NAIFA – Dallas Meeting

Shannon P. Meroney

Senior Manager, State Government Relations Aetna

October 2012

Health Insurance Reform: What does the Future Hold?

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Guaranteed issue Individual coverage mandate

Individual subsidy

State individual and small group exchanges operational

Rating rule changes

Insurer taxes Employer “Pay or Play” Mandate Essential health benefits Medicaid expansion

90-Day maximum waiting period

Auto-Enrollment Annual reporting of

employee coverage Definition of full-time

employees Wellness incentives

Health Insurance Reform Timeline 2010 – 2020

Benefit coverage changes- Preventive Care at 100% in network- Dependents < age 26 - No pre-ex < age 19- Prohibits rescissions except fraud- No lifetime limits/ annual limits on essential benefits- Patient protections- Grievance and appeals updates

Temporary high-risk pool Uniform MLR definition (NAIC) Federal rate review process

Source: Patient Protection and Affordable Care Act

Minimum MLR requirements Medicare Advantage plans begin

to have payments frozen Medicare Advantage cost sharing

limits effective Pharmaceutical fee Rate review implementation

Increased penalties on individual mandate

Increased insurer taxes States must allow groups

with <100 employees into exchanges (2016)

“Cadillac tax” (2018)

2010 2011 2012 2013 2014 2015-2019

Patient Centered Outcomes Research fee

MLR reporting goes “live” Administrative

Simplification begins to phase in

Uniform summary of coverage

Medical Device fee

Exchange coverage notice

FSA Cap

Tax deduction for Medicare Part D subsidy eliminated

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Individual Mandate

Tax Credits and Subsidies

Taxes and Fees

Risk Management Mechanisms

Key ACA Provisions effective in

2014

Prohibits health plans from denying coverage or rating applicants based on their health status

Levels the playing field between health plans and mitigates the impact of Guaranteed Issue and pricing uncertainty in the short term

Institutes penalties for failing to purchase health insurance

Lowers the cost of coverage for the low and middle income populations in the Individual market

Levies against health insurers and other groups to fund subsidies and risk management mechanisms

Institutes penalties for employers who fail to offer affordable comprehensive coverage

Creates government regulated Individual and Small Group health insurance marketplaces

Insurance Exchanges

Employer Mandate

Guaranteed Issue (GI) and Rating

Changes

Prominent ACA Provisions in 2014

Key ACA provisions, which will become effective in 2014, will have a significant impact on the health insurance marketplace.

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Impact of Affordability Challenges on Individual Plan Premiums

ILLUSTRATIVE

* This example uses the 2011 Plan Premium of Aetna’s popular PPO 5000 plan for a 40-year-old male in Dallas, TX as its starting point** Represents ability to capture a more balanced risk pool due to risk mitigation provisions and incentives created by the individual mandate and

subsidies in the ACA

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Source: AHIP: Health Insurance Exchanges; Developing an Industry Playbook: March 2, 2011

Promote and regulate marketing of products and services

Marketing Oversight

Determine who may participate and who is eligible for subsidies

Eligibility/Subsidy DeterminationProvide assistance in navigating the

shopping, subsidy eligibility, and enrollment process

Navigator

Premium Collection/Reconciliation

Determine premium obligations and combine with subsidies to ensure payment for coverage

Interoperability with Health Plans

Build technology and operational interoperability with health plans

Certify and select health plans for the Exchange; Monitor health plan quality and

performance

Health Plan Certification and Quality Oversight

Comparison Shopping and Customer Service

Provide information that consumers and small businesses can use to identify, review, and select

products. Respond to inquires

Enrollment and Eligibility Maintenance

Support standard enrollment processes and ongoing maintenance

Specify products will be available and what information is required

Product Availability/Specifications

Mandated Exchange Functions and Capabilities

Exchanges will need to develop a broad array of capabilities. The robustness of these capabilities will likely vary from state to state.

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Update on Essential Health Benefit (EHB) Plans

• Federal law requires essential health benefits to include coverage for ten categories of coverage;

• Each state may define an essential health benefits standard by selecting a benchmark plan;

• The benchmark plan will comprise the essential health benefits package, which must be covered by all individual and small group plans in and out of the Exchange in 2014;

• Texas must pay the cost of any state mandates that apply to individual or small group plans that are not contained in the benchmark plan;

• TDI is working with carriers to estimate the cost of such mandates as required by Rider 19;

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Update on Essential Health Benefit (EHB) Plans

Required Categories of Coverage • Ambulatory patient services • Emergency services • Hospitalization • Maternity and newborn care• Mental health and substance use disorder services, including behavioral health treatment • Prescription drugs Rehabilitative and habilitative services and devices• Laboratory services • Preventive and wellness services and chronic disease management • Pediatric services, including oral and vision care

Required Categories of Coverage • Ambulatory patient services • Emergency services • Hospitalization • Maternity and newborn care• Mental health and substance use disorder services, including behavioral health treatment • Prescription drugs Rehabilitative and habilitative services and devices• Laboratory services • Preventive and wellness services and chronic disease management • Pediatric services, including oral and vision care

Benchmark Plans

• HHS proposes 4 types with 10 options

• Benchmark Plan will represent the EHB standard in each state

• If excludes a required coverage, must be supplemented

• States cannot modify the chosen option

• Largest small group plan is the default plan

• Deadline was September 30 for states to choose or default;

Benchmark Plans

• HHS proposes 4 types with 10 options

• Benchmark Plan will represent the EHB standard in each state

• If excludes a required coverage, must be supplemented

• States cannot modify the chosen option

• Largest small group plan is the default plan

• Deadline was September 30 for states to choose or default;

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Update on Essential Health Benefit (EHB) Plans

Plan Types Plan Options TX Enrollment

Largest 3 Sm Grp BCBSTX BestChoice PPO 345,781 UHC Choice Plus PPO 181,105 BCBSTX BlueEdge HSA 83,532

Largest State EE ERS HealthSelect 440,104 TRS ActiveCare Plan 2 270,490 UT UT Select 180,299

Largest 3 Nat’l Federal Employee Plans BCBS Standard Option PPO Not available

BCBS Basic Option PPO Not available GEHA Standard Options PPO Not available

Largest Insured Commercial Non- Medicaid HMO Aetna Open Access Managed Choice (POS) 153,588

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Update on Essential Health Benefit (EHB) Plans

• Public Forum was held August 28; 122 attendees and 114 by phone.

• TDI believes they do not have clear guidance from HHS on the process to submit a benchmark plan.

• HHS posted the default plan (BCBSTX Best Choice PPO), for public comment.

• TDI believes the September 30 deadline was “soft,” giving them additional time to select a benchmark plan. For now, they have not done so.

• A minority of states (approx 15) have made an affirmative selection by Oct 1.

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What is next…..

• The Supreme Court decision did not change our business strategy or commitment to system reforms that make quality care more affordable and accessible.

• At the same time, we know that much more must be done to fix the problems that remain in our health care system. We believe there is still time -- if people can come together in a bipartisan way -- to improve quality and affordability. That security is what Americans want and need.

• We are focused on delivering the next generation of health care through innovative solutions that improve quality and health outcomes, which ultimately makes care more affordable.

• We remain committed to working with policymakers and other stakeholders to make our health care system work better for everyone.