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The Latest Scoop on Enrollment: Broker Regulations

Friday, June 14th, 2013

As open enrollment approaches, consumers will need accurate information to choose the right health plan. The Affordable Care Act provides assistance to consumers in a variety of flavors, from Navigators to In-Person Assisters to Certified Application Counselors. These roles, all governed by HHS regulations, are slated to help millions of people enroll starting in October. While the ACA created new, regulated roles for helping with enrollment, insurance brokers and agents have often been the means of purchasing coverage, especially for small businesses. Since brokers and agents will continue to play a role in enrolling people in insurance, federal regulations governing their role are necessary to ensure consumer needs come first throughout the outreach and enrollment phase of the ACA. Recently, HHS released guidance for their conduct in selling insurance through the Exchanges.

First, the regulations leave it up to states to decide whether they will permit brokers to sell qualified health plans (QHPs) through the Exchanges at all. If states opt in (which most or all will), then all brokers who intend to sell Exchange plans must register, complete an online Exchange-specific training course, and agree to comply with all federal regulations. The training will include Medicaid and CHIP so brokers are able to effectively refer consumers to the relevant agencies if they meet eligibility criteria for these services. The broker training will be different from the training for Navigators and other assisters. The regulations then distinguish between two pathways through which brokers can assist consumers in plan selection, purchase, and enrollment: the issuer-based pathway and the Exchange pathway.

Through the Exchange pathway, brokers would assist consumers using the same Exchange website consumers see if they sign up unassisted by a broker. This web portal ensures all plan options are directly displayed to the consumer. In contrast, through the issuer-based pathway, brokers use an insurer’s website to aid with plan selection and enrollment, and are redirected to the Exchange only to determine a consumer’s eligibility for financial assistance or other programs. This means brokers do not have to display all options to the consumer, which could mean people would not see the full range of options based on affordability, quality and benefits. However, CMS states that although they recognize brokers may try to push certain plans based on financial incentives, they are required to disclose to the consumer that they are doing so, and provide them the option of using the Exchange website themselves. What is unclear, however, is how oversight of this provision will happen.

The regulations differ between states with Federally-Facilitated Exchanges (FFEs) and those who have State-Based Exchanges (SBEs). For FFEs, CMS is responsible for registering brokers and conducting training. In SBEs, the state is responsible for licensing and regulating brokers and establishing continuing education requirements. All types of Exchanges, state-based or Federal, can require additional state-specific training or additional rules as a condition of licensure.

It is critical to the success of health reform implementation to enroll as many people in health plan options as possible. To achieve this goal it’s important to have everyone with enrollment experience, including brokers helping insure people. However, we need to make sure brokers are not steering consumers toward certain plans based on financial incentives, and are acting in the best interest of the consumer they are serving. One way to do this would be to track their enrollment practices and monitor experiences to ensure consumers are getting adequate assistance. Moving forward, oversight and enforcement will be key to ensuring brokers in the Exchanges are putting consumer needs first.

 – Sarah Gordon, Private Insurance Team intern
& Christine Barber, senior policy analyst

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Cross post: Competition And Transparency Bring down Health Insurance Costs—Here’s The Proof

Friday, May 31st, 2013

As we near open enrollment in new health plans, all eyes are on insurance premiums and the rates they are based on. As we have blogged about here before, industry-backed sources have been fueling the media with doomsday scenarios about cost increases due to the ACA. But what if those increases never materialize?

In a number of states that have recently released proposed premium rates for plans under the ACA, including California, Washington and Maryland, prices are reasonable and lower than many anticipated. And in Oregon, as the post below details, public posting of the insurance premiums actually lowered prices from their original bids. While certain interests continue to stress concern over the “rate shock” myth, the reality is that the ACA is meeting its promise in bringing greater transparency and competition between health plans to keep prices fair.

Oregon, as the below post from Jesse Ellis O’Brien of OSPIRG indicates, is a success story in reviewing premiums rates. While many states do not have the same regulatory infrastructure as Oregon, there are steps advocates can take to push for more accountability from insurers. Interested in learning more about these advocacy strategies? Read Jesse’s blog (originally posted here) and check our new toolkit.

Something remarkable just happened to health insurance costs here in Oregon. Last week, after the state’s health insurers posted their proposed premium rates for next year, two insurers publicly reversed course and moved to cut their prices.

Why? Because thanks to Oregon’s new health insurance exchange, Cover Oregon, insurers will be competing head to head for customers, and those customers will be able to make true apples-to-apples comparisons between plans for the first time. And thanks to an OSPIRG-backed law, the state’s insurance regulators now post proposed rates and all supporting documents online, enabling the public to compare rates—and insurers’ justifications for their rates—before they go into effect.

For example, see here for a price comparison of proposed rates for individual and family plans in the Portland area. (For information on proposed rates for plans available in your area, see here.)

Looking at these proposed rates, it is easy to see why insurers like Providence and FamilyCare would backtrack. To bring in customers, their rates must be competitive, and the rates they proposed are more expensive than the competition.

Why is this exciting? Because in our fragmented health insurance market, this kind of competition is new, and now we have concrete evidence that competition on a health insurance exchange can help bring down premium costs.

The events of the past week have shown that Oregon’s approach—advancing transparency and fostering head-to-head competition between insurers—can lead to real gains for consumers. But as experts warn that a third or more of health care spending wasted on things that do not improve health, we know we can do better. See OSPIRG Foundation’s recent report, Advancing Accountability, Cutting Health Care Waste, for ideas about how Oregon can take the next steps to tackle this waste and bring down the cost of care for all Oregonians.

– Jesse Ellis O’Brien, Health Care Advocate
OSPIRG

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Did Issuers Get a Free Pass on the Inclusion of Essential Community Provider Requirements?

Monday, May 6th, 2013

The Affordable Care Act requires qualified health plans participating in health insurance marketplaces (aka Exchanges) to maintain a sufficient number of Essential Community Providers (ECP) in their provider network. ECPs are safety-net providers within the following categories: federally qualified health centers, family planning clinics, Ryan White HIV/AIDS centers, American Indian health providers, public or non-profit hospitals, and others such as mental health and substance abuse providers and STD Clinics. They are the ‘essential’ and trusted source of primary care for poor and low-income communities with the greatest health needs. Many of them work to reduce health disparities as well as provide culturally and linguistically competent services.

“A remarkably generous policy”

Earlier this month, the Department of Health and Human Services (HHS) released its final Letter to Issuers on Federally-Facilitated and State Partnership Exchanges. This letter provides directions to insurers that want to participate in the Federally-Facilitated Exchanges. Compared to the draft version published for comments on March 1, this letter establishes much weaker standards for the inclusion of ECPs—essentially giving a free pass for insurers to sidestep building a robust network of providers for populations at risk.

According to the final letter, there are two levels of standards issuers need to meet. The ‘safe harbor’ standard is granted to participating health plans that contract with at least 20 percent of all ECPs in each county in the area the plans serve, meaning all available American Indian health providers and at least one ECP in each category mentioned above. In cases where a health plan fails to meet the safe harbor standard, an even less demanding option exists. In this instance, at the minimum the plan needs only to contract with 10 percent of these providers as long as it can present a justification as to how low-income and underserved communities can access needed care under its approach.

In addition, despite the low bar, HHS continues to offer further flexibility. While the draft letter suggested that health plans would not likely be certified if they did not meet the minimum expectation, the final letter suggests otherwise. Instead, HHS promises to “take into account factors and circumstances” in evaluating compliance. This suggests health plans are allowed to go below the 10 percent minimum expectation.

What can advocates do?

Advocate for a higher minimum standard to at least 50 percent

The safe harbor standard and the minimum expectation plainly fail to ensure reasonable and timely access to a broad range of providers for low-income, medically underserved individuals, and could prevent vulnerable individuals from getting adequate care. In a geographically large rural county, one health center located in one corner of the county may not be accessible for those who reside in the other side of the county. Therefore, a more rigorous minimum standard of at least 50 percent is needed. The Connecticut Health Insurance Exchange requires qualified health plans to contract with at least 75 percent of the essential community providers in any county and at least 90 percent of the federally qualified health centers or “look-alike” health centers in the state. In addition to the 50 percent rule, it is important to include specific criteria on enrollee to provider ratios, travel time and distance to providers.

Help safety-net providers build relationships and start the negotiation process with issuers

Safety-net providers are not automatically included in qualified health plans’ provider networks. Recently, the Center for Consumer Information and Insurance Oversight (CCIIO) published a list of essential community providers. As stated in the notification letter, the list does not include all eligible providers and will not be updated prior to 2014. A starting point is to review the list to identify any missing qualified ECPs. The next is to work with state insurance commissioners and other state officials to help build relationships and begin the negotiation process between safety net providers and qualified health plans. In Maryland, the Maryland Health Benefit Exchange, along with the Maryland Community Health Resource Commission and the Maryland Department of Health and Mental Hygiene will host several regional “Meet and Greet” sessions to help safety-net providers and qualified health plans begin discussions on contracting.

 – Quynh Chi Nguyen, Program and Policy Associate

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The “Rate Shock” Myth

Friday, April 26th, 2013

As Affordable Care Act opponents continue grasping at straws to find fault with the law, an assertion perpetuated by the insurance industry that the ACA’s coverage expansions will significantly increase premiums has gained prominence. Lately, many insurance industry-funded studies and the resulting news coverage of them have focused on the potential for “rate shock” for the young and healthy, fear mongering young adults and others into thinking their rates will skyrocket come 2014. None of these reports address all of the protections written into the bill to prevent steep rate changes and many fail to accurately represent the true scope of benefits and costs. Community Catalyst has prepared this fact sheet to help cut through some of the confusing arguments swirling around.

Very few people will be affected by significant rate changes. To give a sense of how small this number is, more than half of employed 19-44 year-olds were covered through their employers. Of those who are not offered insurance through an employer, 92 percent of young adults expected to enroll in individual plans with subsidies through the Exchanges would not be subject to premium increases. This is not to say that nobody will experience rate changes, but it is important to understand the relative impact of increases and the small number of people affected.

Rate changes will primarily impact young men between the ages of 19-27, who have incomes higher than 400 percent of the federal poverty level (more than $45 thousand per year) and are not covered through their employers. And even these individuals will only experience moderate changes – on average an increase of 10-13 percent compared to current non-group rates, according to the Congressional Budget Office.

Most importantly, the ACA means everyone will gain increased value per health care dollar through better benefit packages and limits on how much patients can pay out-of-pocket. New plans will be required to meet certain standards of benefits, including covering maternity, mental health, prescription drug coverage, and charging no co-pay or deductible for preventive services including cancer screenings and contraception. These new standard benefits ensure that consumers will get greater value and better protections than many plans currently provide. Young adults will also have the option of enrolling in a catastrophic coverage plan that covers the same benefits but offers lower premiums with a higher deductible.

The law also makes the system fairer across gender and age groups. Currently, insurers commonly charge women more than men, simply because they have the potential to incur more costs through maternity care. This unfair practice costs women in the private market approximately $1 billion per year, but is outlawed under the ACA starting in 2014. Similarly, insurers are allowed to charge older adults significantly higher rates. The ACA places limits on this practice so older adults can only be charged a maximum of three times as much as younger adults. This change reflects a more accurate approximation of the health cost differences between young and old, correcting years of overcharging adults for their health care services. Finally, the ACA ends discrimination against those who have preexisting conditions. This is not irrelevant for young adults, since 16 percent of 16-24 year olds have preexisting conditions and either are unable to gain coverage or are pay higher rates because of their medical history.

When it all shakes out, the benefits of the ACA for young adults far outweigh any costs. The impact of premium changes will be limited, will help make the health insurance system fairer, and will ensure consumers get more bang for their buck.

– Sarah Gordon, Private Insurance Team Intern

 

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Cross Post: Potential Costs and Challenges in Boston

Wednesday, April 24th, 2013

This blog was originally posted on CHIRblog.

With much of the country still reeling from the Boston marathon bombings, many of the victims – as well as their families and friends – have already begun the long road to recovery. With estimates that total medical costs could be as high as $9 million, there have been widespread reports of funds being established for individuals (here, here, and here, to name a few). And Governor Deval Patrick and Boston Mayor Thomas Menino established The One Fund Boston to help cover medical and other costs that raised more than $7 million in 24 hours, with contributions from the Boston Celtics, the Boston Red Sox, and Bain Capital, among others. (For ways to help, USA Today published this helpful guide.) With this outpouring of support from family, friends, and strangers, we’ve begun to consider some of the costs and challenges that the victims might face in obtaining the care they need to recover.

What kind of costs are we talking about? Given that Massachusetts has the highest insured rate in the country, many local victims are likely to have private or public coverage. For those that are covered, many will turn to this coverage for their medical expenses. However, even with private coverage in Massachusetts or another state, victims could face significant costs for their care. Although coverage may vary (and individuals should review their policies to understand the extent of their coverage), here are some of the potential costs worth considering:

Coverage Limits. Some plans have limits on the amount or type of coverage you can receive. Although the Affordable Care Act prohibited lifetime dollar limits on essential health benefits (such as ambulatory patient services, emergency services, hospitalization, prescription drugs, mental health, and rehabilitative services and devices), consumers might face costs because plans can 1) impose other restrictions, such as a limit on the number of visits for physical and occupational therapy; or 2) vary in the ways they define these categories so that a benefit that seems to fall within one category might not be clearly covered. Further, while the Affordable Care Act prohibited annual dollar limits on essential health benefits in 2010, some insurers received a waiver to maintain an annual dollar limit (currently, $2 million annually) until 2014. If a victim has this type of coverage, they could face high out-of-pocket costs depending on their medical condition.

In addition, some plans might not cover certain benefits at all, which places the burden on the consumer to pay for the service or benefit. Health insurance policies may, for example, exclude coverage for making changes to a victim’s home, such as installing a wheelchair ramp or safety grab bars. What’s more, health insurance policies may specifically exclude coverage for “acts of war” or “terrorism,” which – depending on how these terms are interpreted – raises the possibility that victims might not be covered. (In response to the attacks on September 11, 2001, the National Association of Insurance Commissioners (NAIC) considered whether it was appropriate to allow exclusionary language for acts of terrorism in health insurance policies (in addition to other lines of insurance) and adopted a policy statement concluding that “terrorism exclusions are not necessary for individual life and health products, and are generally not necessary to maintain a competitive market for group life and health products.” Many states, such as Kansas and North Carolina, issued subsequent guidance to insurers stating that they would disapprove exclusions for terrorism unless an insurer could show that it would face insolvency without the exclusion. It is unclear how many states currently prohibit exclusions for terrorism. For more on the coverage of terrorism-related events, see this GAO report and this NAIC resource list.)

Finally, those without comprehensive medical care – such as a limited benefit policy or drug discount plan – could find that they face significant out-of-pocket costs because their plan covers less than expected. Such policies are not regulated in the same way as comprehensive health insurance coverage and include far fewer protections to ensure that consumer needs are adequately met in the event of catastrophic need.

Cost-sharing Limits. Depending on the type of plan that a victim has, they may face out-of-pocket costs associated with their care. Most types of comprehensive health coverage include a deductible, an out-of-pocket maximum, and coinsurance requirements. If a consumer’s costs exceed the deductible and the out-of-pocket maximum for covered benefits and services, the insurer will typically pay for the remaining services. However, not all benefits or services may apply towards a deductible or out-of-pocket maximum; some plans might exclude mental health or prescription drug coverage from this amount, leaving the consumer to pay these additional costs. Other plans may place cost-sharing requirements on durable medical equipment, such as artificial limbs, that require the consumer to pay 20 percent of the cost of the equipment even after a deductible is met. Still others might be enrolled in high-deductible plans, which have become popular among employers in recent years, and require a consumer to pay out thousands of dollars before the insurer covers the costs.

Out-of-Network Care. Victims, particularly those from outside of Massachusetts, may face additional costs because they are receiving care outside of their typical provider network. If, for example, an individual lives in a different state and has coverage through an HMO or PPO, her insurer is likely to have a provider network based in her state that contracts with the insurer to provide services. But, outside of this established network of providers, most states allow consumers to be penalized – in the form of higher cost-sharing – by using an out-of-network provider, such as perhaps Brigham and Women’s Hospital in Boston. Even where state law requires an insurer to help cover the costs of coverage for out-of-network care, very few restrict the practice of balance billing (where a provider, such as a physician or hospital, seeks to collect from the patient any difference between the charges billed for a service and the amount that the insurer paid on that claim).

What could help? Given the outpouring of support for the victims, one would hope that at least their initial medical costs – such as hospitalization, prosthetic limbs, and out-of-pocket costs for other immediate needs – will be taken care of. Victims or their families should check with their insurer to understand what services are covered, how much the individual will face in out-of-pocket costs, and whether there are certain coverage exclusions. And, for the uninsured, hospitals might provide free or discounted services to those injured. Beyond these initial costs, however, there will be a critical need to ensure that the victim’s continuing needs – such as rehabilitative services and mental health treatment – are met.

One thing is certain – we will continue to reflect on the Boston Marathon bombing and what it means for our society to be faced with senseless violence perpetrated by others. As health policy professionals, we naturally turn to assessing our health care system’s ability to respond to the needs of the victims, including the level of public health preparedness and access to life-saving care and rehabilitative services. While we do not yet know all of the costs that the victims will face on the road to full recovery, it will be important to understand whether they have access to the services they need without significant financial hardship.

– Katie Keith, Assistance Research Professor and Project Director
The Center on Health Insurance Reforms
Georgetown University Health Policy Institute

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From the Feds Down to the States: Using Navigators to Promote Health Equity

Tuesday, April 23rd, 2013

HHS recently released the cooperative agreement funding opportunity for organizations interested in serving as Navigators in states with a Partnership or Federally Facilitated Exchange. Navigators, designed to assist individuals and families by identifying and explaining the insurance coverage options in the Exchange, can be social service organizations, consumer health advocates, community-based organizations, as well as a host of other entities that undergo specific training.

HHS requires at least one Navigator in each state to be a community and consumer-focused non-profit, opening up the possibility of advancing some of the key elements of the ACA that aim to reduce health disparities. Navigators will be on the ground in communities enrolling people in coverage and educating community members about their health insurance options. This role gives Navigators the ability to advance health equity as they are on the ground recognizing and responding to the economic and social barriers many face in accessing quality health care.

We’re heartened to see that the cooperative agreement proposal includes several elements that make health equity a clear priority. These include the requirements that those applying to serve as Navigators must be capable of:

  • • addressing the needs of underserved and vulnerable populations, such as rural populations and individuals with limited English proficiency
  • • conducting public education activities to raise awareness about Exchanges
  • • providing information and services in a fair, accurate, and impartial manner
  • • providing referrals to any consumer assistance or ombudsman program to address consumer grievances, complaints, or questions about their health plan, coverage, or a determination
  • • providing information in a manner that is culturally and linguistically appropriate to diverse communities and accessible to individuals with disabilities

Additionally, HHS recently issued a proposed rule that would establish standards to provide culturally and linguistically appropriate services and help that is meaningfully accessible to persons with disabilities, for all Navigators serving consumers in Federally Facilitated and Partnership Exchanges.

While we know that enrollment will be an ongoing process, requiring a true “all hands on deck” approach, these guidelines are an encouraging start. Moreover, while $54 million is not enough to execute a comprehensive education, outreach, and enrollment strategy in the 34 states eligible to apply for the funding, it’s a good starting point. This funding provides a strong opportunity for state advocates to leverage federal dollars with local and regional funders committed to reducing health disparities.

The amounts available to each Partnership and Federally Facilitated Exchange state for the Navigator program can be found here, but it is worth noting that those states with higher numbers of uninsured people, and many states with higher total populations of low-income communities and people of color, have been allocated higher funding levels. While the minimum amount any state may receive from the funding is $600,000, those states with greater uninsured populations can receive more funding, helping ensure that those with greater systemic disadvantages have more support to enroll in health insurance. We checked out these breakdowns according to 2010 Census data and matched against Kaiser’s tracking of a state’s total uninsured.

Given that these proposals are due by June 1, now is the time for consumer health advocates and smaller community-based organizations to coordinate. Organizations that work with targeted groups are more trusted and better able to engage with particular constituencies, making this proposal an opportunity for collaboration and true impact. For those consumer health advocates looking to partner with other groups on the proposal, consider regional or even local organizations outside of the health world that already provide social services. For smaller community-based organizations, identify your region’s or state’s consumer health advocacy organization and plug into their efforts to assist in outreach, education, and enrollment. Even if you haven’t yet been involved, uninsured people in your community need your help now!

Finally, if you and your organization are interested in learning the basics of federal grants and federal grant writing, join The Office of Minority Health Resource Center (OMHRC) on April 25, 2013 for a Capacity Building Webinar, Technical Assistance: Foundations of Grant Writing. RSVP online to ensure you can join the webinar.

– Emily Polak, State Advocacy Manager

 

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Spring NAIC Meeting: Insurance Commissioners Take Houston

Thursday, April 11th, 2013

This past weekend, insurance commissioners and their staff, along with insurance companies, brokers, other industry representatives, and a few intrepid consumer representatives gathered at the Spring meeting of the National Association of Insurance Commissioners (NAIC) in Houston. While the meeting did not hold as may controversies as in the past, there were discussions on a few important topics that give us an idea of what insurance departments are thinking about as we near open enrollment and full implementation of the ACA.

The Consumer Information working group has turned their attention to developing materials for insurance departments’ use in working with consumers on questions and complaints. Through a collaborative project with consumers, insurers, and regulators, that committee compiled a list of likely questions from consumers and is working on drafting responses. The goal is to finalize this information by July.

The NAIC is also starting to look at their role in overseeing the insurance market as the ACA rolls out. One of the most important jobs of state insurance departments is to conduct oversight of health insurers and make sure they comply with the law. But right now, most insurance departments don’t have the processes and structures in place to collect data (e.g. consumer complaints), track and analyze the data, and conduct audits for ACA-specific reforms. A small working group at NAIC will attempt to develop a market oversight framework that DOIs can implement in their own states.

Finally, discussion at a number of working groups turned back to the role of Navigators. As we have discussed in this blog, Navigators play a critical role in providing unbiased information about health plan options to consumers and in working with people through the application and enrollment process. Exchanges must train and certify Navigators to ensure they are capable of performing these duties. A recent proposed rule clearly outlines the differences between Navigators and brokers.

However, the broker community continues to pursue further regulation of Navigators at the state level, some of which could have a chilling effect on the number of community-based organizations that apply to be Navigators. For instance, many argue that Navigators should be required to be licensed or carry errors and omissions coverage to practice in a state.

A number of consumer representatives responded to the broker arguments, arguing that while it is true that Navigators must be trained and certified, additional state requirements could be duplicative or overly onerous. Navigators already must pass an exam and undergo extensive training. The consumer representatives underscored the need for unbiased help with the numerous options available in the ACA and, with millions newly eligible for coverage, there will be more than enough work for everyone to have a role. Unfortunately, not all of the commissioners are yet on board with the consumers’ perspective.

The NAIC will continue to work on these issues between now and their next meeting over the summer. There is much to do in a short time frame – stay tuned.

Christine Barber, Senior Policy Analyst

 

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Partnership Exchanges – Coming into Focus

Tuesday, January 15th, 2013

With a year to go before Exchanges open for business, the pace of new guidance continues to pick up. Just this past week, HHS released guidance on State Partnership Exchanges. The Partnership Exchange is not an option presented in the Affordable Care Act (ACA), but rather a regulatory approach to giving states an opportunity to be included in Exchange development and management without establishing a State-Based Exchange (SBE). The Partnership model offers states a seat at the table in two areas: plan management and/or consumer assistance. In addition, a Partnership Exchange may serve as a stepping-stone to an SBE and allow some political cover for states that are slow starters on Exchange implementation.

Plan management involves many tasks related to the successful selection and administration of Exchange health plans. Specifically, the guidance details it as the development of qualified health plans (QHP) inclusive of certification, recertification, and decertification. As a reminder, QHPs must be certified by the U.S. Department of Health and Human Services (HHS) and face penalty of decertification if the plan does not comply with standards drafted by HHS and the state; plans must also be re-certified annually. In a Partnership Exchange, plan management also entails daily oversight and administration of QHPs.

States also have the option of managing the consumer assistance portion of the Exchange. This work includes day-to-day management of Navigators and the development and management of a separate Assister program. As a reminder, Navigators are guides that help people understand and enroll in the Exchanges. The Assister program is a not in statute but is a new optional program that is distinct from Navigators yet serves as an additional consumer assistance tool and can be funded through Federal Exchange grant dollars (you can find a handy chart about consumer assistance here). Finally, the state may also opt to be responsible for outreach and educational activities. With respect to consumer assistance in Partnership Exchanges, HHS will operate the call center and website and be responsible for funding and awarding Navigator grants in states.

The guidance sheds some light on the distinctions between what activities HHS will spearhead and what activities state governments will lead for the two options available in a partnership – plan management and/or consumer assistance. While a few questions remain, the guidance does present a helpful outline of activity responsibilities and a general timeline as we count down to open enrollment for Exchanges in October 2013.

We thought that it would be helpful to highlight some of the necessary Partnership Exchange activities that will be underway in 2013. The dates presented in the guidance are not all deadlines but rather guideposts for states to follow in order to successfully launch plans and consumer support in time for open enrollment.

In addition, the guidance does outline in greater detail the approach for QHP certification for 2014 and is worth reviewing. Key highlights include the development of agreements between HHS and states, details about the amount of time that is allowed for HHS and state communications about certification, and data requirements for states. Tim Jost nicely summarizes them in his blog on the guidance, as does Christine Monahan on Georgetown’s CHIRblog. You can learn more about the state Partnership Exchange model and consumer strategies for a robust Exchange in a new paper by Community Catalyst, here.

With respect to consumer assistance, the guidance summarizes much of what we already know – however, the summary is helpful and better articulates the distinctions and overlap between Navigators and Assisters (referred to in the guidance as In-person Assistance). Some key highlights on consumer assistance from the include a description of responsibilities for development of training materials and how states may tailor the materials for their state; opportunities to fund Assisters through federal grant money (next application date is February 15); and a reminder all states will have a Navigator program that must be funded by the state. Please stay tuned for future discussion about the various tools available for consumer assistance.

Overall, the information in the guidance is a reminder states need to pick up the pace to meet the open enrollment deadline. That being said, HHS reminds us they will structure Exchanges where states do not.

 – Eva Marie Stahl, Policy Analyst

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The ACA Does That Too?! Moving to Curb LGBTQ discrimination in Health Care

Friday, January 4th, 2013

A woman in New Jersey was denied insurance coverage for an annual mammogram despite her plan’s typical coverage for such services. The reason: she’s transgender and her plan denies any coverage related to sex reassignment. She filed a lawsuit and eventually gained access to the coverage afforded to other women after battling the denial of care for two years.

A man in Connecticut was denied the care he sought for a routine procedure by two separate doctors’ offices. The reason: he’s transgender and was asking for a hysterectomy. One doctor deemed the procedure medically unnecessary and the other office would not provide services to transgender patients.

Lesbian, gay, bisexual, transgender, and queer (LGBTQ) people face mountains of barriers in obtaining health care—whether from insurers, employers, or providers. According to the Institute of Medicine, LGBTQ people are more likely, on average, to be without health insurance than the general population, with one in ten reporting being refused medical care outright because of sexual orientation and/or identity. According to a 2010 survey, nearly 30 percent of transgender and gender nonconforming people postponed medical care when they were sick or injured due to concerns about discrimination.

Moreover, people with multiple marginalized identities—in particular queer people of color—face greater discrimination. Nearly one-third of all transgender people of color report being uninsured. And upwards of 24 percent of transgender people of color report being refused medical care because of provider and insurer bias.

But there’s now an opportunity to change these statistics.

HHS recently announced that employers, insurers and providers cannot deny health insurance coverage or benefits based on “gender identity or failure to conform to stereotypical notions of masculinity or femininity.” We believe the rollout of Health Insurance Exchanges stand as an opportunity to level this playing field through decreasing gaps in coverage and ensuring all consumers—including LGBTQ people—have awareness of and access to the care they need.

In fact, there are victories tied to work on Exchanges already worth celebrating. In Colorado, consumer health advocates and LGBTQ advocates successfully partnered to complete an environmental needs assessment to identify current coverage limitations. In Maryland, that same type of partnership has resulted in the state including sexual orientation and identity on their patient satisfaction forms for a new health care program for low-income people. New York has taken this opportunity to ensure their Exchange has an LGBTQ workgroup, with other workgroups standing as allies when advocating for consumer-friendly Exchange principles.

As Exchange development moves along, we’ll also begin to see consumers use Navigators—individuals trained to support Exchange enrollment. By engaging with LGBTQ advocates now, consumer health advocates can help ensure states contract with LGBTQ-friendly non-profits to support consumer access by recognizing disparities, and approaching enrollment with true cultural competency.

Consumer health advocates and LGBTQ advocates are partnering to advance equitable health care through increased access to coverage, public education and consumer engagement, and data collection, by:

1. Increasing Access to Coverage:

  • • Working with Departments of Insurance and Exchange staff to build strong Exchanges that follow non-discrimination guidelines, and ensuring individuals are not denied access to Exchange coverage on the basis of sexual orientation or gender identity

2. Engaging in Enrollment Opportunities:

  • • Ensuring state-selected Essential Health Benefit benchmark plans avoid transgender exclusions
  • • Identifying LGBTQ community-based organizations (CBOs), and even more specifically, LGBTQ Community of Color CBOs, to serve as Assisters and Navigators in the Exchange enrollment process
  • • Ensuring Navigators and Assistors are trained in LGBTQ cultural competency; Ensuring LGBTQ-friendly language on enrollment forms, such as asking for ‘Adult 1’ and ‘Adult 2’ , and ‘Partner’ to recognize varied types of families

3. Promoting Public Education:

  • • Developing listening tours to identify health needs from the LGBTQ community throughout Exchange implementation
  • • Highlighting the ‘Best Practices’ of those employers who have eliminated transgender exclusions, and who provide domestic partner benefits;
  • • Encouraging comprehensive voluntary data collection –including sexual orientation, gender identity, and relationship status —on enrollment forms and patient satisfaction surveys.

– Emily Polak, State Advocacy Manager

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Cross Post: Pass the Stuffing: There’s a lot going on in the new essential health benefit rules

Monday, November 26th, 2012

This blog entry was originally posted on CHIRblog, a blog from the Center for Health Insurance Reforms, Georgetown University Health Policy Institute.

Last week, right before the Thanksgiving holiday, the Obama Administration released its proposed rule establishing the new, minimum standards for health insurance benefits. For the roughly 29 million Americans who face financial hardship because their health insurance doesn’t cover their needs, this is welcome news. It’s also undoubtedly welcome news to employers and insurance company executives, who need to know the rules of the road before they can design and develop plans that comply with the sweeping insurance reforms set to go into effect in 2014.

Establishing the essential health benefits (EHB) package is just part of a series of proposed rules. The Administration also released new standards for the 2014 market rules (i.e., guaranteed issue, modified community rating, and the prohibition on pre-existing condition exclusions), wellness programs, and rate review. And we’ll likely see more rules coming soon on multi-state plans and exchanges, as well as information about how the federally facilitated exchanges will operate.

While my family debated football and the merits of white meat over dark, I spent some time reading over the new guidance on EHBs. The Administration essentially formalized its bulletin from December 2011, allowing states to choose a benefit package benchmark that reflects local needs and meets the statutory requirement of being equal in scope to a “typical” employer plan. A few policy decisions and questions stood out:

State Benefit Mandates

One of the more controversial provisions of the Affordable Care Act is the requirement that states pick up any additional premium costs associated with benefit mandates that are not included in the EHB. HHS provided some good news for benefit mandate proponents, who have worried that consumers might lose access to important benefit protections in states where a benchmark with less coverage is chosen:

  • • State benefit mandates enacted on or before December 31, 2011 may be considered EHB, so the state would not be required to pay for any additional costs associated with them. However, those mandates would apply only to the markets originally determined under the state law. In other words, if a pre-2012 state law applies a mandate only to the individual market, it would not become a requirement in the small group market simply because it will now be considered part of the EHB.
  • • HHS interprets the Affordable Care Act to affect only those benefit mandates specific to the care, treatment and services that an insurer must offer to its enrollees. If a state has rules regarding provider types, cost-sharing, or reimbursement methods, HHS would not consider those benefit mandates, and states would not be required to defray any additional costs associated with them.

HHS also laid out the enforcement scheme for states to pay any additional premium costs. Exchanges will be required to identify which additional state-required benefits are in excess of the EHB. HHS also proposes that insurers should be responsible for determining the cost, if any, of additional benefits. HHS is asking for comment on whether states should make payments based on the statewide average costs of a benefit, or on each insurer’s actual cost.

State Benchmark Selections

HHS lists states benchmark selections in an appendix to the rule. For states that did not select a benchmark, HHS provides the default selection. However, states can make a selection or change their current selection up to December 26, 2012, the end of the comment period for the EHB rule. As outlined in the December bulletin, the state’s benchmark would be in effect for 2014 and 2015, after which time HHS will revisit its policy on EHBs. HHS has addressed a number of outstanding policy questions, and raised some of its own:

  • • Treatment of Multi-State Plans. HHS is proposing that multi-state plans will NOT be subject to a state’s benchmark plan, but instead must meet a standard set by the U.S. Office of Personnel Management (OPM). This could raise concerns about a level playing field among plans within a state, but we don’t yet know what rules OPM will have them follow.
  • • Defining habilitative care. Coverage of habilitated services is required under the Affordable Care Act. However, this benefit is frequently not covered in employer sponsored plans and insurers may define it differently. As a result, HHS is proposing that states may define habilitative services, if the benefit is not included in their benchmark plan. If the state does not define habilitative services, then the insurers may define it.
  • • Discriminatory benefit design. The Affordable Care Act prohibits insurers from using benefit design to discriminate against high-need enrollees. However, there are no set metrics for determining whether a benefit plan is discriminatory. HHS proposes that states review plans for outlier provisions, such as unusual cost-sharing or limits on benefits, that would suggest possible discrimination.
  • • Parity. HHS confirms its previous guidance that plans, in order to meet the EHB requirements, must provide mental health and substance abuse services in a manner that complies with federal mental health parity law.
  • • Substitution. HHS is proposing that insurers be able to substitute benefits within benefit categories, but not between benefit categories. The proposed substitution policy does not apply to prescription drugs. Insurers must supply an actuarial certification, attesting that any substituted benefit is actuarially equivalent to the original benefit in the EHB benchmark plan. HHS also clarifies that states have the authority to restrict substitution or prohibit it entirely.
  • • Prescription drugs. HHS has broadened its approach to prescription drugs, originally outlined in the December 2011 bulletin. Instead of requiring insurers to cover at least one drug in each category and class, HHS is now proposing that plans must cover at least the greater of: one drug in every category and class or the same number of drugs in each category and class of the EHB-benchmark plan. Thus, if the EHB benchmark plan covers more than one drug in a category or class, then all plans must offer at least that number.

Cost-sharing

The proposed rule also provides details on the Affordable Care Acts cost-sharing limits. The proposed rule ties the annual limit on cost-sharing to the out-of-pocket limit for high-deductible health plans provided under tax law. For the year 2013, the limits would be $6,250 for self-only coverage and $12,500 for family coverage. However, HHS is offering insurers a waiver from the limits on deductibles, if it can’t reasonably meet a Bronze level of coverage without raising the deductible.

Actuarial value

The law requires non-grandfathered individual and small group insurers to meet set levels of coverage, often called the “precious metal” tiers of Bronze, Silver, Gold, and Platinum. HHS has provided an actuarial value calculator for insurers to determine a plan’s precious metal level. HHS is proposing a fair amount of flexibility for insurers in this part of the proposed rule. In addition to allowing insurers to have a “de minimis” deviation from the prescribed levels of +/- 2%, HHS will also allow insurers with innovative benefit designs, such as tiered networks, to use actuarial certifications to attest to their compliance.

For another great summary of the EHB rule, check out Professor Tim Jost’s blog on Health Affairs’ website. There will be lots more to come from the federal government and the states as we gear up for 2014. Keep an eye on CHIRblog for the latest developments.

– Sabrina Corlette, Research Professor and Project Director
The Center on Health Insurance Reforms, Georgetown Health Policy Institute

 

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