Becker's Hospital Review

74 Sign up for the COMPLIMENTARY Becker's Hospital Review CEO Report & CFO Report E-Weeklies at www.BeckersHospitalReview.com or call (800) 417-2035 when developing strategies for patient access and building financial projections. For patients in between 75-200 percent of the federal poverty level, there are two issues. The first is whether or not patients at up to 138 percent of FPL will be covered by Medicaid, which will be determined by the state's decision on Medicaid expansion. Secondly, studies indicate that between one-third to one-half of patients with incomes in this range are likely to slip into or out of the range.4 The churning that results will create confusion regarding coverage for both patients and providers if patients change plans or go on and off Medicaid over a period of time. and their physicians. Both hospitals and patients will need to understand what the patients' expected outof-pocket costs are. Providers will need to educate frontline staff on the pertinent details of health exchanges, especially patient financial service personnel. Many providers are proactively conducting education sessions with community groups (e.g., parent teacher associations, town hall meetings, chambers of commerce) to clarify questions regarding signing up for coverage, subsidies and what they mean regarding access to care. Providers who are well educated about health exchanges can better serve their communities and ensure that consumers take full advantage of the new resource. Education and outreach Conclusion What steps is your organization taking to improve understanding about health exchanges in your community? Are consumers aware of the available plans and which plans you participate in? If consumers and businesses are confused, they will expect greater clarity from the hospitals As the first major new federal healthcare program since the introduction of Medicare and Medicaid in 1965, health exchanges promise to bring plenty of strategic and operational challenges for even the savviest providers. Proactively addressing these challenges head-on will help any provider achieve success with exchanges in the new health reform era. n Footnotes: 1 ttp://money.cnn.com/2013/04/23/news/economy/ h obamacare-subsidies/index.html. 2 mall business exchange delay source: http://www.nytimes. S com/2013/04/02/us/politics/option-for-small-businesshealth-plan-delayed.html?_r=0. Large employer penalty source: http://www.nytimes.com/2013/07/03/us/politics/ obama-administration-to-delay-health-law-requirementuntil-2015.html?pagewanted=all. 3 atient obligations are based on actuarial estimates for P annual healthcare spend under the plan, as required by federal law. 4 ick Curtis and Ed Neuschler, Income Volatility Creates R Uncertainty about the State Fiscal Impact of a Basic Health Program (BHP) in California, Institute for Health Policy Solutions, with support from the California HealthCare Foundation, September 2, 2011. 5 Operation statistics as of July 2013. 6 ttps://www.healthcare.gov/glossary/essential-healthh benefits. 7 https://www.healthcare.gov/glossary/qualified-health-plan. 8 ttp://kff.org/infographic/the-requirement-to-buy-coverh age-under-the-affordable-care-act. 9 ttp://kff.org/infographic/employer-responsibility-underh the-affordable-care-act. Exchange Category Description Exchange Basics Exchange open enrollment period begins Oct. 1, 2013. Exchange plan coverage becomes effective Jan. 1, 2014. Each state will offer an individual/family exchange and a small employer exchange (SHOP). In most States the SHOP will be delayed until 2015. Exchanges are responsible for providing a side-by-side comparison marketplace for consumers. Operation Status The exchange can be operated under one of three structures.1 State-operated exchange (16 states and Washington, D. C.). Federally facilitated exchange (27 states). State-federal government partnership exchange (seven states). Plan Tiers Health exchange plans will be offered in five tiers differentiated by the percentage of patient responsibility, based on actuarial value (platinum – 10% patient responsibility, gold – 20%, silver – 30%, bronze – 40% and catastrophic). Each successive level provides higher coverage and a correspondingly higher premium. Essential Health Benefits All plans on the exchanges must provide care within each of the 10 service categories: ambulatory services, emergency services, hospitalization, maternity care, mental health services (including behavioral health treatment), prescription drugs, rehabilitation services, laboratory services, wellness services and pediatric services (including oral and vision).1 Qualified Health Plan Insurance plans that meet the actuarial value and provide the essential benefits are qualified.1 Subsidies Individuals/families will be provided a sliding-scale subsidy to purchase insurance (from 138% of FPL to 400% of FPL). The plan cost is based on the second-lowest-cost silver plan available. Health insurance cost is limited to 9.5% of a consumer's gross income at the top of the scale and 2.0% at the bottom of the scale. Penalties Individuals – People who do not receive coverage from their employer and forego purchasing coverage on their own are subject to a fine.1 Employers – Only employers with more than 50 full-time employees (adjusted for hours worked) are subject to penalties if they do not offer affordable insurance that provides at least bronze-level coverage to their employees. Penalties were supposed to begin in 2014 but have been delayed until 2015.2 Grace Period Consumers have a grace period of 90 days to pay their premium before the health plan is no longer responsible for coverage and paying claims on that plan. Health plans are responsible only for the months that the premium is paid. Providers must be notified by the health plan if a claim is at risk of nonpayment due to the premiums not being paid in months two and three of the grace period.

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