Posts Tagged ‘state health benefit exchange marketplace’

New Kentucky state benefit enrollment portal to include Medicaid E&E

March 10th, 2016 Comments off

Kentucky: State Launches New Website for Medicaid and Public Assistance Programs. The Cabinet for Health and Family Services launched Benefind, a new web portal through which residents can enroll in Medicaid, Supplemental Nutrition Assistance Program and the State’s cash assistance program. Program enrollees can also use Benefind to renew benefits, check benefit amounts, report changes, upload verification documents, check claim status, make claim payments and receive electronic notices. The rollout of Benefind comes shortly after Governor Matt Bevin (R) announced plans to dismantle kynect, Kentucky’s State-based Marketplace, and transition to by the end of the year.

Source: Manatt on Health Reform: Weekly Highlights – March 2016 | Manatt, Phelps & Phillips, LLP – JDSupra

This latest development in Kentucky comes as the state shifts from a state-based health benefit exchange (kynect) to a federally supported state-based exchange. Benefind allows Kentucky residents to enroll online in Medicaid as well as the state’s supplemental nutrition assistance and cash assistance to families with children programs.

Benefind appears at odds with the Patient Protection and Affordable Care Act’s “no wrong door” policy that requires a single application to determine eligibility for subsidized individual plans sold on all state health benefit exchanges as well as for state subsidy programs such as Medicaid and CHIP. It’s contained at ACA Section 1413, titled Streamlining Of Procedures For Enrollment Through An Exchange And State Medicaid, Chip, And Health Subsidy Programs.

With its own portal for Medicaid eligibility as well as for individual plans offered on the exchange, the Bluegrass State won’t have a single application door but rather two: one offered though the state health benefit exchange and another through its Benefind web portal. The Benefind portal will also refer applicants to the exchange portal if it determines their household income potentially qualifies them for enrollment in an exchange plan, Vickie Yates Brown Glisson, Kentucky’s health and family services secretary, told state lawmakers.

While perhaps not compliant with the ACA’s single, no wrong door policy, Kentucky’s model may address problems in some state exchanges getting Medicaid-eligibles quickly qualified and enrolled in coverage due to difficulty interfacing with state Medicaid computer systems.


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 or call 530-295-1473. 

Head Of California Exchange Scolds UnitedHealth For Blaming Woes On Obamacare | California Healthline

February 3rd, 2016 Comments off

Amid growing questions over the future of insurance exchanges, the head of California’s marketplace said the nation’s largest health insurer should take responsibility for nearly $1 billion in losses and stop blaming the federal health law.In a blistering critique, Covered California’s executive director, Peter Lee, said UnitedHealth Group Inc. made a series of blunders on rates and networks that led to a $475 million loss last year on individual policies across the country. The company estimates a similar exchange-related loss of $500 million for this year.

Source: Head Of California Exchange Scolds UnitedHealth For Blaming Woes On Obamacare | California Healthline

This story reflects the natural tension that exists in the state health benefit exchange marketplace. Health plan issuers are subject to competitive market forces as well as pressure from active purchaser exchanges like Covered California to keep premium rates down while offering provider networks that adequately serve the needs of plan members. But if they set premiums too low or create provider networks that are too large, plan issuers can suffer losses.


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 or call 530-295-1473. 

Diminished premium stabilization safety net possible factor in UnitedHealth Group’s decision to reevaluate exchange participation 2017 forward

November 20th, 2015 Comments off

UnitedHealth Group’s announcement this week that it’s reassessing its participation in state health benefit exchange markets for plan year 2017 cites deteriorating loss experience and increased risk. There’s another factor not mentioned by UnitedHealth that warrants discussion and analysis.

For plan years 2014-2016, health plan issuers participating in state exchanges are shielded from losses by a triple safety net built into the Patient Protection and Affordable Care Act known as premium stabilization programs. The three programs were put in place recognizing health plan issuers had no prior experience calculating premiums using new community rated statewide risk pools put in place by the law. Also, there’s the expectation that people who were previously medically uninsured are likelier to come with pent up needs for medical care and thus be costly to cover. The programs include:

  • Risk corridors, which level losses among health plan issuers so that issuers with lower than expected claims make payments to plans with higher than expected claims;
  • Reinsurance, which essentially insures health plan issuers when a covered individual’s medical costs exceed a set dollar amount and;
  • Risk adjustment, which like risk corridors also levels the field among health plan issuers by taking money from plan issuers with lower-risk enrollees and transferring it to plan issuers with higher-risk enrollees.

The first safety net, risk corridors, developed a huge hole out of the box and faces an uncertain future. The federal government announced this year that due to federal budget cuts in the program and higher than expected claims, health plan issuers would receive just 12.6 percent of what they requested for plan year 2014 claims experience.

Come plan year 2017, both risk corridors and the reinsurance programs expire, leaving only one safety net intact: risk adjustment. By placing expiration dates on two of the programs, the Affordable Care Act implies the exchange marketplace is expected to have achieved a degree of financial stability after three years of operations. UnitedHealth Group’s announcement suggests the company isn’t so confident. That said, it could opt to remain in more populous states such as California where there are more “covered lives” in the exchange marketplace. With a greater number of enrollees, the insurance principle works to naturally spread the risk of losses and is less dependent on the premium stabilization programs to keep the market financially viable.

Meanwhile, Aetna and Anthem reacted to the UnitedHealth development by emphasizing their commitment to the exchanges. Anthem is “continuing our dialogue with policymakers and regulators regarding how we can improve the stability of the individual market,” Chief Executive Officer Joseph Swedish said in a statement. Aetna has slightly pared back the number of state exchanges that it will offer plans in 2016 (15 versus 17), according to this Forbes item by Bruce Japsen.


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 or call 530-295-1473. 

Business groups, broker association urge 2-year delay in expansion of small group market starting in 2016

March 20th, 2015 Comments off

Seventeen business groups and the National Association of Health Underwriters have requested the U.S. Department of Health and Human Services delay implementation of a Patient Protection and Affordable Care Act provision requiring states to expand the small group health insurance market starting next year.

Section 1304(b)(2) of the law defines the small group market as employers who employed at least 1 but not more than 100 employees on business days in the previous calendar year. Section 1304(b)(3) allows states to temporarily define the small group market as 50 or fewer employees for plan years starting before January 1, 2016.

In a February 18, 2015 letter to HHS Secretary Sylvia Burwell, the signatories urge extending that date to January 1, 2018. Doing so would allow organizations employing 51 to 100 employees to continue to purchase company rated coverage not compliant with Affordable Care Act requirements for small group coverage including modified community-based rating based on a single statewide risk pool, specified essential health benefits and standards for minimum actuarial value and affordability for participating employees. They warn broadening the scope of the small group market will lead to market disruption among health insurers that could limit employer coverage options as well as potentially lead to premium increases. The signatories cite an Oliver Wyman study finding that two thirds of employers affected by the expansion would see premiums rise by an average of 18 percent in 2016. That could lead some employers to choose to self-insure, reducing the size of the risk pool and putting additional upward pressure on premiums, they contend. The implication is employers with 50 or fewer workers tend to employ less healthy staff with higher medical utilization than firms with 51 to 100 employees, degrading the quality of the risk pool if all employers of 100 or fewer employees were forced to jointly pool their risk.

In an issue brief examining the effect of the expansion of the small group market, the American Academy of Actuaries concluded premiums could increase for some employers – such as those employing relatively younger, healthier workforces – and conversely decline for those with less healthy staff members. The brief noted that since there are more than twice as many covered employees in the 1-50 employee group size cohort than in the 51-100 category, the impact on premium rates would be moderated.

John Arensmeyer, founder and CEO of Small Business Majority, opposes the requested delay that would continue to segment off the smallest employers given no states have opted thus far to define their small group markets as employers with up to 100 employees. Businesses with fewer than 50 employees would benefit from the increased spread of risk of more covered lives by having larger employers in the small group market, Arensmeyer wrote in a March 5, 2015 blog post. “The entire pool becomes bigger,” he observed.

That larger pool, Arensmeyer wrote, would help boost the struggling Small Business Health Options Program (SHOP) of the state health benefit exchange marketplace and benefit brokers. “We’ll also see more broker involvement in SHOP as firms of this size are more likely to utilize the help of agents,” Arensmeyer added.


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 or call 530-295-1473. 

Health benefit exchanges post modest premium increases in 2015; ability of narrow networks to continue to moderate premiums uncertain

March 18th, 2015 Comments off

A review of plan year 2015 premium rates by the Robert Wood Johnson Foundation and the Urban Institute found premiums in state health benefit exchange marketplaces increased by 2.9 percent over 2014 plans. The report cautions continued overall modest premium rate growth is dependent on market forces in the provider and patient segments. On the provider side, health plan issuers have been able to get fewer providers to care for larger patient panels for lower reimbursement rates.

[W]hether these arrangements are sustainable and remain attractive to consumers over time is unknown,” the report concludes. “If consumers prefer broader networks and are willing to pay for them, the market will respond by offering such products, and premiums will consequently increase.”

Most observers, however, believe keeping premiums as low as possible – particularly in a mostly subsidized market like the exchanges – will trump other consumer desires, including wider provider networks. But as the report notes, the sustainability of the narrow provider network model is under pressure from patients who complain to regulators and public policymakers when they have problems finding a provider who will accept their coverage. That in turn could generate legislation and regulations making it harder for plans to rely on narrow networks to moderate premium rates. “States and the federal government could also engage in greater regulation of network adequacy; this, too, could cause premiums to increase,” the report notes.

In addition, the report cautions if underlying health care costs begin to grow at historical rates versus lower rates seen in recent years, “it will be hard for insurers to avoid reflecting this in their premiums.”

Click here for the full report.


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 or call 530-295-1473. 

IRS updates individual health insurance mandate exemption filing instructions

January 22nd, 2015 Comments off

Just in time for tax season, the Internal Revenue Service recently updated information on how to file for an exemption from the Individual Shared Responsibility requirement to maintain qualifying health insurance coverage for tax year 2014. The update (linked below) lists 19 types of exemptions and how to file for them using IRS Form 8965. Most can be claimed directly on the form while six types of exemptions require a certificate of exemption be obtained or requested from the taxpayer’s state health benefit exchange. Three exemption categories can be claimed either with an exchange certificate of exemption or directly on Form 8965.

Individual Shared Responsibility Provision – Exemptions: Claiming or Reporting.


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 or call 530-295-1473. 

Rulemaking would allow employers to offer part timers ancillary benefits to supplement individual plans

December 23rd, 2014 1 comment

The federal government has issued proposed rules apparently intended to help put health benefits offered to low wage, part time employees more on a par with those offered full time employees in terms of coverage and affordability. The proposed rulemaking recognizes that part time employees may find their premium share for group coverage offered full time workers unaffordable and will thus turn to subsidized individual coverage sold in the state health benefit exchange marketplace in order to meet the Patient Protection and Affordable Care Act mandate to have health coverage.

The proposed rules would allow employers to offer ancillary, non-group health benefits to part time employees (those expected to work on average of 30 hours a week or less) and their dependents. The ancillary benefits would supplement or “wrap” individual health plans but could not cover out of pocket cost sharing or work in a coordinated manner with individual health plans. Examples include expanded in-network medical clinics or providers; benefits for long-term, nursing home, home and community-based care or any combination thereof; coverage for specific diseases or illnesses and hospital indemnity or other fixed indemnity plans. These are “excepted benefits” that don’t fall within the definition of group health plans under the Employee Retirement Income Security Act of 1974.

The proposed rules would limit the annual amount of the wraparound ancillary benefit coverage to the maximum for flexible spending accounts (FSAs) — $2,500 for 2014. In addition, the cost of the coverage cannot exceed 15 percent of the cost of coverage for an employer’s primary health plan offered to employees eligible for the ancillary benefit wrap coverage.

Comment on the proposed rules is due by January 22, 2015.


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 or call 530-295-1473. 

Are high deductibles truly a barrier to necessary medical care?

December 4th, 2014 Comments off

One of the goals of opening the government exchanges was to enable more Americans to get health insurance to help cover the costs of needed medical treatments. While many Americans have gained insurance, there has been no downturn in the percentage who say they have had to put off needed medical treatment because of cost. This may reflect high deductibles or copays that are part of the newly insured’s plans, although separate research has shown that most of the newly insured in 2014 are satisfied with their health coverage. (Emphasis added)

Variation in the pricing for medical treatments, not to mention differences in how much insurance plans cover, could be confusing Americans or making them fear a needed treatment is too expensive. And while the costs of medical procedures aren’t rising as rapidly as they once were, it is still too early to tell if that is an effect of the Affordable Care Act and how prices may change in the future

via Cost Still a Barrier Between Americans and Medical Care.


This excerpt is from a Gallup poll released last week. Being that this is a public opinion poll, a more nuanced view of the results is called for.

First, it is important to distinguish between individual health plans sold on state health benefit exchanges and employer-sponsored plans. Many of the latter category are increasingly coming with high deductibles. The distinction is important because employer-sponsored plans do not come with premium and out of pocket cost sharing subsidies for low and moderate income households like those sold in the exchange marketplace.

Second, according to the poll, 22 percent of Americans say they have put off medical treatment for a “very” or “somewhat serious” condition in 2014, the percentage having increased slightly since 2013. This is based on a subjective but undefined “serious condition,” so it’s not clear as to the nature of the underlying “serious” condition. If a serious condition was defined in terms of having a serious adverse affect on daily life functioning, it’s unlikely care for the condition would be deferred due to out of pocket costs so this is probably a highly subjective measure.

High deductible plans are being cited by the U.S. Health and Human Services Department’s Centers for Medicare & Medicaid Services (CMS) as a contributing factor to slowing spending on health care in 2013. (Click here for news release). This is based on the conventional wisdom that health care is like other consumer goods and services is subject to the economic principle of price elasticity: demand falls as cost increases and vice versa. But is it really? Do people reason, “Oh, I’ve got a low deductible plan. I think I’ll schedule a few medical appointments?” Highly doubtful since going to the doctor isn’t as an attractive form of spending as, say, going shopping at a retailer to take advantage of a sale providing an inducement to shop. 


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 or call 530-295-1473. 

Proposed rules for 2016 and post individual, small group and exchange marketplace issued

November 24th, 2014 Comments off

The U.S. Department of Health and Human Services last week issued a proposed rulemaking governing the individual and small group health insurance markets and the state health benefit exchange marketplace for plan year 2016 and later years. Happy holiday reading: comment on the proposed rules (Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for 2016, CMS-9944-P) is due December 26, 2014.

There’s a lot to digest in the rulemaking with some of the key proposed rules summarized below. As usual, Timothy Jost has taken his customary deep dive into the rulemaking with posts on the Health Affairs blog that can be viewed here and here.

  • Plan issuers must publish up-to-date, (updated at least monthly) accurate, and complete provider directories including information on which providers are accepting new patients, the provider’s location, contact information, specialty, medical group, and any institutional affiliations in a manner that is easily accessible to plan enrollees, prospective enrollees, the State, the Exchange, HHS and OPM. Directories will be considered easily accessible when the general public is able to view all of the current providers for a plan on the plan’s public website through a clearly identifiable link or tab without having to create or access an account or enter a policy number. The general public should be able to easily discern which providers participate in which plan(s) and provider network(s) if the health plan issuer maintains multiple provider networks and the plan(s) and provider network(s) associated with each provider should be clearly identified on the website.
  • For the purposes of the employer shared responsibility mandate, large employer-sponsored plans must meet both minimum actuarial value and minimum standard of benefits. Plans must provide substantial coverage of both inpatient hospital services and physician services.
  • Health plan issuers must establish pharmacy and therapeutics (P&T) committees to ensure plan formularies cover a sufficient number and type of prescription drugs. P&T committee standards that must be met for prescription drug coverage meet prescription drug essential health benefits requirement for individual and small group plans.
  • New special exchange enrollment period for individuals in non-Medicaid expansion states when their household income increases to meet exchange minimum income eligibility standard, i.e. 100 percent of federal poverty.
  • Individual market open enrollment period for plan years 2016 and later: October 1 to December 15.
  • Expansion of special enrollment period to individuals enrolled in non-calendar year individual health insurance coverage when their policy year ends in 2014 to all years.
  • Small employers participating in state exchange Small Business Health Options Programs (SHOP) can elect to offer SHOP coverage to former employees, retirees and also provide required continuation coverage via the SHOP.
  • Exchanges, QHP issuers, and web brokers must provide oral interpretation services to include telephonic interpreters in at least 150 languages.
  • Health plan issuers may optionally count cost sharing for out-of-network services toward annual cost sharing limits.



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 or call 530-295-1473. 

Health exchanges’ finances face test in 2nd year – US News

November 24th, 2014 Comments off

PROVIDENCE, R.I. (AP) — The federal government shelled out billions of dollars to get health insurance marketplaces going in the 14 states that opted to run their own. Now they must act like true marketplaces and start paying for themselves.

Under President Barack Obama’s Affordable Care Act, state-run health insurance exchanges need to be financially self-sustaining starting in January. Some appear to be on that path, while others have shaky funding models or even none at all.

Some states, prohibited from using state money, are imposing fees on plans sold on the marketplaces. Others are spreading costs more widely — which, in one instance, has drawn a federal lawsuit.

via Health exchanges’ finances face test in 2nd year – US News.

The AP reports state-based exchanges (SBEs) present a mixed outlook of their ability to operate financially independent of the federal government when federal exchange establishment grant funding ceases January 1, 2015. The less than certain finances of some SBEs could alter their relationship with the feds. In order to gain initial federal approval, SBEs were required to submit operational “blueprint” plans by January 1, 2013 showing how they intended to fund their operations after the grant funding ends.

Lacking adequate funding to be financially self-sufficient could put SBEs technically in violation of federal rules. States operating SBEs “must ensure that its Exchange has sufficient funding in order to support its ongoing operations beginning January 1, 2015…” (45 Code of Federal Regulations 155.160(b) – Financial support for continued operations.)


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 or call 530-295-1473. 

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