Transcript Health Benefits Exchange

Kentucky Health Benefit Exchange
FRYSCKy Fall Institute
October 30, 2012
Miriam Fordham, Division Director
Melea Rivera, Insurance Program Manger
Office of the Kentucky Health Benefit Exchange (KHBE)
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Health Insurance Reforms that are
Affecting You Now
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Temporary High Risk Pool (PCIP)
New coverage options for young adults
No lifetime limits on health benefits
Coverage for children with pre-existing conditions
Affordable prescription drugs for seniors
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Health Insurance Reforms that are
Affecting You Now
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Preventive services with no deductible or co-pay
Rate Review and MLR Rebates
Rescissions
Uniform Explanation of Coverage and Standard
definitions
• Appeals
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Kentucky Health Benefit
Exchange
Executive Order (2012- 587) signed by Governor
Beshear July 17, 2012 created the Exchange and
administrative structure:
• Organized Office of KHBE under CHFS with 4
divisions (with up to 30 employees);
• Established an Advisory Board; and
• Authorized Board to create sub-committees.
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Kentucky Health Benefit Exchange
Advisory Board
• First meeting held September 27, 2012
• Six subcommittees formed:
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Behavioral Health
Dental and Vision
Education and Outreach
Navigator/Agent
Qualified Health Plans
Small Employer Health Options Program (SHOP)
• Navigator/Agent, Qualified Health Plans, and SHOP
subcommittees have met.
• Meeting schedules and materials posted on the KHBE website
(healthbenefitexchange.ky.gov).
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A health benefit exchange is an
organized marketplace for individuals and
employees of small businesses to shop for
health insurance offered by insurers
(insurance companies, CO-OPs, and OPM)
based on price and quality. Individuals will
also be able to apply for Medicaid coverage
through the Exchange.
Like
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When must the Exchange be
operational?
Fully Operational - January 1, 2014
Open Enrollment - Begins October 1, 2013
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Exchange Options for States
Federal exchanges include both a state partnership and federallyfacilitated exchanges
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Why is Kentucky pursuing a
State-Based Exchange instead of a
Federal Exchange?
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Support from interested stakeholders;
Prevent dual regulation of health insurance market;
Determine benefits provided in Kentucky’s Exchange;
Allow Kentucky to have flexibility, including
determinations of Medicaid eligibility; and
• Consider Kentucky’s unique regional and economics
needs.
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Will Qualified Health Plans (QHPs) in
the Exchange be different compared to
the insurance plans you have now?
•A New Way to Shop
•Consumer Protections
•Essential Health Benefits
•Health Care Quality Ratings
•Levels of Coverage
•Navigator Program
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What are Essential Health Benefits?
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Must be defined by Secretary of Health and Human
Services. Sec.1302 of the ACA; and
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Must include items and services within the following
categories:
Ambulatory Patient Services;
Emergency Services;
Hospitalization;
Maternity and Newborn Care;
Mental Health and Substance Use Disorder Services;
Prescription Drugs;
Rehabilitative and Habilitative Services and Devices;
Laboratory Services;
Preventive/Wellness Services/Chronic Disease
Management; and
Pediatric Services, including Oral and Vision Care.
Kentucky’s Navigator Program
Navigators - Individuals or Entities that:
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May include: Community/consumer-focused nonprofit groups, Chambers of
commerce, resource partners of Small Business Administration, Health Care Providers,
etc.
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Maintain expertise in eligibility, enrollment and programs;
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Provide information/services in fair, accurate, impartial way;
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Facilitate selection of QHPs;
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Provide referrals to any applicable office, health insurance consumer assistance or
ombudsman, or State agency for grievances, complaints, or questions about health
plan; and
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May not be compensated with funds from Federal government or health insurers.
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Small Business Health Options Program
(SHOP)
Through an Exchange, states are required to have a SHOP to provide
health insurance options to Small Businesses (Small Group Employers).
SHOP will ease administrative burden on employers than now
administer their group health plans ( e.g., collect employee premium
payments).
Each State has the option of operating a stand-alone SHOP Exchange or
merging the SHOP with individual market Exchange.
Kentucky’s SHOP Exchange will be merged with the individual market
Exchange for administrative and financial simplification.
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Eligibility Standards for SHOP
Employers may purchase coverage through the SHOP, if the
employer:
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Is a small group employer (2 to 50 employees);
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Elects to offer, to all full time employees, coverage under
a QHP purchased through the SHOP;
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Has a principal business address in the SHOP service area
or the employer offers coverage to employees through
the SHOP, serving the employees’ primary worksite; and
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Employees are eligible to enroll in SHOP if the employee
receives an offer of coverage from the employer.
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Who will qualify for Premium Assistance and
Tax Credits?
Individuals with a household incomes (for the taxable year)
between 133% and up to 400% of the federal poverty level
(FPL); and
Small Businesses may qualify for tax credits if:
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The Employer has fewer than 25 full-time equivalent
employees for the taxable year;
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The average annual wage of Employee in group is less than
$50,000; and
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The Employer pays at least 50% of the premium for each
employee.
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Example of Premium Assistance Amounts for
family of four at different income levels
Percent
of FPL
Annual
Income
Annual
Premium
Before
Premium
Assistance
Annual
Premium
Assistance
Amount
Annual
Premium
After
Premium
Assistance
Monthly
Premium
Before
Premium
Assistance
Monthly
Premium
Assistance
Amount
Monthly
Premium
After
Premium
Assistance
133%
$30,657
$12,000
$11,080
$920
$1,000
$923
$77
150%
$34,575
$12,000
$10,617
$1,383
$1,000
$885
$115
200%
$46,100
$12,000
$9,096
$2,904
$1,000
$758
$242
300%
$69,150
$12,000
$6,122
$5,878
$1,000
$510
$490
Up to
400%
$92,200
$12,000
$3,241
$8,759
$1,000
$270
$730
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IRS Tax Credit Example
Auto Repair Shop with 10 Employees Gets $24,500
Credit for 2012
Main Street Mechanic:
Employees: 10
Wages: $250,000 total, or $25,000 per worker
Employee Health Care Costs: $70,000
2012 Tax Credit: $24,500 (35% credit)
2014 Tax Credit: $35,000 (50% credit)
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KHBE Implementation Update
2012
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July & August – Public Forums in Erlanger, Louisville,
Owensboro, Paducah, Prestonsburg, and Somerset. More
scheduled for 2013.
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August – Request for Quote (RFQ) for Marketing/Outreach
vendor issued.
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September – Advisory Board members (19) appointed.
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October 1 – EHB benchmark submitted to HHS.
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Sept/October– Contract signed with IT vendor.
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October– Website healthbenefitexchange.ky.gov launched.
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November 16 – Application (Blueprint) must be filed with HHS.
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