ACA, Health Insurance Exchanges and ATRIO – What You Need to Know.
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Transcript of ACA, Health Insurance Exchanges and ATRIO – What You Need to Know.
101 EducationACA, Health Insurance Exchanges and
ATRIO – What You Need to Know
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.
Today’s Goal
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
Agenda
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!
Goals of the ACA
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
Key ACA Requirements-2014
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)
Cover Oregon – The New Marketplace
Enrollment starts October 1, 2013Coverage becomes effective January 1, 2014
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)
Cover Oregon – Key Features
Plan Design StandardizationPlan Tier Plan Covers Member Pays
Bronze 60% 40%
Silver 70% 30%
Silver CSR 201-205% FDL 73% 27%
Silver CSR 151-200% FDL 87% 13%
Silver CSR 133-150% FDL 94% 6%
Gold 80% 20%
Platinum 90% 10%
Catastrophic Plans Qualified young adults < age 30
Child-Only Plans Individuals less than age 21
Innovative Health Plans Offered within Metal Tiers
Dental Plans Free standing | Pediatric Dental
Non-Standard Plans Carriers may offer up to two NSPs in each Metal Tier in each service
area.
Why Enter the Exchange/Commercial Markets?◦ Business objectives◦ Risk considerations
Innovative Plan Approach
ATRIO Health Plans
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
ATRIO Business Objectives
New Risks◦ Elimination of Pre-existing conditions◦ Merging of high risk pool◦ Coverage expansion and pent up demand for
services
Risk Considerations
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 Product Offerings
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)
ATRIO Exchange Products
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.
Innovative Health Plans
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
Population Demographics
Provider networks / contracting◦ PPO “wrap” networks
Leverage existing ATRIO network First Health (regional) Multi-Plan (national)
Provider Matters
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.
Medical Management
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.
Quality Assurance
ATRIO website changes to accommodate under-65 products and links to Cover Oregon
Companion educational website:
www.OregonHealthAnswers.org
Website(s)
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
Excellent Resources