__________________________________ Lisa Summers, CNM, DrPH

Peter McMenamin, PhD

Department of Nursing Practice & Policy

THE CRITICAL ROLE OF NURSES & NURSING

State Health Insurance Exchanges:

Acknowledgement

Laura Brennaman, MSN, RN, CENDoctoral Fellow RWJF Nursing & Health Policy CollaborativeUniversity of New Mexico

Overview

State Health Insurance Exchanges 101– What are they?– Why should you be engaged?

Stories from the States– Colorado– Maryland– Mississippi

Questions and Discussion

President’s address June 28, 2012

if you’re one of the 30 million Americans who don’t yet have health insurance, starting in 2014 this law will offer you an array of quality, affordable, private health insurance plans to choose from. Each state will take the lead in designing their own menu of options…

Once states set up these health insurance marketplaces, known as exchanges, insurance companies will no longer be able to discriminate against any American with a preexisting health condition. They won’t be able to charge you more just because you’re a woman. They won’t be able to bill you into bankruptcy. If you’re sick, you’ll finally have the same chance to get quality, affordable health care as everyone else. And if you can’t afford the premiums, you'll receive a credit that helps pay for it.

What is an Exchange?

Portals for individuals & small businesses to buy affordable & qualified health plans.Intended to: – Enhance competition in the health insurance

market– Improve choice of affordable health insurance to

individuals– Give small businesses the same purchasing clout

as large businesses.

Timeline for Exchanges

Federal government will assess states’ readiness to operate Exchanges January 2013Scheduled to start open enrollments in October 2013. Insurance effective dates beginning January 1, 2014.

Consumer assistance toolsToll-free call center

In plain language That are accessible and timely mannerinterpretive services for people who have limited English proficiency

Up-to-date websitestandardized comparison of all qualified health plans

Essential Health Benefits PackageAmbulatory patient servicesEmergency servicesHospitalizationMaternity & newborn careMental health & substance use disorder services, including behavioral health treatment

Prescription drugsRehabilitative & habilitative services & devicesLaboratory servicesPreventive & wellness services & chronic disease managementPediatric services, including oral & vision care

Plan Levels & Cost SharingInsurers contribute

60% of costs of EHBP for Bronze plans 70% of costs of EHBP for Silver plans 80% of costs of EHBP for Gold plans 90% of costs of EHBP for Platinum plans

Comparing Plan Value in the

ExchangeConsumers want it to be easy to compare

premiums and benefits covered.Premium costs comparisonStandardized actuarial rating (metal level)Quality ratings by accreditation agenciesMedical loss ratios Up-to-date provider directories

Medical Loss Ratio (MLR)

20%

80%

Column1Administrative costsHealth care services and quality improvement

The MLR requirement is 80% for plans sold inside the Exchange

NavigatorsAssist Exchange users to select a health planConduct public education activities to raise awareness about the ExchangeRefer complaints or problems to appropriate agencies for resolution.

Seamless Streamlined Process

“one-stop shopping” where people with lower and moderate incomes can learn if they qualify for - Medicaid CHIP benefits Premium subsidiesTax credits for eligible small benefits

ANA Advocacy

APRNs should recognized as primary care providers in qualified plansNurse Managed Health Clinics, School-Based Health Clinics, and Free Standing Birth Centers should be Essential Community ProvidersAPRNs should be team leaders in Patient Centered Medical HomesNurses should be on the governing boards of State Health Insurance Exchanges

Progress on ExchangeDevelopment

From Kaiser Family Foundation Updated April 13, 2012

Network Adequacy

Offers sufficient choice of providers in-network and out-of-network while assuring reasonable access to quality primary and specialty care.

The National Association of Insurance Commissioners (NAIC) Model Act for network adequacy includes all types of licensed health care professionals, including APRNs.

CMS affirms the network must assure that all services will be available without unreasonable delay

APRNs Provide Essential Benefits

Ambulatory ServicesMaternity & Newborn CareServices during HospitalizationsChronic disease managementMental health & substance use disorder services

All four APRN roles need to be included in health Exchanges

Essential Community Providers

Essential community providers are those healthcare delivery providers that serve predominantly low-income, medically underserved individuals.

They are to be included in qualified plan networks as long as the provider accepts the generally applicable payment rates of the plan.

Essential Community Providers

Should include Nurse-managed health centersSchool-based health centersFreestanding birth centers

Provider Directories Should list all credentialed providers • Online

version• Print version

ADVOCACY AT THE STATE LEVEL

Nurses and state associations will need to monitor the evolvement of Exchanges in their states to deliver the evidence of quality, improved access, and cost saving available through APRN directed primary care

Resources

ANA Issue Brief, State Insurance Exchanges: The Critical Role of Nurses and Nursing is available on line.

http://nursingworld.org/statehealthinsuranceexchanges

It includes links to good sites for keeping abreast of developments. Upcoming HHS Forums (email invitation 7/17)

Stories from the States

ColoradoFran Ricker, Executive Director, Policy Director and Lobbyist, Colorado Nurses AssociationMarylandRobyn Elliot, Lobbyist, Maryland Nurses AssociationMississippiTeresa Malone, Executive Director, Mississippi Nurses Association

For more information: NursingWorld.org