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101 Education. ACA, Health Insurance Exchanges and ATRIO – What You Need to Know. Today’s Goal. Provide information about the ACA and the new state-based health insurance exchange, Cover Oregon, Review decisions ATRIO Health Plans has made to participate in the exchange,

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101 education

101 Education

ACA, Health Insurance Exchanges and ATRIO – What You Need to Know

Today s goal
Today’s Goal

  • Provide information about the ACA and the new state-based health insurance exchange, Cover Oregon,

  • Review decisions ATRIO Health Plans has made to participate in the exchange,

  • Gain an understanding of impacts to current administrative operations to accommodate new product lines.


  • ACA Overview

  • Cover Oregon - The New Marketplace

  • ATRIO Health Plans and Cover Oregon

  • Provider Matters

    • Networks

    • Medical management and Authorizations

    • URAC Accreditation and Quality Assurance

  • Resources

Goals of the aca
Goals of the ACA

  • Decrease the number of uninsured Americans

    • Require citizens to have coverage, or pay a penalty

    • Penalize employers not providing qualified coverage

    • Establishes Health Insurance Marketplace

    • Expand Medicaid coverage to more Americans

  • Reduce the overall cost of health care

    • Tax credits (refundable and advanceable)

    • Cost-share reductions within health plans

    • Incentivize wellness

  • Ultimately, create a healthier population!

Key aca requirements 2014
Key ACA Requirements-2014

  • Individual (mandate) Shared Responsibility

  • Employer (mandate) Shared Responsibility

  • Establishment of Health Insurance Exchange Marketplaces

  • Individual Tax Subsidies to Offset Costs

  • Medicaid Expansion

  • Small Business Tax Credits to Offset Costs

Cover oregon the new marketplace
Cover Oregon – The New Marketplace

  • New on-line commercial insurance marketplace where qualified employers and individuals can shop for and enroll in private health insurance plans—as well as determine qualification for and gain direct access to financial subsidies.

  • More choice, selection and tools

    • Standardization and transparency

    • Managed Competition

    • Online tools (e.g., qualification assistance, calculators)

Enrollment starts October 1, 2013

Coverage becomes effective January 1, 2014

Cover oregon key features
Cover Oregon – Key Features

Shop / Compare / Enroll

  • Simple Selection – apples to apples comparisons of costs and benefits through CoverOregon.com

  • Easy Enrollment – one online application for individual/family for any health plan offered

  • Financial Assistance – qualification and access to funds for those who need help with premiums or cost share

  • Personal Service – extensive help finding the right coverage through Cover Oregon staff, agents and community partners (navigators)

Atrio health plans
ATRIO Health Plans

  • Why Enter the Exchange/Commercial Markets?

    • Business objectives

    • Risk considerations

  • Innovative Plan Approach

Atrio business objectives
ATRIO Business Objectives

  • Diversify revenues

  • Better serve our provider partners

  • Better serve our current member families

  • Open new markets to MA offerings

    • PEBB Retirees

    • OEBB Retirees

    • Federal Employees Health Plan Retirees

Risk considerations
Risk Considerations

  • New Risks

    • Elimination of Pre-existing conditions

    • Merging of high risk pool

    • Coverage expansion and pent up demand for services

Atrio product offerings
ATRIO Product Offerings

  • Inside the Cover Oregon exchange

    • 6 Standard individual PPO products

    • 6 Innovative individual products (EPO/HMO)

    • 3 Standard small group PPO products

    • 3 Innovative small group products (EPO/HMO)

  • Outside the exchange (open market)

    • 3 Standard small group PPO products

    • 3 Innovative small group products (EPO/HMO)

  • All products designs are based on Metal Tiers to delineate the level of coverage

Atrio exchange products
ATRIO Exchange Products

  • Individual

    • Gold Premium ID1300 & Pioneer

    • Silver Choice ID2500 & Pioneer

      • Silver Choice CSR 150 & Pioneer

      • Silver Choice CSR 200 & Pioneer

      • Silver Choice CSR 250 & Pioneer

    • Bronze Access ID5000 & Pioneer

  • Small Group

    • Gold Premium SG1300 & Pioneer (On and Off Exchange)

    • Silver Choice SG2500 & Pioneer (On and Off Exchange)

    • Bronze Access SG5000 & Pioneer (On and Off Exchange)

Innovative health plans
Innovative Health Plans

  • Cover Oregon allows carriers to offer plans that demonstrate innovation through the use of networks, wellness programs, or other options that do not include premiums or benefits.

  • ATRIO will offer an innovative plan designed to exclude from the cost of coverage those treatments that, proven through evidence-based medicine, do not improve the health status of the patient. Our Pioneer Plans are modeled after the OHP Prioritized List and are referred to as Evidence-Based Health Plans.

Population demographics
Population Demographics

  • Under 65

  • Most already have some sort of coverage

  • Kids

  • Some very sick, some acute, some who don’t use any services

  • Not as much medical management as Medicare and Medicaid

  • Expecting small enrollment in 2014

Provider matters
Provider Matters

  • Provider networks / contracting

    • PPO “wrap” networks

      • Leverage existing ATRIO network

      • First Health (regional)

      • Multi-Plan (national)

Medical management
Medical Management

  • Different timeliness and Prior Auth rules than Medicare and Medicaid

    • Standard Plans - See attached PPO Authorization List

    • Pioneer Plans - See attached EPO Authorization List

  • Formulary

    • MedImpact will continue to support our formulary management. There will be 1 formulary for all plans. PA Criteria may differ depending on adherence to preferred list.

  • Delegation

    • ATRIO will continue to partner with the SACs for Case Management, Disease Management, Transitions of Care and other QA programs.

Quality assurance
Quality Assurance

  • Quality Assurance is a component with several requirements from both Cover Oregon.

  • Much of this is not yet defined

  • The plan must have some form of accreditation.

    • ATRIO has chosen to become URAC Accredited.

      • This is the easier one

    • All of this will leverage many programs and policies already in place.

Website s

  • ATRIO website changes to accommodate under-65 products and links to Cover Oregon

  • Companion educational website:


Excellent resources
Excellent Resources

  • OregonHealthAnswers.org

  • CoverOregon.com

  • Oregon Insurance Division

    • http://www.cbs.state.or.us/ins/

  • Center for Consumer Information and Oversight

    • http://www.cms.gov/cciio/resources/regulations-and-guidance/index.html

  • DOL.gov

  • IRS.gov

  • KFF.org