Tag Archive: individual exchange marketplace

California bill would bar higher out-of-network cost sharing when timely in-network care unavailable

Pending California legislation would bar health plans and insurers from imposing higher out of pocket costs for out of network services in instances where a plan or insurer is unable to ensure timely access to a medically necessary, covered service by a contracted provider.

Under existing law, California managed health care service plans are required to provide members timely access to providers. AB 2533 would require the California Department of Insurance to develop similar rules for insurance plans it regulates including waiting time for doctor appointments.

The proposed legislation comes amid reports of individuals in plans purchased through the state’s health benefit exchange marketplace, Covered California, being turned away by providers they believed were included in their plans. (Additional background here)

The measure passed its first policy committee this week in the state Assembly. Click here for the text of AB 2533 as amended April 22, 2014.

 


Need a speaker or webinar presenter on the Affordable Care Act and the outlook for health care reform? Contact Pilot Healthcare Strategies Principal Fred Pilot by email fpilot@pilothealthstrategies.com or call 530-295-1473. 

Small group most voluntary market segment under ACA – and faces unique viability risks

Of the three major health insurance market segments – large group, small group and individual – small group is the most voluntary market under Patient Protection and Affordable Care Act rules that take effect January 1, 2014.

Large employers, defined by the ACA as employing 50 or more full time workers, are subject to the employer shared responsibility requirement to offer coverage to nearly of these employees. All individuals must have some form of health coverage under pain of a tax penalty for going bare. Small employers on the other hand have the greatest degree of freedom of choice as to whether to play in the small group market.

The ACA strengthens the functionality of the small group market with several provisions. It eliminates risk rating of small employers by health plan issuers. The ACA also enhances the risk pooling power of small employers by combining them into single statewide risk pools. Finally, the law affords small employers the purchasing power of large employers through the Small Employer Health Options Program (SHOP) of the state health benefit exchange marketplace. The SHOP also serves as a benefit administrator of sorts for small employers, helping them select plans and billing them for monthly premiums.

The extent to which these reforms work as intended to shore up the small group market will become clearer over the next few years. There are several factors that could result in the leakage of potential covered lives out of the small group market, potentially adversely affecting the viability of the small group pool and the SHOP, particularly if a significant number of small employers now offering health coverage to their employees adopt them. They include:

  • Opting to participate in “private” exchanges set up by health benefit plan administrators and insurance brokerages instead of the SHOP
  • Offering a defined contribution benefit or stipend to help workers buy their own coverage on the state exchange individual marketplace instead of directly offering coverage
  • Self-insuring for employee health care costs.
 


Need a speaker or webinar presenter on the Affordable Care Act and the outlook for health care reform? Contact Pilot Healthcare Strategies Principal Fred Pilot by email fpilot@pilothealthstrategies.com or call 530-295-1473. 

Washington exchange garners strong plan interest for individual market, but limited for SHOP

The Washington Health Benefit Exchange reports nine health plan issuers have filed with that state’s Office of the Insurance Commissioner (OIC) to offer 57 Qualified Health Plans (QHPs) totaling 229 plan options for individuals and families through Washington Healthplanfinder, the state’s new online health insurance marketplace.

Plan issuers however demonstrated less interest in participating in the exchange’s Small Business Health Options Program (SHOP).  SHOP plans will be offered in only some of the state’s counties beginning Oct. 1, 2013.  In a news release, the exchange cited limited carrier participation that did not allow the Exchange to offer SHOP coverage options statewide.  Kaiser Foundation Health Plan of the Northwest will offer SHOP coverage in a limited number of counties to be determined, according to the exchange.

“Like our individual market, the SHOP was prepared to be operationally ready on Oct. 1,” said Washington Healthplanfinder CEO Richard Onizuka. “Ultimately, insurers informed us their inability to participate was a resource issue,” Onizuka explained, adding that additional issuers have expressed interest in participating in the SHOP market starting October 2014.

 


Need a speaker or webinar presenter on the Affordable Care Act and the outlook for health care reform? Contact Pilot Healthcare Strategies Principal Fred Pilot by email fpilot@pilothealthstrategies.com or call 530-295-1473. 

2014 premiums for California exchange plans lower than forecast

At first glance, premium increases among health plan issuers set to participate in California’s health benefit exchange individual marketplace in 2014 are not coming in nearly as high as forecast in an actuarial study issued in March.  The Milliman study commissioned by the exchange, Covered California, projected that market changes due to Patient Protection and Affordable Care Act requirements would increase 2014 premiums by 14 percent on average.  Consumers buying richer coverage due to the Affordable Care Act’s essential health benefits requirement would add 4.8 percent and higher average actuarial value for existing covered services another 11.5 percent.

Instead of a total increase of more than 30 percent based on these numbers, average 2014 premium rates for one of the large participating plan issuers, Blue Shield of California, will rise 13 percent for plan year 2014.  While still in the double digits, it’s not that much above the underlying annual nine percent rate increase “trend” driven by increases in provider reimbursement, increases in utilization due to new procedures and technology and higher prescription utilization and costs per the Milliman projection.

Several factors are likely keeping rate increases lower than expected in California, whose exchange marketplace is being closely watched as a harbinger of where individual health insurance rates may be headed next year in other state exchange markets.

  • Rates are for 2014 only under the one year term of the contract between Covered California and participating plan issuers.  That gives the 13 plan issuers initially participating in the marketplace time to determine if their rates are adequate and to assess initial enrollment numbers.
  • Covered California is one of a handful of state exchanges using an “active purchaser” model in which it negotiates terms and conditions for participation in its exchange marketplace, the largest in the nation with potentially more than an estimated 2 million enrollees signing up for individual plans in 2014.  That provides the exchange with a degree of bargaining power with participating plan issuers, who in turn responded by narrowing their provider networks in order to hold down costs.
  • Increased plan issuer confidence in the Affordable Care Act’s reinsurance and risk adjustment provisions designed to mitigate high claims costs from sicker individuals using more costly medical services.
  • Last but not least, politics.  Had rates for exchange plans come in as high as actuarially predicted, taxpayers would have had to absorb a larger amount of the premium increases for those earning 400 percent or less or federal poverty guidelines in the form of premium subsidies.  Those earning more than 400 percent of poverty would have experienced substantial “rate shock” since they are ineligible for the subsidies — advance personal income tax credits to offset premiums for coverage purchased through state exchanges — creating pressure for more regulatory reforms.  A measure that will appear on the November 2014 ballot — after the 2014 rates will have been in effect for more than 10 months — will ask California voters if health insurance rates should be subject to prior regulator approval.
 


Need a speaker or webinar presenter on the Affordable Care Act and the outlook for health care reform? Contact Pilot Healthcare Strategies Principal Fred Pilot by email fpilot@pilothealthstrategies.com or call 530-295-1473. 

New Mexico joins Utah with split state-federal exchange

New Mexico is following Utah in having the federal government operate the individual side of its health benefit exchange marketplace while opting to run its own Small Business Health Options Program (SHOP).

The Associated Press reports state officials made the decision because there isn’t sufficient time to build the eligibility and enrollment system to serve the individual market segment for plan year 2014; the federal government will do so initially.  New Mexico was one of the last states to decide whether to operate a state-based exchange marketplace.

 


Need a speaker or webinar presenter on the Affordable Care Act and the outlook for health care reform? Contact Pilot Healthcare Strategies Principal Fred Pilot by email fpilot@pilothealthstrategies.com or call 530-295-1473. 

Utah to operate its own SHOP, have federally-facilitated individual exchange under deal with federal government

Early this year, Utah received conditional approval to operate a state-based health insurance exchange marketplace from the federal government.  The approval was somewhat surprising given the state’s insistence on operating only what amounted to a scaled down, online Small Business Health Options Program (SHOP) that it put in place before the 2010 enactment of the federal Patient Protection and Affordable Care Act.  Utah’s Avenue H wouldn’t have met federal exchange requirements, primarily because it didn’t offer plans for individuals.  The likely outcome would have been disapproval of Utah’s state-based exchange status and the feds taking over Utah’s exchange.

Under the terms of an agreement between the state and the federal government reported today by The Salt Lake Tribune, the feds will run the Utah’s individual exchange marketplace while the state will operate Avenue H as a state-run SHOP exchange.  Avenue H will operate “without a competing SHOP exchange or interjection by the federal government” Gov. Gary R. Herbert wrote in a May 9, 2013 letter to U.S. Health and Human Services Secretary Kathleen Sebelius conveying his understanding of the deal.

The newspaper notes if the deal is approved as expected this week, Utah would be the only state exchange operating under such an arrangement:

The agreement is unique to Utah and essentially opens up a fourth alternative for operating the federally-mandated exchanges. Previously states had only three choices — a state-run exchange, a federally-run one, or a state-federal partnership exchange

 


Need a speaker or webinar presenter on the Affordable Care Act and the outlook for health care reform? Contact Pilot Healthcare Strategies Principal Fred Pilot by email fpilot@pilothealthstrategies.com or call 530-295-1473. 

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