July 19, 2018 LPRO : L EGISLATIVE P OLICY AND R ESEARCH O FFICE UNIVERSAL ACCESS TO CARE WORK GROUP 2018 1
LPRO : L EGISLATIVE P OLICY AND R ESEARCH O FFICE AGENDA Welcome, Opening Remarks ……………………..……………………………………8:30— 8:35am • Representative Salinas, Chair, Workgroup Oregon Health Insurance Marketplace..……………………………………………8:35— 9:15am • Chiqui Flowers, Administrator, Health Insurance Marketplace • Elizabeth Cronen, Communications & Legislative Manager Medicaid Buy- in, State Options………………….…………………………………..9:15— 10:00am • Staff House Resolution 6097………………….……………………………………………10:00— 10:15am • Workgroup Members Public Testimony………………………………………………………………………..10:15— 10:30am Adjourn …………………………………………………………………………………………………….. 10:30 am 2
LPRO : L EGISLATIVE P OLICY AND R ESEARCH O FFICE Today’s Objectives ➢ Learn about Oregon’s Health Insurance Marketplace including coverage, enrollment, activities and operations ➢ Marketplace landscape 2018/19 ➢ Explore the concept of a Medicaid buy-in option in Oregon; identify key questions and next steps ➢ Brainstorm potential policy goals ➢ Identify initial design considerations ➢ Discuss next steps – August/September ➢ Understand House Resolution 6097 (115 th Congress) 3
The Marketplace’s practical functions and policy roles
Legislative intent for the Marketplace (ORS 741.001) • Increase the quality, reliability and availability of health insurance for all Oregonians and lower or contain the cost of health insurance so that health insurance is affordable to everyone • Be accountable to the public, and promote the public interest and the benefit of those obtaining health insurance through the exchange • Empower Oregonians through information and tools for making health insurance choices 5
Legislative intent for the Marketplace (ORS 741.001) • Improve health care quality and public health , mitigate health disparities , control costs and ensure access to affordable, equitable and high-quality health care • Encourage the development of new health insurance products with innovative benefit packages, care delivery, and payment mechanisms 6
Functions of the Marketplace Marketplace framework: • Division of the Dept. of Consumer and Business Services • State-based Marketplace using the federal platform • State-level partner to HealthCare.gov, helping Oregonians get health insurance and financial assistance 7
Practical functions of the Marketplace Oregon has more authority than most other states using the federal platform. The Marketplace: • Assesses a fee on insurance companies selling plans in Oregon through HealthCare.gov • Funds and manages a community partner (navigator) program • Certifies plans offered here through HealthCare.gov 8
Practical functions of the Marketplace • Fields an ad campaign for open enrollment • Conducts outreach and assistance, including a call center • Works closely with Oregon’s insurance regulator on design of standard plans 9
The Marketplace’s most visible work Advertising and marketing 10
The Marketplace’s most visible work Outreach, education, and assistance 11
The Marketplace landscape: our audience • Any Oregonian who wants coverage or to learn about insurance (no wrong door) • 156,105 Oregonians enrolled in private plans through HealthCare.gov for 2018 • 115,889 enrollees qualified for premium subsidies • A total of 268,588 Oregonians are estimated to qualify for premium subsidies 12
Subsidies through the Marketplace • People with incomes under 400 percent of the poverty level usually qualify for premium subsidies - Less than $48,000 for one person - Less than $98,400 for a family of four 13
Subsidies through the Marketplace • Average subsidized premium was $138 • Premium subsidies are designed so that no one with income under 400 FPL pays more than 9.56 percent of income for a midrange plan • People with lower incomes pay less , e.g. about 4 percent at 150 FPL, about 8 percent at 250 FPL 14
Subsidies through the Marketplace • People with incomes under 250 percent of FPL may qualify for lower costs when they get care - Less than $30,150 for one person - Less than $61,500 for a family of four • This year, 55,231 people got lower costs when getting care • The subsidies continue even though the federal govt. stopped paying to support them 15
The Marketplace landscape: 2018 plan choices • Plans are available on HealthCare.gov for every county in Oregon • Choices vary around the state, with the Portland metro area having the most options (5 insurance companies, 31 plans) • Lincoln and Douglas counties have the fewest (1 insurance company, 3 plans) 16
The Marketplace landscape: 2018 plan choices 17
The Marketplace landscape: 2019 plan choices • Expect plans on HealthCare.gov for every Oregon county • Once again, choice will vary around the state, with the Portland metro area having the most options (5 insurance companies, 39 plans) • Lincoln and Douglas counties have the fewest (1 insurance company, 4 plans) 18
The Marketplace landscape: 2019 plan choices 19
The Marketplace landscape: 2019 costs for consumers • Final rate decisions will be announced July 20 • Final specific rate information will be available by August 20 • Preliminary 2019 Silver Standard Plan premiums for a 40-year-old in Portland range from $414 to $486 a month • Subsidy calculation will expect 9.86 percent of income from consumer at 400 percent FPL • 400 FPL will go up to $100,400 for 4 people 20
LPRO : L EGISLATIVE P OLICY AND R ESEARCH O FFICE M EDICAID B UY - IN : O REGON C ONSIDERATIONS 21
Medicaid Buy-In: Defined • A state proposal to provide healthcare coverage to individuals with incomes above the current state Medicaid eligibility level by leveraging Medicaid in some way – such as using the following to offer a more affordable or accessible coverage option in the state: • Medicaid provider network • Medicaid reimbursement • Medicaid infrastructure • Medicaid-like benefits State Health and Value Strategies | 22
State Goals for Medicaid Buy-In Access and Competition • States may have a range of goals, some of which might be in conflict Affordability • Meeting multiple goals — even when goals do not directly conflict — can be a challenge: prioritization is key Market Alignment Between • State policymakers will need to Medicaid and Marketplace understand and account for divergent stakeholder perspectives (e.g., advocates, insurers,providers) Single Payer Glide Path A state may need to obtain a 1332 waiver depending on its goals and Medicaid buy-in design State Health and Value Strategies | 23
Primary Models for Medicaid Buy-In State Health and Value Strategies | 24
Model 1: State-Sponsored Product on the Marketplace State Health and Value Strategies | 10
Key Model 1 Features State designs a product to meet Marketplace standards and qualify for advance premium tax credits (APTCs) State procures the product through its Medicaid managed care plans State may set the provider rates as part of product design State aligns eligibility with Marketplace coverage State Health and Value Strategies | 26
Model 1: Operational Considerations and Implementation Authority • 1332 Waiver Considerations • Obtaining a 1332 waiver may not be necessary to implement this model if the state’s plan meets all the requirements to be certified as a qualified health plan (QHP) in order to receive APTCs • If a state wants to “stand in the shoes of the issuer,” or receive tax credits directly, a 1332 waiver may be necessary; risk adjustment is an additional complexity if the state-sponsored product is not a certified QHP • Agency collaboration between the state Medicaid agency and state insurance department is essential for successful implementation State Health and Value Strategies | 27
Model 2: Medicaid Buy-In Outside of the Marketplace State Health and Value Strategies | 28
Key Model 2 Features A state would create a Medicaid buy-in product outside the Marketplace for people with incomes above Medicaid eligibility levels Benefits in this buy-in model could be similar to Medicaid or Marketplace, but with rates, premiums and cost-sharing set by the state Structured to allow consumers to use their APTCs to purchase the buy-in product The product would not be subject to private insurance rating requirements and would not be considered individual insurance coverage Eligibility levels above Medicaid and could mirror Marketplace eligibility State Health and Value Strategies | 29
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