to other state administrative activities

  • Enhanced ability to coordinate with other state activities

  • May work better with “market organizer” approach

  • Potential to coordinate with other state health purchasing strategies


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STATE AGENCYDISADVANTAGES

  • Unlikely that any one state agency has expertise necessary to operate Exchange

    • Medicaid lacks expertise in insurance market

    • Dept. Ins primary role regulatory, not marketing

    • State employee benefit agencies lack knowledge of small and non-group markets


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STATE AGENCYDISADVANTAGES

  • Active purchaser Exchanges may need to be nimble and move quickly

  • Procurement may slow down process

  • Employment rules may place limits on hiring strategies

  • Close proximity may cause decisions to be politicized


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QUASI-GOVERNMENT OR INDEPENDENT AGENCY

  • Advantages

  • Possible exemption from procurement regulations

  • Possible exemption from personnel regulations

  • Less potential for decisions to be politicized

  • Board composition can bring wide variety or skills and viewpoints; access to business expertise


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QUASI-GOVERNMENT OR INDEPENDENT

  • Disadvantages

  • Potential challenges communicating with state agencies

  • May require more time and resources for start-up

  • Without careful consideration of Board composition conflict of interest issues arise


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PRIVATE NON-PROFIT

  • Advantages:

    • Greater flexibility in decision-making

    • Less Chance for politics to influence

  • Disadvantages

    • Isolation from state gov’t presents carriers to coordination/communication

    • Potential legal issues if Exchange performs government function (eligibility for Medicaid)