New challenges and opportunities that come with health insurance marketplaces

1. Health
Insurance
Marketplaces
New
Challenges
and
Opportuni4es
Sage
Growth
Partners

2. 1
Topics
for
Today
State
and
Federal
Insurance
Exchanges
–
what
to
expect
Impact
of
Exchanges
on
the
marketplace
Impacts
of
Exchanges
to
providers
AcDons
to
consider
to
survive/flourish
in
an
Exchange-­‐driven
market
1
2
3
4

3. 2
The
Big
QuesDons…Here
They
Come
Can
you
sa'sfy
their
pent
up
demand
for
healthcare
services?
Do
you
understand
how
they
will
impact
your
business?
Who
are
they
and
what
will
they
need?

4. Will
Consumers
Ever
Understand
Exchanges?

5. CBO
Exchange
Enrollment
EsDmates
2013
&
2014
February
2014
Baseline

6. Health
Insurance
Exchange
–
Enrollment

7. Enrollment
StaDsDcs
6

8. 2021
ProjecDon
-­‐
What
Will
Exchange
PaDents
Look
Like?
7
2021
Exchange
Pa'ent
Profile
Race
The
majority
are
white.
Health
status
The
majority
are
in
relaDvely
good
health.
Marital
status
Most
are
not
married.
Language
One
in
five
speak
a
language
other
than
English
at
home.
Educa4onal
a6ainment
Three-­‐fourths
do
not
hold
a
college
degree.
Employment
status
More
than
half
are
employed
full-­‐Dme.
White
Excellent/
Very
good/
Good
Married
Non-­‐English
No
college
degree
Employed
full-­‐Dme
Median
Age
Median
income
33
238%
FPL
Individual
exchange
members
Sources:
PwC
HRI
analysis
for
year
2021,
Current
PopulaDon
Survey,
Medical
Expenditure
Panel
Survey
and
CBO
78%
92%
38%
19%
76%
56%

9. Average
DeducDbles
8

10. Bronze
&
Silver
Plans
Cost-­‐Sharing
Category
Average
for
a
Bronze
Plan
DeducDble
for
an
Individual/Family
$5,081/$10,386
Doctor
Visit
30%
of
visit
charged
as
coinsurance
(54%
of
plans
have
coinsurance
fees)
Specialist
Visit
30%
of
visit
charged
as
coinsurance
Annual
cap
on
out-­‐of-­‐pocket
costs
for
individual/family
$6,267/$12,569
9
Cost-­‐Sharing
Category
Average
for
a
Silver
Plan
DeducDble
for
an
Individual/Family
$2,907/$6,078
Doctor
Visit
$32
Specialist
Visit
$56
Annual
cap
on
out-­‐of-­‐pocket
costs
for
individual/family
$5,730/$11,495

11. Gold
and
PlaDnum
Plans
Cost-­‐Sharing
Category
Average
for
a
Gold
Plan
DeducDble
for
an
Individual/Family
$1,277/$2,846
Doctor
Visit
$24
Specialist
Visit
$46
Annual
cap
on
out-­‐of-­‐pocket
costs
for
individual/family
$4,081/$8,649
10
Cost-­‐Sharing
Category
Average
for
a
Pla'num
Plan
DeducDble
for
an
Individual/Family
$347/$698
Doctor
Visit
$16
Specialist
Visit
$30
Annual
cap
on
out-­‐of-­‐pocket
costs
for
individual/family
$1,855/$3,710

12. Minimum
EssenDal
Coverage
aka
Individual
Mandate
• Coverage
is
required
in
2014
unless
you
have
an
exempDon
• States
without
Medicaid
expansion
have
the
big
GAP
• Federal
premium
subsidy
up
to
400%
of
the
FPL
• $45,960
for
an
individual
• $94,200
for
a
family
of
four
• Subsidy
eligible
–
may
chose
to
have
the
exchange
send
the
money
directly
to
the
insurer
every
month
OR
may
receive
a
tax
credit
when
they
file
taxes
the
following
year
• Penalty
for
no
coverage
in
2014
=
$95
or
1%
of
your
income
in
2014
whichever
is
greater
unless
you
quality
for
an
excepDon

13. Delays
12

14. CompeDDon’s
Impact
on
“The
Math”
Premium
=
Administra've
Costs
+
Medical
Costs
ACA
caps
administra4ve
costs
at
a
fixed
percentage
–
exceeding
the
cap
generates
member
rebates
FACT
–
Individuals
will
shop
based
on
price
(premium)
especially
those
with
lower
incomes
FACT
-­‐
Benefit
Plan
Designs
are
VERY
largely
dictated
only
very
fine
variaDons
are
allowed

15. CompeDDon’s
Impact
on
“The
Math”
Medical
Costs
=
Units
Used
(uDlizaDon)
X
Price
Paid
Price
Paid
=
YOUR
REIMBURSEMENT
Units
used
is
affected
by:
• PaDent
demand
• PaDent
health
• EffecDve
healthcare
management
Which
is
the
easiest
to
“Dnker
with”
to
keep
premiums
low?

16. Current
Exchange
Examples

17. Success:
Kentucky
• 48,611
people
have
selected
a
marketplace
plan
• In
2012,
Obama
lost
116
of
the
state's
120
counDes
• TesDng
well
before
October
1;
began
in
June
• Simplicity:
“doesn’t
have
all
the
bells
and
whistles
that
other
states
tried
to
incorporate,”
• “It’s
very
straighvorward
in
allowing
consumers
to
browse
plans
without
first
creaDng
an
account.”
• Technology
staff
had
recent
experience
sewng
up
other
complex
systems,
such
as
a
prescripDon-­‐drug
monitoring
database.
• Pre-­‐exisDng
systems,
including
one
for
document
management,
that
could
be
folded
into
the
health
exchange.
16

18. Failure:
Maryland
• State
officials
had
esDmated
that
150,000
to
180,000
Marylanders
would
sign
up
for
private
health
plans
• As
of
February
7,
the
tally
was
at
29,059.
• Maryland’s
main
contractor
—
Noridian
—
has
a
contract
worth
$193
million
• The
system
has
“serious
IT
defects”
that
have
made
it
difficult
for
Marylanders
to
enroll
• That
has
resulted
in
“substanDal
manual
work,”
and
heavy
reliance
on
call
centers
with
more
than
400
employees.
17

19. Federal
Exchange
Problems
18

20. VerificaDon
Issues
19

21. ConfirmaDon
Issues
20

22. Billing
and
Payment
Issues
21

23. What
can
you
do?

24. 23
Review
Clinic
Workflows,
Make
Hard
Decisions
Eligibility
verifica'on
–
real
'me
valida'on
of
coverage
and
benefit
levels
Develop
process
and
view
on
how
to
handle
the
uninsured
-­‐
Refer
them
to
the
Exchange
Navigator
and/or
report
them?
-­‐
Require
full
payment
up
front
if
no
insurance?
Accurate
determina'on
of
pa'ent
liability
and
collec'on
at
the
point
of
care
-­‐
Collec4on
before
or
aMer
treatment?
Manage
referrals,
manage
complex
cases,
track
pa'ent
compliance,
manage
u'liza'on

25.
Do
you
understand
your
payer
mix
and
reimbursement
versus
cost
mix
by
payer
to
add
in
negoDaDons?
What
level
is
required
to
assure
costs
are
covered
and
you
achieve
desired
margins?
Do
you
leverage
predicDve
analyDcs
to
straDfy
paDents
and
idenDfy
those
requiring
specific
intervenDon?
How
do
you
esDmate
paDent
collecDons
PRIOR
to
claims
adjudicaDon?
What
compensaDon
programs
do
you
offer
staff
to
incent
desired
clinical
behaviors?
24
Manage
Risk
to
Insure
Financial
Stability
Contract
Review
Capita'on
Rates
Bad
Debt
Pa'ent
Risk
Stra'fica'on
Programs

26. 25
25
Conclusions
Change
is
here
and
along
with
it
uncertainty
PaDent
volumes
and
expectaDons
will
increase
Financial
pressure
on
reimbursements
will
grow
–
you
must
manage
your
risk
PopulaDon
management
and
the
delivery
of
proven,
quanDfiable
quality
will
enable
success
Measurement
is
becoming
a
requirement
1
2
3
4
5

27. 26
Don’t
get
caught
unprepared!