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 ◦ 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
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
State-based Exchange State-based Exchange State Partnership State Partner p Federally- Federally- Exch Exchan ange ge facilitated facilitated Exchan Exch ange ge State operates activities State operates all for: HHS operates. Exchange activities. Plan management State may elect to States may use • Consumer assistance; perform or may Federal government • or use Federal services for: Both government Premium tax credit • • State may elect to services for: and cost sharing perform or may have the Reinsurance reduction • federal government Medicaid and determinations • perform: CHIP eligibility Mandate • Reinsurance exemptions • Medicaid and CHIP Risk adjustment • • eligibility Reinsurance • National Association of Community Health Centers 4
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
Expected Dates Expected Dates Activity Activity Issuers Submit QHP Applications in April 1- April 30, 2013 HIOS CMS Reviews QHP Applications May 1 – June 16, 2013 CMS releases QHP Application June 17, 2013 Results to Issuers Issuers Revise QHP Applications June 17 – June 21, 2013 Based on any Identified Deficiencies and Resubmit to HIOS National Association of Community Health Centers 6
Expected Date Expected Date Activity Activity As Applicable, HHS Receives Final July 31, 2013 State Evaluation Findings in HIOS CMS Review of State Evaluation August, 2013 Findings and Recommendations Issuers Review Data During Plan Aug. 22 – Aug. 26, 2013 Preview Period and Submit Data Corrections National Association of Community Health Centers 7
Expected Date Expected Date Activity Activity September 4, 2013 CMS Notifies all Issuers of QHP Certification Decisions for the FFEs Issuers Sign Agreements with CMS Sept. 5 – Sept. 9, 2013 Open Enrollment Begins October 1, 2013 Coverage in Qualified Health Plans Jan. 1, 2014 begins National Association of Community Health Centers 8
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
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
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 ongoing 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
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 on 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
Outreach and enrollment ◦ Navigators, consumer assisters ◦ CMS is funding navigators in each FFE – ◦ Navigator duties include conducting public outreach, facilitating selection of a QHP; ◦ See upcoming NACHC Issue Brief National Association of Community Health Centers 13
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 of primary care provider. Eligibility and enrollment HHS – developed a single streamlined application for the ◦ individual market National Association of Community Health Centers 14
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
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