Robert E Goff

• Small business tax credit • Prohibitions against lifetime benefit caps & rescissions • Phased-in ban on annual limits • Annual review of premium increases • Public reporting by insurers on share of premiums spent on non-medical costs • Preventive services coverage without cost-sharing • Young adults on parents’ plans • State insurance exchanges • Medicaid expansion •Phased-in ban on annual limits •States adopt exchange legislation and begin implementing exchanges • Insurers must spend at least 85% of premiums (large group) or 80% (small group / individual) on medical costs or provide rebates to enrollees • Small business tax credit increases • Insurance market reforms including no rating on health • Essential benefit standard • HHS must determine if states will have operational exchanges by 2014; if not, HHS will operate them • Premium and cost sharing credits for exchange plans • Premium increases a criteria for carrier exchange participation • Individual requirement to have insurance • Employer shared responsibility penalties • Penalty for individual requirement to have insurance phases in (2014-2016) • Option for state waiver to design alternative coverage programs (2017)

2010 2011 2013 2014

Source: Commonwealth Fund Analysis of the The Affordable Care Act (Public Law 111-148 and 111-152).

2015-2017

2014 The Year of the Health Insurance Exchanges

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Simply put:



Health Insurance products, different benefit packages, different plans available for purchase at a single “market”

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Two markets

▪ Small Business Health Options Program (SHOP) 50 or less ▪ Individual Market

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No pre-existing condition restrictions Subsidies based on income available

http://www.nystateofhealth.ny.gov/PlansMap 6

Who is offering in the NY HIX?

Dental Plans

http://www.nystateofhealth.ny.gov/PlansMap 7

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

Ambulatory patient services Emergency room services Hospitalization Maternity and newborn care Mental health and substance abuse disorders Prescription drugs Rehabilitation and habilitation services and devices Laboratory services Preventive and wellness services and chronic disease management Pediatric services, including oral and vision

SAMPL E

What is being offered Platinum, Gold, Silver, Bronze

Exchange Responsibilities

Only Available in Exchanges • Subsidies for individuals from 133%-400% of FPL • Small employer tax credits

Exchange Functions

Operate a toll-free telephone hotline to help users Enroll applicants in their chosen plan Maintain a website to sell plans Work with federal and state agencies regarding subsidies and tax credits Enroll eligible individuals into Medicaid Set annual Open Enrollment Period and special Enrollment Periods Certify and rate plans

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Organized marketplace

     One-stop shopping for subsidized and unsubsidized coverage Easily compare health plan options The only place to check eligibility and apply for financial assistance Enroll in qualified health plans

Two programs

  Individual Marketplace Small Business Marketplace 12

Health Plan Marketplace enrollment is estimated to be 1.1 million New Yorkers

Individual Marketplace (58%) Small Business Marketplace (42%)

450,000 615,000

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 Open Enrollment begins on

October 1

 Individuals may enroll in health plans during open enrollment October 1, 2013 - March 31, 2014) or with a qualifying event  Individuals who qualify for Medicaid/CHP may enroll any month of the year  Small employers may choose open enrollment dates for their employees any month of the year 14

 Assistance available in over 170 languages  Many staff will be bilingual and oral interpretation available for remaining languages. •  Will take applications over the phone starting in October Can refer to in-person assistors 15

IPA/Navigators • Complete Applications • Compensation from DOH grant program • Training and certification required • Serve Individuals and Small Business Marketplace Insurance Brokers/Agents • Complete Applications • Commission-based compensation • Training and certification required • Choose to certify in Small Business Marketplace, Individual, or both Certified Application Counselors • Complete Applications • No compensation from Marketplace • Training and certification required 16

Individual Responsibility

• Jan. 1, 2014: Individuals must enroll in coverage or pay a tax penalty

Penalty amount:

• Greater of $ amount or a % of income – 2014 = $95 or 1% – – – 2015 = $325 or 2% 2016 = $695 or 2.5% Family penalty capped at 300% of the adult flat dollar penalty or “bronze” level premium

Family Responsibility

Penalty amount:

Greater of $ amount or a % of income – 2014 = $285 or 1% – 2015 = $975 or 2% – – 2016 = $2,085 or 2.5% Family penalty capped at 300% of the adult flat dollar penalty or “bronze” level premium

Please note that the information in this chart is based on an interpretation of the Patient Protection and Affordable Care Act. This chart is for general information purposes only and is not intended to constitute legal advice or a recommended course of action in any given situation and should not be relied upon in making decisions of a legal nature.

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     Individuals may be eligible for premium assistance – 133% to 400% FPL if employer: Doesn’t offer minimum essential coverage

or

 Offers coverage, but premium isn’t affordable  However, if employer does offer affordable MEC and the employee purchases on HIX, not eligible for subsidy  Cost sharing assistance Individuals 133%-250% of FPL  Must purchase silver plan  Small employer tax credits Employers < 25  Must purchase on SHOP, other requirements apply Penalties for not having/offering health insurance 20

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1.1 million New Yorker's added to the “insured population”

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Reduced bad debts

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Increased access to care

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Increased demand for services

 These “new” patients come with lower reimbursement rates   Most of the HIX offering are paying between 6% and 25% LESS than the commercial rates for the same company Some plans are making participation mandatory  There “new” patients come with continued risk of bad debts    Federal regulations put the physician at risk of not being paid when patients are late in paying their premiums. Carriers HIX products must provide a 3 month grace period to enrollees that haven’t paid their premiums. During the first 30 days plans must pay claims, but in the last 60 days, the payer will hold the claims. If the patient coverage is cancelled after 90 days for failure to pay premiums, plans are not required to pay any claims in those last 60 days. It falls to the practice to go after the patient, for services rendered.

  Do you need this volume?

Do you believe increasing your access to patient sis the ‘right” thing to do?

 Are you “par” by virtue of your current participation agreements?

    Can you limit your participation to x number of HIX plans? X number of enrollees?

Know what you are getting into reimbursement wise.

Verify each patient’s benefit plan at time of 1 appointment scheduling and 2- at time of service.

Require a contingent credit card authorization on all patients

Stuff you want to ask

Thank you Robert E. Goff 25