Tony Mira: What Anesthesiologists Should Know About Health Insurance Exchanges

The following article was written by Tony Mira, president and CEO of Anesthesia Business Consultants.

Health Insurance Exchanges

A year from now, under the Affordable Care Act, a health insurance exchange should be up and running in every state.
Insurance exchanges are online marketplaces where qualified individuals and small groups will engage in comparison shopping for health coverage. Those health plans must be ready to accept enrollment no later than October 1, 2013. Qualified individuals include U.S. citizens and legal immigrants who do not have access to affordable employer coverage. The ACA also provides for separate Small Business Health Options Program (SHOP) Exchanges from which small businesses with up to 100 employees can obtain coverage for their employees. Prior to 2016, states can limit Exchanges to businesses with 50 or fewer workers, and, beginning in 2017, states can allow businesses with more than 100 employees to purchase coverage from an Exchange.

All health plans offered in the individual and small group markets, both inside and outside of the Exchanges, will be required to offer a core package of items and services known as "essential health benefits," which must include items and services within at least the following 10 categories:

1. Ambulatory patient services
2. Emergency services
3. Hospitalization
4. Maternity and newborn care
5. Mental health and substance use disorder services, including behavioral health treatment
6. Prescription drugs
7. Rehabilitative and habilitative services and devices
8. Laboratory services
9. Preventive and wellness services and chronic disease management
10. Pediatric services, including oral and vision care

The ACA provides that the essential health benefits package must be equal in scope to benefits offered by a "typical employer plan." To meet this requirement in every state, the proposed rule defines EHB based on a state-specific benchmark plan, including the largest small group health plan in the state. The qualified health plans that participate in the Exchanges will be required to offer the benefit package at four levels of value, making comparisons across plans easier. The four levels of coverage, which vary depending on how much the insurer pays, include:

Bronze: benefits equivalent to 60 percent of the full actuarial value of plan benefits,
Silver: benefits actuarially equivalent to 70 percent of full value,
Gold: benefits actuarially equivalent to 80 percent full value, and
Platinum: benefits actuarially equivalent to 90 percent of full value.

Qualified health insurers must offer at least one plan at the Silver level and one plan at the Gold level in each Exchange in which their plans are offered.

States also have the option of establishing a Basic Health Plan for uninsured individuals with incomes between 133 percent and 200 percent of poverty in lieu of those individuals receiving premium subsidies to purchase coverage in the Exchanges, effective January 1, 2014. States that offer the Basic Health Plan must ensure that the benefits are at least equivalent to the essential health benefits and that premiums are not higher than those in the Exchanges. Only three states have shown interest in a Basic Health Plan, according to a November 30th item in American Medical News.

The federal government's Office of Personnel Management is required to certify Multi-State Plans that must be included in every Exchange.
A Kaiser Family Foundation brief on health insurance exchanges describes the minimum set of functions to be performed by the Exchanges:

• certify whether health plans are qualified to be offered in the Exchange, including examining their premium increases;
• require of plans and make public disclosure of the following information in plain language: claims payment policies and practices; periodic financial disclosures; data on enrollment, denied claims, and rating practices; information on cost sharing and payments for out-of-network coverage; and enrollee and participant rights;
• require qualified health plans to make available timely information about the amount of cost sharing for specific items or services;
• operate a toll-free telephone assistance hotline;
• maintain an Internet website where enrollees can obtain standardized comparative information about the health plans;
• assign a rating to each health plan in the Exchange based on the relative quality and price of their benefits;
• use a uniform enrollment form and a standardized format for presenting health benefits plan options;
• inform people about the eligibility requirements for the Medicaid, CHIP or other State or local public programs and coordinate enrollment procedures with them;
• make available an electronic calculator to determine the actual cost of coverage after any premium tax credit and any cost-sharing reduction has been applied;
• grant certifications for individuals who are exempt from the individual responsibility penalty if there is no affordable qualified health plan available through the Exchange or the individual's employer;
• establish a Navigator program to award grants to entities to promote public education about and enrollment in Exchanges.

In order to be certified by the Exchange as a qualified health plan, plans must meet marketing requirements (to assure that they will not discourage enrollment of those with significant health needs), ensure a sufficient choice of providers, include essential community providers that serve the low income, be accredited on clinical quality measures including consumer assessment surveys, and use a standard format for presenting health benefits plan options. In addition, qualified plans in the Exchanges must abide by insurance market regulations relating to guaranteed issue, premium rating, and prohibitions on pre-existing condition exclusions.

The requirement that plans "ensure a sufficient choice of providers" is the only provision addressing the interests of one very important group of stakeholders – the providers, including anesthesiologists and pain physicians. The state insurance commissions are going to retain their important role in determining the adequacy of provider panels.

In states where the insurance market is highly concentrated, physicians may benefit from an increase in competition through the Exchanges.  Of course, the competition is likely to involve preferred provider networks that constrain costs through restricted panels of participating physicians, and it will be important for anesthesiologists and others to offer the value that Exchange plans will be demanding. As a consultant quoted in the August 27, 2012 American Medical News article Health Insurance Exchanges: The Big Unknowns observed, in Massachusetts, insurers selected a limited number of physicians "and offered a lower-cost plan. That product ended up being a sought-after option in the state, Stento said. Doctors aligning themselves with those top payers and being in a good position to be preferred members of the network ‘could be important in navigating the plan dynamic in these new marketplaces,' she said."

The other most significant way in which physicians will be able to influence the operation of Exchanges will be to participate in their governance.  That option may be available only in the states that set up their own Exchanges. In those states that elect not to create their own Exchanges or are unable to do so, CMS will establish a Federally-facilitated Exchange. FFEs are not required to have any physician representation. Individual states, on the other hand, may choose to have physicians on their Exchange governing boards, or at least on advisory panels.

The states had until December 14th to inform the Obama administration whether they intended to set up their own State-based exchanges or instead leave that task to the federal government, either wholly or in partnership with the states.  Eighteen states and the District of Columbia have now committed to operating their own exchanges, and seven more have opted for partnership with CMS. The remaining 25 states will default to the FFE, in most cases, or apply for a Partnership Exchange, for which the deadline is February 15, 2013.

It is ironic that so many states with Republican governors and legislators have chosen to do nothing, thereby giving the federal government total control over the exchanges. As Jacobs and Ario commented in Post Election, The Affordable Care Act Leaves the Intensive Care Unit for Good (Health Aff 2012;31(12), 2603-2608), "Once a federal exchange is fully established and gains a constituency, it will create a high bar for states later considering setting up their own exchange. Supporters of a national public option similar to the one omitted from the final Affordable Care Act may gain leverage in persuading a future administration or Congress to add one as an offering on the federal exchange."

Eight states — Colorado, Connecticut, Kentucky, Massachusetts, Maryland, New York, Oregon, and Washington — and the District of Columbia had received conditional approval of their health insurance exchange programs, according to American Medical News on December 24th. What these Exchanges will look like is impossible to predict because regulations on such key issues as the operation of the insurance markets, the product choices available and the mechanics of risk adjustment programs will only be issued within the next few months. As always, we will keep our readers posted.

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