Roger Schwartz rschwartz@nachc.org ACA established State Exchanges - - PowerPoint PPT Presentation

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Roger Schwartz rschwartz@nachc.org ACA established State Exchanges - - PowerPoint PPT Presentation

Jun 13, 2023 94 likes •266 views

Roger Schwartz rschwartz@nachc.org ACA established State Exchanges ACA established State Exchanges Functions Functions: Provide individuals and small business employees with access to enrollment in Qualified Health Plans

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Roger Schwartz rschwartz@nachc.org

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 ACA established State Exchanges

ACA established State Exchanges

 Functions

Functions:

  • Provide individuals and small business employees with access to

enrollment in Qualified Health Plans

  • Eligibility determinations for premium tax credit and cost sharing

reductions

  • Consumer and stakeholder engagement, outreach
  • Operate call center, website, in-person assistance
  • Establish Navigator program
  • Agents and brokers-determine role, enter into agreement,

registration

National Association of Community Health Centers 2

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 Exchange Functions Cont’d

Exchange Functions Cont’d

  • Eligibility determinations and enrollment for

premium tax credits and cost sharing reductions

  • Process enrollments into Qualified Health Plans
  • Certify QHPs and ensure compliance
  • Operate a Small Business Health Options Program

(SHOP Exchange) for small businesses

National Association of Community Health Centers 3

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State-based Exchange State-based Exchange State operates all Exchange activities. States may use Federal government services for:

  • Premium tax credit

and cost sharing reduction determinations

  • Mandate

exemptions

  • Risk adjustment
  • Reinsurance

State Partner State Partnership p Exch Exchan ange ge State operates activities for:

  • Plan management
  • Consumer assistance;
  • r
  • Both

State may elect to perform or may have the federal government perform:

  • Reinsurance
  • Medicaid and CHIP

eligibility Federally- Federally- facilitated facilitated Exch Exchan ange ge HHS operates. State may elect to perform or may use Federal government services for:

  • Reinsurance
  • Medicaid and

CHIP eligibility

National Association of Community Health Centers 4

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Final rule regarding establishment of Exchanges and QHPs: 77 Fed. Reg. 18310 et seq (3/27/12).

Final rule regarding standards related to essential health benefits actuarial value and accreditation 78 Fed. Reg.12834 et seq. (2/25/13)

General Guidance on FFEs (5/16/12)

CCII0/CMS Guidance on the State Partnership Exchanges (1/3/13)

CCII0/CMS’ Letter to Issuers on FFE and State Partnership Exchanges (3/1/13)

CMS’ FAQs on Exchanges, market reforms and Medicaid (12/10/12)

National Association of Community Health Centers 5

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 Expected Dates

Expected Dates

April 1- April 30, 2013

May 1 – June 16, 2013

June 17, 2013

June 17 – June 21, 2013

 Activity

Activity

Issuers Submit QHP Applications in HIOS

CMS Reviews QHP Applications

CMS releases QHP Application Results to Issuers

Issuers Revise QHP Applications Based on any Identified Deficiencies and Resubmit to HIOS

National Association of Community Health Centers 6

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 Expected Date

Expected Date

July 31, 2013

August, 2013

  • Aug. 22 – Aug. 26, 2013

 Activity

Activity

As Applicable, HHS Receives Final State Evaluation Findings in HIOS

CMS Review of State Evaluation Findings and Recommendations

Issuers Review Data During Plan Preview Period and Submit Data Corrections

National Association of Community Health Centers 7

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 Expected Date

Expected Date

September 4, 2013

  • Sept. 5 – Sept. 9, 2013

October 1, 2013

  • Jan. 1, 2014

 Activity

Activity

CMS Notifies all Issuers of QHP Certification Decisions for the FFEs

Issuers Sign Agreements with CMS

Open Enrollment Begins

Coverage in Qualified Health Plans begins

National Association of Community Health Centers 8

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FQHC services are not a EHB although FQHCs provide many of the services that qualify as EHB

EHBs include ambulatory patient services, mental abuse and substance abuse disorder services (including behavior health treatment), maternity and newborn care, prescription drugs, laboratory services, preventive and wellness services, pediatric services, including oral and vision care. 45 CFR 156.11O(a)

States can select a base-benchmark plan (largest small group, FEHBP, state employee plan, etc) but if base-benchmark plan does not provide any coverage in one or more of the EHB categories it must be supplemented by addition of the entire category of such benefits offered under any other benchmark plan option 45 CFR 156.110(b)

Regarding prescription drugs, must include one drug in every U.S. pharmacopeia category and class or same number of prescription drugs in each category and class as EHB-benchmark plan 45 CFR 156.122.

National Association of Community Health Centers 9

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 QHPs must have sufficient number and

geographic distribution of essential community providers to ensure access for low-income, medically underserved individuals

 Defined: Providers that serve predominantly

low-income medically underserved individuals including:

  • 340B entities
  • Entities eligible for nominal priced drugs

National Association of Community Health Centers 10

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 QHPs must ensure that its provider network:

  • Includes essential community providers as defined;
  • Maintains a network sufficient in number and types of

providers, including for mental health and substance abuse services, to assure that all services are available without unreasonable delay.

 Specific standards, enforcement and monitoring

  • ngoing compliance are the responsibility of the

Exchange.

  • Will vary state to state
  • FFE Guidance on ECPs (see Jan. 3 and March 1, 2013

CCII0 document)

  • NACHC submits comments on 3/15/13 to March 1,

2013 CCIIO CMS Letter.

National Association of Community Health Centers 11

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If an item or service covered by a QHP is provided by a FQHC, the QHP must pay the FQHC an amount that is not less than the Medicaid PPS

  • payment. 45 CFR 156.235(e)

FQHCs may contract with QHPs and may agree to payment rates other than those under the Medicaid PPS as long as the mutually agreed upon rates are at least equal to the generally applicable payments for essential community providers.

QHPs must pay FQHCs the Medicaid PPS rate for items and services provided to a QHP enrollee if the FQHC and the QHP have not contracted

  • n a mutually agreed upon rate. (Letter of June 8, 2012 to Dan Hawkins

from Timothy Hill, Deputy Director, CCII0)

 But cost sharing rule may undercut this protection - 45 CFR 156.130 (c)

Premiums and cost-sharing in Exchanges vs. HRSA Section 330 grant requirements regarding sliding fee scale, etc.

National Association of Community Health Centers 12

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 Outreach and enrollment

  • Navigators, consumer assisters
  • CMS is funding navigators in each FFE –
  • Navigator duties include conducting public
  • utreach, facilitating selection of a QHP;
  • See upcoming NACHC Issue Brief

National Association of Community Health Centers 13

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Enroll Enrollmen ment in the Excha in the Exchanges ges

  • Eligibility and enrollment functions will be conducted by CMS in State Partnership

Exchanges and FFEs

  • CMS plan to provide detailed guidance to state-based exchanges in the future
  • Individual that wants to purchase health insurance in FFE, will:

1. Complete the eligibility application for coverage and, if desired, insurance affordability programs through the Exchange, 2. Evaluate available QHPs to compare the options, 3. Make a plan selection, 4. Select the desired amount of APTC, if eligible, and 5. After being re-directed by the Exchange to the appropriate issuer’s website, follow instructions provided by the issuer to determine how to make the first premium payment (unless the APTC are greater than the premium) and provide any additional information required by the QHP issuer to process the enrollment, such as a selection

  • f primary care provider.
  • Eligibility and enrollment HHS – developed a single streamlined application for the

individual market

National Association of Community Health Centers 14

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 Medicaid Expansion into the Exchanges?

 Arkansas – type premium assistance program arrangement

 December 10, 2012 CMS’ Q/A 38 and39  Impact on FQHC service and payment protection in Section 1937(b)(4)

National Association of Community Health Centers 15