Health Insurance Exchanges: Impact on Healthcare...

Health Insurance Exchanges:

Impact on Healthcare Providers Navigating Legal Developments on Exchanges and Analyzing the Interplay With Managed Care Contracts

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TUESDAY, FEBRUARY 12, 2013

Presenting a live 90-minute webinar with interactive Q&A

Jackie Selby, Member, Epstein Becker Green, New York

Jane L. Kuesel, Senior Attorney, Epstein Becker Green, New York

Kathrin E. Kudner, Member, Dykema Gossett, Ann Arbor, Mich.

Christina Hage, General Counsel, HealthyCT, Wallingford, Conn.

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Health Insurance Exchanges And

Healthcare Providers

Presented by Kathrin E. Kudner

313-568-6896

[email protected]

February 12, 2013

Exceptional service. Dykema delivers. 6

Overview

• Affordable Care Act (ACA) allows each State the

opportunity to establish an Affordable Insurance

Exchange to assist individuals and small employers to

purchase affordable health insurance through Qualified

Health Plans (QHPs)

• Premise is that the Exchanges will permit comparison of

plans, increase access to coverage, and increase

competition among plans


Time Line

• Coverage through the Exchanges will begin January 1,

2014 with enrollment beginning on October 1, 2013

• Extension of deadline to submit Blueprint Application to

operate a State Exchange to December 14, 2013

• Declaration Letter and Blueprint Application to operate a

Partnership Exchange by February 15,2013

• State may apply to operate an Exchange at any time in

future

• State Exchanges must be self-sustaining by January 1,

2015


How Will Exchanges Operate?

• Establishment and operation of Exchange

– Non-profit established by State, independent public

agency or as part of existing State agency

– State Exchange, Regional Exchange, Federally-

facilitated Exchange (FFE) or Partnership Exchange

– Qualified Health Plans

– Enrollment eligibility – individual and through Plan

– Employer eligibility in Small Business Health Options

Program


How Will Exchanges Operate? (cont’d)

• Qualified Health Plans (QHPs)

– Health plans must be certified as QHPs to operate

through Exchange

– Must meet minimum statutory standards

• May impose additional standards

• Eligibility

– Web-based system for individual to apply

• Enrollment


Exchange Functions

• Federal/state coordination with state continuing

traditional regulatory review

• Participant eligibility and enrollment

• Plan management

– Certification and oversight of QHPs

– Assess network adequacy

– Issuer account management

• Operation of website for plan comparison

• Consumer technical assistance and support

• Data collection and reporting


Options – State, Federal or Partnership

• State Exchange (or Regional with more than 1 State)

• ACA authorizes the Secretary to establish and operate

an FFE in any State that either:

– Chooses not to establish an Exchange; or

– Has been determined by the Secretary to be unlikely

to have an operable Exchange by January 1, 2014

• States also have the option to enter into a Partnership

with an FFE


State Exchange

• State must submit a declaration letter and blueprint for

approval or conditional approval by HHS

– HHS determined by January 1, 2013 whether State

Exchanges are ready to perform Exchange

operations by January 1, 2014

• State responsible for all Exchange functions

• Greatest flexibility for States

– Can determine how selective to be with QHPs


Federally-Facilitated Exchange

• HHS intends to work with States to preserve State

regulatory role

– Licensure and solvency

• HHS responsible for all Exchange functions

– Certification of QHPs

– Eligibility determination


State Partnership Exchanges

• State must submit a Declaration Letter and Blueprint

Application for approval or conditional approval by HHS

– Mirrors application for State Exchange plus standards

for data sharing and coordination

• Viewed as potential transition to State based Exchange

• ACA requires HHS to retain overall authority over FFE

but HHS will look to States for recommendations

• Intent is to integrate into existing State policies

• Reliance on State for regulatory approvals


Who Does What?

Task State HHS

QHP Certification Process application Collect data Rate determination Recommend certification actions Transmit data

Develop standards Review and determine approval of credentialing decisions

QHP Issuer Account Management

Day to day management Point of contact for communications

Coordination and technical assistance Respond to consumer complaints

QHP Oversight and Monitoring

Compliance with standards Enforcement actions under State law Recommend Exchange compliance actions to HHS Coordinate with HHS on operational oversight

Oversee QHPs related to Exchange rather than State regulatory issues Coordinate with State on oversight Determine Exchange enforcement decisions

Quality Coordinate with HHS on data collection Conduct quality/performance monitoring Provide web link to quality data

Develop quality rating, quality improvement, quality data standards


Where is your State?

California* Colorado* Alabama Alaska Arkansas*

Connecticut* Dist. of Columbia* Arizona Florida Delaware*

Hawaii* Idaho* Georgia Indiana Illinois

Kentucky* Maryland* Kansas Louisiana Iowa

Massachusetts* Minnesota* Maine Missouri Michigan

Mississippi** Nevada* Montana Nebraska North Carolina

New Mexico* New York* New Hampshire New Jersey West Virginia

Oregon * Rhode Island* North Dakota Ohio

Utah* Vermont* Oklahoma Pennsylvania

Washington* South Carolina South Dakota

Tennessee Texas

Virginia Wisconsin

Wyoming

* Received HHS Conditional Approval

** Rejected by CMS – Will be Federal

STATE PARTNERSHI

P FFE


Progress of States

• Default to the Federal

– For political reasons – Not willing to support ACA

– Waited for Supreme Court case and election so not ready

• Partnership

– Compromise – Not ready but want State involvement

(Michigan, Illinois)

• State

– Well developed (NY, Calif., NV, Connecticut)

– In progress (just received conditional approval)

– Rejected (Mississippi)

Christina Hage

HealthyCT, Inc., General Counsel

203-949-1602 x 1007

[email protected]

Connecticut Health Insurance

Exchange

Access Health CT

Connecticut’s Health Insurance Exchange

Scope of Outlined Duties:

Administer the HIX for both qualified individuals

and qualified employers

Survey individuals, small employers, and health

care providers on health care coverage issues

Implement procedures for certifying, recertifying,

and decertifying health benefit plans as QHP,

consistent with CT and HHS guidelines

19

Access Health CT

Operate a toll-free consumer assistance

hotline

Provide for enrollment periods (provided for in

PPACA)

Maintain an internet website where consumers

may obtain standardized comparative

information on QHPs, including enrollee

satisfaction survey information and other tools

to assist in evaluating the plans

20

Access Health CT

Publish on its website the average costs of licensing, regulatory fees, and any other payments the Exchange requires as well as the Exchange’s administrative costs, including information on amounts lost to waste, fraud, and abuse

Rate each QHP offered through the Exchange and determine each plan’s level of coverage in accordance with HHS criteria and regulations

Use a standardized format for presenting health benefit options in the Exchange

21

Access Health CT

Screen applications to determine if applicants are eligible for Medicaid, the State Children’s Health Insurance Program, or other state public insurance programs; enroll eligible applicants in such programs

Collaborate with DSS to allow a person to stay enrolled in his or her plan and provider network, if he or she loses premium tax credit eligibility and becomes eligible for Medicaid

Establish and make available a calculator that allows individuals to determine their actual cost of coverage, taking into consideration any applicable federal premium tax credit and cost-sharing reduction

22

Access Health CT Qualified Health

Plans

Exchange must make QHPs available to qualified individuals and employers by January 1, 2014

“Qualified Health Plan”: Health benefit plan certified as meeting criteria outlined in the PPACA and the Connecticut Public Act

“Qualified Individual”: State resident, seeking to enroll in a qualified health plan offered to individuals through the Exchange, who is a U.S. citizen, national, or lawful alien and not incarcerated (except for pretrial inmates)

“Qualified Employer”: A small employer with its principal place of business in Connecticut that elects to make its full-time employees eligible for one or more qualified health plans offered through the Exchange

Employer may also elect to make some or all part-time employees eligible

Employer must provide coverage through the Exchange to either all its eligible employees wherever they work or all its eligible employees employed in Connecticut

23

Access Health CT Certifying

Qualified Health Plans

Plan must provide the federally designated essential health benefits (with a few small exceptions)

Insurance Commissioner has approved the premium rates and contract language

The Plan provides at least a “bronze” level of coverage (covering 60% of the cost of essential health benefits) unless it is certified as a catastrophic plan offered only to people eligible for such plans

24

Access Health CT Certifying

Qualified Health Plans

The plan must comply with federal limits on

out-of-pocket costs

The plan meets the Exchange’s certification

requirements and those in HHS regulations

The Exchange determines that making the

plan available is in the interests of qualified

individuals and employers in the state

25

Access Health CT Health Carrier

Requirements

Be licensed and in good standing to offer health insurance in Connecticut

Offer through the Exchange at least one plan at the “silver” coverage level (covering 70% of the cost of essential health benefits) and one plan at the “gold” coverage level (covering 80% of the cost of essential health benefits) through each Exchange in which it participates

Charge the same premium rate for each QHP whether offered:

Through the Exchange or outside it

Directly by the carrier or through an insurance producer

26

Access Health CT Health Carrier

Requirements

Charge no coverage termination fee or penalty

if an individual enrolls in another type of

minimum essential coverage because he or

she is newly eligible for the coverage or his or

her employer-sponsored coverage has

become affordable under federal standards

Comply with HHS regulations and any other

requirements the Exchange may establish

27

Access Health CT Navigators

Purpose:

Educate the public about the availability of QHPs sold through the Exchange

Distribute fair and impartial information about enrollment in QHPs and the availability of premium tax credits and cost-sharing reductions under the federal PPACA

Facilitate enrollment in QHPs

Refer individuals with a grievance, complaint, or question about a plan, a plan’s coverage, or a determination under a plan’s coverage to the healthcare advocate or any customer relations unit the Exchange establishes

Provide information in a culturally and linguistically appropriate manner

28

Health Insurance Exchanges and Healthcare Providers

Jane Kuesel 212-351-3723 [email protected]

Jackie Selby 212-351-4627

[email protected]

mailto:[email protected]

mailto:[email protected]

NEW YORK

30

NY Health Benefit Exchange

New York QHP’s must: • Offer Essential Health Benefits • Meet network adequacy standards: Federal and NY Department of

Health • Apply to provide coverage for their entire service area • Offer an out-of-network offering for their Exchange product for any

county in which they are currently offering an out-of-network offering outside of the Exchange – but only at the silver and platinum levels -- for both the Individual Exchange and the SHOP Exchange

• Comply with quality component—and reporting • Have a treatment cost calculator for both in-network and out-of-

network providers

31

NY Plans

• One time chance to apply to participate for 2014-2015

• Provider network part of the application due April 12th

32

Federally Facilitated Exchanges

• Half of the exchanges will be FFEs

• Still awaiting detailed guidance from HHS

• Application for QHPs to be published “early 2013”

• Multi-State Payers (MSPs) will contract with Office of Personnel Management (OPM)

33

Where is Your State on this Spectrum?

Essential Health

Benefits Identified

Will Have Its Own

Exchange, FFE or

Federal Partnership ?

Requirements for QHPs

Identified – Any Willing

QHP?

Any Other Requirements (e.g. NY OON

requirement if offered outside

exchange)

Exchange Networks

Identified By QHPs

QHP’s Provider

Agreements Amended re:

Exchange Products

Network Requirements Identified (e.g.

network adequacy, options for limited

networks)

Plan Premiums Proposed by

QHPs/Approved By State

QHPs Approved By State

34

Let’s Get Practical…

35


The Plan Perspective

• Plans seem to be viewing the Exchange as a new

benefit category or product

– Between general commercial products and Medicaid

plans

– Anticipate rates in range between commercial and

Medicaid

• Larger national plans moving forward; smaller plans

taking “wait and see” approach


Considerations for each Plan

• Will the Plan participate in the Exchange?

• What products will the Plan offer through the Exchange?

• What is needed to be certified as a QHP?

• Are changes in Plan structure or operations needed?

• Review of provider networks

• Review of Participation agreements

– New agreements or amendments to current

agreements

– Expiration and evergreen provisions

– Termination


The Provider Participation Agreement

– the Plan’s View

• Form of Agreement – New, amendment to current

amendments to separate “Exchange” agreements

– Consistency of terms and definitions

– Application to new products or lines of business

– Compliance with changes in law

• Rate structure

• Benefit levels

• Expiration and evergreen provisions

• Termination – Tied to Exchange participation?

• Imposition of Exchange requirements on provider

The CO-OP Perspective

CO-OPs are required to be non-profit

New entity – new contracting opportunity for all

providers

Patient-centered medical homes are

HealthyCT’s core approach

39

From the Provider’s Perspective: Do YOUR Agreements With QHPs (or plans expected to be QHPs)

Already Apply to Exchange Products?

• Look at the definitions of: – “Benefit Plan” or “Benefit Program”

– “Product”

– “Line of Business”

– “Payer” or “Payor”

– “Member” or “Customer”

• Does agreement automatically apply to ALL commercial products?

40

How Does YOUR Agreement Define “Product”?

Example – Mutual Consent Required to Add Products Not Already Covered: “Products mean the list of healthcare benefit Products and Programs offered by Payor to its Members attached hereto as Exhibit A. Persons not enrolled in a Product listed in Exhibit A shall not be entitled to access this Agreement. Any and all amendments to Exhibit A shall require the mutual prior written consent of the parties…”

41

How Does YOUR Agreement Define “Product”?

Example – Provider Consent Not Required to Add New Products:

“Payor may add or remove Products and Programs at any time and from time-to-time. At Payor’s sole election, Provider shall be required to participate in any new Product or Program offered by Payor on the same terms and conditions as set forth under the Agreement…”

42

Are Exchange Products Covered by Existing Rates and Fee Schedules?

Can Payer Change Unilaterally?

• Review fee schedules and rate attachments

• Review payer’s ability to amend fee schedules and rates, or to amend more generally

43

Mutual or Unilateral Consent to Amend?

Example:

“This Agreement, including any and all exhibits, attachments and appendices hereto, can be modified or amended only by a written document, expressly referencing this Agreement and the parties’ mutual intent to amend it…”

44

Does YOUR Agreement Address Limited or Tiered Network Products?

Example:

“The parties acknowledge that Payor offers or may offer Benefit Plans or Products which include tiering of Providers on the basis of cost and/or quality performance, as determined by Payor, and which provide Enrollees with financial incentives to utilize Providers from tiers with lower cost and/or higher quality performance…”

45

Does YOUR Agreement Address Increases In “Bad Debt” (uncollected

amounts from members)?

• Does HMO hold harmless clause apply?

• If not, will Payer negotiate?

• Member Cost Share (Copays, Coinsurance, Deductibles) may be harder to collect

46

Some Members Will Switch Between Medicaid and Exchanges

• Does your agreement cover Medicaid?

• What are continuation of care requirements for exchange members?

47

For Primary Care Providers

• Most exchange products will be gatekeeper models, requiring referrals and prior authorization

• Does your agreement require open panels for exchange members?

48

Health Insurance Exchanges: Impact on Healthcare...

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