Tag Archive: state-based exchange marketplace

Back to the future for Nevada’s Silver State Health Insurance Exchange

Nevada’s Silver State Health Insurance Exchange (SSHIX) is asking the federal government to revert from a federally supported health benefit exchange back to an independent state-based exchange. The Nevada exchange began using the federal government’s online enrollment platform soon after its own platform faltered amid technical glitches in the first open enrollment for plan year 2014.

Prompting the move is concern over service quality and rising costs. “The Nevada Exchange is set to spend an estimated $7.2 million dollars to lease HealthCare.gov’s eligibility and enrollment platform in 2018; this number represents a fee increase from the estimated $5.5 million that will be spent in 2017,” SSHIX Executive Director Heather Korbulic wrote in an October 12, 2017 report to the exchange’s board of directors. “The decrease in service and increase in cost is unacceptable.”

Following a September meeting with federal officials, Korbulic reported the exchange received approval to move forward with a “blueprint” application – a business plan to make the case to the feds that the exchange can sustain itself financially and fulfill core functions of plan selection and consumer outreach and enrollment. “This is the first step in getting the Exchange on a sustainable pathway whereby we will have our own technology with sustainable cost structures and regular access to consumer information,” Korbulic wrote.

 


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. 

California exchange undertakes review of November ballot measure calling for prior approval of individual and small group health plan premium rates, cost sharing

California’s health benefit exchange marketplace, Covered California, is undertaking an analysis of the potential impact of a November 2014 ballot measure that would institute prior regulatory approval of individual and small group health insurance rates. The initiative statute, titled the Insurance Rate Public Justification and Accountability Act, would subject these rates to an initiative statute ratified by voters in 1988 that placed most types of property/casualty insurance under prior rate approval regulation.

An outline of the analysis raises various questions as to how prior approval will jibe with Covered California’s annual schedule to select and finalize qualified health plans (QHPs) to be sold through the exchange and on what terms and conditions within Covered California’s standardized benefit framework. Under the schedule, health plan regulators review QHPs and their coverage terms and conditions in a two month window in the late summer and early fall for QHPs effective January 1 of the following year. But the scope of that review does not give regulators the final word on what plans can charge for premiums and out of pocket costs.

The ballot measure would afford California’s elected insurance commissioner that oversight authority as well as the authority to hold hearings to obtain public testimony. The Act would overlay federal regulations issued under the Patient Protection and Affordable Care Act at 45 Code of Federal Regulations (CFR) 154 authorizing federal and state regulators to jointly review (or the federal Department of Health and Human Services alone if a state opts out) small group and individual rates and require health plan issuers justify rate increases of 10 percent or more per year.

Both Covered California as an active purchaser exchange and regulators negotiate final QHP rates, which also affect plans sold outside the exchange since plans must offer the same plans both inside and outside the exchange marketplace. If approved by voters, the November ballot measure would increase the negotiating leverage of the insurance commissioner, who could opt to hold up rate approval pending a public hearing. That could potentially complicate Covered California’s annual QHP negotiation and approval process (and by extension its marketing and enrollment functions) and result in some plans being withdrawn before they take effect the following January if their premium rates and cost sharing are deemed excessive by the commissioner and disapproved.

In addition, since the underlying cost trend of annual health insurance rate increases has generally exceeded 7 percent in recent years, most if not all proposed plan rates would trigger a provision of the proposed law that allows the public and consumer groups to request the commissioner to hold a public hearing to determine if rate increases at or above 7 percent would result in rates that are unfair, discriminatory or excessive, introducing the prospect of further delay before the rates could be used. Further complications could come under a provision in the ballot initiative creating a transition period where plan issuers could hit the reset button and issue new plans that the commissioner could opt to exempt from prior rate approval provided they use rates in effect on or before January 1, 2014.

Proponents of the measure — including the current insurance commissioner — are likely to downplay the issues raised in the Covered California operational analysis. They will likely argue that premium rates are a matter between the plans and consumers (and not the exchange) and plans are responsible for ensuring they are using only approved rates and refunding any excess rates. However, if premium rates and cost sharing for the next to lowest cost silver actuarial value plan are involved in a lengthy challenge and hearing process, it could seriously affect the exchange marketplace since advance premium tax credits are keyed to that plan.

While a majority of states require prior approval of rates in the individual health insurance market (California is in a minority that employ a “file and use” scheme) according to this Kaiser Family Foundation chart, a half dozen states including California have state-based health benefit exchange marketplaces that actively select QHPs and negotiate with health plan issuers according to this Kaiser Family foundation compilation. Of those six states, all are prior approval states except California. Covered California’s analysis should undoubtedly examine how those state-based exchanges navigated their states’ prior approval regulatory schemes for plan year 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. 

Troubled state-based exchanges face critical decision

A half dozen troubled state-based health benefit exchange marketplaces (Maryland, Massachusetts, Oregon, Hawaii, Minnesota and Nevada) have been clobbered by IT glitches that have hamstrung their eligibility and enrollment functions. This circumstance calls into question the exchanges’ viability going forward since under the Patient Protection and Affordable Care Act, they must be able to financially support themselves starting in 2015 based on fees paid by health plan issuers collected for individuals and small employer groups enrolling in coverage. Getting too few people enrolled in 2014 suppresses that fee revenue and produces a knock on effect of reducing fees that could have been generated by 2014 plan renewals this fall for plan year 2015.

Each of the states must now consider their plan year 2015 options since too little time remains to recover sufficient enrollments with the close of the 2014 open enrollment period only about a month away.

The default option is to allow the federal government to take over exchange operations – the course chosen by nearly three dozen states for 2014. The federal government could also designate a non-profit organization to run the exchange marketplace in the affected states. In addition, the states have the option under Section 1311(f) of the Affordable Care Act that permits states to form “regional or other interstate exchanges,” subject to federal approval. That raises the possibility that the affected states – three of them are in the West – could opt to form a western regional marketplace, possibly with the federal government acting as a partner at least initially.

 


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. 

Maryland mulls high risk pool fallback for individuals with exchange enrollment problems

Maryland Health Exchange Emergency Bill to be Submitted Next Week « CBS DC.

The proposed legislation would enable individuals seeking coverage through the Maryland’s health benefit exchange but whose enrollments encountered processing glitches to obtain coverage through the state’s high risk pool. According to the story, the coverage would be retroactive to January 1, 2014, when state high risk pools were to end operations under new Patient Protection and Affordable Care Act market rules barring medical underwriting for individual health plans effective that date or later.

Several other states operating their own health benefit exchanges that experienced severe problems with the launch of their web portals face a similar predicament as Maryland including Hawaii, Oregon, Minnesota, Vermont and Massachusetts.

The account also quotes Maryland Gov. Martin O’Malley as stating Maryland is considering the possibility of switching from a state-based to federal exchange either completely or in part, as well as partnering with other states.

Section 1311(f) of the Affordable Care Act authorizes the operation of “Regional or Other Interstate Exchanges” operating in more than one state, subject to the approval of the involved states and the federal Department of Health and Human Services.

 


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. 

Multi-State plans roll out in 30 states, including some large ones and those operating state-based exchanges

The federal Office of Personnel Management (OPM) this week announced a pact with the Blue Cross and Blue Shield Association to offer more than 150 Multi-State Plan (MSP) options in 30 States and the District of Columbia on the Health Insurance Marketplace for plan year 2014.

Section 1334 of the Affordable Care Act creates a federally chartered (via OPM) Multi-State health plan (MSP) that must be offered in 60 percent of the state health benefit exchange marketplace in 2014 and all state exchanges by 2017. Section 1334 requires each state exchange to offer at least two MSPs (one must be a nonprofit) in their individual and small business exchanges. The policy intent is to bolster competition and consumer choice, particularly in states with smaller populations and fewer payers. The Affordable Care Act deems MSPs qualified health plans, according them presumptive eligibility for listing on state exchange marketplaces.

I expected to see MSPs first introduced in federally facilitated and partnership exchanges for 2014 and particularly in less populated states having fewer health plan issuers. Turns out the federal government decided otherwise, opting to initially roll out MSPs in some large states such as Pennsylvania, New York, Illinois and Texas as well as on state-based exchange marketplaces such as California, Maryland, Washington and Nevada. A staggering three dozen MSP options will be offered in Alaska.

 


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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