Health Reform and Health Insurance Markets2014 Changes in New Hampshire

New Hampshire Insurance DepartmentTyler Brannen – Health Policy Analyst October 17, 2013

1

The ACA and NH

• Federal law vs. state laws• Health insurance rules• Expanding health insurance coverage• “Exchanges” and the individual mandate

2

NH’s Health Commercial Insurance Markets• About 55% of “insured” people covered by self-

funded employers• 76% of people covered by large employers

• Of those people, 29% are regulated as insured (140,000)

• 24% of people in small employers or individual market• 110,000 small employer members• 40,000 individual members

3

- 50,000 100,000 150,000 200,000 250,000 300,000

Anthem

CIGNA

Harvard Pilgrim

Aetna

MVP

Usable

Assurant

HealthMarkets

United

NovaSys_Health

Celtic

American Republic

Golden Rule

Health Insurance Carrier/TPAMember Distribution by Funding

Fully-Insured Members Self-Insured Members

4

Factors in Insurance Company Competition

Main Factors:• Medical claims costs• Provider contracts

• Insured population health status

• Other Factors:• Membership• Underwritten & self-funded

• Organizational efficiency• Return on Investments• Customer service

5

RSA 420-J:7 Network Adequacy (Ins 2700)• Anthem’s Pathways Network• Complied with NH Network Adequacy

requirements• Does not apply to most of Anthem’s members• Anthem indicates premium savings of at least 25%• Primary issue – 10 of 26 hospitals in NH not

included• Anthem only medical carrier on the

exchange/Marketplace• Significance - only place to access subsidies• Why only Anthem?

• Will there be a legislative solution?• How involved should the government be?

6

What is happening in the delivery system?

• Investment in Community Health Centers• Increased use of mid-level providers (NPs, PAs), health coaches,

and community health workers• Telemedicine• Hospitalists• Urgent care centers and walk in clinics• Accountable Care Organizations and medical homes• Hospital services provided in non-traditional settings• Incentives exist for restructuring the delivery system with a lower

cost structure

7

2014 Changes to Insurance

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What’s New in 2014?• Individual mandate• New rules for individual and small group markets • Essential health benefits – 10 Categories

• Emergency services, hospitalization, Maternity & newborn care• Guaranteed issue• New rating factors for calculating premiums

• PAST: age, health status, group size, industry, tobacco• FUTURE: Age, tobacco, geographic (not used in NH)

• Metal levels

• Requirements for large employers (2015)

9

“The Marketplace” and SHOP Exchange• Individuals and small employers ONLY• NOT Medicare

• Federal –state partnership model• https://www.healthcare.gov/

• Medicaid• Subsidies for individuals • Tax credits for small employers• Online Oct 1, 2013 for coverage Jan 1, 2014

• Annual Open Enrollment Periods after that start October 15 and end December 7• Special Enrollment Periods

• You can still buy insurance outside the Marketplace

10

Subsidy Availability

• Substantial subsidies are available through the Marketplace for those at 100%-400% of federal poverty (FPL)• Individuals: $11,490 - $45,960• Family of 4: $23,550 - $94,200

• Those under 100% FPL are not eligible for subsidies

• Assumed to be covered by Medicaid

11

12

Percentage of poverty

line

Annual dollar amount (2013)

Premium contribution

as % of income

Monthly premium

contribution

100 – 133% $11,490 - $15,282 2% $19 - $25

133 – 150% $15,282 - $17,235 3 – 4% $38 - $57

150 – 200% $17,235 - $22,980 4 – 6.3% $57 - $121

200 – 250% $22,980 - $28,725 6.3 – 8.05% $121 - $193

250 – 300% $28,725 - $34,470 8.05 – 9.5% $193 - $272

300 – 350% $34,470 - $40,215 9.5% $272 - $318

350 – 400% $40,215 - $45,960 9.5% $318 - $364

Sliding Scale for Eligible IndividualsSliding Scale for Eligible Individuals

The Individual Mandate• In 2014:• Every individual must have health insurance• Employer coverage, individual coverage, Medicaid, Medicare• Limited exemptions to penalty requirement (e.g., low income)

• Administered and enforced by IRS• Penalty amounts: • 2014: $95 per household member (up to $285) or 1% of income (whichever is

higher).• 2015: $325 per household member (up to $975) or 2% of income (whichever

is higher).• 2016: $695 per household member (up to $2095) or

2.5% of income (whichever is higher).• After 2016 – cost of living adjustments

13

Consumer Assistance

• Federal website (HealthCare.gov) and toll free call center• Navigators • Certified Application Counselors• Small Business Administration• NH Health Plan• Agents and brokers• Health insurance companies• IRS• Department of Labor• Consumer advocates

14

Federal Resources

U.S. Department of Health and Human Services Health Reform Website/Marketplace http://www.healthcare.gov Help Center: 800-318-2596 (24/7)

Small Business Administration (Employer information)http://www.sba.gov/healthcare http://business.usa.gov/healthcare

SBA Hotline: 800-706-7893 (M - F, 9-5)15

New Hampshire Resources

NH Insurance Department (603) 271-2261 Consumer Hotline: 800-852-3416http://www.nh.gov/insurance

NH Department of Health and Human Serviceshttp://www.dhhs.nh.gov

Medicaid – Client Services: (800) 852-3345, ext. 4344

NH Health Planhttp://www.nhhp.org/nhhp/consumerassistance.asp 16