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High-Risk Pools For Uninsurable Individuals

In the debate over the future of the Affordable Care Act (ACA), proposals have emerged that would repeal or weaken rules prohibiting health insurance discrimination based on health status, instead offering high-risk pools as a source of coverage for people who would be uninsurable due to pre-existing conditions.

In Congress, HR 2653 was introduced by members of the House Republican Study Committee to repeal the ACA and replace it with other changes, including state high-risk pools.  This bill would authorize $50 million for seed grants to help states establish high-risk pools, and $2.5 billion annually for 10 years to help states fund high-risk pools.  Recently, House Republicans released their proposal to replace the ACA, entitled A Better Way.  This plan would significantly modify ACA insurance market rules to provide a one-time open enrollment opportunity; thereafter, only individuals who maintain continuous coverage would be guaranteed access to insurance without regard to their health status.  This plan also would provide $25 billion over 10 years in state grants to help fund high-risk pools.  Pools would be required to cap premiums (at unspecified levels) and would be prohibited from imposing waiting lists.

For more than 35 years, many states operated high-risk pool programs to offer non-group health coverage to uninsurable residents.  The federal government also operated a temporary high-risk pool program established under the ACA to provide coverage to people with pre-existing conditions in advance of when broader insurance market changes took effect in 2014.  This issue brief reviews the history of these programs to provide context for some of the potential benefits and challenges of a high-risk pool.

Read the full article here.

Aetna is Quitting 70 Percent of Obamacare Markets

The insurer says it’ll walk away from more than two-thirds of exchange markets it participated in this year, dropping from 778 counties to 242 counties next year. Aetna will maintain a presence in just four states, it says — Delaware, Iowa, Nebraska and Virginia — down from 15 states this year.

… Aetna says the market’s financials are unworkable, pointing out that it has lost more than $430 million since January 2014 on its individual products. It’s not the only major player to walk away from the Obamacare exchanges.

“More than 40 payers of various sizes have similarly chosen to stop selling plans in one or more rating areas in the individual public exchanges over the 2015 and 2016 plan years,” CEO Mark Bertolini said in a statement. “As a strong supporter of public exchanges as a means to meet the needs of the uninsured, we regret having to make this decision.”

See Aetna’s announcement: http://aet.na/2aVKWgJ
More for Pros from Paul Demko: http://politico.pro/2aWI6hh

One state feeling the pain: Arizona. Aetna is just the latest insurer to pull out of the state this year — and “means Pinal County, as of now, has no ACA insurers” set to offer plans on the exchange this fall, the Arizona Republic’s Ken Alltucker reports. According to HHS data, there were 9,667 plan selections in Pinal County as of Feb. 1, 2016.

HHS: This doesn’t change the realities on the ground. Marketplace CEO Kevin Counihan pointed to data released last week that the exchange risk pool is getting healthier and less expensive, and suggested that the new market is creating winners and losers.

Democrats: This is a negotiating tactic. The agency also says that Aetna quickly — and conveniently — changed its tune on Obamacare. Bertolini told investors in April that while Aetna was losing money on the exchanges, the early losses were “well, well below” the company’s pain points and “we see this as a good investment.”

Read the full article here.

Why Does Healthcare Cost So Much?

Healthcare spending in the United States is $3 trillion a year, straining the budgets of families, businesses and taxpayers alike.

The price of medical care is the single biggest factor behind healthcare costs. These expenditures reflect the cost of caring for those with chronic or long-term medical conditions, an aging population and the increased cost of new medicines, procedures and technologies.

The new health reform law also has expanded access to insurance to millions of Americans. We’ve transitioned to a healthcare system in which everyone can obtain health insurance regardless of age or health status, and many individuals who are newly insured need ongoing medical attention.

Though medical costs are the main reason for the persistent growth in healthcare spending, too much of this money is not well spent. In fact, studies indicate that 30 cents of every healthcare dollar goes to care that is ineffective or redundant.

We can all play a part in helping to make America healthier–and curb healthcare costs. Our healthcare system itself must focus more on quality care for patients that helps them get healthy faster and stay healthy longer.

Read the full article here.

CMS Releases 2017 Enrollment Manual For Individual And Small Business Marketplaces

On July 19, 2016, the Centers for Medicare and Medicaid Services released the Federally-facilitated Marketplace (FFM) and Federally-facilitated Small Business Health Options Program (FF-SHOP) Enrollment Manual for the fourth (2017) marketplace open enrollment period. The 167 page manual covers in detail the rules and procedures governing the FFM and FF-SHOP, issuers of qualified health plans (QHPs) and qualified dental plans (QDPs) in the FFM and FF-SHOP, qualified individuals and employers who apply for coverage in the FFM and FF-SHOP, and brokers and agents (including web-brokers) and others who assist applicants and enrollees. The manual applies in FFM states and in State-based marketplace states that use the FFM or FF-SHOP enrollment platforms.

Topics covered by the manual include:

  • Enrollment in the individual marketplace (including data matching issues, redeterminations and renewals, auto-enrollment, premium payment due dates, and free look provisions under state law);
  • Enrollment in FF-SHOP (including minimum participation rates, special enrollment periods, premium payments, terminations, and renewals);
  • Direct enrollment in the individual market through insurers or web-brokers;
  • Special enrollment periods;
  • Premium payments (focused on terminations for nonpayment and grace periods, including complex situations spanning more than one coverage year, and rules governing minimum premium payment thresholds, but also including situations involving over-billed and under-billed premiums);
  • Terminations (including terminations due to death and aging off);
  • Retroactivity;
  • Reinstatements following mistaken disenrollments;
  • Reconciliation of enrollments between the FFM and QHP/QDP insurers; and
  • Generation and reconciliation of 1095-A tax reporting forms by FFMs.

The manual also includes appendices with a sample welcome letter, non-payment notice, termination letter, and mandatory attestation.

Read the full article here.

Employer Marketplace Notice Has Short, 90-Day Appeal Window

Employers may receive notices from the Marketplaces indicating that they may be subject to the shared responsibility payment because an employee requested and received a subsidy. Employers have a short window of 90 days to respond and provide documentation if they wish to appeal information in the notice, so it is important to act quickly.

  • The Marketplaces are looking for verification that the employer has met the shared responsibility (employer mandate) requirements under the Affordable Care Act (ACA).
  • Employers may appeal the notice if the employee waived affordable minimum value coverage or enrolled in employer-sponsored minimum essential coverage  for 2016.
  • The appeal may determine that an employee received subsidies through the Marketplace at the same time the employer offered him or her affordable health coverage.
  • If the employer is successful, the Marketplace will send a notice encouraging the employee to update the Marketplace application to show that he or she was offered or was enrolled in other qualifying coverage. The notice will also explain that the failure to update the application may result in tax liability.
  • Important: This appeal will not determine if an employer has to pay the shared responsibility payment.  Only the Internal Revenue Service, not the Health Insurance Marketplace or the Marketplace Appeals Center, can determine which employers will have to make the required payment. The employer notice, however, appears to be the first step in that process.
  • Learn more about the employer shared responsibility payment on IRS.gov.

Read the full article here.