Market Reform and Policy Issues for Implementation of Health Reform in North Carolina In-Person TAG Meeting #11 December 12, 2012
Agenda � 2:00 – 2:10 Welcome and Agenda Review 2:10 – 2:20 Goals/Objectives of Work Group and Today’s Discussion 2:20 – 3:30 EHB Items for Discussion in Work Group • Habilitative Benefits – Should the state define habilitative benefits or leave it to insurers to define? • Benefit Substitution -- Should North Carolina allow benefit substitutions? 3:30 –3:40 Break 3:40 – 4:50 Report Out/Consideration of Draft Guidance and Workgroup Recommendations: • Draft Guidance: Employee Choice in SHOP; Insurer Participation in SHOP; Employer Size Calculation; Minimum Participation Rates Agent/Broker Compensation • Work Group Recommendations: Age Curve; Tobacco Rating; Geographic Rating Areas 4:50– 5:00 Wrap Up and Next Steps
Agenda � 2:00 – 2:10 Welcome and Agenda Review 2:10 – 2:20 Goals/Objectives of Work Group and Today’s Discussion 2:20 – 3:30 EHB Items for Discussion in Work Group • Habilitative Benefits – Should the state define habilitative benefits or leave it to insurers to define? • Benefit Substitution -- Should North Carolina allow benefit substitutions? 3:30 –3:40 Break 3:40 – 4:50 Report Out/Consideration of Draft Guidance and Workgroup Recommendations: • Draft Guidance: Employee Choice in SHOP; Insurer Participation in SHOP; Employer Size Calculation; Minimum Participation Rates Agent/Broker Compensation • Work Group Recommendations: Age Curve; Tobacco Rating; Geographic Rating Areas 4:50– 5:00 Wrap Up and Next Steps
Project Goal and Meeting Objectives � Project Purpose: Develop policy options and considerations and identify areas of consensus to inform the NC DOI actions and recommendations for Exchange-related market reform policies. (pursuant to North Carolina Session Law 2011-391) “It is the intent of the General Assembly to establish and operate a State-based health benefits Exchange that meets the requirements of the [ACA]...The DOI and DHHS may collaborate and plan in furtherance of the requirements of the ACA...The Commissioner of Insurance may also study insurance-related provisions of the ACA and any other matters it deems necessary to successful compliance with the provisions of the ACA and related regulations. The Commissioner shall submit a report to the...General Assembly containing Objectives for Today’s Meeting recommendations resulting from the study.” -- Session Law 2011-391 � Review recent federal guidance related to Essential Health Benefits and make recommendations for state action, if any, on habilitative benefits and benefit substitution � Review where new guidance intersects with previous TAG recommendations and address what action, if any, is needed to reconcile recommendations
Market and Exchange Rules/Regulations � Where we are today 1/1 3/1 5/1 7/1 9/1 11/1 1/1/2013 2013 & 2012 beyond NC Leg. Activity NCGA Legislative NCGA Legislative Session ; ACA not Session starts in addressed January 2013 Planning Development of a Federal Exchange Testing Federal Guidance and Activity Dec 14; SBE March 2012 Sept 30: Initial Blueprint Feb 15; • Establishment of Exchanges Deadline to Dec 26; Final Partnership & QHPs Final Rule EHB Blueprint Select EHB Plan • “3Rs” Reinsurance, Risk selection Corridors & Risk Adjustment Final Rule November 2012 Relevant Guidance • Health Insurance Premium • Insurance Market Reform Tax Credit Final Rule Proposed Rule Forthcoming • Medicaid Eligibility Changes • Wellness Program • Medicaid Expansion Under the ACA Final Rule Proposed Rule • IRS Guidance re: • EHB, Actuarial Value & Individual Mandate Accreditation Proposed May 2012 • Employer Rule Guidance on Responsibility • Multi-State Plans FFE/BluePrint • Insurer Tax Proposed Rule July 2012 • Notice of Payment & EHB Data Benefit Parameters Collection & Dec. 2011 QHP Accred Dec. 2012 EHB Bulletin Final Rule PCORI Tax
Statement of Values to Guide TAG Deliberations � The TAG will seek to evaluate the market reform policy options under consideration by assessing the extent to which they: • Expand coverage; • Improve affordability of coverage; • Provide high-value coverage options in the HBE; • Empower consumers to make informed choices; • Support predictability for market stakeholders, competition among plans and long-term sustainability of the HBE; • Support innovations in benefit design, payment, and care delivery that can control costs and improve the quality of care; and • Facilitate improved health outcomes for North Carolinians.
Agenda � 2:00 – 2:10 Welcome and Agenda Review 2:10 – 2:20 Goals/Objectives of Work Group and Today’s Discussion 2:20 – 3:30 EHB Items for Discussion in Work Group • Habilitative Benefits – Should the state define habilitative benefits or leave it to insurers to define? • Benefit Substitution -- Should North Carolina allow benefit substitutions? 3:30 –3:40 Break 3:40 – 4:50 Report Out/Consideration of Draft Guidance and Workgroup Recommendations: • Draft Guidance: Employee Choice in SHOP; Insurer Participation in SHOP; Employer Size Calculation; Minimum Participation Rates Agent/Broker Compensation • Work Group Recommendations: Age Curve; Tobacco Rating; Geographic Rating Areas 4:50– 5:00 Wrap Up and Next Steps
Proposed Rule Summary: Standards Related to Essential Health Benefits, Actuarial Value, and Accreditation � • Allows states until December 26 th to select a benchmark plan from one of ten options in the state or change selection already made. Areas for Further � States that do not make a selection will default to the largest plan by enrollment in the Consideration small group market. � Proposes a standard process for selection of benefits not covered in the benchmark package, such as pediatric dental and vision, and a minimum standard for coverage of prescription drugs • Proposes flexibility for habilitative services regardless of if a state defaults • Proposes to allow states the option of permitting insurer substitution of EHB benefits, within certain parameters • Adopts AV standard for allowable variation of plans from the metal levels of +/-2 % Report Out • Implements Section 1311 of the ACA, requiring that QHPs be accredited on the basis of performance by an accrediting entity recognized by HHS • Provides guidance on determining prescription drug benefit and payment for state- required benefits beyond EHBs, and broadens non-discrimination testing to outside of the Exchange
Previous NC DOI & TAG Analysis of Benchmark Plan Options � The TAG discussed the EHB selection process on April 9 th , and • reached consensus that North Carolina should further investigate the relative advantages of defining the benchmark package at the state-level. On May 14 th , the NC DOI issued a report to inform North • Carolina’s potential selection of a benchmark plan. The report stated that “there appear to be few clear reasons for North Carolina to choose one benchmark option over another, although certain factors suggest eliminating the FEBHPs as preferred options.” On May 14 th , the NC DOI issued it’s Study Report to the NCGA and stated that: • • the benchmark plan options available to the State from which to choose the benchmark plan do not differ significantly in either the benefits covered or the overall impact on premiums. • the plan option that would be selected by default (should the state not make an active choice) does not appear to be detrimental to the citizens of North Carolina in either the range of benefits offered or cost of coverage. • the default option may result in the least amount of disruption to current policyholders. The report of the benchmark plan options and the NC DOI Study Report can be found at: http://www.ncdoi.com/lh/Documents/HealthCareReform/ACA/NC%20DOI%20Session%20Law%202011-391%20Study%20Report.pdf
Benchmark Plan Options in North Carolina � Plans Eligible for Benchmark North Carolina Plans Status � Option: State Employees Health Plan State Employees Health Plan � State only has two plans; difference in cost-sharing, only � Analyzed as 1 plan � Option 1: BCBS Standard Option Federal Employees Health Benefit Plans (FEHBP) � Option 2: BCBS Basic Option � Option 3: GEHABP Standard Option � Option 1: BCBSNC Blue Options Small Group Insurance Plans Default Plan � Option 2: UHC Choice Plus � Option 3: BCBSNC UW Small HAS � Option: WellPath Select, Inc. Largest Non-Medicaid HMO North Carolina defaulted to the largest small group option plan, BCBSNC Blue Option in September 2012 and the proposed rules offer no compelling reason to alter the default plan. A complete listing of the benefits offered under BCBS Blue Options can be found at: http://cciio.cms.gov/resources/EHBBenchmark/proposed-ehb- benchmark-plan-north-carolina.pdf ; The report of the benefit plan options can be found at: http://www.ncdoi.com/lh/Documents/HealthCareReform/ACA/NC%20DOI%20Session%20Law%202011-391%20Study%20Report.pdf
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